Every finding on record at Sunnyside Healthcare Center

Based on observation, interview, and record review, the facility failed to provide supervision and implement care plan interventions to prevent a resident-to-resident altercation for 2 of 8 residents (Resident 1 and 2) reviewed for avoidable accidents. This failure placed the residents at risk for physical abuse, serious pain and injury, and emotional distress. Findings included. Review of a policy titled, Safety and Supervision of Residents, revised 07/2017, showed resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The care team would obtain information from assessments and observations to identify hazards or risks for individual residents. The care team would target interventions to reduce individual risks related to hazards including adequate supervision. Implementing the interventions included communicating these specific interventions to all relevant staff and ensuring the interventions were implemented. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including Down Syndrome (a genetic condition that alters how the brain and body develop, resulting in distinct physical features and intellectual disabilities), post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event), and anxiety. The 02/23/2026 comprehensive assessment showed Resident 1 required set up assistance of one staff member for activities of daily living [(ADLs) activities related to personal care] and was dependent on one to two staff members for showering. The assessment also showed Resident 1 had a moderately impaired cognition (a group of thinking and social symptoms that interferes with daily functioning). Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a decline in memory, thinking, and reasoning that interferes with daily life). The 05/19/2026 comprehensive assessment showed Resident 2 required assistance of one staff member for ADLs. The assessment also showed Resident 2 had a severely impaired cognition. Record review of a facility investigation dated 06/20/2026 at 12:15 PM, showed Resident 2 was in the dining room passing out clothing protectors to the other residents. Resident 2 attempted to give a clothing protector to Resident 1 by placing it on their lap. Resident 1 became agitated and slapped Resident 2 on their arms a few times. Record review of Resident 1's care plan dated 05/27/2026, showed they had five prior dining room related resident-to-resident altercations dated 08/04/2022, 12/29/2022, 01/26/2023, 12/12/2023, and 03/11/2026. A care plan behavior management intervention, dated 01/26/2023, showed please help resident obtain clothing protector when (Resident 1) goes into dining room for meals. Record review of Resident 2's care plan dated 05/27/2026, showed the resident required cueing, reorientation, and supervision related to their memory loss and impaired decision making. During an observation on 06/24/2026 at 12:07 PM, Resident 2 was in the dining room in their wheelchair. There were six other residents in the dining room. Resident 2 wheeled over to the sink/cabinet area, stood up, and obtained sugar/sweetener packets from the cabinet area. They obtained napkins and silverware from the same area. Resident 2 gave the sugar/sweetener packets and silverware to a resident sitting at their table. Resident 2 went back to the cabinet area, obtained additional sugar/sweetener packets and silverware and returned to their table. Resident 2 gave silverware to a second resident sitting at the same table. There were no staff present in the dining room, despite Resident 2 obtaining items from the cabinets and requiring supervision. During a concurrent observation and interview on 06/24/2026 at 12:57 PM, Staff C, Nursing Assistant (NA), was standing in the dining room, observing residents at mealtime. They stated there were usually two NAs in the dining room to supervise during meals. Staff C stated Resident 2 always goes around and helps everyone, and were unsure if they were care planned to help out in the dining room with clothing protectors. They stated they would look on the Kardex (a quick reference guide that identifies essential resident information) if there were care needs identified for Resident 1 or Resident 2 related to the dining room. Staff C stated they were not aware of any identified needs for either resident. During an interview on 06/24/2026 at 1:26 PM, Staff E, Resident Care Manager, stated Resident 1 was territorial with their spot in the dining room. They stated Resident 2 liked to help the other residents in the dining room by passing out clothing protectors. Staff E stated they had talked to Resident 2 after the altercation and reminded them to place the clothing protectors on the table. They stated Resident 2 had cognitive and memory impairments and would not remember the conversation. Staff E stated there was supposed to be staff supervising the residents when they were in the dining room. Upon review of Resident 1's care plan, Staff E stated the NAs would not know to put the clothing protector on Resident 1 as they entered the dining room, because the intervention was not entered correctly on the care plan and did not populate on the Kardex for staff to see. During an interview on 06/24/2026 at 1:39 PM, Staff B, Assistant Director of Nursing, stated there should always be at least one staff member supervising the dining room. They stated the resident-to-resident altercation occurred because Resident 2 gave Resident 1 a clothing protector, and Resident 1 reacted to that. They stated the NAs would not have been aware of the intervention to place a clothing protector on Resident 2 to avoid an altercation. Staff B stated the NAs did not have access to the residents' care plans, and the intervention was not on the Kardex. They stated the residents care plans were not followed and there was clearly no supervision. During an interview on 06/24/2026 at 1:50 PM, Staff A, Director of Nursing, declined to respond to questions related to the resident-to-resident altercation as they had not yet completed their full investigation. Staff A stated Resident 2 required more supervision, and the plan would be to move them to an area that would provide them with the additional supervision. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to allow residents the right to make choices related to the time of day for showering for 3 of 4 residents (Residents 1, 2, and 3) reviewed for self-determination. This failure placed the residents at risk for distress, poor hygiene, and an undignified existence.Findings included. Review of a policy titled, Resident Rights, 02/2021, showed resident rights included the right to a dignified existence and self-determination. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including a dislocation of the right knee, anxiety, and need for assistance with personal care. The 01/06/2026 comprehensive assessment showed Resident 1 was independent with activities of daily living [(ADLs) activities related to personal care] and had a moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The assessment also showed it was very important for Resident 1 to make choices regarding their customary routines and activities. During an interview on 03/09/2026 at 12:50 PM, Resident 1 stated they were not informed of the change in the shower schedule. They stated they were assigned to the evening shower schedule and preferred their shower during the day. Resident 1 stated I wish they would have come to me and asked what I wanted because I don't like evening showers. Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including left sided weakness/paralysis after a stroke (damage to brain cells when the blood supply is blocked or a blood vessel in the brain bursts), lung disease, and high blood pressure. The 01/19/2026 comprehensive assessment showed Resident 2 was dependent on one to two staff members for ADLs and had a moderately impaired cognition. The assessment also showed it was very important for Resident 2 to make choices regarding their customary routines and activities. During an interview on 03/09/2026 at 9:16 AM, Resident 2's Representative (RR) stated the staff wake Resident 2 up early and take them to the shower. They stated Resident 2 doesn't like that. The RR stated Resident 2 did not have choices as they liked to sleep in and wanted to have their shower in the afternoon. They stated, if they (staff) would work with their (Resident 2's) choices, they would be happier in the facility. During an interview on 03/09/2026 at 12:59 PM, Staff C, Nursing Assistant (NA), stated they were the shower aide prior to the changes in the shower schedule. They stated they always completed Resident 2's shower first, before breakfast. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including diabetes (a group of diseases that affect how the body uses blood sugar), paraplegia (the inability to voluntarily move lower parts of the body), and depression. The 12/10/2025 comprehensive assessment showed Resident 3 required substantial/maximum assistance of one staff member for showers and was cognitively intact. The assessment also showed it was very important for Resident 3 to make choices regarding their customary routines and activities. During an interview on 03/09/2026 at 2:42 PM, Resident 3 stated a NA had told them the shower aide would no longer be providing the showers. They stated, I don't agree with it, they did not give us a choice of day or evening showers. During an interview on 03/05/2026 at 9:13 AM, Staff B, Director of Nursing Services, stated there were changes to the shower schedule that included, starting 03/01/2026, the NAs would be doing their own resident showers. They stated the facility would no longer have a shower aide. Staff B stated there were a couple resident complaints with the change. Staff B stated the change was due to budget cuts. During a follow up interview on 03/09/2026 at 1:58 PM, Staff B stated when the change to the shower schedule was made, the residents were not given the choice between day and evening showers. They stated residents should have been given the choice but did not think anyone would want an evening shower and they had to split the workload between the shifts. During an interview on 03/09/2026 at 2:12 PM, Staff A, Administrator, stated they had moved the shower aides to work the floor to increase floor staff. They stated the showers were split between the day and evening shifts. Staff A stated the residents should have been given a choice for their shower time. Staff A stated they did not know residents were not given the choice. Reference WAC: 388-97-0180(2)

Based on interview and record review, the facility failed to ensure residents were provided the opportunity to be involved in making decisions about care and treatment for 2 of 3 residents (Residents 3 and 2) reviewed for rehabilitation services. This failure placed the residents at risk for a decline in physical functioning, worsening mobility, and frustration.Findings included. Review of a policy titled, Care Plans, Comprehensive Person-Centered, dated 03/2022, showed the resident's comprehensive person-centered care plan was consistent with the resident right to participate in the development and implementation of the care plan, including the right to participate in determining the type, amount, frequency, and duration of care; receive the services included in the care plan; and see the care plan and sign it after significant changes were made. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including diabetes (a group of diseases that affect how the body uses blood sugar), paraplegia (the inability to voluntarily move lower parts of the body), and depression. The 12/10/2025 comprehensive assessment showed Resident 3 required partial/maximum assistance of one staff member for activities of daily living [(ADLs) activities related to personal care). The assessment also showed Resident 3 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Record review of a Therapy RA (Restorative Aide) Referral Form dated 02/17/2026, showed Resident 3 had a restorative nursing (person-centered nursing care designed to improve or maintain the functional ability of resident to achieve their highest level of well-being) plan for active range of motion [(AROM) movement of a joint by actively engaging muscles) with a frequency of six times a week. Record review of a care plan dated 12/08/2025, showed Resident 3 had an AROM plan with a frequency of six times per week, initiated on 10/30/2025. Further review of the care plan showed the AROM frequency was reduced to three times per week on 03/05/2026. During an interview on 03/09/2026 at 2:42 PM, Resident 3 stated they were frustrated about the change in their therapy services. They stated they were not informed of the change from six days to three days a week. They stated the facility also cut the length of time for their sessions from 30 minutes per session to 20 minutes per session. Resident 3 stated I am here for therapy, and I feel like I am now restricted as to what I can do. I am frustrated and angry. Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including left sided weakness/paralysis after a stroke (damage to brain cells when the blood supply is blocked or a blood vessel in the brain bursts), lung disease, and high blood pressure. The 01/19/2026 comprehensive assessment showed Resident 2 was dependent on one to two staff members for ADLs. The assessment also showed Resident 2 had a moderately impaired cognition. Review of a care plan dated 01/05/2026, showed Resident 2 had an AROM program initiated 12/20/2024, with a frequency of six times per week. Further review of the care plan showed the AROM frequency was reduced to three times per week on 03/05/2026. During an interview on 03/09/2026 at 9:16 AM, Resident 2's Representative stated at a recent care conference (02/26/2026) they were told Resident 2 was receiving restorative nursing services every day. Resident 2's Representative stated they did not know if that was happening and were not informed of any changes in services. During an interview on 03/05/2026 at 1:27 PM, Staff D, Director of Rehab, stated they had heard that residents were unhappy about the change in restorative services. They stated therapy services wrote the restorative programs, and they were implemented by nursing staff. Staff D stated restorative services were now three days per week. During a follow up interview on 03/09/2026 at 3:00 PM, Staff D stated the therapy department was not consulted on the changes to restorative services. They stated residents would show a decline in their condition in probably three to six months with the new changes. Staff D stated any resident that was on a ROM program for contractures (a permanent tightening of the muscles, tendons, and skin that causes the joints to shorten and become very stiff) or splinting should remain at a higher frequency than three days per week to maintain ROM. During an interview on 03/09/2026 at 1:58 PM, Staff B, Director of Nursing Services, stated the residents were not notified of the change in restorative services that occurred on 03/01/2026. They stated the process should have been to send out a letter to the residents and their representatives informing them of the change. They stated the facility did not involve therapy and did not complete new assessments; they decreased the frequency of visits from six to three visits per week due to budget cuts. Staff B stated there was no plan in place to ensure the residents did not decline. During an interview on 03/09/2026 at 2:12 PM, Staff A, Administrator, stated the facility knew of the upcoming changes to restorative services in February 2026, and should have notified the residents and/or their representative prior to the change on 03/01/2026. Reference: WAC 388-97-0200(2)(3)

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of drugs) to meet the needs of 1 of 3 residents (Resident 1) reviewed for pharmacy services. This failed practice placed the residents at risk for ongoing, uncontrolled pain and emotional distress. Findings included. Review of a policy titled, Administering Medications, dated 04/2019, showed medications were administrated in a safe and timely manner as prescribed. Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including rheumatoid arthritis (a chronic, progressive disorder where the immune system attacks joint linings, causing painful inflammation, stiffness, and potential deformity) and a history of compression fractures (a collapse of weakened bones that cause severe back pain) in the spine. The 01/09/2026 comprehensive assessment showed Resident 1 required maximum assistance/dependent on one to two staff members for activities of daily living: independent with eating. The assessment also showed Resident 1 had an intact cognition. Review of Resident 1's January 2026 Medication Administration Record (MAR), showed they had a 10/01/2025 physician order for their narcotic pain medication to be given every six hours for rheumatoid arthritis. The MAR showed missed doses of the narcotic pain medication on 01/27/2026 at 6:00 PM, 01/28/2026 at 12:00 AM, 6:00 AM, 12:00 PM, 6:00 PM, and 01/29/2026 at 12:00 AM. An observation and interview on 02/02/2026 at 9:48 AM, showed Resident 1 lying in bed on their back. Their fingers on both hands were deformed. Resident 1 stated the facility did not have their narcotic pain medication available and they had missed six doses. They stated they had pain all over their body, including their hands, back, feet, and elbows. Resident 1 stated the staff told them they had ran out of their narcotic pain medication and the pharmacy would not refill it until a doctor wrote a new prescription for the medication. They stated they used an over-the-counter anti-inflammatory and pain reliever for temporary pain relief. Resident 1 stated the facility did not have a back up for the narcotic pain medication and they were not able to get it from the emergency supply. During an interview on 02/02/2026 at 10:31 AM, Staff C, Licensed Practical Nurse, stated the process for reordering medications included reviewing the medication card and placing the refill request when the remaining medication in the card was in the blue section (indicating seven doses left). Staff C stated if the medication ran out before they received the refill, they could obtain a dose from the emergency backup supply by using a pharmacy authorization code to open the medication dispenser. Staff C stated, for Resident 1, there was a problem with receiving their narcotic pain medication from the pharmacy. They stated the provider was contacted and a new prescription was sent to the pharmacy, however they were unable to obtain an authorization code from the pharmacy to pull the narcotic pain medication due to confusion with the order. Staff C stated Resident 1 went without until the pharmacy straightened out the orders. During an interview on 02/02/2026 at 12:28 PM, Staff B, Director of Nursing Services, stated the process for refilling narcotic medication included the provider sending a prescription, either by telephone or signing a paper prescription in the facility, and faxing that to the pharmacy. They stated refills needed to be requested at least seven days prior to the resident running out of medication to ensure they were available for use. Staff B stated narcotics were available in the emergency supply, however the staff would need to get an authorization code from the pharmacy to obtain the medication. Staff B stated the process for refilling/administering medications was not followed. During an interview on 02/02/2026 at 4:06 PM, Staff A, Administrator, stated the licensed nurses should be communicating with the provider and the pharmacy to ensure the residents have the medications they need and to ensure they are requesting refills of medication prior to the resident running out. Reference: WAC 388-97-1300(1)(a)(b)(ii)

Based on observation, interview and record review the facility failed to ensure staff maintained components of an infection prevention control program to prevent the development and transmission of infections for, 1) hand hygiene and glove change for 5 of 9 staff (Staff Q, P, K, F, and R) reviewed during resident cares and meal service and, 2) use of Personal Protective Equipment (PPE) in an enhanced barrier precaution (EBP, indicated with high contact resident care activities with an infection, a long term wound, central line device or colonization [the presence of a bacteria that has not yet started its infection process] of an multi drug resistant organism) room for 1 of 3 residents (Resident 44) reviewed for infection control. This failure placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of Centers for Disease Control and Prevention (CDC) recommendations titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024 showed that hand hygiene was to be implemented to reduce the harmful spread of infections in the healthcare setting. Common situations that required staff to perform hand hygiene were before/after contact with a resident, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after touching a resident or their surroundings, and immediately after glove removal. Review of CDC recommendations titled, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs, bacteria that has become resistant to certain antibiotic medications), dated 04/02/2024 showed EBP was the implementation of putting on PPE, a gown and gloves, for high-contact resident care activities, which included dressing, bathing/showering, transferring, providing hygiene, and when changing linens/briefs or assisting with toileting. Additionally, EBP's were to be used with residents that had indwelling devices like urinary catheters (device that can be placed with the bladder to drain urine) or any skin opening that required a dressing. Hand Hygiene Observations on 12/08/2025 at 12:27 PM showed meal trays being delivered to residents on the 300 hallways by Staff Q, Nursing Assistant (NA), and Staff P, NA. Staff Q was observed entering a resident's room to deliver them their lunch meal tray and did not perform hand hygiene prior to entering or when they exited. Staff Q then grabbed another meal tray and entered another resident room and proceeded to set up the meal tray for the resident to eat. Staff Q observed touching the resident beside table and used the resident's utensils to cut up their food without gloves or performing hand hygiene. After, Staff Q proceeded to pull the resident's curtain back to the closed position and exited the room without performing hand hygiene to grab another resident's meal tray. Staff P observed entering a resident room to deliver a meal tray, without performing hand hygiene, touched the bedside table and set up meal for resident then exited the room and grabbed another meal tray to head into another resident's room without performing hand hygiene. During an interview on 12/08/2025 at 12:41 PM, Staff Q stated there were no hand sanitizing stations that were convenient or in all the resident rooms and they would usually have put hand sanitizer in their pocket so they could perform hand hygiene before and after delivering resident meal trays. Staff Q stated they did not perform hand hygiene in-between delivering resident meal trays. During an interview on 12/11/2025 at 8:57 AM, Staff B, Director of Nursing Services, stated that staff should be performing hand hygiene any time before entering and when exiting a resident room when passing meal trays. Staff B stated the correct process was not followed by staff delivering meal trays. Resident 92 Review of the resident's medical record showed they were admitted to the facility with diagnoses of a below the knee amputation of their right leg and diabetes. The 12/07/2025 comprehensive assessment showed Resident 92's cognition was moderately impaired and had an unhealed unstageable pressure injury (PI, full-thickness skin/tissue loss where the base of the ulcer is obscured by non-viable tissue) to their left heel. An observation and concurrent interview on 12/09/2025 at 3:38 PM, showed Staff K, Licensed Practical Nurse (LPN), providing wound care to Resident 92. Staff K placed a brown bath towel (used as a barrier) underneath a surgical incision to the right leg amputation site. The incision was reddened, had staples in place, and was not previously covered. Staff K applied gloves, and clean wound supplies were placed on Resident 92's bed without a barrier. Staff K cleansed the incision site and then placed the soiled gauze onto the bed with the clean gauze. Staff K, without changing their gloves, then place a non-stick dressing, followed by rolled gauze. Staff K, without changing their gloves, reached into their shirt pocket and pulled out a pen to put their date and initials on the dressing, then placed the pen back into their pocket. Staff K then removed gloves, did not perform hand hygiene, placed a new pair of gloves and moved to the PI to the left heel. Staff K placed the same brown bath towel used for the incision site, underneath the left heel, the heel had no dressing in place to remove, and Staff K cleansed the heel with wound cleanser. Staff K, without changing their gloves, applied a protective coating to the wound bed, then a foam dressing. Staff K exited the room to get Resident 92 pain medications, removed their gloves, and did not perform hand hygiene. Resident 60 Review of the resident's medical records showed they were admitted with diagnoses of kyphosis (excessive curving of the spine causing a hunch back) and Spondylosis (degeneration of the spinal column). The 11/11/2025 comprehensive assessment showed Resident 60's cognition was intact and required substantial to maximum assistance with toileting. During an observation on 12/10/2025 at 11:49 AM, Staff R, NA, assisted Resident 60 to the bedside commode. Staff R donned gloves to clean the resident after they had a bowel movement, removed their soiled gloves, donned a new pair and did not perform hand hygiene. Staff R then called Staff F, Registered Nurse, into the room for assistance, Staff F donned gloves, assessed open areas to the area to the top of their right buttock, and then Staff R applied pink barrier cream to that area. Staff F then removed a brown protective wound dressing from Resident 60's lower back, assessed an open area, then reapplied a new patch without cleansing the area or changing gloves and performing hand hygiene, and then applied a new patch to the area above the right buttock with the same gloves. Staff R and Staff F then assisted the resident from the commode without either removing their soiled gloves or performing hand hygiene. During an interview on 12/12/2025 at 1:44 PM, Staff C, Infection Preventionist, stated staff had yearly hand hygiene training and when they completed audit rounds and competencies. Staff C stated Staff F, Staff R, and Staff K should have removed their gloves after completing dirty tasks and performed hand hygiene and then applied new gloves. During an interview on 12/12/2025 at 2:12 PM, Staff B, Director of Nursing Services, stated the process for hand hygiene was to perform hand hygiene, don gloves, perform dirty tasks, remove gloves, perform hand hygiene, and then don new gloves before moving on to clean tasks. Staff A stated Staff F, Staff R, and Staff K did not follow the correct process. EBP Precautions Resident 44 Review of the resident's medical records showed they were admitted on [DATE] with diagnoses to include a blood clot in the lungs and obstructive uropathy (a blockage of the urine) with the use of an indwelling catheter (a tube inserted into the bladder to drain urine). The 11/30/2025 comprehensive assessment showed Resident 44's cognition was moderately impaired. During an observation and concurrent interview on 12/09/2025 at 3:57 PM Staff U, NA, entered Resident 44's room to provide personal care and clean them up. Staff U stated Resident 44 had an indwelling catheter and used a small leg bag (a medical device used to drain urine) attached to their right leg. Staff U had no PPE on while providing personal care and catheter care. Resident 44 had no sign for EBP on the outside of their door to notify staff they were required PPE, and no PPE bin was outside of their door. During an observation on 12/10/2025 at 12:11 PM, showed Staff R entered Resident 44's room and provided catheter care and transferred them to their wheelchair. Staff R had no PPE on and there were no EBP precautions posted on the outside of Resident 44's room. During an interview on 12/12/2025 at 1:44 PM, Staff C stated any resident with an indwelling catheter, whether they used a regular drainage bag or a leg drainage bag, should be on EBP. Staff C stated NAs were aware they were to wear PPE when providing care to anyone with a catheter. Staff C stated they thought they had placed EBP signage on Resident 44's door but I must have missed that. Reference: WAC 388-97-1320 (1)(a)(c)(2)(b)

Based on observation, interview, and record review the facility failed to ensure cleanliness, discard expired foods, and to follow the thawing and cooling process of foods in 1 of 1 kitchen reviewed for safe and sanitary kitchen. This failed practice placed all residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]). Findings included . Review of the July 2024 Food and Drug Administration code showed bacteria grew quickly when food was not properly cooled. The code showed hot food should be cooled in a two-step process in order to reach 70 degrees Fahrenheit (a unit of measure) over a two-hour period to be free of bacterial growth, and then further cooled to 41 degrees Fahrenheit or less before storing. During an initial tour of the kitchen on 12/08/2025 at 9:10 AM, showed: the four refrigerator and freezers against the wall inside the door with dried, stuck on white fingerprint smears on the door handles and the doors. Inside the first refrigerator was a deep, full sheet metal pan that had thawed pork and juices with a pull date (the date the food was taken out of the freezer to start the thawing process) of 11/29/2025 (nine days past the pull date) and no use by date. On top of the pork (mentioned above), was a deep, half sheet metal pan with thawed chicken and was over filled with blood and juices that were dripping down into the pan of thawed pork. The chicken had a pull date of 12/02/2025 and a for use date of 12/06/2025 (six days past the pull date). There were two full bags of chicken pieces with no pull date or no use by dates. There were three 10-pound (a unit of measure) rolls of ground beef, with no pull date or use by date. There was a bag of diced pork sausage with an open date of 08/18/2025, and no use by date (112 days after open date). On the shelf above the thawed meat was a resident's breakfast tray that was still warm to the touch On the shelf to the right of the breakfast tray was a clear container of chilaquiles (a Mexican breakfast dish made with tortillas) that was unlabeled and undated and still hot to the touch. A clear dish with scrambled eggs, dated 12/08/2025, still hot to the touch A clear dish with ground up sausage, dated 12/08/2025, still hot to the touch One gallon of Thousand Island salad dressing, one quarter full, with two opened dates of 07/23/2025 and 08/08/2025 and no expiration date was on the container or use by date. One opened gallon of mustard, half full, with no open date, expiration date, or used by date. Inside the 2nd freezer showed: A plastic bag of meat, unlabeled, dated 12/07/2025, and no expiration or use by date. Opened cinnamon rolls dated 03/13/2025 with no expiration or use by date. Five rolls of Chorizo (a spicy pork sausage) meat with no open date or use by date. Eight round meat patties, unlabeled, and no open or use by date. A 27-ounce (a unit of measure) coconut cream pie with no dates at all. An observation of the dry storage area in the kitchen on the same day, 12/08/2025 at 9:35 AM showed a black rack to the right of the doorway, with clean dishes on it. The rack had personal staff items placed on the top shelf, lotion bottles, two spiral binders, open bags of candy, a bottle of salsa, a pink water cup, a bottle of lens cleaner, and a bottle of tums (medication used for stomach acid). Further observation showed: A bag of Turkey gravy mix, opened, half full, with, no opened or use by date or expiration date. A three-pound (unit of measure) bag of almonds with an open date of 07/01/2025 and no expiration or use by date. A box of corn flakes cereal, the bag was not sealed closed and had no dates. A 28-ounce (a unit of measure) bag of vanilla pudding pie filling, opened, with no dates. During an interview on 12/08/2025 at 10:01 AM, Staff V, Cook, stated after the Surveyor's observations, they had cleaned out the refrigerator with the thawed-out meats. Staff V stated they discarded the pork and the chicken in the half sheet metal pan. Staff V stated they did not discard the bags of chicken because they had worked on 12/05/2025 when the two bags of chicken pieces were pulled from the freezer. Staff V stated they should have been dated. During an interview on 12/08/2025 at 10:17 AM, Staff L, Food Service Manager, stated the process for thawing meats was to pull the meat out of the freezer three days before using it and put it in the refrigerator to thaw out. Staff L stated the staff should have documented on the food or the container, the date the food was pulled out of the freezer and the use by date. Staff L stated they would ensure the thawed meats were discarded because they were past the date it would be safe to use them and/or there was no pull date for when they were pulled. Staff L stated the dried foods should have an open date and they should be sealed closed in between uses. Staff L stated cooked food that was placed in the refrigerator should be labeled and have a date on them. Staff L stated the cooked food goes from the food warmers straight to the refrigerator and they did not have a process for cooling food down prior to placing in the refrigerator. Staff L stated they did not keep salad dressings long because they got used up quickly but the Thousand Island dressing did not get used as often as the other dressings and should have been discarded. Staff L stated they had been present when the three rolls of ground beef had been pulled on Friday, 12/05/2025, and they had watched the staff member pull them. Staff L stated they should have been dated. On an additional visit to the kitchen on 12/11/2025 at 11:21 AM, showed in the middle refrigerator, there was two 2-pound bags of thawed out turkey breast lunch meat that had no pull date and a use for dinner date of 12/09/2025. In an additional refrigerator by the laundry room area, there were two blocks of Swiss cheese with an open date of 11/04/2025 in a plastic bag with no expiration date or use by date and a 24-ounce package of cream cheese with an open date of 11/16/2025 and no use by or expiration date. During an interview on 12/11/2025 at 12:42 PM, Staff W, Cook, stated they would not know when meats were pulled from the freezer or if they were still good to eat without a pull date documented. Staff W prepared a resident's lunch tray and placed it directly into the refrigerator. Staff W stated the resident stayed awake all night and wanted their food at different times than the time they were served so they would either put their tray in the warmer or the refrigerator and reheat it when they got up. Staff W stated they did not have a cool down process for placing hot foods into the refrigerator. During an interview on 12/12/2025 at 2:54 PM, Staff A, Administrator, stated they would expect the kitchen staff to have followed the process for thawing out foods and dating foods. Staff A stated expired foods, and undated foods should have been checked and discarded daily. Staff A was not aware the kitchen staff did not have a process for cooling foods prior to refrigerating them, there's a process, they just aren't following it. Reference: WAC 388-97-1100 (3)

Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASRR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) accuracy prior to admission and have the required Level 2 referral sent if the residents had a positive Level 1 PASRR as required for 3 of 5 residents (Resident 62, 33 and 8) reviewed for PASRR. This failure placed the residents at risk for inappropriate long term care placement and not receiving necessary mental health care and services. Findings included . Review of an undated policy titled PASRR (Pre-admission Screening & Resident Review, showed every resident would be screened for mental illness or ID prior to admission. The policy showed if a Level 2 referral was required, that had to be completed prior to admission by the designated authority. Resident 62 Review of the residents' medical records showed they were admitted on [DATE] with diagnoses to include substance use disorder and anxiety. The 09/23/2025 comprehensive assessment showed Resident 62 was cognitively intact, and the resident admitted with psychotropic medications. Review of Resident 62's Level 1 PASRR, dated 06/23/2025, showed no SMI indicators or SMI diagnoses and a Level 2 referral had not been completed. Review of Resident 62's Level 1 PASRR, dated 06/27/2025, showed after the resident admitted , the SSD completed the PASRR again and identified the anxiety diagnosis under SMI indicators but not the SUD. The PASRR showed a Level 2 referral was required. Review of an electronic mail (email) dated 07/25/2025 (28 days after the updated PASRR Level 2 referral was required) the referral was sent to the PASRR department for review. Resident 33 Review of the residents' medical records showed they were admitted on [DATE] with diagnoses to include dementia, anxiety, and insomnia and insomnia (the inability of a normal sleep pattern). The 11/11/2025 comprehensive assessment showed Resident 33's cognition was moderately impaired, and the resident admitted with psychotropic medications. Review of Resident 33's Level 1 PASRR, dated 11/05/2025, showed the resident did not have any SMI indicators or SMI diagnoses and a Level 2 referral had not been completed prior to admission. Review of Resident 33's Level 1 PASRR, dated 11/14/2025 (nine days after admission), showed diagnoses to include anxiety, dementia, and a substance use disorder (SUD, a complex condition in which there is uncontrolled use of a substance despite harmful consequences), which the resident did not have a diagnosis of, and the resident received an antidepressant. The PASRR showed a Level 2 referral was required. Review of an email dated 11/26/2025 (12 days after the determination of a Level 2 referral was required) the referral was sent to the PASRR department for review. Resident 8 Review of the medical record showed the resident was admitted on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions) with agitation, anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome), and heart complications. The 04/28/2025 comprehensive assessment showed the resident had severely impaired cognition and admitted on psychotropic medications (medications capable of affecting the mind, emotions, and behavior). Review of Resident 8's Level 1 PASRR, dated 04/22/2025, showed the resident did not have any SMI indicators and a Level 2 evaluation was required, and the referral had not been completed. The PASRR did not include documentation of the resident's diagnosis of anxiety. Review of Resident 8's Level 1 PASRR, dated 05/01/2025, showed Staff D, Social Services Director (SSD), completed Resident 8's PASRR again, stating the resident was on psychotropic medications for their dementia/ anxiety and that a Level 2 referral would be completed (nine days after the resident was admitted ). Review of an email dated 05/13/2025 (12 days after the updated PASRR Level 2 referral was required) the referral was sent to the PASRR department for review. During an interview on 12/11/2025 at 4:22 PM, Staff D stated they did not review PASRRs until the resident arrived at the facility. Staff D stated they did not know it was a requirement to review the PASRRs prior to the residents' admission. Staff D stated they had trained a few months ago on PASRRs and used the updated form. Staff D stated the Admissions Director (AD) was responsible for reviewing residents prior to admission and thought they were reviewing the PASRRs during that time. During an interview on 12/11/2025 at 5:04 PM, Staff I, AD, stated they reviewed PASRRs prior to admission and as far as they were aware, they were correct. Staff I stated the hospital must have incorrectly completed them and I missed that. During an interview on 12/12/2025 at 2:36 PM, Staff A, Administrator, stated the process was to review the PASRRs for accuracy and completion prior to the residents' admission. Staff A stated the facility would review them and update them upon admission if they were incorrect or if they needed to be changed. Reference: WAC 388-97-1975(1)

Based on observation, interview, and record review, the facility failed to ensure psychotropic medications (medications capable of affecting the mind, emotions, and behavior) had specific person-centered behaviors being monitored to reflect adequate need of the medication for 2 of 5 residents (Residents 33 and 62) and failed to obtain informed consents prior to administering psychotropic medications for 1 of 5 residents (Resident 33) reviewed for unnecessary medications. This failed practice placed residents at an increased risk for duplicate therapy, receiving medications they no longer needed and/or increased behaviors due to inadequate dosing of medication. Findings included.Resident 33 Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses to include dementia (the loss of the ability to think, remember, and reason to levels that affect daily life and activities), anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome), and insomnia (the inability of a normal sleep pattern). The 11/11/2025 comprehensive assessment showed Resident 33's cognition was moderately impaired, and no behaviors had been exhibited. The assessment showed Resident 33 received an anti-depressant medication. During an observation and concurrent interview on 12/09/2025, Resident 33 was lying in bed, eyes droopy, and the resident could barely stay awake to have a conversation with me. The Resident Representative (RR) was at bedside and stated the resident was shaky, did not eat breakfast, and was not feeling well. Resident 33 appeared sleepier than when seen on 12/08/2025 when they were alert, talkative, and socializing with their visitors. Review of Resident 33's November 2025 Medication Administration Record (MAR), showed on 11/05/2025 two orders; 1) Temazepam (a brand of anti-anxiety medication used for Insomnia as needed) and 2) Alprazolam (a brand of anti-anxiety medication used for anxiety as needed), on 11/06/2025 an order for Duloxetine (a brand of anti-depressant medication used for anxiety), and on 11/13/2025 an order for Trazodone (a brand of anti-depression medication used for insomnia) and Melatonin ( an over the counter sleep aid). The November 2025 MAR showed no sleep pattern monitoring to show how effective the Temazepam or Trazodone was, and the behavior monitoring and non-pharmacological interventions were not individualized and specific to the resident. The MAR showed the monitoring for side effects of the anti-depressant and hypnotic/sedative medications did not start until 11/10/2025and no monitoring of side effects for the anti-anxiety medications. An observation and concurrent interview on 12/10/2025 at 3:35 PM, the RR stated they were not aware the resident had started two medications that were considered anti-depressant medications, and they were not talked to regarding risks and benefits, nor did they sign a consent for Resident 33 to receive the medications. When the RR asked Resident 33 about the two medications, the resident shook their head from left to right (indicating no) and did not know anything about them either. Review of Resident 33's medical records showed informed consents were not obtained for the use of the Duloxetine or the Trazodone prior to the resident receiving the psychotropic medications. During an interview on 12/11/2025 at 3:49 PM, Staff G, Licensed Practical Nurse/Resident Care Manager, stated the provider started the Duloxetine for Resident 33's anxiety. Staff G stated the resident had Xanax and Temazepam for their anxiety and the provider decided to go with the anti-depressant instead. Staff G stated they were informed in a psychotropic meeting they no longer had to monitor the sleep pattern of a resident when using a psychotropic medication for insomnia, so they were not monitoring the effectiveness of the Trazodone. Staff G reviewed Resident 33's record and stated there were no consents, verbally or signed, in the record and they must have overlooked them. Staff G stated the behaviors and care plans were completed by the Social Services Director (SSD). Resident 62 Review of the resident's medical records showed they admitted to the facility on [DATE] with diagnoses to include anxiety and substance use of opioids (a class of drugs that are used for pain), nicotine, and other stimulants (a substance that increases the activity of the central nervous system). The 09/23/2025 comprehensive assessment showed Resident 62's cognition was intact, and they were independent for most activities of daily living (ADLs). The assessment showed the resident displayed no behaviors and received anti-depressant medication. An observation on 12/08/2025 at 3:32 PM showed Resident 62 lying in bed, the room was dark, they were still in night clothes and appeared sleepy. The resident's oxygen tubing was lying on the floor, and the humidified water container was on the floor in front of the oxygen machine. An observation and concurrent interview on 12/09/2025 at 11:38 AM showed Resident 62 lying in bed, the room was dark, and the resident stated they were sleeping and did not want to answer any questions. An observation on 12/10/2025 at 9:33 AM showed Resident 62 lying in bed, the room was dark, the resident was still in their night clothes, not fully alert/awake and had their cell phone up to their ear. Resident 62 did not want to answer any questions. An observation and concurrent interview on 12/12/2025 at 1:26 PM, showed Resident 62 lying in bed, sleeping, and the room was dark. Upon knocking, the resident stated they did not want to answer any questions. Review of the resident's July 2025 MAR showed an order dated 06/27/2025 for Sertraline (a brand of anti-depressant medication) 50 milligrams (mg, a unit of measure) daily and behavior monitoring for agitation, hallucinations, and delusions. The MAR showed two times in the month of July the resident experienced behaviors, once on 07/01/2025 with no documented behavior, intervention, or effectiveness and again on 07/16/2025 with agitation and the intervention was effective. Review of August 2025 and September 2025 MARS showed Resident 62 experienced no behaviors. Review of the October 2025 MAR showed one documented behavior of the resident wanting their medication from the morning, given in the evening and redirection was effective. The MAR also showed a new order to increase the Sertraline from 50 mg to 100 mg without any progress note to show who ordered the increase or why the increase was ordered. Review of November 2025 MAR showed Resident 62 had no documented behaviors. The MAR showed on 11/20/2025 (26 days after the Sertraline was increased) the provider added Buspirone (a brand of anti-depressant medication) for anxiety (without documented change or increase in behaviors). Review of the 12/01/2025 through 12/11/2025 December MAR showed the resident had no documented behaviors. Review of Resident 62's nursing progress notes showed no additional behaviors were documented other than those listed on the July 2025 through December 2025 MARs. The nursing progress notes showed no documented behaviors for Resident 62's Sertraline to be increased or the Buspirone to be added. During an interview on 12/11/2025 at 4:22 PM, Staff D, SSD, stated they were responsible for completing behavior monitors for the residents on psychotropic medications. Staff D stated they were not aware that behaviors were to be specific to each individual resident. Staff D stated the Nursing Assistants (NA) would not all know what specific delusions, hallucinations, or agitation behaviors were. Review of a provider note on 11/18/2025 showed the provider seen Resident 62 for increased anxiety (no documented anxiety in the behaviors or nursing progress notes) and gave new orders for the Buspirone twice daily to augment (the combination of two or more drugs to achieve better treatment results). The note showed Appetite, mood, sleep, mentation, bowel movement, weight remains stable and at baseline. The note showed for the facility to monitor depression (persistent feelings of sadness, low mood, and a lack of interest in activities that one usually enjoys), anxiety, and effectiveness of the new medication. During an interview on 12/12/2025 at 12:15 PM, the Contracted Physician (CP), stated they got their information from talking with the staff and on 11/18/2025, Resident 62 called the CP into their room with increased anxiety. The CP stated they worried about the non-socialization of the resident and was aware they were sleeping all the time. The CP stated the Buspirone was started for their depression, breathing, and panic attacks and would have expected those to be monitored. During an interview on 12/12/2025 at 1:56 PM, Staff B, Director of Nursing Services, stated their expectations would be for resident behaviors to be more specific than just delusions, hallucinations, or agitation. Staff B stated they would have expected informed consents to be completed prior to a resident starting a psychotropic medication and for the consent to be in the medical record and if they were not able to obtain them, the medication should have been held until the consent was obtained. Staff B stated there should have been increased behaviors, monitored behaviors, or a reason as to why a medication had been increased, and then documented in the resident's record. Reference: WAC 388-97-1060 (3)(k)(i)

Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain communication abilities for 1 of 3 residents (Resident 13) reviewed for the use of hearing aid (HA) devices. This failure placed the resident at risk for unmet care needs and the inability to participate in daily activities to the highest extent possible. Findings included . Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain communication abilities for 1 of 3 residents (Resident 13) reviewed for the use of hearing aid (HA) devices. This failure placed the resident at risk for unmet care needs and their inability to participate fully in daily activities to the highest extent possible. Findings included . Resident 13 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included. Alzheimer disease (a progressive brain disorder that slowly destroys memory) and congestive heart failure (the heart is unable to keep up with the needs of the body). Review of the comprehensive assessment dated [DATE] showed the resident had impaired cognition and used a hearing device to enhance their hearing ability. Additionally, the resident required substantial staff assistance for dressing, grooming, toileting and personal hygiene. During a concurrent observation and interview on 12/08/2025 at 1:50 PM, showed Resident 13 in their room resting and they were not wearing their HAs. The Collateral Contact (CC) stated they thought the resident's HAs were kept in the nurse's cart. The CC further stated that Resident 13's confusion was definitely worse when they were not wearing their HAs and was not sure why staff did not put them in the resident's ears daily. The CC stated they had the HAs serviced recently at an audiology clinic and changed the batteries to ensure they were in good order. During an observation on 12/09/2025 at 9:30 AM, showed Resident 13 in the hallway at the nurse's station sitting in their wheelchair without their HA's. Further observation showed the resident place their hands behind their ears to push them forward in a cupping motion to enhance hearing when conversing with staff. During an interview on 12/10/2025 at 10:50 AM, Staff S, Licensed Practical Nurse, stated that Resident 13 was supposed to wear their HAs daily and that they were kept in the nurse's cart to be placed in the morning and removed at bedtime. In an interview on 12/10/2025 at 2:30 PM, Resident 13 stated they liked to wear their HAs so they could hear better and were not sure where they were. During the conversation the surveyor was required to speak in a loud tone so the resident could hear as they had no HAs in. The resident again placed their hands behind their ears and cupped them forward during the conversation to enhance their ability to hear. During an interview on 12/10/2025 at 4:21 PM, Staff T, Resident Care Manager, stated the resident had their HAs recently serviced and they were working. Staff T stated the HAs were kept on the nurse's medication cart and placed in the morning by the nurse on duty and removed at bedtime and placed back in the cart. During an interview on 12/12/2025 at 10:10 AM, Staff B, Director of Nursing Services, stated they did expect the nurses to ensure Resident 13 had their HAs in daily so they could enhance their ability to hear and communicate better with staff. Reference WAC 388-97-1060(2)(a)(v)

Based on interview and record review, the facility failed to ensure grievances (resident and/or resident representative concerns that can be voiced or written), conveyed by the resident, underwent prompt resolution through to their conclusion nor were residents appropriately updated on their grievance progress/conclusion for 2 of 5 residents (Residents 8 and 62) reviewed for the grievance process. This failure placed residents at risk for unresolved concerns and unmet care needs. Findings included. Review of the facility policy titled, Grievances, dated 08/01/2024, showed the facility .actively seeks resolution to concerns and attempt to keep the individual who filed grievance updated on progress toward resolution. The policy showed that residents could convey grievances verbally or in writing and the grievance officer would be responsible for overseeing the receiving, investigating, and tracking the grievances through to their conclusion. The policy showed that grievances would be documented on the grievance logbook, have a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the finding or conclusions and that follow-up with the resident would be completed to communicate a resolution. Resident 8 Review of the medical record showed the resident was admitted on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), anxiety, and heart complications. The 10/28/2025 comprehensive assessment showed the resident had severely impaired cognition and a resident representative (RR) was involved in their care. During an interview on 12/09/2025 at 10:31 AM, Resident 8's RR stated they had reported a grievance about the resident's sweaters and a donut style pillow had gone missing from their personal belongings. The RR stated the facility staff were unable to find the four sweaters or pillow and the RR had not been updated on the progress toward resolution of their grievance from the facility staff since they reported it months ago, and not sure if they were going to get reimbursed for the missing items. Review of the grievance log for July 2025 through October 2025 showed that a grievance was filed on 07/10/2025 for four missing sweaters and the resolution was .If not found facility will reimburse . On 10/14/2025 a grievance was filed for a white pillow with a hole in the middle and the resolution was .pillow has not been found, facility will reimburse . Review of Resident 8's grievance investigations showed that on 07/10/2025 the RR had conveyed that four of Resident 8's sweaters had gone missing and Staff D, Social Service Director, documented on 07/15/2025 the resolution of the grievance was for the facility to reimburse the RR if the sweaters were not found. The grievance investigation on 10/15/2025 showed the RR reported that a donut pillow had gone missing from the resident's personal belongings. Staff D documented a resolution on 10/20/2025 as .Pillow has not been found, facility will reimburse. During an interview on 12/12/2025 at 11:12 AM, Staff D, stated they were the grievance officer and was responsible for overseeing the receiving, investigating, and tracking the grievances through to their conclusion and conveying the resolution to the individual that had reported the grievance. Staff D stated that the grievance process for a missing resident item would take around five days and then if the item was not found the resident or their RR would be reimbursed. Staff D stated they had been waiting on Resident 8's RR to bring in a receipt for the cost of the four sweaters and donut pillow. Staff D stated that a conclusion/resolution had not been completed since the RR had not been reimbursed yet. Staff D stated the RR should have been reimbursed since it had now been 150 days since Resident 8's four sweaters had gone missing and 58 days since the donut pillow had was missing. During an interview on 12/12/2025 at 12:49 PM, Staff A, Administrator, stated that Resident 8's RR should have been reimbursed for the items, and the grievance process was not being completed correctly. Staff A stated the resolution, and conclusion would have been the facility completing the reimbursement with the RR. Resident 62 Review of the resident's medical records showed they were admitted to the facility with diagnoses to include a stroke (when part of the brain does not receive adequate blood flow) affecting their right side, respiratory and heart failure, and nicotine dependence. The 09/23/2025 comprehensive assessment showed Resident 62's cognition was intact and independent for their activities of daily living (ADLs, basic self-care tasks to maintain their health and well-being). During an interview on 12/08/2025 at 3:32 PM, Resident 62 stated they were frustrated because they had ordered a package that arrived at the facility, but the resident never received the package. Resident 62 stated they reported it to the facility in writing and to the activities department verbally and no one has ever done anything about it. Resident 62 stated they had all the tracking information for the package in their personal cell phone that showed the package was delivered to the facility but still had not heard anything. Resident 62 stated it happened weeks ago but had recently (within the last few weeks) reported it to the activities department since they were the department that handled passing out the mail and still had not heard anything. Review of the grievance log showed on 10/06/2025 an unknown [resident] grievance was written up by Staff D, Social Services Director. The grievance showed a resident had documented on a piece of paper that was dated 08/05/2025, they were missing a package that had been delivered to the facility three days prior. The resident also wrote they were missing a vape (an electronic device used for inhaling vapor juice such as nicotine) device that they believed the staff took and lost. The grievance showed the resident was pissed off and wanted the issue to be fixed promptly. Staff D wrote on the grievance that management was aware, and the grievance was discussed in the morning meeting. During an interview on 12/12/2025 at 9:05 AM, Staff J, Activities Director, stated the mail and packages would go to the Business Office Manager (BOM), sorted, and then brought to activities for delivery to the residents. Staff J stated Resident 62 had reported a missing package to the Activities Assistant who then reported it to Staff D and Staff D would then write up the grievance. Staff J stated they could also write up a grievance, but for this particular resident, it was verbally reported to Staff D. During an interview on 12/12/2025 at 12:07 PM, Staff D stated they were not aware of any missing packages for Resident 62 nor did they recall the activities department reporting a missing package to them. Staff D then checked the grievance logs and did not find a report of a missing package that had been logged. Staff D was given a copy of the unknown resident 08/05/2025 grievance that they had completed themselves and stated they remembered that grievance and had found it in their mailbox, but they did not know who had written it and did not do any further follow-up to investigate who could have possibly written it. Staff D stated they discussed all concerns/complaints/grievances in their morning meeting, and Staff D did not realize the two grievances were connected when the Activities Director brought it up, if they brought it up. During an interview on 12/12/2025 at 2:49 PM, Staff A, Administrator, stated they had not heard about any missing packages for Resident 62 or for an unknown resident. Staff A stated they would have expected Staff D to do some further investigating/follow-up on the unknown resident grievance and had they been made aware of it, that would have been done. Staff A stated they could have interviewed all the residents that used a vape, which were very few, to figure out who the grievance was from. Staff A stated anyone could write up a grievance, as it was not something only Social Services had to do. Reference: WAC 388-97-0460(2)

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice regarding a residents central venous access device (CVAD, also known as a central line, is a thin, soft tube that is inserted into a main vein in the arm, leg, or neck for long-term administration of antibiotics, medication, nutrition, and/or blood draws) for 1 of 2 residents (Resident 30) reviewed for quality of care. This failed practice placed residents at risk of further infection, a delay in treatment, and adverse outcomes regarding their CVAD. Findings included .Review of the facility's guidance titled, Central Venous Catheter Care and Dressing Change, revised June 2025, showed the facility's purpose was to prevent complications associated with intravenous therapy (IV, the administration of medications or fluids directly into a person's vein) and central line related infections .with contaminated, loosened, soiled, or wet dressings. The policy showed a CVAD dressing should be changed .at least every seven days . or if it becomes loosened/visibly soiled. The policy showed that peripherally inserted central line catheter (PICC, a specific type of central line) needed monitoring for the arm circumference (a measurement around the arm, used to compare with a baseline measurement to detect possible swelling or blood clots) and external catheter length measurement (a measurement that can show if the catheter has been pulled out or not) with each dressing change or if suspected dislodgement. Additionally, monitoring of the CVAD site was to be completed with assessing for complication like dislodgement, redness, tenderness, swelling of the site or loosened, damp, soiled, wet dressing that could require a change. Resident 30 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a bone infection after right and left partial foot amputation with surgical aftercare. The 10/15/2025 comprehensive assessment showed the resident was receiving antibiotic therapy, had moderately impaired cognition, but was able to make their needs known. Review of the Resident 30's physician's orders for November 2025 through December 2025, showed the resident had been receiving IV antibiotics therapy, a replacement of the resident's PICC line was ordered on 11/12/2025 and a dressing change was completed one time when it was replaced. No orders for monitoring of PICC line site/dressing complications, external catheter length, arm circumference nor weekly changing of the dressing were noted. During a concurrent observation and interview on 12/08/2025 at 11:40 AM, showed Resident 30 in their room with a PICC line in their right upper arm. The dressing was saturated in a reddish/brown liquid and was falling off on the sides of the dressing, unable to stick to the resident arm anymore. The external catheter length, arm circumference and time of the dressing had been changed were not noted on the dressing. The resident stated the last time the PICC line dressing change was preformed was two to three weeks ago. During an interview on 12/10/2025 at 1:43 PM, Staff C, Infection Preventionist (IP), stated the process for residents with PICC line was to have the dressing changed once a week and daily monitoring of the PICC line for complications at the insertion site or with the dressing. Staff C stated with each dressing change the external catheter length and arm circumference were to be measured and checked with a resident's baseline measurements to rule out the PICC line migration (move or pulling out of the catheter line) or swelling complications. Additionally, with each dressing change the nursing staff would label the date it was changed. During an interview on 12/10/2025 at 2:11 PM, Staff F, Licensed Practical Nurse, stated they had been working with Resident 30 since 12/08/2025 and decided to change Resident 30's PICC line dressing on 12/09/2025. Staff F stated the dressing was soiled (unclean), wet and had been falling off the resident's arm. Staff F did not know when the last PICC line dressing changed had been performed on the resident nor had they measured the external catheter length or arm circumference. Additionally, Staff F was unaware of the resident's baseline external catheter length or arm circumference and where they would find it. During an interview on 12/10/2025 at 2:53 PM, Staff C stated that Resident 30's PICC line was originally placed on 11/05/2025. Staff C stated that Resident 30's PICC line needed to be replaced on 11/12/2025 and no orders were assigned for dressing changes, monitoring of complications, the external catheter length monitoring nor the arm circumference measurement monitoring. Staff C stated they would have expected nursing staff to have been performing dressing changes weekly with Resident 30 PICC line, but it had not been changed since 11/12/2025 (three weeks and six days after being placed). During an interview on 12/11/2025 at 8:57 AM, Staff B, Director of Nursing Services, stated that three weekly dressing changes had been missed on Resident 30's PICC line and nursing staff should have been monitoring and documenting the external length/arm circumference. Staff B stated that it had been missed by multiple staff and the correct process was not followed. Reference: WAC 388-97-1060(3)(j)(ii)

Based on observation, interview, and record review, the facility failed to assess, monitor, or treat new skin issues to prevent the worsening of two facility-acquired pressure injuries (PIs, sores (ulcers) that happen on areas of the skin that are under pressure) for 1 of 3 residents (Resident 60) reviewed for PIs. This failed practice placed residents at risk for worsening or new PIs, increased pain, and unmet care needs.Findings included .Review of the 09/2020 policy titled Skin at Risk/Skin Breakdown showed when a resident has a PI, they were to receive treatment and services to promote healing, prevent infection, and prevent worsening or new PIs. The policy showed when a new PI was identified the Licensed Nurse (LN) would document the skin impairment (measurements, size, and description), assess pain, document on the skin form, notify the provider and obtain new orders, update the Treatment Administration Record (TAR), and notify the Resident Representative (RR). Additionally, the policy showed if the PI was identified after admission, the LN was to initiate alert charting, assess skin risk and current interventions and implement new ones as needed, update the care plan, and notify the dietician, supervisor, and Resident Care Manager (RCM). Resident 60 Review of the resident's medical records showed they admitted with diagnoses to include spondylosis (degeneration of the spinal column) and kyphosis (excessive outward curvature of the spine, causing hunching of the back). The 11/25/2025 comprehensive assessment showed Resident 60 was cognitively intact and during the seven days of the assessment period, the resident had not been rolled from their left to their right side for repositioning. The assessment showed Resident 60 was at risk for developing pressure injuries and used a pressure reduction device for their chair and their bed. An observation and concurrent interview on 12/08/2025 at 11:11 AM, showed Resident 60 sitting in their recliner alongside their bed. Resident 60 had the chair in a reclined position with feet resting on the foot stool of the chair and sitting on their bottom. Resident 60 stated they had a sore on their bottom that started out to be small but had gotten out of hand. Resident 60 stated the sore was very painful but received pain medication that was effective. An observation on 12/09/2025 at 9:07 AM, showed Resident 60 sitting in their reclined chair, on their bottom, with their feet on the footrest of the chair, visiting with a visitor. An observation on 12/09/2025 at 3:31 PM, showed Resident 60 lying back in their recliner chair, on their bottom, sleeping. Resident 60 had their chin and head rested into their chest. An observation and concurrent interview on 12/10/2025 at 11:49 AM, Staff R, Nursing Assistant, stated Resident 60 preferred to stay in their recliner chair 24 hours a day due to their back and neck pain. Staff R stated they did not encourage or assist Resident 60 to reposition themselves because they were in the recliner. Staff R stated if Resident 60 needed or wanted to reposition, they would ask the staff for assistance. Staff R stated Resident 60 had two opened areas to their right side above their buttock, and there was a scab (a dry, rough protective crust that forms over a cut or wound) in the middle of the two opened areas. Staff R, along with Staff F, Registered Nurse, assisted the resident to the commode and there was an area the size of an index finger in length, and at each end there was an open area slightly smaller than a dime, and in the middle of both opened areas was a scabbed over area with a thick application of pink barrier cream over the entire area. Additionally, there was a brown wound dressing (undated and no initials) applied to the middle of the spine and Staff F stated that was just a protective barrier patch. Staff F removed the patch and towards the lower part of the spine was an open area the size of a dime on a bony area of the spine. Staff R applied more pink cream to the open area on the bottom and Staff F replaced the patch on the spine and placed a patch to the bottom. There was no patch to the bottom prior to providing toileting assistance. An observation on 12/11/2025 at 8:51 AM, showed Resident 60 sitting in their chair, slightly reclined back, sitting on their bottom with their feet resting on the footrest. Review of Resident 60's December 2025 Treatment Administration Record (TAR) showed an order on 01/31/2025 to apply a protective dressing to prevent opening of the skin every three days. The order showed no location where the protective dressing was to be applied and showed it was last changed on 12/09/2025 by Staff F. The TAR showed on 03/06/2024 an order to monitor a red pressure area to the lower back/spine for worsening once a week on Wednesday. The TAR showed an order on 07/05/2023 for a weekly skin assessment to be completed every Wednesday and if there was a skin issue, a skin form and incident report was to be completed, the resident/family and provider were to be notified, the TAR updated with new orders, and a progress note completed, Follow Skin at Risk policy. Lastly, an order on 01/30/2025 showed an ointment was to be applied to the buttocks twice daily and as needed for excoriation (scratching or rubbing of the skin causing the skin to wear). Additional review of the 12/10/2025 (Wednesday) and 12/11/2025 (Thursday) TAR showed Staff F did not complete their scheduled skin assessment or document the lower spine monitoring. Both orders were not signed as completed. Furthermore, there were no new orders for the new skin issues that were identified on 12/10/2025. Review of the 12/10/2025 and 12/11/2025 nursing progress notes showed Staff F had no documentation of the new skin issues that were observed on 12/10/2025, nor a documented notification to the resident/family, or provider. Review of Resident 60's 02/01/2024 (last revised) skin care plan showed the resident was at risk for new or unavoidable skin impairment due to their risk factors, had a score of 20 (which meant they had low risk for skin breakdown) for their skin risk assessment, was to be encouraged to change position as frequently as they allowed (with no schedule initiated as to how frequent), and to float heels while in their recliner as they allowed. Review of Resident 60's skin/wound assessments showed the last assessment completed was 10/29/2024. An observation and concurrent interview on 12/11/2025 at 9:00 AM, Resident 60 was sitting on their bottom in their reclined chair with their feet resting on the footrest. Resident 60 stated they did not like to call staff for assistance because they knew they were too busy. Resident 60 stated they felt like they might be able to move themselves from side to side off their bottom in their recliner. Resident 60 demonstrated repositioning themselves and could make small, slight adjustments but did not have the energy to move completely off their bottom or their spine. Staff R entered the room and stated the NAs did not have a schedule to encourage turning and repositioning for Resident 60 and if the resident asked them to, they would. Staff R stated, we needed to offer it (repositioning) to [Resident 60] rather than waiting for [Resident 60] to ask. During an interview on 12/11/2025 at 3:49 PM, Staff G, Licensed Practical Nurse (LPN)/RCM, stated when new skin issues were identified, the nurse should call to notify the RR and the provider and obtain new orders. Staff G stated an incident report and skin assessment should have been done with measurements and documented in the progress notes. Staff G stated Staff A, Director of Nursing Services, should have been notified, the LPN/RCM should have been notified, and the care plan updated, none of which had been completed at that time. During an interview on 12/12/2025 at 1:56 PM, Staff A stated they were not aware of the new skin issues Resident 60 had until after Staff G was made aware by the Surveyor. Staff A stated Staff F did not follow the correct process. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 52) with a retention catheter (a small plastic or rubber tube inserted into the bladder to drain urine) reviewed for catheter care, received appropriate care and services to mitigate the risk of infection in the urinary tract. This failure placed residents at risk for illness and a decline in health status. Findings included . Record review of the facility's policy titled Catheter Care, Urinary dated 08/2022 showed that staff were to always position the drainage bag lower than the resident's bladder to prevent urine from flowing back into the urinary bladder. Review of Lippincott's Essentials for Nursing Assistants 4th edition page 574 showed, * Raising the urine drainage bag up higher than the bladder can cause old, contaminated urine to run back into the bladder, which can lead to infection. * Always make sure that the drainage bag is placed at a level lower than the person's bladder. Resident 52 Review of Resident 52's medical record showed they were admitted with diagnoses including congestive heart failure (the heart is unable to keep up with the needs of the body), diabetes, benign prostatic hyperplasia (BPH enlargement of the prostate gland) and urinary tract infection (UTI an infection in the urinary system). The comprehensive assessment dated [DATE] showed the resident had moderate cognitive impairment, required total staff assistance with dressing, grooming and utilized a mechanical lift for transfers. Additionally, the assessment showed the resident utilized an indwelling retention catheter for urinary elimination needs. During an observation on 12/08/2025 at 9:25 AM, showed Staff Y and Staff Z, Nursing Assistants (NAs) prepare the resident for transfer from their wheelchair to the bed using a mechanical lift. The NAs hooked the resident up to the lift with a specialized sling. Staff Y then unhooked the resident's catheter drainage bag and hung it five inches above the resident's bladder on the transfer sling as they were lifted onto the bed. The resident's catheter tubing was observed to have yellow urine which flowed back into their bladder as they were lifted out of the wheelchair onto the bed. During an observation and concurrent interview on 12/11/2025 at 9:54 AM, Staff AA, NA, and Staff BB, NA, prepared Resident 52 for transfer from their bed to the wheelchair. Staff AA and Staff BB hooked the resident up to the mechanical lift with the sling. Staff AA then hung the resident's catheter drainage bag on the sling four inches above their bladder during the lift. Urine was observed flowing backwards from the tube into the resident's bladder. During an interview Staff AA stated they placed the urine bag on the mechanical lift sling during transfers to avoid it getting tangled up when lifting the resident from the wheelchair to the bed. During an interview on 12/12/2025 at 9:16 AM, Staff B, Director of Nursing Services, stated the appropriate way to transfer a resident with a catheter was to keep the drainage bag at or below the level of the resident's bladder. Staff B stated their expectation was for staff to not hang the catheter bag above the resident's bladder to avoid the risk of a UTI. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to develop comprehensive resident centered care plans for 2 of 6 residents (Residents 52 and 30) reviewed for care plan development. This failure placed residents at risk for unmet care needs. Findings included .Resident 52 Review of the resident's medical record showed they were admitted to the facility with diagnoses to include benign prostatic hyperplasia (BPH a condition in which the prostate gland is enlarged and blocks urine flow), respiratory disease, and diabetes. Review of the comprehensive assessment dated [DATE] showed the resident had moderately impaired cognition, required total staff assistance for dressing and transferring and utilized a retention catheter (a flexible plastic or rubber tube inserted into the bladder to drain urine) for urinary elimination needs. Record review of Resident 52's physician orders dated September 2025 to December 2025 showed medical orders for use and justification of the retention catheter related to the resident's BPH diagnosis. Review of the resident's care plan dated 10/20/2025 showed no directions for care and monitoring of the resident's retention catheter. During an interview on 12/10/2025 at 2:40 PM, Staff T, Resident Care Manager (RCM), stated they had not developed Resident 52's care plan for use and care of their retention catheter as they had overlooked it. Resident 30 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a bone infection after a right and left partial foot amputation with surgical aftercare. The 10/15/2025 comprehensive assessment showed the resident was receiving antibiotic therapy, had moderately impaired cognition and was able to make their needs known. During a concurrent observation and interview on 12/08/2025 at 11:40 AM, showed Resident 30 in their room with a peripherally inserted central line catheter (PICC, a thin, soft tube that is inserted into a main vein in the arm, leg, or neck for long-term administration of antibiotics, medication, nutrition, and/or blood draws) in their right upper arm. The dressing was soiled (in a dirty state or stained) and falling off. The date and time of the last dressing change was not noted on the dressing. The resident stated the last time the PICC line dressing change was preformed was two to three weeks ago. Review of Resident 30's care plan, last completed 10/14/2025, showed no resident focused goals or interventions related to their PICC line. During an interview on 12/19/2025 at 4:09 PM, Staff L, Infection Control Nurse, stated they were also the RCM for Resident 30 and when reviewing the resident's care plan, did not see goals nor interventions that pertained to resident CPAP device use. Staff L stated that Resident 30's CPAP device should have been care planned and the correct process was not followed. During an interview on 12/10/2025 at 2:53 PM, Staff C, Infection Preventionist, stated that Resident 30's PICC line was originally placed on 11/12/2025. Staff C stated that Resident 30's PICC line had not been care planned. Staff C stated they would have expected that a care plan would have been developed for the resident specific goals and interventions regarding specifics like changing the PICC lines dressing weekly and monitoring for complications at the insertion site and with the dressing. During an interview on 12/11/2025 at 8:57 AM, Staff B, Director of Nursing Services, stated that care planning of Resident 30's PICC line had been missed. Staff B stated the correct process was not followed. Reference: WAC 388-97-1020(1)(2)(a)

Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment for 1 of 2 shower rooms (100 hall), 1 of 1 weight room, 1 of 1 laundry room, and 5 of 3 Hoyer (a type of device that safely transfers a resident with limited mobility, such as inability to stand safely) lifts reviewed for a safe and sanitary environment. This failure placed residents at an increased risk of not feeling safe and secure with their environment and unmet care needs. Findings included . Laundry Room During a concurrent observation and interview on 12/10/2025 at 4:30 PM, Staff E, Maintenance Director, was in the laundry's dirty linen sorting room with the surveyor. On the wall, by the door that entered the rest of the laundry area, was a six inch (a unit of measure) long by five inches wide hole in the dry wall behind the rubber base board that was peeling off. The section of missing dry wall had been broken into numerous pieces that lay in a pile below the hole in the wall. Staff E stated they were unsure of what happened, but it needed to be fixed and was an area that would not be able to be cleaned until it was fixed. 100 Hall Shower Room During a concurrent observation and interview with Staff V, Nursing Assistant (NA) and shower aide, on 12/11/2025 at 11:01 AM, showed the shower stall part of the room had broken off caulking (a waterproof filler and sealant) all around the bottom of the shower stall and on top of the tiles that were halfway up the wall in the shower stall. There were areas of a black substance on the shower stall floor and the top of the tiles, and the room had a wet moldy odor to it. Staff V stated they used the shower room daily and the shower stall had been that way for a long time. Staff V stated water seeped from both the floor of the shower stall and the top of the tiles in the shower stall to under the plastic walls of the shower stall and into the adjacent weight room. Observation of the wall behind the shower stall in the weight room showed approximately four inches up from the floor where the sheetrock was wet and broken off in multiple places. There were four batteries in the weight room that were plugged into a wall outlet where the area was wet and approximately 10 batteries sitting on the wet floor of the room. Staff V stated all the batteries in the room were for charging the facility Hoyer lifts and sit to stand lifts (mechanical devices used to safely lift and transfer residents with limited mobility from one surface to another) and the batteries that were unplugged from the outlet were broken and would no longer take a charge. During the same observation and interview, a large metal weighing surface that wheelchairs could be rolled up on to weigh a resident in a wheelchair or shower chair showed to take up most of the floor surface of the room. The machine was noted to be in two pieces, one to roll the chair onto the weight machine and the weight machine itself. There was an uneven gap between the two pieces making the weight machine higher than the rolling on surface. Staff V stated they had noticed the floor under the weight machine would get wet from the leaking shower room and over time had made the weight machine uneven and leaving a gap between the two pieces made it unsafe to roll the residents up on to it. During a concurrent observation and interview on 12/12/2025 at 9:09 AM, showed the resident shower room on the 100's hallways was still wet from being utilized from a resident shower. The shower room had a musty (having a stale, moldy, or damp smell) odor upon entering. The top half of the shower walls were tiled along with the floors, while the bottom half of the walls were a hard plastic sheet that had been seemed together with the tiled sections by caulking. Along the top and bottom caulking seams were holes and missing section of caulking where water had been getting into the back of the plastic shower walls. Black growth was noted all along the caulking and the sections of silver handles, which were attached to the shower walls for support, had the same black growth around the connection of the handle to the wall. The back top section of plastic wall was unattached from the wall and the wall behind the plastic was a dark black color and smelled of mold. When Staff E observed the black growth along the caulked seams of the shower, .possible growing something . Staff E looked behind the plastic section of the shower wall and noted the dark black growth and stated the black growth was not cleanable and that it was not safe for residents to be taking showers in the room. Observations of the wall in the adjacent room from the resident shower room showed previous water damage (an accidental leakage or discharge of water that caused possible losses or value of materials) to the floor beneath the linoleum (a common floor covering). Staff E stated they had replaced the top flooring but did not replace the bottom wood sheet that had water damage and laid the new flooring on top of it. Staff E did not remember when the shower leak was first fixed after being brought to the staff members attention, but they had redone the caulking on the shower seams a couple of months ago and they did not see the black growth at that time. During an interview on 12/12/2025 at 9:53 AM, Staff C, Infection Preventionist, observed the 100-hallway shower room with the surveyor. Staff C stated the black growth looked like mold and that the mold growth was spreading to behind the shower walls, was no longer a cleanable surface, not safe for residents nor a homelike environment. Staff C stated the shower stall needed to be fixed and no longer used by residents. During an interview on 12/12/2025 at 12:49 PM, Staff A, Administrator, stated the 100-hallway resident shower room was not clean or safe and the correct process for providing a comfortable homelike environment was not being followed with the shower room. Hoyer Lifts During an observation on 12/11/2025 at 3:37 PM showed a Hoyer lift sitting in the 200 Hall. The base of the lift had crushed debris including food crumbs. The legs had a black grime substance covering both legs and the body of the lift was dusty and dirty. During an observation on 12/12/2025 at 1:07 PM showed a Hoyer lift and a sit to stand lift (a lift which assists the resident to stand during the transfer process) sitting in the hallway. The Hoyer lift showed crushed food debris and black grime on the legs of the lift. The sit to stand showed a white dried substance on the body of the lift which appeared to be dried milk. During an observation on 12/12/2025 at 1:22 PM, the Hoyer lift on the 100 Hall showed food crumbs crushed into the base of the lift, black grime on the legs and dust on the body of the lift. The sit to stand lift showed dust and dirt on the base. During a concurrent observation and interview on 12/12/2025 at 2:52 PM Staff S, Licensed Practical Nurse, acknowledged the lift equipment was dirty and stated the lift equipment was supposed to be cleaned by the nursing assistants. During an interview on 12/12/2025 at 3:00 PM, Staff A, Administrator stated the facility did not have a schedule for cleaning the resident lift equipment and that the NA staff were supposed to clean them. Reference: WAC 388-97-3220(1)

Based on observation, interview, and record review, the facility failed to serve meals at a preferred temperature for 3 of 4 residents (Resident 1, 2, and 3) reviewed for food temperatures. This failure placed the residents at risk for inadequate nutritional intake, weight loss, and dissatisfaction with their dining experience. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), paraplegia (the loss of muscle function in the lower half of the body, including both legs), and depression. The 03/27/2025 comprehensive assessment showed Resident 1 was independent with activities of daily living (ADLs); dependent on one to two staff for transfers and showering. The assessment also showed Resident 1 was cognitively intact. A concurrent observation and interview on 06/17/2025 at 12:16 PM, showed Resident 1 sitting in their wheelchair in their room at their over the bed table. They stated they were waiting for their lunch tray. Resident 1 stated their food was often cold when it was delivered. They stated they were told that Staff B, Dietary Manager, was trying to buy something to keep the food warmer. Resident 1 stated they had voiced their concerns about the cold food to Staff B, but their concerns go in one ear and out the other (heard but disregarded or quickly forgotten). At 12:18 PM, Resident 1's meal tray was delivered. Observation of the meal showed cooked spinach, chicken strips, and french fries. Resident 1 stated the meal did not look appetizing. They picked up a chicken strip and stated it was not even lukewarm (slightly warm). Resident 1 stated the lack of hot meals made them feel frustrated and it's not right, I pay to stay here (at the facility), and they should be giving me quality food to eat that is nutritious and hot. Resident 1 stated they had filed a grievance regarding the food temperature but nothing was done. Record review of a grievance dated 06/02/2025, showed Resident 1 had reported their concerns with cold food. The grievance showed management was aware of the resident's concern and was working on getting a better system to keep food warm . <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including rheumatoid arthritis (a condition where the body's immune system attacks its own tissues, causing joint pain, swelling, stiffness, and fatigue), muscle weakness, and depression. The 04/18/2025 comprehensive assessment showed Resident 2 was dependent on one to two staff for ADLs; independent with eating. The assessment also showed Resident 2 had an intact cognition. A concurrent observation and interview on 06/17/2025 at 12:26 PM, showed Resident 2 lying in bed with an over the bed table across the bed. Resident 2 stated the food was consistently cold and was frequently delivered without the plate warmers or covers. At 12:29 PM, a meal tray was delivered to Resident 2. A nursing assistant (NA) placed the tray on the over the bed table and removed the plate cover. Resident 2 touched their plate and stated, the plate is cold, how can the food be hot when the plate is cold, please feel my plate. Resident 2's plate was cool to the touch and the plate cover was cold. They picked up a chicken strip and took a bite. Resident 2 stated it was not warm; its cooler than the temperature of my mouth. Resident 2 stated that was the normal temperature of their meals. They stated they were very frustrated with their dining experience. They stated they have reported their concerns and filed grievances, but nothing ever changes. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including heart failure, high blood pressure, and diabetes. The 05/20/2025 comprehensive assessment showed Resident 3 was dependent on one to two staff members for toileting and bathing and was independent with eating. The assessment also showed Resident 3 was cognitively intact. During an interview on 06/17/2025 at 1:02 PM, Resident 3 stated their meals were not always hot. They stated they had told staff the food was cold. Resident 3 stated they would prefer my food hotter. During an interview on 06/17/2025 at 1:34 PM, Staff B stated they were aware of the complaints of cold food. They stated the facility had purchased thermal pellets (a heated device that is placed under a plate to keep food warm for up to 60 minutes) to improve food temperatures. They stated they did not have the approval to purchase the warming device to heat the pellets. Staff B stated the kitchen did not have insulated carts to keep the food warm. They stated they had identified issues with the length of time it took for staff to deliver the food once it left the kitchen, which could be contributing to the cold food complaints. During an interview on 06/18/2025 at 7:49 AM, Staff A, Administrator, stated they were aware of the concerns with cold food. They stated they had purchased the pellets for the plate warmers but needed to purchase additional parts. Staff A stated they were not able to identify why the food was cold when it reached the residents when it left the kitchen at the appropriate temperature. Staff A stated the plan was to purchase the additional parts to ensure food arrived at the resident warm, but did not have the funds to purchase the additional parts. Reference: WAC 388-97-1100(2)

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment in 1 of 1 kitchen (Main Kitchen) reviewed for food preparation and storage safety. This failure placed all residents, staff, and visitors that ate out of the Main Kitchen at risk for food contamination (the unintended presence of potentially harmful substances including microorganisms or chemicals in food) and food borne illnesses. Findings included . Review of a policy titled, Sanitation, dated 11/2022, showed the facility would maintain a clean and sanitary food service area. During an interview on 03/25/2025 at 3:58 PM, Staff F, Maintenance Director, stated there was a pipe under the kitchen floor, about four feet underground that had broken. They stated they had put the restrooms, located on the other side of the kitchen wall of the dishwasher area, out of service and the doors were locked so they could not be used. They stated the dishwasher was also out of service, not because it was broken, but because it could not drain. They stated the incident happened yesterday (03/24/2025). In a concurrent observation and interview on 03/25/2025 at 4:13 PM, Staff E, Cook, in the Main Kitchen, stated the water from the restrooms was coming up into the kitchen through the drains. They stated there was a pipe under the kitchen that had broken and did not allow the catch basin to drain properly. An observation of the dishwasher area showed a 10 inch by seven-inch white catch basin that was inset into the floor under the dishwasher counter space. There were two pipes that drained into the catch basin, including one from the dishwasher. There was a hole in the bottom of the catch basin to drain the water. The bottom of the catch basin was soiled with a dark brown residue. There was a folded blanket placed over the corner of the catch basin, and a second folded blanket over a drain in the floor, three feet from the catch basin. Staff E stated water also came out of that floor drain. There was a shop vac (a powerful vacuum that can suck up wet or dry substances and blows out exhaust) located in the dishwasher area that had a long hose pushed into the catch basin. Staff E stated they were able to run the dishwasher if they used the shop vac to suck the water out of the drain. Staff E turned on the dishwasher and water began to drain into the catch basin. Staff E turned on the shop vac, which blew exhaust onto three open meal delivery carts, that were located across from the dishwasher area. Staff E stated they had been using the three-compartment sink sanitation method until Staff F, Maintenance Director, put the shop vac in use so they could use the dishwasher. Staff E stated the dishwasher area and Main Kitchen was not sanitary and should not be used. During a follow up interview on 03/25/2025 at 4:17 PM, Staff F stated they knew about the issue on Monday (03/24/2025). They stated they had a contractor create a proposal for the repairs. Staff F stated the repairs had not been scheduled, as they needed approval from Staff A, Administrator, before scheduling. Staff F stated they had removed the shop vac from the Main Kitchen and staff would have to go back to not using the dishwasher until the drain was fixed. Record review of a plumbing invoice dated 03/21/2025, showed a camera was used in the main sewer line and found a potential break/separation or offset in kitchen under concrete that was no allowing full drainage. During an observation and interview on 03/25/2025 at 4:21 PM, Staff B, Director of Nursing Services, toured the Main Kitchen and observed the dishwasher area where the shop vac was set up. Staff B stated the kitchen was not sanitary and I would not eat out of this kitchen. During an observation and interview on 03/25/2025 at 4:54 PM, Staff G, Infection Preventionist, toured the dishwasher area of the Main Kitchen. Staff G stated they were not involved in the plans for preventing cross contamination in the Main Kitchen. Staff G stated they were not aware that the toilets had backed up into the kitchen. They stated they were only told there was a broken pipe. During an interview on 03/26/2025 at 12:29 PM, Staff D, Dietary Manager, stated the drain problem started Thursday (03/20/2025) or Friday (03/21/2025) of the previous week. They stated they had made the decision to switch to the paper products because they were not able to use the permanently fixed three-compartment sink for cleaning and sanitizing the dishes. Staff D stated the drains backed up into those sinks as well. They stated they were currently using a smaller two-compartment sink with a bin that contained sanitizer and were not able to keep up with the number of dishes that were used per meal. Staff D stated they were in the Main Kitchen when the drain first backed up. They stated they saw the back flow of water and it smelled like bathroom water; it was brown and gunky. Staff D stated the backflow stayed in the dishwasher area. They stated Staff F contacted a plumber that came out that same day and found a broken pipe. Staff F closed the restrooms that same day and put the dishwasher out of service. Staff D stated Staff F brought them the shop vac on Tuesday (03/25/2025) and told the kitchen staff they could use it to suck up the dishwasher drainage. During an interview on 03/28/2025 at 8:35 AM, Staff A stated the pipes went down on Friday (03/21/2025). They stated they formulated a plan with Staff F that included using the three-compartment system. They stated they the plan also included collecting drainage and disposing of it in a sink that had a working drain. Staff A stated they were not aware that they were using a shop vac for drainage and that was not the plan I had put in place. Reference: WAC 388-97-2980(1)(3)(6)

Based on observation, interview, and record review, the facility failed to provide a dining experience that promoted resident respect and dignity for 1 of 6 residents (Resident 1) reviewed for dignity. This failure placed the resident at risk for low self-esteem and an undignified dining experience. Findings included . Review of a policy titled, Resident Rights, dated 02/2021, showed federal and state laws guarantee certain rights to all residents, including the right to a dignified existence and the right to be treated with respect, kindness, and dignity. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including heart failure, arthritis, and weakness. The 03/12/2025 comprehensive assessment showed Resident 1 required substantial assistance of one staff member for activities of daily living and supervision for eating. The assessment also showed Resident 1 had a moderately impaired cognition. Resident 1 was able to make their needs known. A concurrent observation and interview on 03/25/2025 at 3:16 PM, showed Resident 1 sitting in their room in their wheelchair with the bedside table in front of them. There was a Styrofoam cup of ice water on the bedside table. Resident 1 had their head down and was crying. Resident 1 stated They take away my dignity. I get my food in a paper plate or Styrofoam. They say the dishwasher is not working and the patients are suffering. I am treated like an animal, I sit with my paper plate and tiny spoon [(spork) a small, plastic combination utensil that is shaped like a spoon, with two to four fork-like tines). Resident 1 stated one of the girls told them the dishwasher had been broken. Resident 1 stated they had been served on paper plates for a long time and asked, how long can a dishwasher be broken - they took away my dignity. During an interview on 03/25/2025 at 4:21 PM, Staff B, Director of Nursing Services, stated they were not aware that the facility was using paper products for meal service. During a follow up interview on 03/27/2025 at 1:44 PM, Staff B stated the process for maintaining respect and dignity for the residents included training staff and using the grievance process. Staff B stated they were not involved in switching to paper items because that was a kitchen issue. Reference: WAC 388-97-0180(1)(2)(3)

Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Resident 2 and 3), reviewed for activities of daily living, received goods and services to maintain their ability to eat independently. This failure placed the residents at risk for low self-esteem, the inability to feed themselves, and dissatisfaction with their dining experience. Findings included . <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including rheumatoid arthritis (a chronic arthritis that affects the small joints in the hands and feet, often causing joint deformity) and muscle weakness. The 12/09/2024 comprehensive assessment showed Resident 2 was independent with eating. The assessment also showed Resident 2 was cognitively intact. A concurrent observation and interview on 03/26/2025 at 11:59 AM, showed Resident 2 lying in bed. Both hands were on top of the blankets and showed deformed fingers. Resident 2 was able to slightly flex their fingers with difficulty. They stated they preferred to eat with metal silverware. They stated plastic silverware was acceptable but all they gave us to eat with is a spork (a small, plastic combination utensil that is shaped like a spoon, with two to four fork-like tines. Resident 2 stated they were unable to use the plastic spork due to their arthritis. They stated one of the nursing assistants told them they were having problems with the water when they brought their meal tray on maybe Thursday of the previous week. Resident 2 stated the meals were served in Styrofoam containers and it was hard for them to eat out of those containers. They stated it was difficult to get to the food with the angle of the Styrofoam container and use of the plastic spork. Resident 2 stated they used to look forward to eating but now it is just a problem. Resident 2 stated they told staff they were unable to use the plastic spork for eating, but it came with every meal. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), anxiety, and depression. The 02/19/2025 comprehensive assessment showed Resident 3 required step-up assistance from one staff member for eating. The assessment also showed Resident 3 was cognitively intact. An observation and interview on 03/26/2025 at 2:51 PM, showed Resident 3 lying in bed with a Styrofoam cup on the bedside table. Resident 3 stated they were getting their meals on thin paper plates, but they are better than the Styrofoam ones. They stated that had been going on for about two weeks. Resident 3 stated they had heard it was the dishwasher's fault, but no one had specifically told them. They stated they had problems using the plastic spork, it's garbage, I am not able to eat with it. Resident 3 stated they had neuropathy (a condition that affects the nerves with a gradual onset of numbness or tingling in the hands or feet) and could not feel their fingers. They stated they were able to feed themselves with a metal fork, and somewhat with a plastic fork, but not at all with the plastic spork. During an interview on 03/26/2025 at 11:30 AM, Staff C, Nursing Assistant, stated they did not remember when the facility started using the paper plates. Staff C stated the residents had complained to them about using the sporks. They stated they would exchange the spork for a regular plastic fork, if there was one available. During an interview on 03/26/2025 at 12:29 PM, Staff D, Dietary Manager, stated they were using sporks because a pipe had broken in the kitchen and they were unable to use the dishwasher. Staff D stated they ran out of the regular plastic forks, knives, and spoons and provided the residents with a spork to eat their meals. During an interview on 03/27/2025 at 1:44 PM, Staff B, Director of Nursing, stated they were not aware that the facility had switched to paper/plastic products. Staff B stated they were not involved with that decision as it was a kitchen issue. During a telephone interview on 03/28/2025 at 8:35 AM, Staff A, Administrator, stated when the pipe broke in the kitchen, they had put a plan in place to use the paper/plastic items for just one meal, the lunch meal on Friday (03/21/2025), and had put a system in place to return to use of the regular dishware after that one meal. They stated they were not aware that the facility had continued to use the paper/plastic items. Reference: WAC 388-97-1060(1)(2)(a)(iv)(b)

Based on observation, interview, and record review, the facility failed to ensure a sanitary and homelike environment by not consistently cleaning the heating and air exchange vents and/or changing the filters for 4 of 4 dining rooms (DR) ([NAME], Garden, Transition Care Unit [TCU], and Private), 3 of 3 hallways (Hallways 100, 200, and 300), and 1 of 1 kitchen. Additionally, the facility failed to ensure 1 of 1 laundry room was free from built-up dust and lint to the dryers and the water and exhaust pipes. This failed practice placed residents at risk for an undignified existence, infections, and safety hazards. Findings included . <Dining Rooms> An observation in the Garden DR on 01/30/2025 at 10:19 AM, showed a white vent to the wall directly across from the refrigerator had visible built-up brown dust to the slats that extended to the white walls surrounding the vent. The DR showed three white vents along the length of the window that also had built-up brown dust to the slats. An observation in the Private DR on 01/30/2025 at 10:22 AM, showed the white vent above the sliding doors had built-up black dirt on the blades of the vent that extended to the wall surrounding the vent. The DR showed the vent on the ceiling to the right of the main entrance had thick, built-up brown dust. An observation of the TCU DR on 01/30/2025 at 10:27 AM, showed the white vent on the ceiling in front of the sink had thick black dirt and visible spider webs all along the square vent holes. The black outlined circle of the vent hole could be seen standing more than five feet (a unit of measure) away from the vent. An observation of the [NAME] DR on 01/30/2025 at 10:55 AM, showed the wall to the right of the sink had a white vent with thick brown/black dust and spider webs. The DR showed a group of residents sitting at tables in the center of the DR, that had a less than three feet by one-and-a-half-foot vent over the top of the tables. The vent had slats to all four sides that had thick, built-up brown, stringy dust hanging off them. <Hallways> An observation of Hallway 100 on 01/30/2025 at 9:56 AM, showed two white vents with slats on the ceiling outside of rooms [ROOM NUMBER] with built-up black/brown dirt on the slats. The Hallway showed a larger white ceiling vent outside of room [ROOM NUMBER] with built-up dust to the slats of the vent as well as to the filter that could be observed through the slats. An observation on 01/30/2025 at 10:26 AM showed a white vent outside the Chef's Nest door at the end of Hallway 200, had built-up thick, brown dust. An observation of Hallway 300 on 01/30/2025 at 10:31 AM, showed outside of rooms [ROOM NUMBER], two white ceiling vents with thick, black dirt and spider webs dangling from them. The hallway showed a larger white vent on the ceiling outside of room [ROOM NUMBER] that had blackened areas of built-up dust. The large vent had white square ceiling tiles that surrounded the vent and showed blackened built-up dust extending from the vent. An observation of the entrance way to Hallway 100 on 01/30/2025 at 10:54 AM showed three white wall vents near the nurse's station that had built-up black dust to the slats. <Kitchen> An observation on 01/30/2025 at 11:17 AM, showed a white vent on the ceiling in the dry storage room, above the black refrigerator that was 12 inches by 12 inches with four sections in the middle of the vent. The sections of the vent had built-up black dust as well as stringy dust hanging from the vent. Additionally, five of the slats were broken exposing a black hole. The white vent above the dish washing area also showed built-up black dust. <Laundry Room> An observation on 01/30/2025 at 11:01 AM, showed in the clean part of the laundry room, there was a white vent that had thick stringy, built-up dust on the slats. The laundry room showed the vent above the middle dryer had built-up black dust on the slats as well as the large round cylinder exhaust pipes to the back of the dryers (less than eight feet tall and 12 feet in length). Additionally, inside the encasings around the two dryers, there were vents around the motors that had thick built-up brown dust and lint. The laundry room also showed the metal water piping that went across the width of the laundry room had built-up dust to the top areas of the piping. During an interview on 01/30/2025 at 11:05AM, Staff C, Housekeeper, stated they were responsible for cleaning areas that were low enough for them to reach and maintenance was responsible for areas that were up high. During a telephone interview on 01/30/2025 at 2:13 PM, Staff B, Maintenance Director, stated they cleaned vents every six months and they did not have a schedule for changing the filters. Just changed them when they needed to be. Staff B stated they expected laundry staff to clean the lint and dust in the laundry room every shift. Staff B stated they provided the laundry staff with Swiffer Jet (a brand of duster/cleaner) cleaners so they could reach higher areas. Staff B stated they were also responsible for cleaning the vents in the ceilings. Staff B stated they had last changed the filters four to five months ago. Review of a 2025 Vent Log showed the kitchen and laundry vents had been cleaned on 01/14/2025. The log showed the Hallway 100 vent filter and other filters had been replaced on 01/22/2025, and the main entrance vents had been cleaned on 01/22/2025 (even though Staff B stated it had been four to five months ago). Review of the 12/18/2024 through 01/28/2025 Maintenance communication book, showed an entry on 12/30/2024 that the [NAME] DR ceiling vents were dirty. The entry showed it had been completed with no documented initials of who completed the work or a date that it had been completed. An observation and concurrent interview on 01/30/2025 at 3:35 PM, Staff A, Administrator, along with the Surveyor, walked through the facility. Staff A stated Staff B should have completed daily walk throughs of the facility to identify if things like the dirty vents needed to be cleaned more often than every six months, they [the vents] shouldn't be like that. During a follow-up interview on 01/31/2025 at 1:00 PM, Staff B stated they needed to restructure their process for cleaning vents and changing filters in the vents. Staff B stated the vents needed to be monitored more frequently, cleaned when they started to have dust build up, and the filters changed. Reference WAC: 388-97-3220 (1)

Based on observation, interview, and record review, the facility failed to set-up a visually impaired resident's room to ensure it accommodated the individualized needs and preferences for 1 of 2 residents (Resident 6) reviewed for accommodation of needs and preferences. Resident 6 experienced psychosocial harm as evidenced by changes in their activity, behavior, and mood from their baseline due to their new physical environment that was not individualized for their preference of independent functioning. Findings included . <Resident 6> Review of the medical record showed Resident 6 admitted to the facility on [DATE] with diagnosis to include blindness (visually impaired), anxiety (a feeling of worry, nervousness, or unease), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant). The 09/30/2024 comprehensive assessment showed the resident required supervision or touching assistance with walking and transfers. The assessment showed listening to music was very important to them, had severely impaired vision, rarely socially isolated, and had an intact cognition during the review period. Review of Resident 6's care plan, dated 11/01/2024, showed the resident was legally blind in both eyes, high risk for falls, and preferred to have their room and belongings arranged to promote their independence. The care plan showed the resident liked their bed on the right side for a home like environment. The care plan did not address the change to the resident's new physical environment, nor addressed the bed currently being on the left side (which was a change from what Resident 6 was used to from the set up in their previous room). Review of a progress note, dated 09/14/2024, showed Resident 6 was on alert charting to be monitored for adjustment to a new roommate. Resident 6 stated they were uncomfortable with the new roommate due to the new roommate being messy, had a bad odor, and kept the air conditioner on all day. Resident 6 had conveyed these concerns to staff and the need for something to be done. Review of a nursing progress note, dated 11/15/2024 at 9:55 PM, showed Resident 6 had been moved to a new room (after two months residing in the same room with roommate that made them uncomfortable). Review of the medical record showed no documentation of Resident 6 being oriented to their new physical environment by nursing or therapy staff. Review of a nursing progress note, dated 11/16/2024 at 11:13 PM, showed Resident 6 had complained to nursing staff of disliking the set-up of their new room. Resident 6 was accustomed to their old room setting. The resident verbalized their dislike the day after they had been moved to their new environment. Review of a nursing progress note, dated 11/17/2024 at 11:12 PM, showed the resident had complained of disliking the set-up of his new room and the closet was too small, two days after they had been moved to their new environment. During an interview on 11/17/2024 at 2:17 PM Resident 6 stated, I'm not happy with the new room. The resident stated they were blind and had trouble getting around their new room. Resident 6 stated that their bathroom was too small, and the toilet was too small. The resident stated they were frustrated and embarrassed because they had been told they had urinated all over the place. Review of a nursing progress note, dated 11/18/2024 at 6:50 AM, showed Resident 6 stated they were angry due to having to move out of their old room, three days after they had been moved to their new environment. During an interview on 11/18/2024 at 8:37 AM, Staff LL, Licensed Practical Nurse (LPN), stated that Resident 6 had previously complained about their new roommate. Staff LL stated that Resident 6 requested to have either their new roommate moved or they (Resident 6) would need to be moved. Staff LL stated that Resident 6 was moved to a new room on 11/15/2024, per their request. Staff LL further stated therapy staff were not involved with the move, and Staff LL, with help from maintenance staff, moved Resident 6 into the new room. Staff LL, stated an orientation to the new room should have been done. An observation on 11/19/2024 at 1:29 PM, showed Resident 6 fully dressed wearing a gray t-shirt, brown sweatpants, and shoes exiting the restroom when they had tripped over a bed control cord that was lying on the ground. The resident fell forward as they grabbed the bottom of bed and stood straight up, holding on to the handle of their wheelchair and frame of the bottom of bed. Resident 6 walked along the bed, touching the edge of the bed with their hand to determine where they were at since they could not see, until they were in the middle of the bed and sat down. During an interview on 11/20/2024 at 9:02 AM Resident 6 stated I'm so frustrated with this place, I have been in the same clothes since Saturday. Resident 6 stated they could not find any of their clothes in the closet, they did not like being in the same clothes day after day. Resident 6 was in the same clothing as the previous day, a gray t-shirt and brown sweatpants. The resident stated, I'm not good in here (the new room they were placed in). Resident 6 explained the restroom was too small to sit down, and it did not flush well. Resident 6 stated they were having trouble washing their hands due to not being able to find the sink. They stated they could not get into the closet to find clean clothing to put on. I just don't know where I'm at. Resident 6 stated when they were in the old room they knew where everything was and felt comfortable going in and out of their room independently. The resident explained in the old room they knew when they got to the doorway because the window was on their left and all they had to do was turn right to walk down the hallway until they heard people around the dining room, and then turned left to get to the dining room for meals. The resident stated, I can't get out of this room because I'm not sure where I am. During an interview on 11/20/2024 at 10:07 AM Staff Y, Nursing Assistant (NA), stated Resident 6 was very upset with the new room. Resident 6 reported to Staff Y they could not find the sink, they could not get into the closet easily, and that the bathroom was too small. Staff Y stated Resident 6 was used to everything being on the right side of their room and now everything was on the left side in the new room. Staff Y stated that Resident 6 had weakness to their left side and their right side was the strong side. Staff Y stated the resident was so upset that they were not doing the things they had done in the past, like walking to the dining room, listening to their music, or playing around and teasing the staff like they normally did. Staff Y stated the resident was mad about the move. Staff Y stated they had encouraged the resident to use their call light for help, so they did not fall in their new room. Staff Y stated the resident really was not doing their normal routine and the resident was afraid they were going to fall when trying to get around in their new room. During an observation and concurrent interview on 11/20/2024 at 11:24 AM, Staff Z, NA, stated Resident 6 had been very quiet and looks sad. The resident was observed lying across their bed, shirtless, with their hands over their face and conveyed their frustration to Staff Z. Staff Z stated when the resident was in their previous room, the resident would sit at the side of the bed teasing/interacting with staff or walk around in the room listening/singing to their music. The resident would independently walk to the dining room with their cane for lunch; Staff Z stated the resident had not been doing that since their move to the new room. During an interview on 11/22/2024 at 10:20 AM, Resident 6's Representative (RR) stated they were very unhappy with the new room change for Resident 6. The RR stated no-one from the facility called to notify either of the RRs about the room change. The RR stated the resident had been in the old room since 2010 ([AGE] years). The RR stated .for a blind person . that was not right . for the facility to move (Resident 6) without even helping them get to know (their new) space is just wrong. The RR stated the resident could not find their way around their new room, they could get really hurt in here. During an interview on 11/22/2024 at 2:20 PM Staff B, Director of Nursing Services, stated the process for moving a resident to a different room, first we do have to ask the resident if they would like to move and notify the resident's family of the room move. Staff B stated that they thought the staff moved the resident into a room with a similar set-up. Staff B stated they were surprised Resident 6 had moved rooms. Reference: WAC 388-97-0860(1)(a)(2)

Based on interview and record review, the facility failed to provide adequate supervision and implementation of care plan interventions to prevent a fall for 1 of 3 residents (Resident 45) reviewed for falls with injury. Resident 45 experienced an avoidable fall when left alone in the restroom, despite the care plan interventions that showed the resident required supervision while in the restroom. This failure resulted in actual harm to Resident 45 who fell in the restroom, experienced a four-to-five-centimeter (cm) hematoma (an abnormal collection of blood outside of a blood vessel that results from an injury or trauma) and required a transfer to the local emergency room for evaluation and intervention. Findings included . <Resident 45> Review of the medical record showed Resident 45 was admitted to the facility on [DATE] with diagnoses including a stroke (damage to the brain from an interruption of its blood supply), flaccid hemiplegia (occurs after a stroke and causes the affected extremity to have decreased muscle tone and cannot be actively moved by the resident), and weakness. The 08/16/2023 comprehensive assessment showed Resident 45 required extensive assistance of two staff members for activities of daily living, including toileting. The assessment also showed Resident 45 had a severely impaired cognition (difficulty remembering things, making decisions, concentrating, and learning). Review of Resident 45's care plan, revised on 08/14/2023, showed the resident was a high fall risk. An intervention, dated 08/23/2023, showed DO NOT leave resident alone in bathroom r/t (related to) risk of fall. Additional review of Resident 45's care plan showed the resident required extensive assistance of two staff members for toileting. Record review of a facility investigation report, dated 09/16/2023 at 8:37 PM (same day as the fall), showed Resident 45 was observed laying with their right cheek on the floor with their right (affected side) towards their back. Resident 45 stated they were trying to clean themselves after having a bowel movement and scooted forward in order to reach back and fell . The investigation further showed Resident 45 was assessed for injury and had a large hematoma to their right temple. Resident 45 was sent to the emergency room for evaluation. Review of Resident 45's hospital records, dated 09/16/2023, showed the diagnosis and from the emergency room physician was blunt head trauma concussion (a brain injury caused by trauma to the head that causes the head and brain to move rapidly back and forth) and right forehead hematoma contusion (bruise). Record review showed the resident returned to the facility on [DATE] at 5:27 AM with a five cm hematoma that was red/purple in color. Resident 45 was placed on alert charting for monitoring of the hematoma, three times a day, by a licensed nurse, until the hematoma resolved on 10/03/2023. During an interview on 10/04/2023 at 8:59 AM, Resident 45 stated they were in the bathroom when they lost strength in their left hand and went down. Resident 45 stated the nurses were not helping at that time. They stated they hit their head and went to the hospital. During an interview on 10/04/2023 at 3:08 PM, Staff D, Nursing Assistant (NA), stated that they were not aware that Resident 45's care plan was changed for transferring and toileting. Staff D stated they had not worked for a few days and did not see the communication alert in the electronic system that showed when a resident had a change in their care plan. Staff D stated, on the day of the fall, they were called to Resident 45's room to assist with helping the resident off the floor. Staff D stated it was clear the resident fell face forward with their arm twisted behind them. Staff D stated Resident 45 told them they were trying to lift themselves off the toilet to clean themself when they fell . During an interview on 10/06/2023 at 12:11 PM, Staff E, NA, stated they did not know Resident 45 needed supervision in the restroom. Staff E stated Staff D helped them transfer Resident 45 to the toilet and they both walked out and left Resident 45 on the toilet. Staff E stated they did not check the electronic communication alerts carefully that day. Staff E stated, it was my mistake. During an interview on 10/09/2022 at 12:22 PM, Staff H, Resident Care Manager, stated the process for communicating care plan changes to the NA's included entering the information into the electronic communication system, in red (font), to alert the staff to the changes. Staff H stated NAs also received the information verbally through daily report. Staff H further stated that the fall could have been avoided had staff read the updated care plan. During an interview on 10/09/2023 at 1:25 PM, Staff B, Director of Nursing Services, stated they expected staff to read the electronic communication alerts at the start of their shift. Staff B stated all staff had the ability to read the alerts as far back as needed and would be expected to read any updates created since their last day worked. Staff B stated that the updated care plan information was in the electronic communication system and staff had the training to review those alerts. Additionally, Staff B stated Resident 45's fall could have been avoided had the staff read the care plan. Reference: WAC 388-97-1060(3)(g) This is a repeat citation from complaint investigation dated 08/24/2023.

Based on observation, interview, and record review, the facility failed to ensure bed equipment was properly assessed prior to use for appropriate settings for safety, to prevent falls for 1of 1 resident (Resident 4), reviewed for fall from specialized air mattress. This failure resulted in actual harm to Resident 4, who fell from their bed, which had an alternating pressure and low air loss mattress (a mattress with air bladders throughout that constantly inflate and deflate, which helps to reduce pressure on the skin and promote blood flow), experienced bone fractures to their hip and pelvis, a subdural hematoma (brain bleed), and pain. Failure to follow alternating air mattress manufacture directions increased at risk for injury for residents who have them on their beds. Findings included . Record review of the facility's policy titled, Fall Risk, dated ,d+[DATE], showed that residents were evaluated for their risk of falls upon admission and annually. A plan of prevention was initiated for identified risks. Record review of an undated Air Advance Mattress owner's manual, provided by the facility, showed it was an alternating pressure and low air loss mattress used for the prevention and treatment of pressure ulcers (localized damage to the skin and underlying soft tissue usually over a bony prominence). Review of the directions for use showed after the mattress was placed and secured on the bed frame and turned on, to set the firmness level to the lowest setting and allow approximately 25 minutes for the mattress to fully inflate. After preparing the mattress surface with bed linen, place the resident on the mattress. Increase firmness for resident comfort, support, and immersion into the mattress for optimal pressure redistribution. Failure to comply with all directions and warnings may result in injury or death; use only as directed. <Resident 4> Medical record review showed Resident 4 was admitted to the facility on [DATE]. Review of the [DATE] comprehensive assessment showed the resident had severe cognitive impairment, required extensive physical assistance from staff for bed mobility and transfers. The resident had a new gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach) tube for nutrition. The resident's diagnoses included dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), stroke (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and dysphagia (a condition that makes it hard to swallow and may cause pain or choking). Resident 4 weighed 111 pounds and had no falls since admission. Review of an [DATE] facility incident investigation showed that at 7:20 AM, Resident 4 fell out of the left side of their bed and landed on their right side, on the floor, hitting their right temple on the metal leg of the overbed table. The investigation showed there were no outward signs of injury; however, Resident 4 was immediately transferred to the hospital due to their inability to communicate pain and the resident's risk for internal bleeding due to taking several blood thinning medication for their atrial fibrillation. The facility completed an investigation that included interview with Staff D, Nursing Assistant (NA), who was in the room when the fall occurred. Administrative staff observed a reenactment of the incident in the resident's room with Staff D and Staff C, Licensed Practical Nurse (LPN) /Staff Development. Staff C laid on the resident's bed, at same height with the alternating air mattress running. Review of Staff D's statement showed they had just finished dressing Resident 4, who was positioned on their right side in the middle of the bed. Staff D was on the right side of the bed and turned to the left to retrieve the resident's wheelchair that was behind the half-closed privacy curtain. Staff D stated as soon as they turned away, they heard the resident fall to the floor off the left side of the bed. The facility investigation concluded the alternating air mattress caused the resident to roll to the left and fall. Record review of the [DATE] hospital discharge summary showed Resident 4 was diagnosed with a subdural hematoma (collection of blood outside the brain usually caused by serious head injuries), closed right hip fracture, right pubic ramus (a group of bones in their lower pelvis) fracture and a right shoulder displacement. The resident's discharge prognosis was poor, and end of life care was discussed with Resident 4's Representative (RR4). During a concurrent interview and observation on [DATE] at 11:00 AM, Staff C showed Resident 4's former room and bed set up as they observed during the reenactment on [DATE]. Staff C stated the bed was elevated at working height and according to where the mattress hit their thigh, the height measured 27 inches to the floor. The resident's wheelchair was positioned to the right of the bed and had the privacy curtain pulled between the bed and wheelchair. Staff D stated the mattress settings were in the middle for both firmness and air alternation. Staff D stated while lying on the bed, as the mattress air sections alternated, they could feel how the mattress could roll a lighter person out of bed. During an interview on [DATE] at 11:33 AM, Staff E, LPN/ Residential Care Manager, stated [Resident 4] had recently transferred from the 300 Hall and I got them an air mattress due to their Stage 1 pressure ulcer (the mildest form where the skin is reddened, painful, and does not turn white when pressed). When asked about how they knew what the air mattress settings should be for Resident 4, Staff E stated that the mattresses were normally preset in the middle and thought it was on the factory settings. Observation with Staff E, of the same model of alternating air mattress, showed the middle settings for alteration cycle was 15 minutes and firmness was four, the middle setting between one and eight firmness, with eight at most firm. Review of Resident 4's care plan, dated [DATE], showed the air mattress was added to prevent skin breakdown due to immobility on [DATE] (11 days prior to their fall). There were no cycle or firmness settings. During a telephone interview on [DATE] at 11:45 AM, Staff D stated that they noticed Resident 4 would sometimes cross their right leg over the left leg and would not stay in the middle of the air mattress. They stated that day, they stepped to the left to get the wheelchair, did not leave the side of the bed, but did take their eyes from the resident and heard the resident hit the floor. During an interview on [DATE] at 12:15 PM, Staff F, Maintenance, stated they installed the air mattresses when the nurses made the request. They stated they could not recall if they set up Resident 4's mattress or if it was their co-worker. They stated they did not change the settings when inflating the mattresses that were usually on middle settings. Staff F showed they had the mattress user's manual on their phone; however, stated they had not read the directions for use and were not aware of starting on the lowest settings. During an interview on [DATE] at 12:35 PM, Staff C stated that they did not have a policy for the alternating air mattress nor were they aware of the inflation directions to individualize the settings according to the resident's weight. Staff C stated [Resident 4] weighed about 110 pounds and the medium settings caused the mattress to be over inflated for [their] weight, making it possible to roll out. Record review of an [DATE] at 10:32 PM progress note showed the resident returned to the facility at 7:30 PM via ambulance, they were alert with minimal verbal response and family was at the bedside. Review of the admission orders included pain medication ordered for every 6 hours and an opioid (a class of drugs used to treat moderate to severe pain) as needed (prn) for breakthrough pain. Review of the [DATE] medication administration record showed the prn opioid was given for pain five times between [DATE] and [DATE] for a five out of 10 (10 being the highest level of pain) and above level of pain. Record review of an [DATE] at 10:32 PM progress note showed RR4 was concerned Resident 4 was not comfortable. The provider was notified and gave an order for morphine (an opioid to treat severe pain) every 4 hours prn for pain. The morphine was given twice prior to the resident's death on [DATE] at 4:53 AM with their family at bedside. During a telephone interview on [DATE] at 3:25 PM, Resident 4's Representative stated that Resident 4's fall was totally preventable, although [Resident 4] had end-stage dementia, we planned to bring them home. [Resident 4's] fall caused a hip and pelvic fracture and a brain bleed and [they] suffered in pain for three days. This should not have happened. Reference: WAC [DATE](3)(g)

Based on interviews and record review the facility failed to evaluate and monitor significant changes in the condition of one of three residents (#1) reviewed for change of condition. Staff failed to recognize the need to evaluate the frequency of the resident's stools in conjunction with her refusals of [MEDICATION NAME] (a laxative used to treat and prevent complications of liver disease; decreases the amount of ammonia in the blood which improves mental status as high levels result in altered mentation, confusion, changes in mood; ammonia is removed from the body in the form of stools) and notify the physician to allow him the opportunity to alter the treatment plan. This resulted in actual harm to the resident due to a delay in obtaining prompt medical treatment. Findings included . Resident #1. Review of the resident's medical record showed she was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of hospital records showed on 07/30/19 the resident was having multiple stools with the goal being two to three stools per day. Review of the resident's comprehensive assessment, dated 08/07/19, showed she had moderate cognitive impairment; and required one staff to assist with turning in bed, transfers, dressing, toileting, and personal hygiene. Review of the resident's Medication Administration Record [REDACTED]. Between 08/01/19 to 08/07/19 the resident refused six of the 21 ordered doses. In addition, she did not receive any [MEDICATION NAME] by staff on 07/31/19 (day of admission) as the medication was not available. Review of the resident's bowel records showed the following: 07/31/19 - no stools on the evening and night shifts 08/01/19 - medium stool on the evening shift 08/02/19 - medium stool on the evening shift 08/03/19 - no stools 08/04/19 - medium stool on the day shift 08/05/19 - large stool on the day shift 08/06/19 - medium stools on the day and evening shifts 08/07/19 - small stool on the day shift Despite the importance of [MEDICATION NAME] in the treatment of [REDACTED]. Review of a therapy assessment, dated 08/07/19, by Staff A, Physical Therapy Assistant, showed the resident kept falling asleep during testing and education. She displayed decreased awareness and difficulty in following directions. Review of a therapy assessment, dated 08/07/19, by Staff B, Speech Therapist, showed the resident exhibited increased drowsiness and significantly decreased alertness and attention to task, nursing notified. Review of Progress Notes (PNs), dated 08/07/19 at 4:05 PM, by Staff C, Registered Nurse, showed the resident was noted to be falling asleep when being spoken to. After calling out to the resident in a louder voice to arouse her from sleep she was able to make eye contact and stay awake. The PN stated, physician to see resident this evening. Review of the resident's medical record did not show the resident was ever seen by the primary care physician since his initial assessment on 08/01/19. Despite the significant changes in the resident's mentation there was no further nursing assessment of the resident until 08/08/19 at 4:25 AM, which showed the resident was yelling out and crying (noted changes from previous assessments) due to open areas on her back. Review of PNs documented by Staff C, Registered Nurse, on 08/08/19 at 4:23 PM, showed the resident was unable to answer questions regarding pain level and/or location. The resident responded with moaning and falling asleep. After calling out to the resident in a louder voice to arouse her from sleep she was able to make eye contact for a brief moment. The physician was notified and orders received to transfer her to the emergency room (ER). Review of the resident's vital sign records showed no vital signs had been taken on the resident since 08/07/19 at 6:58 AM. Review of ER records, dated 08/08/19, showed the resident was seen by the ER physician at 7:16 AM. She was diagnosed with [REDACTED]. She was started on [MEDICATION NAME] every one to two hours until two stools occurred then titrate the medication to maintain two to three stools per day. She remained in the hospital until 08/17/19, then discharged to a community facility on Hospice. An interview on 11/19/19 at 1:45 PM with Staff A, showed usually the resident was awake and alert, however during the therapy session on 08/07/19 at approximately 1:00 PM she was falling asleep which was different for her. Staff A stated she notified a Licensed Nurse (LN) at that time regarding the changes. Staff B stated during a telephone interview on 11/20/19 at 12:05 PM, that on 08/07/19 in the early afternoon the resident was sleepy and it was hard to keep her focused and engaged in therapy. When he worked with her on 08/05/19 she was aware and wanted to work with therapy , pretty engaged. He stated he reported the changes in her mentation to the LN at that time, but was unable to recall who the LN was. During a telephone interview on 11/19/19 at 2:15 PM with Staff C, she stated that she did not recall a [DIAGNOSES REDACTED]. Staff C stated she notified the physician on 08/07/19 and he stated he was coming in that evening. Following the report given to her of the resident having uncontrolled pain by the night shift LN the morning of 08/08/19 she immediately went to assess her. The resident did not look good and was not responding to me. She then notified the physician and transferred the resident to the ER. A telephone interview on 11/19/19 at 2:50 PM with the resident's primary care physician, he stated he did not recall talking with a LN regarding changes in the resident's condition on 08/07/19, nor that she was refusing doses of [MEDICATION NAME]. He stated every time they ask me to see a resident I go. During an on-site post survey conducted on 10/10/19 the following action was taken by the facility to correct the past noncompliance: 1) The facility management team reviewed resident care, progress notes, changes in condition five days per week with each charge nurse to ensure staff was accurately identifying and addressing changes in condition. 2) Licensed nursing staff was educated on performing and documenting timely resident assessments and prompt medical treatment when a change in condition was identified. 3) The Director of Nursing (DON) reviewed new orders daily in the facility computer program. 4) The DON tracked and trended audit findings and reported results to the monthly Quality Assurance Performance Improvement committee to identify opportunities for performance improvement. The facility corrected the past noncompliance on 10/03/19. Reference (WAC) 388-97-1060(1)

Based on interviews and record review the facility failed to provide care in a manner that promoted resident respect and dignity for six of nine residents (#'s 1, 2, 3, 4, 5, 6) reviewed for call lights. This failed practice resulted in actual harm to Resident #1 as the delay caused her pain and emotional distress. Findings included . Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] from the hospital following a fall at home. Review of the resident's comprehensive assessment, dated 08/22/19, showed the resident required extensive assistance with two staff for transfers, turning side to side in bed, dressing, and toileting; and extensive assistance with one staff for personal hygiene. The comprehensive assessment, dated 09/05/19, showed the resident had no cognitive impairments. Review of the resident's Treatment Administration Record for (MONTH) 2019 showed she received an antifungal cream to her peri area rash every shift. Review of a facility investigation report showed the resident put on her call light at approximately 8:00 PM on 08/18/19 to request assistance as she had soiled her brief with stool and urine. The resident stated a NA (Nursing Assistant) initially came in and stated she would return in a few minutes. When the NA returned approximately an hour later she was there to do vital signs. The resident asked the NA if she had forgotten her request for personal care. The NA stated she would return as soon as she completed vital signs on other residents. The resident stated it was 40 minutes to an hour before the NA returned again and she did not have the necessary supplies with her. The NA again left the resident's room stating she would return. Personal care was not provided to the resident until 2:00 AM on 08/19/19 (approximately six hours later). The facility investigation documented the resident's family member was aware of the above call light problem as she had received messages from the resident regarding her having to wait for staff to assist with personal care. Review of the resident's call light log showed her call light was activated on 08/18/19 at 7:48 PM and staff responded six minutes later. The resident again put her call light on at 12:41 AM and 1:21 AM on 08/19/19 with staff responding within five one-half minutes and 15.5 minutes, respectively. Further review of the resident's call light log between 08/15/19 to 09/09/19 showed the following staff response times: 08/15 at 8:21 AM - 49 minutes 08/16 at 11:12 AM - 48 minutes 08/20 at 9:59 AM - 39 minutes 08/21 at 7:46 PM - 56 minutes 08/23 at 8:17 AM - 35 minutes 08/23 at 12:34 PM - 45 minutes 08/27 at 12:14 PM - 32 minutes 08/27 at 9:07 PM - 33 minutes 08/28 at 11:46 AM - 36 minutes 08/30 at 8:37 AM - 29 minutes 09/01 at 1:38 PM - 27 minutes 09/02 at 2:55 PM - 24 minutes 09/04 at 9:58 AM - 65 minutes 09/06 at 8:23 AM - 26 minutes 09/06 at 1:02 PM - 27 minutes 09/07 at 9:23 AM - 25 minutes During a telephone interview with the resident on 09/12/19 at 1:06 PM, she stated she would put her call light on and wait a long time for it to be answered. Staff would take her to the bathroom and instruct her to pull the string when she finished. She pulled the string then waited and waited and eventually placed her head on the bar next to the toilet as she was so tired. It would be close to 30 minutes before someone finally came to assist her. Really upset as I could have fallen, my arms were getting weak as I had to hold onto something. The resident stated during the night she would have to wait a long time and would have incontinent episodes due to waiting. One time she put her call light on and staff turned it off stating they would come back. At that time the resident needed assistance as she was incontinent of stool and urine. She stated her skin was burning from the soiled brief. I was upset, I was burning terrible, reddened peri area .waited for over six hours to be changed. A telephone interview with the resident's collateral contact on 09/11/19 at 2:25 PM showed there were so many call light issues. The collateral contact stated the resident put on her call light at approximately 7:30 PM as she was soiled. A NA came into her room and stated she would get supplies. She was not given care until 2:00 AM. Another time staff left her on the toilet in the bathroom for over 30 minutes. Her call light was on and she was at the point where she almost vomited secondary to the pain and wanted to get up. The resident had previously fallen at home and had pain all over especially in her leg and shoulder. Her bottom was raw due to the sores. The collateral contact stated the resident had texted her the next morning and stated she had a really bad night, they left me until 2:00 AM. Staff A, Physical Therapy Assistant, stated during an interview on 09/12/19 at 9:30 AM, that they (therapy staff) were monitoring the resident's call light as there were multiple times the call light was on and she needed to be changed as she was incontinent. Staff A stated if she saw a call light on for awhile she would let nursing staff know. The resident had complained there were times the call light would be on for a long time - 45 minutes to an hour. An interview on 09/11/19 at 1:05 PM with Staff B, Registered Nurse/Resident Care Manager, she stated that call lights were not being answered in a timely manner. During an interview on 09/11/19 at 1:15 PM with Staff E, Social Services Director, she stated that the resident was pretty accurate with our call light report. When Staff [NAME] questioned the resident as to the description of the NA involved in the allegation the resident stated she had dark hair and a medium build. The resident's family member had been visiting with the resident the evening of 08/18/19 and left to go home at approximately 8:00 PM. Resident #2. Review of the resident's comprehensive assessment, dated 08/09/19 showed she scored 11 out of 15 with 15 showing no cognitive impairments and eight showed moderate impairment. Review of the resident's plan of care, dated 04/04/19, showed the resident was continent of bladder and bowel, and required one staff to assist with toileting and transfers. The resident was identified as being at risk for falls due to swelling, and a history of falls. The resident stated during an interview on 09/12/19 at 4:20 PM, that a couple of nights ago she was needing to use the bathroom and waited approximately two and one-half hours for someone to assist her. The resident stated she was upset as during that time she laid in a wet bed. Staff would walk by her room on all three shifts and not answer her call light. The resident stated the other day she waited and waited, I needed to use the bathroom, I had to go really bad. She stated she finally got up on her own to the bathroom. She had incontinence episodes due to waiting for staff. Review of the resident's call light log between 08/24/19 to 09/11/19 showed the following staff response times: 08/24 at 7:06 AM - 175 minutes 08/24 at 9:08 PM - 91 minutes 08/25 at 6:24 PM - 30 minutes 08/26 at 10:05 PM - 37 minutes 08/28 at 10:17 PM - 110 minutes 08/31 at 6:53 AM - 38 minutes 09/03 at 7:20 PM - 21 minutes 09/05 at 2:13 AM - 25 minutes 09/06 at 10:00 PM - 21 minutes 09/10 at 5:46 PM - 28 minutes 09/11 at 9:38 AM - 84 minutes Resident #4. Review of the resident's medical record showed she was admitted to the facility on [DATE]. Review of Progress Notes, dated 09/10/19, showed the resident had no cognitive impairments, required one to two staff to assist with activities of daily living, and had muscle pain in both arms and shoulders. During an interview with the resident on 09/12/19 at 11:45 AM, she stated that she had to wait 45 minutes last night from the time she put on her call light until she received her pain medication. When she put on her call light for pain medication her pain level was at least an eight to ten (scale of zero being no pain to a ten being severe pain). The resident stated that at home she could just reach over and get the pain medication and did not have to wait for it. They need to understand if a patient needs a pain pill they need a pain pill. Review of the resident's call light log between 09/08/19 to 09/11/19 showed the following staff response times: 09/08 at 5:44 PM - 29 minutes 09/08 at 9:25 PM - 41 minutes 09/09 at 7:44 AM - 25 minutes 09/10 at 10:06 AM - 36 minutes 09/11 at 4:10 PM - 25 minutes Resident #5. Review of the resident's medical record showed he was admitted to the facility on [DATE]. Review of the resident's comprehensive assessment, dated 09/11/19, showed the resident had minimal to no cognitive impairments; and required limited assist with one staff for dressing, transfers, toileting, and personal hygiene. During an interview with the resident on 09/12/19 at 11:55 AM, he stated approximately the second day following his admission to the facility he put his call light on at 1:00 AM and it wasn't until 3:00 AM before someone answered his light. He stated he then asked for something for his hip pain and received it within 15 minutes. He stated now he just gets into his wheelchair and goes to the nursing station to request pain medication. Review of the resident's call light log between 09/04/19 to 09/11/19 showed the following staff response times: 09/05 at 8:40 AM - 39 minutes 09/05 at 9:04 PM - 24 minutes 09/07 at 11:27 AM - 34 minutes 09/07 at 7:29 PM - 22 minutes Resident #6. Review of the resident's medical record showed she was admitted to the facility on [DATE]. Review of a comprehensive assessment, dated 05/29/19 showed the resident was cognitively intact. Review of a comprehensive assessment, dated 08/24/19, showed the resident required extensive assistance by two staff for turning side to side in bed, transfers, dressing, and toileting. During an interview on 09/12/19 at 12:10 PM, the resident stated that staff would tell her they would be back to change her as they needed two staff. She then would have to wait another 30 to 60 minutes and would have to put the call light on again. Often the resident would put her call light on to be changed due to stool issues or to be repositioned in bed. You panic when you need help. Resident #3. Review of the resident's comprehensive assessment, dated 09/04/19, showed he had minimal to no cognitive impairments. Review of the resident's plan of care, dated 06/14/19, showed he required two staff to assist with transfers and toileting. During an interview with the resident on 09/12/19 at 4:55 PM, he stated that it took 20 minutes for staff to answer his call light and it happened frequently. He stated one to two times that week he had to wait for staff to respond. The call light problem was not getting any better. He stated, seems like staff have no incentive to be conscientious .gets frustrating. During a telephone interview with Staff F, Director of Nursing, she stated the call light system (wait times) needed to be addressed. She stated she had spoken with the Administrator to obtain additional pagers for staff to enable call lights to be responded to in a timely manner. Staff F stated she did not even have a pager. Refer to F585 Grievances for further information. Reference (WAC) 388-97-0180(1)(2) This is a repeat deficiency from the Statement of Deficiencies dated 04/18/19.

Based on interviews and record review the facility failed to perform timely assessments and seek prompt medical treatment for one of three residents (#1) who experienced a deterioration in their medical condition. This failure resulted in actual harm to Resident #1 who had to be hospitalized and placed in the Intensive Care Unit (ICU) for treatment. Findings included . Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment, dated 08/22/19, showed the resident required extensive assistance with two staff for transfers, turning side to side in bed, dressing, and toileting; and extensive assistance with one staff for personal hygiene. The comprehensive assessment, dated 09/05/19, showed the resident had no cognitive impairments. Review of Progress Notes (PNs) dated 08/26/19, showed the Licensed Nurse (LN) was waiting for an antibiotic order from the physician to treat a urinary tract infection [MEDICAL CONDITION]. The following day (08/27/19) PNs showed the physician came to the facility, reviewed the resident's lab work dated 08/26/19 noting a UTI, and ordered antibiotics to be started and given for 10 days. Review of the resident's Medication Administration Record [REDACTED]. Review of the above lab report showed the urinalysis was obtained on 08/21/19, however there was no documentation of an assessment of the resident at that time to determine the need for a urinalysis. In addition, despite an antibiotic being administered to the resident twice daily for ten days there were only two assessments (08/30/19 and 09/05/19) of the resident regarding the UTI and effectiveness of the antibiotic therapy. Review of PNs between 09/05/19 to 09/09/19 showed the following documentation: 09/05 at 2:01 PM - resident refused to get out of bed, complains of pain to right foot, physician was in to assess and ordered doppler studies for right foot ischemia (inadequate blood supply) 09/05/19 at 8:53 PM - wound rounds with Nurse Practitioner to assess right knee blister and third digit of right foot, right knee was debrided with 100% granulation tissue present; toe of right foot had 100% stable eschar (dead tissue) 09/06 at 3:15 PM - resident vomited once, resident refused to get out of bed 09/07 at 2:02 PM - resident alert and able to make her needs known 09/07 at 5:52 PM - resident continued to complain of nausea and vomiting - physician contacted and [MEDICATION NAME] (medication used t treat nausea and vomiting) given as a one time dose 09/07 at 4:56 AM - antibiotic for UTI in progress (review of the resident's MAR indicated [REDACTED] 09/08 at 11:07 PM - resident continued on series of antibiotics for UTI, family at bedside, had emesis twice - notified physician and obtained orders for [MEDICATION NAME] to be administered once, no breathing problems 09/09 at 6:33 AM - pain medication given and relief was pending, circulation/motion/sensation was noted to both legs, no breathing or swallowing problems There was no further assessment of the resident following the PN on 09/09/19 at 6:33 AM. Review of hospital records dated 09/09/19 at 2:35 PM showed the resident arrived at the emergency room where she had been ill for approximately three days before the transfer. Records showed the resident's family member had been concerned due to the resident's increased lethargy and fatigue. The resident was found to be in acute kidney failure, elevated potassium level, low pulse rate (33 at 2:47 PM on 09/09/19), low blood pressure (B/P), and severe metabolic acidosis (too much acid in the blood which can lead to shock or death), and acute UTI. Documentation showed the resident was in critical condition and was placed in the ICU for treatment. Review of the resident's MAR indicated [REDACTED]. There was no identified allergy in the resident's medical record to the narcotic. The medication was administered eight times between 09/05/19 to 09/09/19. In addition, three medications used in the treatment of high B/P were held due to low B/P readings: [MEDICATION NAME] was held the evening shifts of 09/06, 09/07, and 09/08/19, and morning and mid day doses on 09/09/19; [MEDICATION NAME] was held the morning of 09/09/19 for a B/P reading of 91/31; and Carvedilol was held the evening of 09/08/19 and the morning of 09/09/19. Review of the resident's Vitals Summary form between 09/01/19 to 09/07/19 showed the average B/P was 123/55 and her pulse rate was 71 beats per minute. The following vitals signs were obtained on 09/08/19 and 09/09/19: 09/08 at 8:40 AM - B/P of 99/62 09/08 at 8:41 AM - pulse rate of 70 09/08 at 11:54 AM - B/P of 101/62 09/09 at 7:56 AM - B/P of 91/31 and pulse rate of 40 Review of Physical Therapy records documented by Staff A, Physical Therapy Assistant, showed on 09/06/19 the resident began vomiting after the third transfer and requested to discontinue the therapy session. Review of Occupational Therapy records showed on 09/07/19 the resident was complaning of nausea and need to have a bowel movement. The resident was given a laxative and then vomited intermittently throughout the rest of day. Staff A stated during an interview on 09/12/19 at 9:30 AM, that on 09/06/19 the resident was vomiting which was reported to nursing, and she was alot more drowsy. When Staff A went back to check on the resident after the therapy session on 09/06/19 she was in bed and did not want to get up, was pale and did not feel good. The resident's collateral contact stated during a telephone interview on 09/11/19 at 2:25 PM, that the resident continued to be in the hospital ICU. She stated on 09/07/19 at approximately 4:00 PM the resident started acting different as she was dozing in and out and stated she was sick to her stomach. She stated that usually she and the resident would watch television together when she visited, however on that day she did not want to do that. The collateral contact stated earlier on 09/07/19 the resident called her at home and she couldn't talk very well. On 09/08/19 at approximately 6:00 PM the collateral contact stated she notified Staff B, Registered Nurse/Resident Care Manager, that the resident was sleeping a lot and was very confused. She then received a telephone call from Staff B at approximately 11:00 PM on 09/08/19 stating the resident was vomiting and her B/P was still low, however she was resting comfortably. On 09/09/19 at approximately 1:15 PM to 1:20 PM she received a phone call from Staff B stating the resident's B/P was low and they were holding her B/P medications, she doesn't look right. The resident's collateral contact arrived at the facility on 09/09/19 at approximately 2:00 PM and the resident was totally out of it, totally confused. The collateral contact insisted the resident be transported by ambulance to the hospital as Staff B had mentioned sending the resident to the hospital by facility van. Staff C, Nursing Assistant, stated on 09/12/19 at 10:34 AM, that when she went to provide care to the resident the evening of 09/07/19 the resident's collateral contact was in the resident's room. The resident was throwing up .quite a bit. The resident stated she had felt nauseated for the past three days and had been refusing her meals. Interviews conducted with Staff D, Licensed Practical Nurse, on 09/12/19 at 2:15 PM and 09/13/19 at 8:35 AM, showed she felt the resident's nausea was due to the [MEDICATION NAME] medication as the resident had stated to her she would get an upset stomach due to an allergy to the medication ([MEDICATION NAME] was not identified in the allergy list and the resident received eight doses despite the possible allergy). On 09/09/19 Staff D stated she became aware of the resident's low B/P and pulse (taken at 7:56 AM that morning) at approximately 8:00 AM. When Staff D checked on the resident she stated she was tired. She stated she took the resident's B/P before 9:00 AM and the systolic reading was in the upper 80's. Initially the resident refused to go to the hospital, however the resident's family member wanted the resident transported to the hospital. Staff D stated she tried to determine if the facility van driver was available to take the resident to the hospital but the family member wanted the resident transported by ambulance. Review of the physician's orders [REDACTED]. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 04/18/19.

Based on interview and record review, the facility failed to ensure an appropriate and safe discharge, including the reduction of factors leading to preventable readmissons, for one of three residents (#1) reviewed for discharges. This failed practice caused the resident harm due to the need to be hospitalized less than four days after the facility discharged and transported the resident to a motel. Findings included . The facility policy titled, Notice of Transfer or Discharge last revised 01/19, showed .Facility-initated transfer or discharge is defined as a transfer or discharge that the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences .Social Services/Designee coordinates transfers and discharges to assist in the resident's adjustment . Resident #1. Review of the medical record showed the resident was initially admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment, dated 02/06/19, showed the resident had intact cognition, no exhibited behaviors, and required extensive assistance with Activities of Daily Living. The assessment showed the resident received insulin, an antidepressant, and diuretics during the assessment period. The resident was discharged on [DATE]. During an interview on 02/20/19 at 7:48 AM with a collateral contact, he stated the resident was discharged from the facility to a Motel 6 in Richland, WA because .his funding ran out at the nursing home . The contact stated the discharge took place during the snow storm that hit the area. The contact stated the resident had many comorbidities and was not sure if he was okay to be in a motel alone. A 10/26/18 history and physical showed the resident had a history of [REDACTED]. During an interview on 02/20/19 at 1:29 PM with Staff C, Social Services Director (SSD), she stated she was responsible in coordinating discharges to ensure appropriate and safe discharges. She stated the resident had planned from his admission, to return to the Tri City area (Richland, WA). She explained the facility discharged the resident to a Motel 6 in Richland and paid for a seven day stay. When asked what the plan was after the seven days, she replied, .I don't know .That's the first time I've ever done one (discharge to motel) . The SSD stated the resident had exhausted his 100 days of Medicare A coverage the day before his discharge. The SSD stated the idea to discharge the resident to a motel and pay for a seven day stay was mostly Staff Bs, Director of Nursing Services (DNS), idea. When asked if she felt the discharge was safe, the SSD stated, .I would have given different options . Review of the medical record showed a progress note dated 11/07/18 for a follow up appointment with the resident's Endocrinologist on 02/11/19 (day of discharge) at 2:20 PM. Record review showed a 02/06/19 Notice of Medicare Non-Coverage for Physical Therapy, Occupational Therapy, and Skilled Nursing Services ending 02/10/19; the resident signed on 02/06/19. Review of the comprehensive care plan, last revised on 01/02/19, showed, .I was living at home, but currently do not have a home to return to .I plan to discharge to a low-income housing unit when I have achieved my optimal level of health and functioning .Potential Referrals: home care services, home health/therapy services, medical alert systems .therapy home evaluations . The medical record showed the resident was transferred to the emergency department for further evaluation related to nausea, vomiting, and diarrhea on 12/10/18 and readmitted to the facility on [DATE]. The resident's history and physical dated 12/10/18 showed the resident required hospital intervention to rehydrate with intravenous (IV) fluids, existing acute [MEDICAL CONDITION], Type 2 diabetes mellitus (insulin-dependent), hospital intervention of IV antihypertensive medications, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Review of the medical record showed a progress note, dated 01/02/19, and documented by Staff C, SSD, about a statement the resident made in regard to harming himself during his therapy session that evening. The resident stated to the SSD that he had a history of [REDACTED]. The resident explained to the SSD he had a phone call with the State agency (regarding his Medicaid application) and was feeling frustrated and depressed and had a brief thought of harming himself at that time, with no plan. The SSD called the local mental health crisis center and spoke with a mental health practitioner to put the resident on alert status. Review of the medical record showed the resident had a planned revision to his arterial vascular fistula (for upcoming [MEDICAL TREATMENT]) to his right forearm on 01/22/19 and returned to the facility on [DATE]. The resident had yet to start [MEDICAL TREATMENT] treatment. During an interview on 02/20/19 at 3:15 PM with Staff D, Transportation (facility van driver), he stated he drove the resident to his (Endocrinologist) appointment on 02/11/19, then took him to the grocery store to get some drinks and snacks to have in the motel as the resident did not have any food or means of preparing/storing food in his motel room. Staff D then drove the resident to the Motel 6. Staff D stated the sidewalks to the motel were in bad condition due to the snow storm. The motel room was tiny and Staff D stated he had to move the resident's stuff out of the way so he could self-propel his wheelchair to and from the restroom. He stated the resident .looked a little depressed . when he dropped him off at the motel. On 02/21/19 at 11:49 AM, Staff F, Nursing Assistant (NA), stated she routinely worked with the resident while he was in the facility. In regard to the resident's discharge, the NA stated the resident talked about the fact his 100 days were up and he was getting kicked out .he was upset. Review of a Physical Therapy Discharge Summary, dated 02/14/19, showed the resident was discharged to .live alone in a private residence . The follow-up recommendations on the summary showed home health and outpatient services. During an interview on 02/20/19 at 1:51 PM with Staff B, DNS, she stated the resident had no home to go to and was discharged on [DATE]. The DNS stated she was part of the decision to coordinate the resident's discharge. She stated the resident was in stable condition on discharge, however .he wasn't making good decisions in the building . The DNS further explained the resident was non-compliant with diet, fluid restrictions, and medication. The DNS stated the discharge was resident-initiated and felt it was a safe discharge. Review of the Discharge Summary/Plan of Care, dated 02/11/19 at 1:00 PM, showed the discharge address at Motel 6 and a follow-up appointment with the resident's Primary Care Physician on 02/19/19. The Discharge summary showed the resident was alert and oriented, had depression symptoms with a history of [MEDICAL CONDITION] and no attempts of self harm, used a wheelchair for mobility, and phone numbers for a Lifeline company and a home health agency. The discharge summary did not document referrals were made to ensure the necessary care and services were in place to ensure continuity of care for the resident, including [MEDICAL TREATMENT] preparation follow-up (related to the resident's high risk of fluid overload). The summary was signed by Staff C, SSD, and Staff G, Licensed Practical Nurse. Review of the medical record showed a 10/26/18 physician order [REDACTED]. A 02/11/19 progress note documented by Staff G showed the resident went on his scheduled appointment with his Endocrinologist and was discharged to the motel after. Staff G documented the resident stated he .was not going to use his oxygen and does not believe he needs it . The note showed the resident was going to call his primary physician for home health orders and medication refills. During an interview on 02/21/19 at 2:56 PM with Staff H, Medical Director, he recalled the resident's medical condition and he had discharged to a Motel 6. The Medical Director stated he asked the facility staff what the plan was after the paid seven days at the motel, and they were unable to give him an answer. The Medical Director stated he felt the resident required assistance and needed to be in a facility where he had assistance, like an Assisted Living Facility. When the Medical Director was asked if he believed the resident's discharge was safe, he stated he did not feel the resident's discharge was safe. During an interview on 02/21/19 at 3:26 PM with the resident (currently at a hospital), when asked how his stay was at the facility, his first statement was, I used up my 100 days and they booted me out . The resident stated his goal was to return to the Richland area (Richland is approximately 42 miles from the facility), because that was where he was born and raised, but he did not expect to be discharged to a motel. He stated the head nurse (DNS) informed him of the motel stay the Friday before he was discharged . The resident stated he did not have any input on choosing the motel. He further explained the Motel 6 he was taken to had no refrigerator and no microwave. He stated he had to call people to bring him food and stated their transportation was difficult due to the snow storm. The resident stated he had a five dollar bill and some ones on him for cash. The resident explained the snow was so bad outside of the motel, he could not get out if he wanted to. The resident stated he took his medications for one day and started vomiting, so he did not take them anymore. He stated the facility sent a glucometer with supplies to check his blood sugar, but could not get it to work after the first day. .Everthing spiraled down . The resident continued to explain he began to have diarrhea and soiled himself and could not make it to the restroom, he just stayed in his wheelchair for a period of time until help came. The resident stated he called 911 at about 2:30 AM on Friday morning (less than four days after he was discharged to the Motel 6). The resident explained the hospital took about 4 L of fluid out of his lungs. When asked if he had started [MEDICAL TREATMENT] treatment yet, he stated it was going to start soon. The resident stated he did not feel it was a safe discharge, What I went through .it was horrible .I thought I was going to die . Review of the medical records from the hospital showed the resident was admitted on [DATE] (less than four days after the facility discharged him), he presented with [MEDICAL CONDITION], nausea, vomiting, diarrhea, and elevated troponin level (cardiac protein used to indicate damage to the heart), an elevated D-dimer level (an indicator of significant blood clot formation), and [MEDICAL CONDITION] (an absence of enough oxygen in the tissues to sustain bodily functions). The hospital record showed a glucose reading of 301 at 4:31 AM. The records showed the resident's oxygen saturation dropped to the 70's (physician recommended oxygen saturation was greater than 90%) while performing vital signs. The record documented, .The patient stated he is technically homeless. He had been to the rehab center, but had to leave because he had used up his '100 days.' He was then sent to Motel 6 for a week. He states he is unsure where he will go from there . During an interview on 02/20/19 at 2:34 PM with Staff A, Administrator, he stated he felt the resident's discharge to the Motel 6 was safe. He felt the discharge was resident-initiated and had nothing to do with his payment source. He explained the facility paid for seven days at the Motel 6 for the room, there was no additional payment for meals. Staff A stated he felt the seven days was enough time for the resident to coordinate with his support system in the area. When asked if there was any other follow-up by the facility, he stated the facility usually called to check on the resident (there was no documentation shown in the medical record) and he had planned to personally stop to check on the resident but had not been able to do so. The Administrator stated if the resident exhausted his 100 days, and was required to pay privately but unable to, the facilty would have to .eat the cost if we had to . Cross Reference F-622 and F-835 for more details. Reference: WAC 388-97-0080

Based on interview and record review, the facility's Administration failed to effectively use its multidisciplinary resources to maintain or sustain facility compliance with regulatory requirements related to a discharge to a motel for one of three residents (#1) reviewed for discharges. This failed practice caused the resident harm by discharging him to a motel to care for himself with active complex medical conditions, while the resident used a wheelchair for mobility, during a snow storm which disallowed the resident to leave the motel, and resulted in the resident calling 911 (less than four days after the facility discharged him) for emergency care and services related to severe nausea, vomiting, and diarrhea, and was admitted to the hospital for approximately one week. Findings included . 1. Refer to CFR 483.15 F-622 Transfer and Discharge Requirements; The facility Administration failed to ensure Resident #1 was able to remain in the facility until the necessary care and services were coordinated for continuity of care for the resident's health and well-being. 2. Refer to CFR 483.21 F-660 Discharge Planning Process; The facility Administration failed to ensure implementation of an interdisciplinary discharge planning process to ensure all care and service interventions were in place to prevent a readmission to a hospital and to the facility. The Administration failed to consider caregiver support and availability to provide the necessary care to maintain the resident's health and safety needs. The Administration failed to ensure the resident's goal and preference of a discharge to a community setting of his choice (low-income housing or an apartment), with the necessary care and services, in the Tri City area, was implemented. The Administration failed to ensure contact with local agencies, entities, including the resident's primary care physician of the discharge plan, to ensure a safe discharge with continuity of care for the resident's active complex medical conditions. During an interview on 02/20/19 at 1:29 PM, Staff C, Social Services Director (SSD), stated she was the person responsible to coordinate resident discharges and the interdisciplinary approach. She stated she partially particiated in Resident #1s discharge, but most of it was coordinated by Staff B, Director of Nursing Services (DNS). The SSD stated she had never discharged a resident to a motel before. When asked if she felt the discharge was safe, she stated, I would have given (the resident) different options. On 02/20/19 at 1:51 PM, Staff B, DNS, stated she was familiar with discharging homeless residents to a hotel where the facility would pay for a seven day stay. The DNS explained the resident was non-compliant with dietary and fluid restrictions and medications. Staff B stated she felt the resident was stable and felt the discharge was safe and resident-intiated. During an interview on 02/21/19 at 2:56 PM, Staff H, Medical Director, stated he recalled Resident #1 and his medical condition at the time of his discharge. He was aware the resident was discharged to a Motel 6 in Richland and stated he asked the Administration staff what would occur after the paid seven day stay; he stated they could not give him an answer. The Medical Director stated he felt he did not have the opportunity to agree or disagree with the discharge plan in place for residents. He stated it was usually Social Services who coordinated the discharge plan and made decisions to advocate for the residents. The Medical Director stated the resident required assistance and needed to be in a facility with assistance available, like an Assisted Living Facility. The Medical Director stated Resident #1s discharge was not safe. During an interview on 02/21/19 at 12:45 PM, Staff A, Administrator, stated he was familiar with a different state he practiced in, implementing a discharge where the facility paid for a resident to stay in a motel for a period of time. The Administrator stated Resident #1s discharge to a Motel 6 was the first one that occurred in the facility while he was the Administrator. When asked what the plan was for the resident after the seven days of the motel stay, he stated he felt that was enough time for the resident to coordinate with his support system in the area. The Administator stated he felt Resident #1s discharge was safe. Cross Reference F-622 and F-660 for further details. Reference: WAC 388-97-1620(1)

Based on interviews and record review the facility failed to ensure 1 of 3 residents (#1) was provided adequate supervision to prevent accidents. Failure to follow the resident's plan of care, which required two people to assist with transfers, and follow the facility policy relative to the use of gait belts, resulted in harm to Resident #1, who sustained a fracture during a fall. Findings included: Resident #1. Review of the resident's medical record showed she was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. In addition, the resident sustained [REDACTED]. Review of the facility policy on gait belts, last reviewed in (MONTH) (YEAR), showed staff would be required to use gait belts during transfers of residents that required assistance, unless medically contraindicated. Review of the resident's plan of care, dated 09/07/18, showed the resident was at risk for falls; and required two staff to assist her with transfers due to gait/balance problems, unaware of safety needs, and poor communication/comprehension. Review of a facility investigation report showed on 12/11/18 Staff A, Nursing Assistant, transferred the resident out of bed to the wheelchair before dinner by herself. A gait belt was not utilzed during the transfer. Staff A stated the resident was fine and had no complaints of pain. When Staff A transferred her back to bed by herself following the dinner meal, the resident complained of pain during the transfer. The resident's representative was also present in the room during the transfer to bed. Upon Staff A and the representative changing the resident into her bed clothes the area below the resident's left knee was observed to be swollen with a bump. Staff B, Licensed Practical Nurse, was notified to evaluate the resident. Following the assessment by Staff B the physician was contacted with orders received to transfer the resident to the emergency room . Review of hospital records, dated 12/11/18, showed the resident sustained [REDACTED]. Per telephone interview with Staff A on 01/02/19 at 1:15 PM, she stated at approximately 4:00 PM on 12/11/18 she transferred the resident from the bed to the wheelchair by herself without the use of a gait belt. The same procedure was used when putting the resident back to bed following the dinner meal. Staff A stated the resident complained of pain during the transfer back to bed. It was the first time she had heard the resident yell in pain, thus knew something had happened. She and the resident's representative (who was in the room at the time of the transfer to bed) observed swelling and a bump to the knee area. Staff A stated she was not aware the resident required two staff to assist with transfers as she had always witnessed other NAs transferring the resident without another person assisting. She was aware of care directives (information on level of assistance required to perform activities of daily living) in the resident's closet, however had not viewed them. Staff B stated during a telephone interview on 01/02/19 at 2:39 PM, she had observed the resident on two occasions prior to the above transfer and noted no problems. She stated the resident had smiled at her when administering medications. When she assessed the resident's left leg, following the transfer, she noted light bruising and a bump below the knee. When she and the physician observed the left knee, approximately one hour later, she was no longer able to visualize the bump due to the increased swelling. She felt the injury was acute due to the swelling. The resident's representative was interviewed by telephone on 01/02/19 at 10:58 AM. She stated when Staff A transferred the resident back to bed the resident's knees were super stiff. One knee can bend slightly and the other one not at all .very stiff knees. The representative questioned Staff A what she was doing as she usually would see two staff transfer the resident. The resident was yelling out in pain during the transfer, and then crying when the bump was observed. Reference (WAC) 388-97-1060(3)(g) This is a repeat citation from the full survey dated 03/22/18.

Based on observation, interview, and record review, the facility failed to: 1) Supervise staff to ensure they were trained and competent related to the use of mechanical lifts and slings for two of two residents (#9, 28) reviewed for injuries related to mechanical lift use; and 2) Trend and analyze data to ensure there was sufficient supervision and interventions related to the prevention of falls for four of four residents (#9, 33, 63, 3) reviewed for falls with and without injuries. These failures caused harm to Resident #9 when she was transferred from her wheelchair to the bed and fell through the sling onto the floor, resulting in serious injury and harm. Further, these failures placed all residents at a potential risk of harm related to avoidable accidents. Findings included: SUPERVISION AND TRAINING RELATED TO SAFE USE OF MECHANICAL LIFTS: 1) Resident #9. Per medical records, the resident was of advanced age and dependent on staff for transfers using a Medcare mechanical lift. She had been admitted in 2014, and had [DIAGNOSES REDACTED]. Review of Resident #9's In-Room Care Plan and comprehensive care plan (dated as reviewed on 03/12/18) revealed there were no directions related to the size of the mechanical lift sling, the placement of the sling, or which colored loops were to be connect the sling to the transfer bar. Review of the facility incident reporting log showed the resident had falls on 11/28/17 (from the bed) and 03/09/18 (from the mechanical lift). Review of the Incident Investigation for Resident #9's fall from the mechanical lift noted she fell on [DATE] at 6:45 PM in her room. She was taken to the hospital where she was diagnosed with [REDACTED]. The facility's investigation determined Staff AF and Staff AG, both NAs were responsible for transferring the resident from her wheelchair to her bed, but the sling holding the resident during the transport was improperly positioned. This caused the resident to slide through the opening in the sling and fall to the floor. Staff C's investigation documented she met with Staff AG on 03/12/18 who said she did not see if the sling was in the wrong position. She said the resident was not slipping until it happened, and it happened very quickly; all she saw was the resident's leg go up. Staff C's investigation documented that on 03/12/18 she had talked with Staff AF the second time and with a hands-on demonstration about the position of the sling. Staff AF placed his hand to the top of his head in the crown area. Staff C demonstrated, by holding the sling up to her back to the position Staff AF indicated, at that point it was evident that the sling was not in the proper position and that the resident had slipped out of the sling. Staff AF then stated he was not paying attention to the sling's position; he was thinking about another resident. During the survey on 03/16/18 at 2:00 PM, Staff AF was interviewed regarding his participation in Resident #9's fall from the mechanical lift on 03/09/18 and he stated Resident #9 was only up for meals and she would sit in her wheelchair on her sling; slings will move up. Further, Staff AF stated on 03/09/18, after dinner, Staff AG took Resident #9 back to her room to assist her to bed. While Staff AG was with Resident #9, Staff AF went with to get another resident ready for bed and that resident needed to use the bathroom. Staff AF knew the resident should not be left alone as he had fallen before. Through the paging system, Staff AF heard the call for transfer assistance with Resident #9 and he went immediately to help but was concerned for the resident he left on the toilet. Staff AF said he saw that Staff AG had put on the resident's nightgown, leaving on her pants. The mechanical lift's sling had been hooked to the lift, but he was not sure which loops Staff AG had used. He had noticed the top edge of the sling was near the top of the resident's head, but it should be about in the area of the resident's shoulder blades. As the transfer continued away from the wheelchair, he heard Staff AG yell and saw the resident slip. He had not observed the resident was in danger of slipping through the opening in the bottom of the sling until then. The resident slid out onto the floor while Staff AF tried to guide her upper body down. He described the resident was in pain. The licensed nurse was called and the resident taken to the hospital. Staff AF was questioned about the facility ensuring that he was trained on how to use the mechanical lift and if he had demonstrated his competency with the lift. Staff AG stated it had not been since the mechanical lift was new, maybe four to five years ago or longer, that someone instructed him on the use of the machine. He knew the size of the sling per the individual resident mattered and which of the three loops needed attached to the bar, but he was the one responsible to decide which loop was to be used. He stated nursing assistants were to train a new hire when they were put with them on their section. Staff AF further stated he had seen the potential for residents falling from the lift and, when he had seen that about to happen, he corrected it immediately by lowering the resident back in the chair to adjust the sling. He stated every caregiver had their own technique. When asked about his ability and training to assess which sling and loop connection was appropriate for each specific resident, he stated a nursing assistant can't assess. He acknowledged that was the responsibility of a licensed professional. He stated the Resident Care Manager (a Licensed Nurse) would tell the nursing assistant when a resident required a mechanical lift, but, from there, the nursing assistant would first look at the resident and decide which size sling and which loop. The nursing assistant would be told if there were special conditions of the resident like broken bones or whatever. During the survey, an interview was held with Staff AG at 3:30 PM on 03/16/18. She said she had taken the NA course in high school as a junior. She said she thought they taught there were three NAs to assist with mechanical lift transfers. She was now working weekends at the facility and did not consistently work on any wing. Staff AG said on the evening of 03/09/18, she was working with Staff AF on the 200 wing. She had gotten Resident #9 ready to be transferred to bed out of the wheelchair by getting her night clothes on her upper body, and the sling that the resident was sitting on during dinner, hooked to the mechanical lift. She said the resident's bottom was on the sling's fabric while she sat in the wheelchair. She described attaching the white loops to the front hooks on the lift and blue loops to the back hooks of the lift bar. She did not lift the resident but called for Staff AF's assistance; she thought he was still in the dining room cleaning. She did not remember how far up on the resident's back the sling was positioned. When Staff AF came, she used the battery powered controls to lift the resident in the sling and described moving her across the floor towards the bed. Then she saw the resident's leg suddenly go up and she quickly fell through the hole in the sling to the floor. She described herself as being stunned and not knowing what to do, but Staff AF gave her quick instructions. The nurse arrived and the resident was taken by the ambulance. Regarding her decisions to use what size of sling and which loops to hook the sling to the lift, she stated she did whatever the other NAs told her, Not every resident was the same and she was not confident, so I ask other NAs. She did not want to evaluate or make a judgment call herself on the slings used on the lifts. Other than a NA showing her how, she had not been trained by a professional. On 03/14/18 at 3:00 PM, the resident's family member was interviewed. She stated the resident had been diagnosed at the hospital as terminal. She said the resident had six broken ribs, a broken hip, and multiple broken vertebra. She stated this was the resident's fourth fall while she was residing in the facility and some had been bad. While at the hospital, the resident was crying and she would wake up calling out Don't let me fall. The family member said she thought the resident had post traumatic stress from the accident. When she discussed the accident, she stated she was surprised Staff AF was involved because he was extremely picky and conscientious and was great with his residents. Additionally, although Staff C, the Regional Nurse Consultant, presented a training to all NAs on 3/10/18 after the incident with Resident #9, to prevent similar accidents from occuring, the training lacked information related to which specific loops to use on the sling, or what size of sling was the safest to use for each resident. Resident #28. Per his medical record, admitted on [DATE]. His [DIAGNOSES REDACTED]. The resident's most recent comprehensive assessment, dated 01/07/18, showed the resident needed extensive assistance for transfers with one to two staff, had bowel and bladder incontinence, and was rarely or never understood or able to understand others. His comprehensive care plan, last updated 01/17/18, showed the resident had impaired mobility, wore a brief for bowel and bladder incontinence, and was unable to call for help; staff needed to anticipate his needs related to his poor cognition. A progress note dated 02/21/18 showed staff could no longer safely use a Sit-To-Stand lift for transfers due to the resident's weakness. Staff contacted Hospice staff who ordered a change in the resident's transfer to a mechanical lift requiring total assistance with two staff. The mechanical lift transfer required staff to place a fabric sling beneath the resident so the mechanical lift could be attached to the loops on the sling for safe transfer. A progress note by a Hospice NA dated 02/26/18 noted the resident has a purple area to his scrotum . The note included that the Hospice RN assessed the area and ordered an ointment to be applied. On 03/15/18 at approximately 1:30 PM, Staff I, NA, waited for help to transfer the resident into bed using the mechanical lift. A fabric sling was visible in the wheelchair, under the resident. The NA explained how the two leg straps on the sling were criss-crossed between the resident's legs before the sling was attached to the hooks on the mechanical lift (see Medcare Products operation manual for mechanical lifts, page 14). On 03/22/18 at 10:45 AM, the resident's Hospice RN reported the resident's reddened scrotum and purple area to the scrotum started when the (mechanical lift) began to be used. She stated, from her investigation of the purple area, it looked like the sling pinched the resident's scrotum with the crossing of the sling straps between his legs. She said the resident's scrotum would fall down between his legs naturally and lent to being pinched by the straps on the mechanical lift. The Hospice RN said she contacted her supervisor and worked with Staff Z, LPN, about the issue. The Hospice RN said, together, they decided to try a pillow case between the resident's legs to cradle the scrotum inside of the incontinence brief. The Hospice RN said when the situation was reviewed, she could see that the area where the scrotum was pinched was the same area where the (mechanical lift) sling crossed. It lined right up. On 03/22/18 at 12:49 PM, when asked to review the facility's investigation into the purple mark on the resident's scrotum, the Director of Nursing Services (DNS) said she was not aware of the incident. She stated there was no investigation completed by the facility. TRENDING AND ANALYSIS OF FALL DATA: Per the guidance, 483.25(d), facility leadership should include the evaluation and analysis of data pertaining to accidents such as trends related to time of day or location. Resident #33. Per record review, the resident's 01/21/18 annual assessment revealed the resident had memory problems, moderate cognitive impairment, required extensive assistance from staff to transfer, and had three falls in the past quarter (one with injury). The summary indicated the resident was attempting to self-transfer and missed her bed landing on her wheelchair; this is the third fall (and) has been referred to PT (physical therapy). The care plan last reviewed on 02/02/18 revealed the resident was at risk for falls related to her muscle weakness. The plan interventions noted she was a one-person extensive assist to transfer, uses call light, keep call light within reach, remind me (resident) not to get up without assistance from staff and PT referral as indicated. Review of the directives to nursing assistants in-room care plan dated 01/30/18 revealed Resident #33's fall risk interventions included a low bed, lock wheels, bed against wall, personal things in reach, remind not to transfer without assist, wear non-skid footwear, keep call light in reach, needs extensive assistance with transfers using gait belt. On 03/16/18 at 10:00 AM, the resident's bathroom door was ajar. She was observed on the toilet and no call lights were on. Two nursing assistant staff were in another room with a mechanical lift and unavailable. Upon returning to the resident's bathroom, she was now in her wheelchair and wheeling out of the bathroom. Later at 10:15 AM, Staff N, NA, stated Resident #33 will toilet herself independently, she forgets to ask for help. Sometimes she will use call light if she needs a brief change or if she feels weak. On 03/19/18 at 10:20 AM, the resident was on her bed with her wheelchair next to the bed and the bathroom door ajar. Staff K, NA stated he did not assist her to bed; she usually toilets herself and will lay down and get up on her own. She is good at calling for help when she feels weak, but added, She has seemed a little more confused this past couple months. He was aware the resident had a recent urinary tract infection stating, She usually wipes herself; if I can catch her in there, I will offer to assist. On 03/20/18 at 03:30 PM, the resident was at the nurses' station and asked to go to the bathroom. Staff N, NA, assisted Resident #33 to the restroom and stated, We need to keep a really good eye on her; she had another fall today and they put an alarm on her bed. I have this pressure alarm to put on her wheelchair seat. I am supposed to tell the nurse if the alarm is bothering her. Later that day at 6:40 PM, the resident's wheelchair alarmed from her room. Staff N responded to find the resident already on the toilet. When the resident was finished, she assisted the resident to her wheelchair. Review of the facilities incident-reporting log revealed Resident #33 had eight falls between (MONTH) 18, (YEAR) and (MONTH) 20, (YEAR). All of the falls were related to failed self-transfer attempts between bed, wheelchair and toilet. Two of the falls resulted in bruises on her hands and arms. Review of the resident's medical record did not evidence any interdisciplinary team meetings on the resident's frequency of falls to ensure all possible interventions were discussed in relation to the risk and benefits to prevent the resident from continued falls and possible major injuries. Resident #63. Record review revealed the resident was admitted for rehabilitation on 01/17/18 with [DIAGNOSES REDACTED]. Since admission, the resident had returned to the hospital several times for [MEDICAL CONDITION]. The latest assessment dated [DATE] indicated the resident required extensive assistance from one staff to transfer between bed and wheelchair. Review of the care plan last revised on 03/16/18 revealed the resident was at risk for falls due to dementia, [MEDICAL CONDITION], and acute [MEDICAL CONDITION]. Review of the facilities incident-reporting log revealed the resident had six falls between 02/15/18 and 02/27/18. All of the falls were a result of failed self-transfer attempts. On 03/21/18 at 3:00 PM, during review of the resident's frequent falls, Staff AH, RN/RCM stated, There is no fall committee here or a formal process to analyze fall trends. We would talk about falls at stand up in the morning, but I have not documented it in the resident's record. On 03/22/18 at 12:15 PM, the DNS stated the facility did not have a fall committee to analyze fall frequencies or trends. Resident #3. admitted , per her record, on 08/23/17 with [DIAGNOSES REDACTED]. The resident's comprehensive assessment dated [DATE] included she was rarely or never understood or able to understand others. She required extensive help from one staff for transfering and weight-bearing support, and used a wheelchair. Her comprehensive care plan updated 02/25/18 noted the resident was assessed to be a fall risk and included the resident became restlessness in the afternoons. Review of progress notes showed the resident fell ten times between 11/30/17 and 01/20/18. The investigations showed the falls were all due to the resident's failed self-transferring attempts. An investigation dated 02/18/18 showed the resident sustained [REDACTED]. Observation on 03/13/18 at approximately noon showed the resident's left foot/ankle encased in a boot. Staff J, NA, when asked if the resident continued to try to get herself out of bed, replied, Since she broke her foot/ankle and has this boot on, she hasn't tried to get up by herself. On 03/21/18, the resident's medical record showed no evidence of analysis of her frequent falls and her documented attempts to self-transfer. On 03/22/18 at approximately 3:00 PM, the Administrator and DNS reported there was no interdisciplinary team in place to review and analyze residents with frequent and/or persistent falls. The DNS stated this resident's falls had not been analyzed/evaluated to ensure all possible interventions were discussed in relation to the risk and benefits to prevent the resident from continued falls and possible major injuries. Reference: WAC 388-97-1060(3)(g)

Based on interviews, and record review, the facility failed to ensure staff provided pain medication in a timely manner to 1 of 3 residents (#1) receiving as needed narcotic pain medication. This failed practice resulted in harm to Resident #1, who experienced increased pain and emotional distress, due to a delay in receiving pain medication. Despite licensed nursing staff being aware of the resident's request for pain medication, the decision was made by staff to receive shift report and count narcotics, which resulted in the resident receiving pain medication over 60 minutes later. Findings included: Resident #1. Review of Progress Notes (PNs) in the resident's medical record, dated 12/22/17, revealed the resident was admitted to the facility from the hospital that day with third [MEDICAL CONDITION](full thickness) to his abdomen, second [MEDICAL CONDITION](partial thickness) to the right thigh, and third and second [MEDICAL CONDITION] both hands. The resident was alert and oriented, and could make his needs known. Review of physician's orders [REDACTED]. In addition, Tylenol was ordered to be administered routinely every four hours. Progress Notes, dated 12/23/17, documented by Staff A, Licensed Practical Nurse, revealed she was notified the resident wanted pain medication (time unknown). After shift report and narcotic count Staff A went to assess the resident's pain status. Staff B, Nursing Assistant, had reported to Staff A that if the resident did not get his pain medication he was going to get dressed and walk out of the facility. [MEDICATION NAME] and Tylenol were administered at 3:30 PM on 12/23/17. At approximately 3:45 PM the resident was seen walking down the hallway with a visitor. By 4:00 PM the resident had left the facility with all of his belongings, and did not return to the facility. Review of a written statement by Staff B, dated 12/23/17, revealed at 2:15 PM on 12/23/17 the resident stated he was waiting for a pain pill, as he had previously informed another staff member. At approximately 2:20 PM Staff B answered the resident's call light. He stated he still had not received his pain pill, and if he did not get it he was going to walk out of the facility. Staff B then reported the above information to the nurse. An interview with Staff B on 01/03/18 at 12:23 PM revealed she had gone into the resident's room at approximately 2:15 PM to obtain his vital signs. When she asked the resident how he was doing he stated he was waiting for pain medication as he had already informed another staff member of his need for medication. Staff B informed Staff A of the resident's request for pain medication. Later Staff B answered the resident's call light and he stated that if he did not receive his pain medication he was going to leave the facility. The resident was upset regarding the delay and was serious about his statement of leaving. Staff B again reported the information to Staff A. During an interview with Staff A on 01/03/18 at 1:45 PM she stated shift report started at approximately 2:15 PM on 12/23/17, as the dayshift Licensed Nurse was behind that day. Staff A stated shift report and the narcotic count usually take slightly less than one hour. Just prior to shift report Staff C, Occupational Therapist (OT), had inquired as to when the last time pain medication was given to the resident. Staff A stated she would have to look but she was about ready to start shift report. Following shift report she administered Tylenol to another resident before going to the resident's room. Staff A stated to the resident, I hear you're having pain. The resident, who seemed upset, stated, I'm having a lot of pain. Upon the surveyor showing Staff A her documentation in the resident's PNs on 12/23/17, relative to Staff B informing her of the resident's request for pain medication prior to shift report, Staff A verified her documentation was correct. Staff C stated on 01/03/18 she had talked with a Licensed Nurse on 12/23/17, following her visit with the resident at 2:00 PM, regarding the resident's request for pain medication. When she returned to the resident's room at approximately 2:30 PM the resident stated a nurse had not yet administered pain medication. Staff C stated she could imagine he would have a lot of pain due to his burns. Review of the above OT's assessment, dated 12/23/17, noted the resident's pain was constant at each burn site. The pain was described as burning and throbbing at times, and the level was five on a scale of zero to ten (zero denoting no pain and ten being severe pain). During a telephone interview with the resident on 01/05/18 at 1:30 PM, he stated his pain level at the time he requested pain medication was severe. He stated it was a burning type pain and it was horrible. He stated he kept asking and waiting, asking and waiting. The Tylenol he received was ineffective for the pain he was having. He stated one of the two reasons he walked out of the facility, against medical advice, was due to not getting his pain medication. Review of the resident's Medication Administration Record [REDACTED]. The next documented dose was given at 3:27 PM (slightly over five hours) for a pain level of 10. Reference (WAC) 388-97-1060(1)

Based on record review and interviews, the facility failed to ensure assistive devices were in place, in order to prevent an accident, for 1 of 3 residents (#1) reviewed for accidents. This deficient practice resulted in actual harm to the resident, as she sustained a fractured ankle, when footrests were not in place during transport. Findings include: Resident #1: admitted to the facility on [DATE], following surgery for [REDACTED]. Review of the resident's medical record and facility investigation report revealed on 12/04/15, following the noon meal, the resident was being transported in her wheelchair by Staff A (Nursing Assistant), from the dining room to the hallway of her room, when her right foot got caught under the wheelchair. The resident screamed ouch and stated she was hurt. She was returned to her room, where a nursing assessment revealed a swollen right ankle. X-rays were obtained, which indicated the resident had sustained a fractured right ankle. She was taken to the emergency room at 6:25 p.m., where a splint was applied to the fractured area. Further review of the investigation revealed the resident had been taken to the dining room for the noon meal by Staff B (Nursing Assistant), without footrests on the wheelchair. The resident was unable to self-propel her wheelchair, so footrests had been utilized by staff since her admission to the facility. Staff A then transported her back to her room following the meal, without the footrests (as they had been left in her room by Staff B). During an interview on 12/09/15 at 2:58 p.m. with Staff A, she stated she had cared for the resident prior to 12/04/15, and was aware she always had footrests on her wheelchair. On 12/04/15, she took the resident back to her room from the dining room in her wheelchair, which she stated was a long way. She stated it was not until about halfway to the resident's room she realized the footrests were not on the wheelchair. However, she continued to transport the resident without them. As she turned the last corner to the hallway of the resident's room, she slowed down her pace, at which time the resident's right foot went under the wheelchair. The resident yelled ouch at that time. A telephone interview on 12/10/15 at 11:05 a.m. with Staff C (Director of Nursing) noted the distance between the dining room and the above incident was approximately 147 feet. On 12/09/15 at 5:12 p.m., the resident's family member stated the resident always had footrests on when up in her wheelchair, as her feet would drag on the floor without them. An interview on 12/09/15 with Staff D (Occupational Therapist) revealed the resident was unable to ambulate or stand in therapy. They discontinued her from therapy services, as she was not making any progress. She stated the resident would not be transported safely without the use of the footrests, as she was unable to lift her legs up. Despite the resident's recent hip fracture, inability to self propel, poor participation in therapy due to weakness, impaired cognition, and consistent use of wheelchair footrests, staff failed to implement an intervention to prevent an accident with injury.

Based on record review and interviews the facility failed to ensure adequate supervision and protective devices were provided to prevent accidents for 1 of 2 residents (#1) reviewed for falls. This deficient resulted in actual harm to Resident #1, who fell from her wheelchair in the facility van and sustained a fractured nose. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed she was at high risk for falls due to her poor balance, unsteady gait, and neurological disorder. She required extensive assistance with activities of daily living. Review of the resident's medical record and facility investigation report revealed on 10/23/14 at 1:10 p.m., the resident was being transported in her wheelchair to a physician's appointment in the facility van. The resident's wheelchair was secured with tie-downs prior to transport, however there was no protective device (waist and shoulder straps) utilized to keep her secure in the wheelchair. During a turn to the left the van hit a "pothole" in the road. The van "jarred" causing the resident to fall forward out of her wheelchair onto the floor of the van. X-rays obtained on 10/24/14 noted the resident had fractured her nose due to the fall. During an interview on 11/5/14 at 10:30 a.m. with Staff A (van driver) he stated the large facility van did not have shoulder or waist straps to use for residents in wheelchairs. He stated he had never been trained to utilize them for residents in wheelchairs during transports in that van. Despite the need for residents in wheelchairs to be protected from injury during transport in a motorized vehicle staff failed to recognize the need for protective devices to prevent accidents.

Based on observation, interview and record review, the facility failed to have systems in place to address the management of pain experienced by 3 of 6 residents (#'s 24, 133 and 136) related to physical impairments, as a result of surgeries; ineffectual equipment; and/or behavioral contributors. The facility also failed to ensure systems were in place to assist 1 of 1 resident (#9) needing timely medical intervention and 1 of 1 resident (#129) requiring monitoring related to use of blood thinning blood pressure medications. The lack of effective systems in these areas resulted in harm to resident #'s 9, 24, 133 and 129 by unnecessary suffering, and/or delayed progress in healing. Findings include: 1. Resident #24. admitted on [DATE] with [DIAGNOSES REDACTED]. His latest comprehensive assessment dated [DATE] revealed he had long and short term memory problems and had moderately impaired decision making skills. He required extensive assistance with toileting and personal hygiene. On [DATE] at approximately 10:15 a.m., Staff Member C, a Licensed Nurse (LN) and Resident Care Manager (RCM) stated Resident #24 had bladder surgery to remove tumors and make repairs from a previous surgery. A urinary catheter was placed after the procedure. She stated she was not certain about the exact date of the catheter placement, but noted a nursing assessment done on [DATE] documented the presence of a catheter. On [DATE] at approximately 9:30 a.m., Staff Member P, a Nurse Aide (NA) worked with Resident #24 to provide cleaning around his catheter. Staff Member P stated she had been with the facility for about one month and the resident had the catheter since she started. As she assisted the resident to gently turn onto his right side, he moaned. The NA stated he always moaned when she moved him because he had an open area on his buttocks that hurt and because he "hurt inside." She stated at first she thought she was hurting him, but was told by other staff it was not her handling technique, but because he was very tender "inside" in his lower abdominal area. She then moved the catheter tubing to clean around the insertion site of the catheter. He moaned again when the catheter tubing was moved. She re-positioned him gently once again to complete the cleaning and care. As she re-positioned him, he cried out, then made a fist with his hand and struck the bed mattress several times rapidly as he continued to cry out. At the conclusion of the care, the resident's face and body posture visibly relaxed. On [DATE] at approximately 10:30 a.m., Staff Member RR, a LN, stated the resident did not verbally report pain to her when he was not moving, but she observed he had pain with any movement. She stated the resident was incontinent of bowel, so he had to be moved often when cleaning him. She said they did not medicate him for pain prior to moving him. Review of the August and [DATE] Treatment Administration Record (TAR) revealed the resident received other treatments which also required moving him. The licensed nurses applied a barrier cream to the resident's buttocks every shift to protect the skin, and applied two additional topical treatments to the resident's groin area twice a day. The open sore on the resident's buttocks was also cleansed and dressed every other day. Review of the Medication Administration Record [REDACTED]. For the month of August, the resident received one dose of Tylenol on [DATE] for a complaint of pain to his buttocks. Review of the MAR indicated [REDACTED]. The resident received one dose of Tylenol on [DATE] for a complaint of pain to his buttocks. On [DATE] at 10:35 a.m., Staff Member C stated she completed the pain assessment dated [DATE], and it was the latest pain assessment done for Resident #24. She explained it was compiled through review of the resident's medical record and talking with staff who worked with the resident. The assessment documented no verbal reports of pain and no nonverbal indicators of pain. She stated staff had not told her about Resident #24's pain during care. She stated they should try "to make sure the resident has something on board." (meaning pain medication should be given). Over the approximately 6 week period since the bladder surgery and placement of the urinary catheter, the facility nursing staff knew about Resident #24's pain, but failed to act to mitigate or minimize the pain. They failed to assess what conditions caused him pain and why he was still significantly painful six weeks after surgery. This caused unneeded pain and suffering for the resident. 2. Resident #9. admitted with dementia, high blood pressure and history of small [MEDICAL CONDITION]. The quarterly [DATE] comprehensive assessment determined the resident had impaired short and long term memory and required extensive assistance by one person for transfers and toileting. The current care plan contained an update on [DATE] identifying the resident was at risk for falls; she did not remember to ask for help when needing to transfer. The official form directing physicians for 'life-sustaining treatment' (POLST) revealed the resident did not want cardiopulmonary resuscitation (CPR) attempted, but she did want interventions that included medical treatment, intravenous fluids, and cardiac monitoring as indicated. (The resident was not receiving comfort measures only or hospice care.) The form was signed by the legal surrogate/representative on [DATE]. However, hand written on the side of the form was a note to call family prior to any transport. An incident investigation form revealed the resident had a fall on [DATE] at 3:40 a.m. She was located on the floor partially under the walker and bleeding from the right side of her head. Three lacerations were noted by the licensed nurse and the physician was notified. He requested family to make the decision to have an emergency room assessment; the resident's representative declined medical treatment. A thorough assessment of the head wound was not documented. On [DATE] at approximately 11:30 a.m., Staff Member QQ, a licensed nurse, in the process of administering medications, obtained a report from a nursing assistant that while she assisted the resident to the bathroom, the resident was dizzy and nauseated (symptoms of a potential serious head injury). Staff Member QQ went to the resident's room where she was lying on the bed with gauze wrapped around her head. Most of the gauze and part of the pillow were red with blood. The resident reported to the nurse she had nausea and dizziness. Staff Member QQ told the resident she would rewrap the dressing on her head. Staff Member QQ then stated the resident had fallen around 4:00 a.m. hitting her head and causing a laceration. The nurse stated the resident was not sent to the hospital for an assessment because the resident's family did not want her to be sent. Nurses were treating the injury with a dressing to stop the bleeding and monitoring her neurological signs. The nurse left to obtain dressing supplies. The resident was moaning and said she did not feel well. Immediately after the observation, the Director of Nursing (DNS) was interviewed. She stated the resident was not receiving 'comfort measures only' nor was she on hospice care. She stated that after the early morning fall, the family member had not wanted the resident to be sent to the hospital for medical treatment. The physician was aware, but deferred to the family's wishes regarding medical attention. When asked about the resident's right to medical care and when informed of the bleeding, the DNS went to the resident's room. She reported back at approximately 12:30 p.m. that a family member had been called to take the resident to the hospital emergency room . At approximately 3:00 p.m., the resident was observed in her room with a clean dressing around her head. Staff Member QQ said the resident's laceration had needed staples to stop the bleeding. The [DATE] hospital emergency department documented report revealed the resident was treated for [REDACTED]. Although the resident's power-of-attorney identified the resident's preference for medical treatment on the POLST form to the physicians, the facility failed to advocate for the resident and seek medical attention following a head injury. The head injury was the result of a fall onto a hard surface, which resulted in a laceration and continued bleeding for approximately eight hours, and further treatment was not initiated until intervention by a surveyor. 3. Resident #129. admitted on [DATE] with [DIAGNOSES REDACTED]. Per the comprehensive assessment dated [DATE], Resident #129 had highly impaired hearing and was described as severely cognitively impaired. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A range of 2.0 - 3.0 is considered to be in the therapeutic range, higher than that level means the blood is too thin). The resident was also on two medications to treat his hypertension. Review of the short term care planning document (MACC) revealed a flow sheet to monitor the resident's INR, and the dosage changes made to [MEDICATION NAME]. It did not include any monitoring of potential adverse effects of [MEDICATION NAME], such as bleeding. Review of the care plan revealed no documentation related to the resident being on [MEDICATION NAME] and no documentation related to monitoring or treatment of [REDACTED]. Review of the MAR indicated [REDACTED]. A progress note dated [DATE] indicated the physician was notified of the 6.7 reading and his instructions were to hold the [MEDICATION NAME], check the INR daily and "monitor vital signs closely." The following day, on [DATE], the INR was 5.9. No physician notification of the 5.9 INR was documented in the progress notes. Review of a flow sheet that contained vital signs, between [DATE] and [DATE], documented the resident had blood pressure readings that were significantly low for him: ,[DATE] on [DATE] at 9:30 a.m., ,[DATE] on [DATE] at 11:15 a.m., ,[DATE] on [DATE] at 12:15 p.m. and ,[DATE] on [DATE] in the p.m. In comparison, the resident's blood pressure at admission and soon after, was ,[DATE] on [DATE], ,[DATE] on [DATE] and ,[DATE] on [DATE]. There was no documented evidence that the physician was notified about the low blood pressure readings. Review of the progress notes and the MAR indicated [REDACTED]. On [DATE], a progress note timed at 10:26 p.m. described the resident as "lethargic today" and described several episodes of diarrhea that were dark colored. The LN noted his blood pressure was ,[DATE] and a INR drawn [DATE] was 5.8. The LN documented she contacted the physician and the resident was transported to a local hospital. Per a progress note on [DATE], the resident was in the ICU of the hospital with a "low H&H (hematocrit and hemoglobin; if low, it is an indication of [MEDICAL CONDITION] and/or blood loss) and INR still high." Per the comprehensive assessment, the resident was readmitted from the hospital to the facility on [DATE]. On [DATE] at 3:15 p.m., Staff Member B, the Director of Nursing Service (DNS) stated residents who are on [MEDICATION NAME] should be monitored for signs of excessive bleeding, such as dark stools. The facility failed to act on low blood pressure readings, despite the resident [DIAGNOSES REDACTED]. This resulted in harm for the resident, who was hospitalized for [REDACTED]. 4. Resident #133. admitted on [DATE] following a surgery for [REDACTED]. Other [DIAGNOSES REDACTED]. Medications included a routine and an "as needed" (prn) narcotic for pain. On [DATE] at approximately 9:30 a.m., the resident was seated in her wheelchair in her room. Her legs were both dangling; footrests were not in place. She stated that her right hip "hurts a lot" but the nurses did not check on her pain unless she called for a pain medication, "they rely on me to call." She further stated that by the time she called, she was usually in "a lot of pain." The resident stated, "I get out of bed and sit in a wheel chair that feels too high" pointing to her dangling legs and feet. She stated staff were "supposed to be looking for a new (wheelchair) but have not gotten it yet." The resident stated the wheelchair was given to her because it was wide and would not rub on her incision, but "it's so high." The resident said she would call the nursing assistants after her legs started hurting and ask for the footrests. She pointed to one lying on the floor next to the wall and said when her feet and legs dangle "like this, it causes pain." In addition, the resident said when she sat, even with the footrests in place, the edge of the pressure relief cushion reached partway down her thigh, but not to the end of the wheelchair seat. She stated it "cuts under" her right thigh, "it's too short," and that amount of pressure caused thigh pain. She continually rubbed her right thigh during the interview. When describing how she got out of the chair for the transfer to bed, the height of the chair caused a problem with reaching the floor. Scooting herself forward caused pain in her right hip but she had to scoot to touch the floor. She could only weight bear on her left leg during the transfers. On [DATE] at approximately 9:45 a.m., one of the resident's family members arrived. She stated staff had been told the wheelchair caused the resident pain and was uncomfortable, but nothing had been done for over a week or so. The family member said they were told extra wheelchairs were stored and they would go check, but "they never returned." Yesterday, the therapist had reportedly noticed her feet "do dangle" but nothing was done. The family member said the nursing assistants did not always put on the footrests. As the interview with the resident and her family continued, the resident had facial grimacing, tried multiple times to shift position, and she stated her hip was "hurting" and her right thigh was "always hurting." The daughter told her it was probably because of how the metal from the surgery procedure went down into her thigh bone. At approximately 10:00 a.m., the resident had poor body alignment in the chair; her hips were not flat on the cushion and she was leaning slightly to the left side (due to her multiple attempts to readjust herself). She said she had to get "straightened out." She put her left foot down between the foot rests, and, with her toe only touching the floor, she attempted to use it as leverage for repositioning herself with her arms. She was unsuccessful in her attempts. The resident continued to grimace, and complained of worsening pain the longer she sat. On [DATE] at approximately 10:05 a.m., Staff Member QQ, a licensed nurse (LN), reviewed the resident medication administration record. She stated the resident received an [MEDICATION NAME] at 7:00 a.m. but she had a prn narcotic pain medication she could take every four hours. The resident had "none today," but Staff Member QQ stated she would take her some. On [DATE] at 10:15 a.m., the resident continued to exhibit non-verbal signs of pain while seated in her wheelchair. She stated she really needed to "have therapy over with" (she had been sitting up waiting for the therapist) as she was in so much pain she needed to lay down. Her spouse, who had arrived, stated her pain needed to be kept "on top of" so it was in better control than he had been noticing. On [DATE] at approximately 11:30 a.m., the resident was returning to her room from physical therapy with Staff Member NN, a part-time Physical Therapist (PT). He stated it was the first time he had worked with the resident. The resident's feet were touching the floor rather than dangling; the wheelchair was lower to the floor. The therapist stated he had just lowered the wheelchair as it was "too high" and she was unable to reach the floor with her feet. He acknowledged that feet/legs dangling caused pain. He confirmed that the lowering of the wheelchair would also help with ease of transfers and decrease pain. On [DATE] at 10:30 a.m., the resident stated that with the wheelchair lowered her pain was lessened. She had an easier time with the transfers as she could put her feet on the floor without scooting forward. On [DATE] at 10:45 a.m., Staff Member P, a nursing assistant, stated that she was not aware of the placement of the foot rests. She did remember that before the wheelchair was lowered, the resident had to scoot forward to try and stand for the transfer. She stated it was "much easier" on the resident when she could reach the floor and then be assisted to stand up. On [DATE] at 3:30 p.m., Staff Member E, the Resident Care Manager, stated she was supposed to be the person "putting it all together," but until the discussion with "(the surveyor) right now, I was not aware of the resident's wheelchair being too high," or the need for footrests to reduce pain. The resident's family member provided documentation related to an [DATE] observation she had made and written down. The note stated the resident had been complaining about severe knee pain which was warm to the touch and very sensitive to touching; which the physician assessed and reported "it should go away." The family member's note on [DATE] revealed the family member arrived at 9:00 a.m. to find the resident being taken to therapy. After she "picked up her room a bit" she went to the therapy room. "She was in therapy in severe pain and crying, nose dripping from crying. (The physical therapist) was still working with her, and she was telling him stop it hurts. When I walked in he stopped and told me "The staff had just given her pain meds about 15 minutes before and it had not taken effect yet." They put her back in bed. Her pain was pretty high. She had occupational therapy just before that, and did not have pain killers then either. So it was two at once in the morning. Too much without the meds. When I asked nurse about it, I was told that it's protocol for therapy to let the nurse know when they will be coming ahead of time so the nurse can give pain meds and prepare patient. That didn't happen either way. Someone dropped the ball..." The 7:00 a.m. progress notes dated [DATE] revealed the resident was given her routine morning pain medication with a 8 of 10 pain scale (on a scale of ,[DATE]) documented, but no further pain assessment completed. The 2:00 p.m. entry revealed the resident had received one tablet of [MEDICATION NAME] (,[DATE] tablets every four hours as needed for pain) at 10:00 a.m. for hip pain. The progress note and the Medication Administration Record [REDACTED]"complained of pain." There was no documentation related to the effects of therapy on the resident's pain level. Progress notes and the Medication Administration Record [REDACTED]. Despite the fact these were identified in the care plan, staff were not following the intervention to ensure the goal of pain relief was met. In addition, the resident usually needed to inform the licensed nurse when she was in pain to obtain the prn (as needed) pain medication; the licensed nurse did not routinely assess the resident to intervene, or to anticipate the resident's need for pain management. Therefore, the resident's pain was not being adequately managed. Further, the resident's dangling feet caused her pain for over two weeks, as staff did not lower the wheelchair, or place the footrests, when the resident sitting up in the chair. 5. Resident #136. admitted to the facility on [DATE] with an extensive surgery of the spine. There was removal of 1 and a half ribs from the left lateral side during surgery. There were 3 incisions from the surgery located on the left side of mid-and lower lateral side of the rib cage. Other [DIAGNOSES REDACTED]. The social service care plan dated [DATE] identified the residents's mood state as a potential for depression related to chronic pain, and inability to be as independent as she once was. The resident was a short stay placement and would return to her home. The comprehensive assessment dated [DATE] documented the resident was alert and oriented, and needed assistance of one person to transfer out of bed. A back brace was to be worn when the resident was assisted out of bed to the wheel chair or while using a walker. The resident had specific procedures from occupational therapy (OT) and physical therapy (PT) to ensure the back brace was correctly placed so it would not increase her pain. According to the [DATE] and [DATE], medication administration records, (MAR) the resident was to have a routine short acting narcotic medication for pain, and a routine long acting narcotic medication for pain. Additionally, there were 2 other narcotic medications that were used as needed for break through pain and a medication for muscle spasms. There were no documented non-pharmacological interventions for pain relief on the MAR indicated [REDACTED] During her stay at the facility, the resident experienced incidents which had the potential to increase her anxiety. She fell on [DATE] when she attempted to use the bathroom after she felt she waited too long for help; on [DATE], she had a disagreement with a LN about her prescribed treatment. OT notes on [DATE] documented that the "resident's functional/cognitive testing indicated that the resident was painful with anxiety. This had limited her progress and pain limits her activities." On the [DATE] progress note the OT documented she had instructed the resident to deep breathe and calm down secondary to increased anxiety. The resident was uncooperative and stated, "she is calling her husband to leave the facility." On [DATE] at 10:00 a.m., Staff Member V, occupational therapy assistant, (OTA) stated that the resident's cognitive assessment showed a decline. The resident was always prepared to work but the pain medications she was receiving decreased her ability to retain and continue her program as she was taught. "Every other day she is getting worse emotionally. The resident's pain level is usually 8 out of 10." On [DATE] at approximately 1:25 p.m., Staff Member B, the DNS, was informed by Staff Member D, an RCM, that the resident was experiencing increased pain levels of 8 out of 10 and 10 out of 10. During the discussion, they acknowledged the resident had increased anxiety as well. On [DATE] at approximately 11:55 a.m., the resident stated she did not participate in therapy related to pain in her upper left side. On [DATE] at approximately 8:50 a.m., the resident stated she had been here since [DATE] and the nursing staff had not really helped her get better. "My therapy is slow and I might as well go home." On [DATE] at approximately 10:00 a.m., Staff Member W, the OT stated the resident was "scared and feels that there are no choices for her. She is upset because she is not progressing." The facility did not thoroughtly evaluate or address the impact the resident's anxiety was having on therapy, pain levels and quality of life in the facility.

Based on observation, interview and record review, the facility failed to ensure anti-psychotic drugs were not used without adequate indication for use, and appropriate monitoring for 1 of 3 residents (#129) reviewed for psychoactive medication use. This failure caused harm for the resident, who experienced increased drowsiness, continued falls and weight loss. Findings include: Resident #129. admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Per the comprehensive assessment dated [DATE], Resident #129 had highly impaired hearing, was described as severely cognitively impaired, but had clear speech and could usually understand and be understood. He required assistance from staff with transferring. Review of the Medication Administration Record (MAR) dated July 2014 revealed the resident was prescribed [MEDICATION NAME], an anti-psychotic medication, 50 milligrams (mg) twice a day upon admission to the facility. The reason noted on the MAR for the use of [MEDICATION NAME] was dementia with behaviors. The MAR also documented use of [MEDICATION NAME], an anti-anxiety medication, beginning 07/29/14, to be given as needed every 6 hours. No reason was documented on the MAR for the use of [MEDICATION NAME]. Review of the care plan revealed the facility identified the resident had dementia with behavioral disturbance. The behaviors the facility identified were physical abuse, verbal abuse, continual yelling, hallucinations and delusions. Some interventions identified to address the behaviors were: assess for pain or discomfort, use distraction tools (Bible, prayer, music, television, activities), accommodate his demands and wants within safety parameters, to attempt to find logical reasons for hallucinations, and attempt reality orientation. Further review of the care plan revealed the goal for the psychoactive medications, [MEDICATION NAME] and [MEDICATION NAME], was "No adverse reaction related to psychoactive medication use." The approaches included administering the medications as ordered, monitor for adverse reactions, and notify the physician if adverse effects occurred. The care plan called for a monthly or as needed review and assessment of the medication use. The care plan did not include information about how the medication's effectiveness would be measured. Further review of the MARs for July 2014 and August 2014 revealed the dose of [MEDICATION NAME] was doubled to 100 mg twice a day, beginning on 07/29/14. Ten days later, on the evening of 08/08/14, the dose of the [MEDICATION NAME] was again doubled to 200 mg twice a day. Note: Per the manufacturer, [MEDICATION NAME] dosage is not recommended to exceed 200-300 mg per day in geriatric patients. Adverse effects can include dizziness and somnolence (drowsiness). [MEDICATION NAME] carries a "Black Box Warning" indicating it is not approved for dementia-related [MEDICAL CONDITION], and can increase the risk of death. Potential side effects of [MEDICATION NAME] were documented on the MARs in July 2014, August 2014 and 09/01/14 through 09/03/14. Possible side effects included sedation, drowsiness, dry mouth, weight gain, [MEDICAL CONDITION], loss of appetite and postural [MEDICAL CONDITION] (decreased blood pressure upon standing). Per review of the MARs, no side effects were noted by nursing. Potential side effects of [MEDICATION NAME] were not monitored on the July 2014 or August 2014 MAR. Review of the September 2014 MAR, revealed possible side effects included sedation, drowsiness, ataxia (drunk walk), dizziness, confusion and blurred vision. No side effects were noted by nursing through 09/03/14. Review of incident reports revealed Resident #129 had no falls between 07/23/14 and 07/28/14, but suffered 8 falls between 07/29/14 and 08/17/14. All falls occurred in the resident's room, and were related to self-transfer attempts. The falls correlated with the first dose increase of [MEDICATION NAME]. In 4 of the 8 falls, [MEDICATION NAME] had been given in the hours prior to them. The incident reports did not evaluate or assess whether medication side effects could have been a causal factor of the falls. The resident was observed multiple times each day on the following days: 08/28/14, 08/29/14, 09/02/14, 09/03/14 and 09/04/14. On all observations, unless he was in the dining room for meals or a snack, the resident was in bed, typically with his eyes closed. Observations on 09/04/14 included evening time observations as well as day time observations. During the evening observation, the resident was escorted to the dining room for a snack, then back to bed. He appeared restless when in bed during the evening hours. On 09/03/14 at 10:10 a.m., Staff Member F, the Social Services Director (SSD) stated she organized monthly meetings to review those residents receiving psychoactive medications. She indicated behaviors were reviewed as a part of the process. For Resident #129, she said his last review was on 08/27/14. Review of the 08/27/14 [MEDICAL CONDITION] drug assessment for [MEDICATION NAME] and [MEDICATION NAME] revealed the reason for the drug use was depression. Indicators for use included "outbursts of anger" and "sometimes feels depressed." The non-pharmacological interventions included: taking the resident outside when weather permitted, encouraging fluids, and encouraging activities. The described benefits of using the drugs were to decrease behaviors. Review of the resident's record revealed his weight had decreased, from 160 lbs. (pounds) on 08/06/14, to 145 lbs. on 08/19/14. In a progress note dated 08/29/14, Staff Member N, the Registered Dietitian (RD), noted the significant weight loss over the last 30 days, and attributed the loss to declined consumption (she noted he was taking only 25% of his dinner meal) and possibly to changes in body fluids. On 09/03/14 at 11:40 a.m., Staff Member C, a Licensed Nurse (LN) and Resident Care Manager (RCM), said she was responsible for coordinating the care of Resident #129. She indicated that she had not seen a lot of behaviors from the resident, but he did have a number of falls. She further stated, "He is a cantankerous guy. As long as you let him have his way, it is fine." She stated the resident's behaviors would be documented on the Behavior Report Sheet, or in the progress notes. After she reviewed the progress notes for the resident, she said she did not see behaviors documented. She stated she did not know why the resident's [MEDICATION NAME] was increased, and did not find documentation in the medical record about the reason for the increased doses. In reviewing the Resident Behavior Report Sheets for July 2014, there were 4 documented episodes of behavior. In 3 of the episodes, the resident exhibited restlessness, and was attempting to self-transfer. During the fourth episode, on 07/29/14, the resident was verbally and physically aggressive toward the Speech Language Pathologist, while in the dining room, during a trial of puree textured food. After he was given different textured food, his aggressive behaviors stopped. The Resident Behavior Report Sheets for August 2014, and 09/01/14 through 09/04/14 did not have any behaviors logged. On 09/03/14 at 12:05 p.m., Staff Member F, the SSD, stated she did not remember what behaviors the resident had. On 09/03/14 at 12:10 p.m., Staff Member B, the Director of Nursing (DNS) stated the doctor did not make a note on why the [MEDICATION NAME] was increased. "I don't see anything in the progress notes about staff communicating with the doctor about the increase in [MEDICATION NAME]." Review of the progress notes dated between 07/23/14 and 08/12/14 revealed frequent episodes of restlessness and/or self-transferring to or from his bed. There were two instances documented of the resident raising his voice to the staff, one instance of yelling out, and one instance when he stated he thought 4 people were in his room and the nurse documented there were not that many people in the room. This episode occurred one day after a room change. On 09/04/14 at approximately 8:00 p.m., Staff Member U, a Nursing Assistant (NA), stated the resident was much easier to care for now that he was on more medicine. She stated before the increase in the medication, he required a lot of attention and time. She explained now "he stays in bed." The resident was observed multiple times each day on the following days: 09/08/14, 09/09/14 and 09/11/14. The resident was observed in one activity. During the activity, the resident was seated in his wheel chair in the chapel with his eyes closed. Most other times the resident remained in bed. The facility failed to ensure there was adequate indication for use of [MEDICATION NAME] (restlessness is not an indication for use). There was a low frequency of other documented behaviors besides restlessness. Despite that, the [MEDICATION NAME] dose was increased twice without a rationale for the increase. The [MEDICATION NAME] was administered with no monitoring for side effects, until 5 weeks after the medication was started. These failures resulted in harm to the resident as evidenced by excessive somnolence (drowsiness), increased falls, and weight loss.

Based on interview and record review, it was determined the facility failed to follow the planned menu for 1 of 2 (#136) residents identified with food allergies. Failure to serve the correct foods to the resident caused harm as evidenced by Resident #136 having an allergic reaction when served pieces of bananas in a dessert to which she was allergic. This facility practice caused the resident harm, as exhibited by an itchy throat and numbness,with a cough that also caused the resident anxiety and fear; medical intervention was required. Findings include: Resident #136. admitted to the facility on [DATE] with a spinal fusion. The resident was alert and oriented and able to make her needs known. The resident's allergy to bananas was identified on the nursing admission assessment, the history and physical, and the nutrition assessment. On 08/29/14 at approximately 10:00 a.m., the resident stated she had consumed banana pieces in pudding at the lunch meal on 08/28/14. She stated she "did not realize the pudding had banana in it." After consuming the pudding the resident experienced "an itchy throat with numbness and coughing." She stated she was given [MEDICATION NAME] (a medication for allergic reaction). According to the progress note the physician came to see the resident that same evening and ordered [MEDICATION NAME] for the resident's increased anxiety related to the incident. On 08/29/14 at approximately 11:00 a.m., Staff Member D, a licensed nurse (LN), said that on 08/28/14 the resident stated she was experiencing a "tickle" in her throat and believed she ate something on her lunch tray that caused an allergic reaction. Staff Member D notified the physician and received an order for [REDACTED]. The kitchen staff made "a mistake" and place the wrong dessert on Resident #136's tray. Staff Member D, stated she was "worried" about the reaction that the resident was experiencing and sat with her for "an hour and a half" after the incident. On 08/29/14 at approximately 1:30 p.m., Staff Member N, a Registered Dietician (RD), stated that the trays were set-up in the kitchen with the resident's dietary card which identified name, room number, diet and allergies. "The kitchen tray line made a mistake placing the dessert with bananas instead of the alternative which was peaches." On 08/29/14 at approximately 3:00 p.m., the Director of Nursing stated she spoke to the dietary manager. The dietary manager told her the dietary aide prepared the peaches as an alternate but placed the pudding with bananas on the resident's tray. On 08/30/14 at approximately 10:00 a.m., the Dietary Manager, stated that there was a mistake in placing the dessert on Resident's #136's tray and the resident was served bananas. She stated the cook dished and labeled the peaches for the resident but it was not placed on the tray. "We have allergies and food likes posted above the steam table for the cooks to look at while serving." The dietary aide had the dietary slip to refer to while setting up the residents tray and that included allergies. She further explained the nursing assistants serve the resident trays in the different dining areas, and to some residents in their room. "They do have the diet slip that is on the residents' trays. It identifies the resident's name and diet allergies." The facility failed to ensure that the resident was not served a food containing a known allergen. This caused the resident to have an allergic reaction requiring medical treatment, and fear for her health. This caused the resident to lack confidence about her care, and resulted in physical and psychosocial harm.

Based on record review, observation, and staff interviews the facility failed to monitor the resident's skin following a splint application to the right arm for 1 of 3 sampled residents (#1) reviewed with pressure ulcers. This failed practice resulted in actual harm to the resident as she developed two pressure ulcers. Findings include: Resident #1: admitted to the facility with [DIAGNOSES REDACTED]. The resident had a recent history of a pressure ulcer to her coccyx area that healed on 3/19/13. Review of the resident's plan of care revealed she was at risk for skin breakdown due to her impaired mobility and bladder/bowel incontinence. Review of Progress Notes dated 3/19/13 revealed a splint with ace wraps holding it in place was applied to the resident's right arm by an orthopedic surgeon due to a fractured elbow sustained during a fall on 3/16/13. Review of physician's orders [REDACTED]. Progress Notes dated 4/1/13 at 2:00 p.m. stated the resident complained of significant pain to her right hand and fingers. Upon removal of the splint two pressure sores were noted - one to her inner right wrist (purple in color with a soft center) measuring 0.4 by 0.52 inches and the second one was to her inner right index finger (color was dark pink) which measured 0.4 by 0.8 inches. Upon removal of the splint the resident had immediate relief of pain to her right hand and fingers. The physician was notified and orders were received to keep the splint off. Observation of the resident's right arm on 4/3/13 at 1:15 p.m. noted pressure ulcers red in color to the inner right wrist and the inner index finger below the knuckle. The right wrist pressure ulcer had a soft darkened center. Observation of the splint (previously used on the resident) noted the edges were in direct alignment with the pressure sores. A telephone interview conducted on 4/3/13 at 1:25 p.m. with Staff Licensed Nurse (LN) B revealed she had not removed the resident's splint to check her skin. She stated she had no reason to think the splint needed to be removed. Further telephone interviews conducted with LNs working between 3/27-4/1/13 revealed the following: 1) 4/3/13 at 1:37 p.m. with Staff C noted that neither the splint or the ace wrap were removed to check the resident's skin. 2) 4/3/13 at 1:50 p.m. with Staff D noted she had worked with the resident on 3/30/13 and did not remove the splint. She stated one of the charge nurses told her she was not to remove it. 3) 4/3/13 at 4:58 p.m. with Staff E noted the splint had not been removed when she checked the resident's skin. 4) 4/10/13 at 4:06 p.m. noted Staff F had not removed the resident's splint when she checked her skin. A telephone interview on 4/3/13 at 4:50 p.m. with the above orthopedic surgeon revealed he had applied a splint to the resident's right arm on 3/19/13 to enable staff to check her skin (by removing the splint) as he was concerned about possible skin problems. He stated a splint was applied rather than a cast due to the resident's impaired cognition and possible inability to inform staff if she was having problems. Despite the resident's history and risk of pressure sores, impaired cognition, [DIAGNOSES REDACTED].

Based on record review, observation, and interviews the facility failed to supervise staff to ensure that care planned interventions were implemented to prevent falls for 1 of 3 sampled residents (#1) reviewed for incidents resulting in injury. This failed practice resulted in harm to Resident #1 who sustained an avoidable elbow fracture due to a fall from her bed. Findings include: Resident #1: admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed she was at risk for falls due to her history of falls and stroke with left sided weakness. She required two staff members to assist with transfers and bed mobility. Review of Progress Notes dated 3/15/13 revealed an air mattress was placed on the resident's bed for relief of pressure to prominant areas. Review of a facility investigation report revealed on 3/16/13 at 4:15 a.m. the resident was lying on her left side in bed receiving personal care by a Nursing Assistant (NA). The NA turned her back to the resident to get a wash cloth at which time the resident rolled over the lip of the air mattress and fell to the floor landing on her right side. The resident's weight at the time of the incident was 198 pounds. Observation of the resident on 4/3/13 at 1:15 p.m. noted a large, obese resident lying on an air mattress with lipped edges. There was minimal space between the edges of the mattress and the resident, thus when turning her she would be at the edge of the mattress. An interview on 4/3/13 at 12:05 p.m. with Staff Licensed Nurse A revealed staff had been trained to refer to the In-Room Care Plan (kept in the resident's room) to ensure proper care was being given to residents. Review of the In-Room Care Plan instructed staff to utilize two staff members when turning the resident and providing care. Despite the resident's risk for falls, stroke with left sided weakness, two staff assist with bed mobility, history of falls, impaired cognition, obesity, and position of resident on the air mattress; the resident was turned to her side by one staff member (who had turned her back on the resident) at which time she fell out of bed sustaining a fractured elbow due to lack of staff supervision.

Based on record review and interviews the facility failed to provide appropriate, timely care and services for 1 of 3 sampled residents (#1) reviewed for falls with injuries. Resident #1 experienced harm as a result of delay in obtaining medical treatment for [REDACTED]. Findings include: Resident #1: admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the resident's plan of care noted she was unable to ambulate, required two staff members to assist with transfers, attempted to transfer herself, and utilized a tilt wheelchair when out of bed. Review of the resident's medical record noted documentation on 10/18/12 at 1:22 p.m. which stated the resident was found on the floor on her right hip next to her wheelchair after breakfast. She was unable to state how she fell but had slipped out of her wheelchair. A bruise was noted to the top of the right knee. Her right leg was externally rotated, slightly shorter than the left leg and she complained of pain with movement of the right leg (all signs of a [MEDICAL CONDITION]). The physician was notified at that time and orders were obtained for a right hip x-ray which was completed that afternoon by a mobile x-ray company. An additional physician order [REDACTED]. Review of documentation between 10/18/12 at 1:22 p.m. to 10/22/12 at 10:14 a.m. (four days) revealed no follow-up to obtain the results of the right leg x-ray which was done the afternoon of 10/18/12. In addition, there was a lack of consistent monitoring of the resident's condition following a fall with injury as evidenced by the following: 10/19/12 - no assessment of the right leg relative to external rotation or shortening as noted on 10/18/12, only one assessment that day at 10:57 a.m. noting the appearance of the right leg 10/20/12 - no assessment the entire 24 hours relative to the appearance/movement of the right leg 10/21/12 - only one assessment documented at 6:03 p.m. which stated minimal [MEDICAL CONDITION] to right knee - no documentation relative to the above documented bruise, external rotation or shortening Documentation on 10/22/12 at 10:14 a.m. stated the resident's right leg was rotated with excessive swelling to the right knee and pain with movement. The mobile x-ray company was called as no x-ray report had been received for the right leg x-ray obtained on 10/18/12 (four days earlier). The report revealed the resident had a right [MEDICAL CONDITION]. She was immediately transferred to the hospital where surgery was performed that day. Review of the resident's Individual Narcotic Record revealed she only received the ordered [MEDICATION NAME] four times between 10/19 - 10/21/12 with none being administered on 10/20/12. An interview on 12/17/12 at 2:30 p.m. with Staff Licensed Nurse (LN) A revealed an x-ray of the resident's right leg was obtained the afternoon of 10/18/12; however, staff did not call or receive the results. The following day (10/19/12) the resident's right leg continued to be externally rotated and she complained of right leg pain. She stated she assumed that if the x-ray results had noted a fracture the imaging company would have contacted facility staff and faxed the report. She stated she did contact the imaging company the afternoon of 10/19/12 stating they had not received the results for which the company stated they would "fax it right over." Licensed Nurse A stated she had to leave work early that day so did not follow-up to ensure the x-ray results were obtained. She stated she failed to communicate to staff prior to leaving that she was waiting for the x-ray results to be faxed to the facility. The LN did not work on 10/20, 21/12. When she returned to work on 10/22/12 there continued to be no x-ray results thus she again contacted the imaging company who stated they had faxed the results to the facility on ,[DATE], 19/12. The LN stated staff responsible for the care of the resident were aware she had fallen on 10/18/12. During a telephone interview conducted on 12/17/12 at 2:35 p.m. with Staff LN B (LN in charge of resident's care on 10/21/12) she stated she observed swelling to the resident's right hip and entire leg that day (10/21/12). The resident denied having pain upon questioning; however, would grimmace in pain. She stated staff had to do "nonverbal assessments as the resident was not reliable with responses." The LN stated she assumed the right hip x-ray obtained on 10/18/12 had been followed up by other staff members thus she had not contacted the imaging company for results. She assumed there must not have been a fracture noted on the x-ray as the resident would have been in the hospital if there had been. She was informed on 10/22/12 the resident had a [MEDICAL CONDITION] as noted on the x-ray done on 10/18/12. She stated there had been previous problems with the fax machine not working. A telephone interview conducted on 12/17/12 at 3:40 p.m. with a staff member from the mobile imaging company revealed the right leg x-ray on the resident was obtained on 10/18/12 at 12:12 p.m. and the report was faxed to the facility that day. He stated he was informed by a staff member the fax machine had been out of toner (ink) for a couple of days. Review of the imaging company records revealed the x-ray report was faxed to the facility on [DATE] at 4:02 p.m. and 5:02 p.m. Despite the resident's fall and significant signs indicative of a [MEDICAL CONDITION] staff failed to obtain x-ray results and closely monitor the resident's change in condition in a timely, consistent manner which delayed medical treatment for [REDACTED].

Based on record review and interviews the facility failed to provide the necessary care and services related to pain management for 1 of 2 sampled residents (Resident #1) transported to the pain clinic. This failure constituted harm as Resident #1 suffered from unrelieved pain for a prolonged period of time. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the resident's Pain Management Flowsheet for March 2011 noted she had received [MEDICATION NAME] every morning between 7:00-9:00 a.m. for back pain for the entire month except for 3/31/11. She did not receive the [MEDICATION NAME] medication until 9:30 p.m. on 3/31/11. Review of Progress Notes documented on 3/31/11 at 8:30 a.m. noted the resident was up in her wheelchair leaning to the left side and when asked by the Licensed Nurse if she was OK she stated, "hurts in my back" and wanted assistance to put on her coat. She was then transported by van, owned by a private transportation company, to the pain clinic approximately 35-40 miles away for a steroid injection into her back to relieve pain. At 9:30 a.m. documentation stated the facility was called by the transport service stating the resident arrived at the pain clinic yelling, "I am in pain and was very upset". The resident was not given the steroid injection into her back as she had a high body temperature and needed to be evaluated by her primary care physician. When the resident arrived back to the facility at 11:15 a.m. she complained of back pain and needed two staff members to assist her to bed. The resident repeatedly stated she did not have a physician to help her with her back pain. A telephone interview on 4/8/11 at 1:20 p.m. with the transport driver (had driven the above van on 3/31/11) revealed that all the way to the pain clinic the resident stated, "Oh God, it hurts. Are we almost there?". He stated he had to pull the van over to the side of the road a couple of times both coming and going to/from the pain clinic due to the resident leaning so far forward in her wheelchair and was bent at the waist. He stated she was in more pain than what he customarily sees when transporting residents and there was no one else in the van to assist him with the resident. An interview with the resident on 4/15/11 at 10:15 a.m. noted the above trip to the pain clinic was "a hard trip" due to the amount of back and left leg pain she was having and the length of the trip as it took an hour. She stated she normally got pain medication first thing in the morning and would have taken something that morning if it had been offered. She stated when she arrived to the pain clinic for her injection that morning she did not receive it because she was running a fever. A telephone interview on 4/19/11 at 2:30 p.m. with a Licensed Nurse at the pain clinic revealed when the resident arrived at the clinic on 3/31/11 she was seated in her wheelchair bent forward at the waist and moaning in pain. Due to the amount of back pain she was experiencing she was transferred by clinic staff from her wheelchair to a recliner. Despite the resident's complaints of back pain prior to leaving for the pain clinic and again on arrival back to the facility on [DATE]; receiving narcotic medication every morning; length of trip to the pain clinic potentially increasing the level of back pain; and not receiving the steroid injection for back pain; staff did not medicate the resident for pain until 9:30 p.m. on 3/31/11 (approximately 13 hours later from her initial complaints of pain).