Every finding on record at Sunshine Health & Rehab

Based on observation, interview and record review the facility failed to ensure 6 of 7 residents (Residents 44, 7, 64, 61, 20, and 49) were accurately assessed for activity preferences to mitigate the risk of boredom and enhance quality of life. Additionally, the facility failed to have a registered nurse ensure the activity assessments were timely and appropriately completed. This failure placed the residents at risk for unmet psycho-social needs and a diminished quality of life.Findings included.Review of the Long Term Care Facility Resident Assessment Instrument 3.0 Manual dated 10/2019 Section F: Preferences for Customary Care and Routine Activities, showed, quality of life can be greatly enhanced when care respects the residents choices regarding activities that are important to them. Information directly from the resident or representative provides specific individualized daily activity planning. Resident 44Review of the resident's medical record showed they were admitted the facility with diagnoses which included a right hip fracture with surgical repair and diabetes (too much sugar in the blood), The comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance from staff for transfers, lower body dressing and mobility. Further review of the assessment showed the area related to activity preferences was not assessed. During a concurrent observation and interview on 01/26/2026 at 11:22 AM, Resident 44 in their room looking out the window. When asked if they wanted to attend an activity they stated no as they were unsure what was available and were not sure if it would interest them. During an observation on 01/28/2026 at 10:16 AM and 01/29/2026 at 3:40 PM showed Resident 44 in their room alone, looking out the window, and not engaged in any activities. Resident 7Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), malnutrition and kidney complications. The 10/29/2025 comprehensive assessment showed the resident had a severe cognitive impairment, but the activity preferences were not assessed. Resident 64Review of Resident 64's medical record showed they were admitted to the facility on [DATE] with diagnoses including a fracture of the lower spine, long term pain, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (a feeling of unease, worry, or fear about something that might happen in the future). The 01/16/2026 comprehensive assessment showed the resident's cognition was intact and they were able to make their needs known, but the activity preference had not been assessed. Resident 61Record review of Resident 61's medical record showed they were admitted to the facility on [DATE] with diagnoses including kidney failure, diabetes, and a right below the knee amputation. Review of the 01/17/2026 resident assessment showed the resident required set-up/moderate assistance of one staff member for activities of daily living (ADLs) and had an intact cognition. Further review of the assessment showed the area related to activity preferences was not assessed. Resident 20Record review of Resident 20's medical record showed they were admitted to the facility on [DATE] with diagnoses including history of bladder cancer, anemia and depression. Review of the 01/09/2026 resident assessment showed the resident required moderate assistance of one to two staff members for ADLs and had an intact cognition. Further review of the assessment showed the area related to activity preferences was not assessed. Resident 49Review of the medical record showed the resident was admitted to the facility with diagnoses including right hip fracture, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and diabetes (a condition that happens when your blood sugar is too high). The 11/11/2025 comprehensive assessment showed Resident 49's cognition was intact and required the assistance of one staff member for ADLs. Further review showed Resident 49 was not assessed for daily and activity preferences. During an interview on 01/27/2026 at 2:49 PM Staff S, Activities Assistant, stated they were responsible for completing the activities assessments with residents who were admitted to the facility. The assessments included resident preferences and a plan to accommodate the identified preferences for activities. Staff S stated they were not always able to complete the assessment as they did not have enough time and realized they were currently behind on the resident activity assessments. During an interview on 01/27/2026 at 4:04 PM, Staff D, Registered Nurse, Minimum Data Set (MDS, a comprehensive assessment tool) Coordinator, stated they were aware that the activities assessments were not consistently being completed and had to mark the activity portion of the assessment as not assessed to be able to transmit it. Staff D stated the incomplete activity assessments had been an ongoing issue which had improved for a while but had gotten worse again. In an interview on 01/29/2026 at 3:46 PM, Staff B, Director of Nursing Services, stated they expected resident activity assessments to be completed timely as required. Staff B stated they would re-visit the issue of incomplete activity assessments as it had been a previous concern. Reference: WAC 388-97-1000(1)(b)

Based on observation, interview and record review the facility failed to ensure that residents, families and visitors had access to grievance forms if they wanted to file a grievance anonymously. The facility also failed to ensure residents knew the process for filing grievances for 4 of 4 residents (Resident's 61,15, 66 and 51) reviewed for the grievance process in Resident Council. Additionally, staff were unaware of the location of grievance forms in the event a resident, family member or visitor requested a form. This failure placed the residents at risk for not being able to voice concerns and have their concerns resolved in a timely manner.Findings included . Review of a facility policy dated 10/2025 titled Resident/Family Grievance Policy a Procedure showed; the facility staff will make grievance forms available to residents, family members and friends. During a Resident Council meeting on 01/28/2026 at 10:42 AM, Resident's 61, 15, 66 and 51 each stated they were unaware of the grievance process to include how to file a grievance anonymously or where the forms were located. Resident 51 stated they thought they would probably call the corporate office if they had any concerns. During an observation on 01/26/2026 at 9:36 AM, showed a bulletin board around the corner from the nurse's station. The board contained information which included the grievance process. Below the board was a plastic letter sized pocket attached to the wall designed to hold papers or forms which was empty. To the left of the plastic pocket was a locked wood box also attached to the wall with an opening on top to place papers or forms. Neither the plastic pocket or wood box were labeled or identified as to what they were used for. In an interview on 01/27/2026 at 9:42 AM, Staff J, Registered Nurse, was asked where the grievance forms were located and they stated, I'm not sure, but they are around here somewhere, maybe you should ask someone else. During an interview on 01/27/2026 at 9:45 AM, Staff G, Licensed Practical Nurse, was asked where the grievance forms were located, and they stated they were unsure but would ask someone where they were kept. Staff G thought they might be at the nurse's station. During an interview on 01/27/2026 at 9:46 AM, Staff C, Infection Preventionist, was asked where the grievance forms were located, and they stated in the file cabinet at the nurse's station. Staff C attempted to find a grievance form however they stated there were none available. I can't find them. I will go and get some because we keep them in the nurse's station. During a concurrent observation and interview on 01/27/2026 at 9:50 AM, Staff B, Director of Nursing Services, observed the bulletin board with the posted grievance process and the unidentified empty plastic pocket and locked wood box. Staff B stated the plastic pocket was empty but should be identified as the grievance form holder. Staff B stated the wood locked box should also be identified as the receptacle for completed grievance forms. Staff B stated they would re-fill and label the plastic pocket as that was where the grievance forms were kept. Additionally, their expectation was that residents or family members should be able to file a grievance anonymously if they chose to and not have to ask for a form at the nurses station. Reference: WAC 388-97-0460

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Four medication errors were identified for 3 of 8 residents (Residents 31, 61 and 75) observed during 25 medication administration opportunities that resulted in an error rate of 16%. This failure placed residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects.Findings included. Review of the Instructions for use (IFU) by the U.S. Food and Drug Administration (USFDA) revised 07/2023, stated to prime the insulin (a medication used to manage blood sugar levels in the blood) pen (a pre-filled disposable device containing insulin) with a new needle prior to each injection administration. Priming was meant to remove air from the needle and the cartridge that may collect during usages. In addition, the IFU stated to insert the needle into the skin, press plunger all the way down, and continue to hold the plunger and slowly count to five prior to removing the needle. These steps were to ensure the insulin pen worked correctly and the proper dosage of medication was administered. Resident 31Review of the medical record showed Resident 31 was admitted with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and hypertension (high blood pressure). The 12/16/2025 comprehensive assessment showed Resident 31 required supervision/substantial assistance of one staff member for activities of daily living (ADLs) and had an intact cognition. Review of Resident 31's December 2025 and January 2026 physician orders, showed the resident had four orders for insulin. One order dated 12/19/2025, showed the resident's insulin was to be administered on a sliding scale based on the resident's current blood glucose (sugar) result. The sliding scale showed that based on blood glucose of 201-250 milligram (mg)/deciliter (dL), the resident was to have six units (unit of measure) of insulin. Resident 31's blood glucose result was 248 mg/dL. A second physician order dated 12/30/2025 showed Resident 31 was to have 15 units administered every morning. The third physician order dated 01/05/2026 showed Resident 31 was to have six units of insulin administered every morning. The fourth physician order dated 01/05/2026 showed Resident 31 was to have four units of insulin administered twice a day. During an observation and concurrent interview on 01/27/2026 at 8:37 AM, showed Staff J, Registered Nurse, (RN), prepare the insulin pen by cleaning both insulin pen tips with an alcohol swab then attached a disposable needle to administer the insulins. Staff J dialed one insulin pen to 12 units and the other insulin pen to 15 units. Staff J did not prime either of the insulin pen needles prior to the administration. Staff J stated they did not know they were to prime the needle of the insulin pens. During an observation on 01/28/2026 at 12:52 PM, showed Staff K, Licensed Practical Nurse, prepared one dose of insulin. Resident 31's blood glucose level was 371 mg/dL. Based on the sliding scale of insulin the resident was to be administered 14 units, in addition to the four units for a total administration of 18 units of insulin. Staff K obtained two insulin pens as one pen did not contain 18 units of insulin. Staff K swabbed the tops of the insulin pens, dialed them each to two units and pressed the plunger, then attached the disposable insulin needles. (This did not allow for the insulin to prime the needles). Staff K dialed one insulin pen to 10 units and the second insulin pen to eight units. Staff K then inserted one insulin pen needle into Resident 31's abdomen, pressed the insulin pen plunger and held for two seconds, then pressed the second insulin pen needle into the other side of their abdomen, pressed the insulin pen plunger and held for two seconds. Resident 61Review of the medical record showed Resident 61 was admitted with diagnoses including diabetes, kidney disease and hypertension. The 01/17/2026 comprehensive assessment showed Resident 61 required set-up/moderate assistance of one staff member for ADLs and had an intact cognition. Review of Resident 61's physician orders showed they had orders for insulin. One insulin order dated 01/19/2026 showed the resident's insulin was to be administered on a sliding scale based on the resident's current blood glucose result. The sliding scale showed that based on blood glucose of 131-150 mg/dL, the resident was to have three units of insulin. Resident 61's blood glucose level was 142 mg/dL. In addition, Resident 61 had another insulin order that showed they were to be administered 10 units of insulin with meals. During an observation on 01/27/2026 at 9:08 AM, showed Staff J prepared Resident 61's insulin pen by swabbing the top of the insulin pen with an alcohol swab, attached a disposable needle, dialed the insulin pen to 13 units, and administered to Resident 61's abdomen. Staff J did not prime the insulin pen needle. Resident 75Review of Resident 75's medical record showed they were admitted with diagnoses including diabetes, kidney disease and COPD. Resident 75's admission care plan showed they required dependent/moderate assistance of one to two staff for ADLs and had an impaired cognition. Review of Resident 75's physician orders dated 01/26/2026, showed the resident's insulin was to be administered on a sliding scale based on the resident's current blood glucose result. The sliding scale showed that based on blood glucose of 131-150 mg/dL, the resident was to have two units of insulin. The resident's blood glucose level was 142 mg/dL. During an observation on 01/28/2026 at 12:52 PM, showed Staff K, prepared Resident 75's two units of insulin by swabbing the top of the insulin pen with an alcohol swab, dialed the insulin pen to two units and pressed the plunger, then attached the disposable insulin needle (This did not allow for the insulin to prime the needle). Staff K then dialed the insulin pen to two units, inserted into the resident's abdomen and pressed the plunger and immediately removed from the skin (Staff K did not hold into the resident's skin and count to five seconds). During an interview on 01/28/2026 at 2:55 PM, Staff B, Director of Nursing Services, stated the process for administering insulin using an insulin pen was to swab the top of the insulin pen with an alcohol swab, attach a new disposable insulin needle, dial the insulin pen to two units and press the plunger to allow the insulin to prime the needle. Staff B stated, following priming of the needle the nurse was to dial the insulin pen to the ordered dose of insulin and inject into the resident's skin for the required time. Staff B further stated they should hold in the skin for 10 seconds or the required time and these processes were to ensure the residents received the entire prescribed dose of insulin and the process was not followed. Reference: WAC 388-97-1060(3)(k)(ii)

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control measures, including Personal Protective Equipment [(PPE) protective garments and gear used to minimize exposure to hazards that can cause injury or illness], intended to mitigate the transmission of shingles (a viral infection that causes a painful, burning rash with blisters) were followed for transmission-based precautions [(TBP) additional precautions used with residents that are suspected or confirmed to have an infection] for 7 of 7 staff members (Staff L, M, N, O, P, Q, K); Additionally the facility failed to ensure medical supplies were maintained in a manner to prevent healthcare-associated infections by failing to remove expired sterile and non-sterile clinical supplies from 1 of 1 treatment storage rooms, reviewed for infection control. The facility's failure to remove expired medical supplies from the clinical environment placed the residents at an increased risk for communicable diseases along with an introduction of pathogens (tiny organisms that can make you sick if they get inside your body into the urinary tract), potentially leading to urinary tract infections (UTI) or urosepsis (a life-threatening, severe medical emergency where a UTI usually in the kidneys spreads to the bloodstream and triggers a body wide, dangerous immune response).Findings included.Review of the facility posted Washington State Hospital Association, Contact Precautions, (precautions used for infections that can be spread through direct or indirect contact with a person or their environment. This included wearing gowns/gloves when interacting with a person or handling their belongings), revised 2019, showed everyone must clean hands when entering and leaving the room, staff must gown and glove at the door. PPEDuring an observation and concurrent interview on [DATE] at 2:41 PM, showed a resident room with a contact precaution sign posted outside their door on the right side. The contact precaution sign instructed all staff to perform hand hygiene and put on a gown and gloves prior to entering the resident room. Staff L, Nursing Assistant, (NA), was inside the resident room and was standing next to the resident on the right side of the room, without a gown or gloves and was obtaining the residents vital signs. When Staff L finished, they exited the room and stated they did not wear a gown or gloves and they should have, as the resident room was posted as contact precautions. During an interview on [DATE] at 12:27 PM, Staff M, NA, stated the resident room with the contact precaution sign was for the resident who had shingles. Staff M stated they were not required to wear a gown when they entered the room. Staff M stated they just wore a mask and gloves. During an observation and concurrent interview on [DATE] at 11:38 AM, showed the resident being wheeled into their room by Staff N, Physical Therapy Assistant. Upon entering the resident room, Staff N removed a gait belt (an assistive device used to help safely transfer and support individuals with mobility challenges) from the resident's waist, removed the resident's oxygen tubing from the portable oxygen on their wheelchair and connected the oxygen tubing to the room oxygen. Staff N placed the resident's call light on their bed and then exited the room. Staff N stated they did not know why the contact precaution sign was posted. Staff N stated the sign would be for staff who would toilet the resident. During an observation on [DATE] at 8:30 AM, showed Staff O, NA, and Staff P, NA, entered the resident's room without performing hand hygiene and did not put on a gown. Staff O and Staff P then put on gloves and transferred the resident's roommate on the left side of the room from their wheelchair and placed them into their bed. Staff O proceeded to the resident on the right side of the room and assisted their feet to the floor and then wheeled them into the bathroom. During a follow up observation on [DATE] at 8:47 AM, showed Staff P entered the contact isolation resident room without a gown. Staff P put on gloves and assisted the resident from the bathroom and wheeled the resident back to the left side of the room. During an observation on [DATE] at 12:05 PM, showed Staff Q, NA, wheeled the resident from the contact isolation room and placed them on the scale in their wheelchair to be weighed, then returned with the resident and entered the contact isolation room after obtaining the resident's weight. Staff Q did not put on gown or gloves upon entering and adjusted the residents breaks on their wheelchair, moved the resident's bedside table to an area they wanted, obtained the resident's oxygen tubing and handed it to the resident and placed their call light on their bed. During an observation on [DATE] at 12:40 PM, showed Staff K, Licensed Practical Nurse, wheeled a resident into the contact isolation room, entered the room without putting on a gown or gloves. Staff K exited the room, obtained blood glucose (sugar) testing supplies from the medication cart and re-entered the contact isolation room, and did not put on all required PPE, and performed a blood glucose fingerstick (a quick test for blood sugar levels). During an interview on [DATE] at 2:29 PM, Staff C, Infection Preventionist, stated the contact precautions sign was dedicated for the room and not a resident and staff should have been following the instructions posted on the contact precautions sign. Treatment RoomReview of the Centers for Disease Control and Prevention (CDC) document titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated [DATE], showed Because the manufacturer's expiration date represents the final date for which the device's sterile (completely free from all living germs) and material integrity are guaranteed, the use of an expired catheter constitutes a breach of aseptic technique (a set of strict procedures used by healthcare professionals to prevent transfer of germs). Review of the Treatment Supply room located on the Lilac Hallway on [DATE] at 10:24 AM, showed these items to be expired: Four sterile, urinary catheters, (a thin, flexible, hollow tube inserted into the bladder to drain urine into a collection bag when a person cannot urinate on their own) 22 French (Fr- a unit of measure) expired on [DATE]. One sterile urinary catheter 18 Fr expired on [DATE]. Two self-catheter kits (a pre-packaged, single-use set of medical supplies designed for individuals to safely empty their bladder at home or on the go) expired on [DATE]. One 18-inch (in- a unit of measure) catheter extension tube (a flexible, hollow piece of plastic tubing that acts as an extension cord for a medical catheter) expired on 09/2016. Ostomy (a discreet, odor-proof, and waterproof bag worn on the outside of the body to collect bodily waste stool or urine) pouch care supplies with one drainable ostomy pouch 2 1/4 in, expired on 01/2021 and four drainable ostomy pouches 2 1/4 in, expired on 10/2023. During an interview on [DATE] at 1:53 PM, Staff B, Director of Nursing Services, stated that Central Supply Assistants were expected to check for expired items weekly. Staff B stated that the current assistant was a new employee who was unaware of this task and requires additional training/education. A follow up interview at 3:33 PM, Staff B stated the resident room was placed on contact precautions and all staff should be performing hand hygiene, putting on a gown and gloves when they entered the room and upon exiting the room, staff were to remove all PPE and perform hand hygiene. Reference: WAC 388-97-1320(1)(a)(5)(b)

Based on observation, interview and record review the facility failed to ensure that resident dignity was maintained for 2 of 3 residents (Resident's 32 and 58) reviewed for resident rights to privacy and a dignified existence. Residents 32 and 58 had their medical information discussed and were assessed in front of other residents and visitors while in the common area. This failure placed them at risk for embarrassment and lack of confidentiality related to their medical care. Findings included .Record review of an undated facility policy titled [Resident Rights showed; as a nursing home resident you have certain rights and protections under federal and state law.including the right to have your personal information kept private. Resident 32 Review of the resident's record showed they were admitted with diagnoses which included Parkinson's ( a movement disorder of the nervous system that worsen' s over time) and dementia. Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance from staff for dressing, toileting and transfers. During an observation on 01/26/2026 at 12:08 PM, showed Resident 32 sitting at a table in the common area waiting for lunch. Two visitors and two residents were sitting at the table with Resident 32. Additionally other residents were seated at tables waiting for their lunch trays near Resident 32. Several minutes later at 12:10 PM, Staff T, Nurse Practitioner, approached Resident 32 while they were waiting for their lunch and placed a stethoscope (an acoustic medical device typically used for listening to the heart or lungs) on the resident's chest and back to listen to their lungs and heart. Staff T discussed the assessment with the resident including their medications. The discussion of Resident 32's medical care could be overheard by visitors and other residents in the area. Additionally, Staff T discussed concerns related to Resident 32's body rash and possible causative factors prior to leaving the room. Resident 58Review of the resident's medical record showed they were admitted to the facility with diagnoses which included pancreatitis (a gland behind the stomach for digestion and hormones which becomes inflamed and swollen) and dementia. Review of the care plan dated 01/23/2026 showed the resident required substantial assistance from staff for dressing, toileting and transfers. During an observation on 01/28/2026 at 11:37 AM, Staff U, Licensed Practical Nurse, was standing at their medication cart across the room from Resident 58 who was in the common room sitting at a table with other residents. In a loud voice Staff U stated to Resident 58 I've got your MiraLAX (a medication to relieve constipation) it should help. The common area had six other residents sitting in the area and one visitor who could overhear the conversation about Resident 58's bowel medication. During an interview on 01/29/2026 at 2:29 PM, Staff B, Director of Nursing Services, stated their expectation was that staff respected resident privacy and dignity and that all medical care or discussions related to medical care should be done in a private area such as the resident room. Reference: WAC 388-97-0180(1)-(4)

Based on observation, interview, and record review the facility failed to review, and validate the Preadmission Screening and Resident Reviews (PASARR, 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) were correct on admission or updated for 1 of 5 residents (Resident 64) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.Findings included.Review of Resident 64's medical record showed they were admitted to the facility on [DATE] with diagnoses including a fracture of the lower spine, long term pain, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (a feeling of unease, worry, or fear about something that might happen in the future). The 01/16/2026 comprehensive assessment showed the resident's cognition was intact and they were able to make their needs known.Review of the facility's Level I PASARR assessment, dated 01/12/2025 (one year prior to Resident 64's admission to the facility), showed the resident had no SMIs documented and was marked as not requiring a Level II PASARR referral.During an interview on 01/27/2026 at 2:40 PM, Staff E, Social Service Director, stated they received Level I PASARR assessments prior to residents being admitted , would review the assessments for accuracy and whether the resident had the required Level II referral sent when needed. After reviewing Resident 64's PASARR, Staff E stated that Resident 64's diagnosis of depression and anxiety were not documented under the SMIs section, and the resident required a Level II PASARR referral. Staff E stated the correct process was not followed and Resident 64's PASARR was not accurate or sent for a Level II referral prior to the resident's admission to the facility.During an interview on 01/29/2026 at 3:14 PM, Staff B, Director of Nursing Services, stated that all residents with diagnoses of SMIs required a PASARR Level II referral sent prior to admission into the facility.Reference: WAC 388-97-1915(1)(2)(a-c)

Based on interview and record review, the facility failed to: A) establish a Quality Assurance Performance Improvement (QAPI) policy for the inclusion/utilization of information from all resident care departments, including residents/resident representatives (RR) feedback/input data that would be used to identify high risk, problem prone areas or opportunities for improvement and, B) implement an effective QAPI program that incorporated a thorough collection/analysis of resident/RR feedback data and information from all departments/staff involved in 1 of 1 QAPI Program. This failure placed residents at an increased risk for unidentified complications, prompted corrective action towards high-risk/problem prone areas and unmet care needs.Findings included .Review of the facility's policy titled, QAPI Policy and Procedure, dated January 2023 showed, the facility's QAPI committee programs purpose was to take a systematic, interdisciplinary, Comprehensive, data driven approach (refers to actions , decisions, or processes that are guided by data rather than personal experience, and the importance of using collected information) to maintaining and improving safety and quality within the facility. The policy showed the QAPI program focused on .indicators of the outcome of care and quality of life, and would collect/obtain data from .several areas including but not limited to, trends, staff and resident input, critical incidents and citations ., which would then be reviewed by the QAPI committee to .identify problems. The policy did not include the systems to obtain resident/RR feedback data or input nor how the information would be used to identify high risk, problem prone areas or opportunities for improvement. Additionally, the policy did not include systems to identify, collect, and use data and information from all departments as required.Review of the facility's policy titled, QAA- QAPI Plan, revised January 2020 showed that QAPI activities would be .data driven . with using the Centers for Medicare and Medicaid Services (CMS) facility resident reports, rehospitalization reports and data from resident medical records. The policy showed the facility's QAPI process shall include review of any formal grievances (complaints or concerns documented) expressed by residents or family member ., and that they .may include input . from residents/RR. The policy showed the facility's resident incident reporting log would be used to guide investigations. The policy did not show resident/RR feedback data or inclusion of input if not documented in a formal grievance nor how the information was to be used to identify high risk, problem prone areas or opportunities for improvement. Additionally, the policy did not show how the facility identified, collected, and utilized information from all department like infection control, pharmacy, or nursing staff data.During an interview on 01/29/2026 at 4:55 PM, Staff B, Director of Nursing Services (DNS), stated they were the QAPI coordinator for the facility and conducted the quarterly meetings with the required members and documented the meeting information. Record review of the quarterly QAPI meeting documents, from December 2024 through January 2026, showed the facility had meetings in March 2025 and November 2025. On 03/24/2025, the QAPI committee records showed they discussed current process improvement projects (PIPs) that had been in place and the facility's five-star report (a CMS facility resident report). The records did not show documentation of what data/information had been brought in from all departments or Staff attending the meeting, resident/RR grievances or feedback data/input and how the information was used to identify high risk, problem prone areas or opportunities for improvement. On 11/03/2025, the QAPI committee records showed they discussed PIPs that had been completed and that had been completed and what PIP would be next. The QAPI meeting reviewed data from the facility's CMS reports. The records did not show documentation of what data/information had been brought in from all departments or Staff attending the meeting, resident/RR grievances or feedback data/input and how the information was used to identify high risk, problem prone areas or opportunities for improvement.Review of the facility grievance log (a document of formal grievances expressed by resident/RR) from December 2024 through January 2026, showed a total of five formal grievances were filed in the year 2025. The document showed that no formal resident/RR grievance had been logged from 07/15/2025 to 01/29/2026 (six months and 17 days).During an interview on 01/30/2026 at 7:59 AM, Staff E, Social Service Director, stated they were in charge of collecting and documenting all the resident/RR grievances and grievance forms filled out by staff on a resident's behalf. Staff E stated that sometimes residents would not fill out a formal grievance form and that sometimes resident concerns were able to be handled quickly, which did not require staff to document it as a formal grievance or on the grievance log. Staff E stated they were involved/attended QAPI meetings and did not have any information that they would bring into QAPI, because there had been no grievances since July 2025. Staff E stated that during the QAPI meeting they would discuss stuff about their department but did not bring in data or information from their department unless there was information the staff member noted on the grievance log. Additionally, Staff E stated they have daily care meetings that went over staff concerns/incidents and Staff V, Therapy Director, had that documentation. During an interview on 01/30/2026 at 8:14 AM, Staff V stated they had documentation of the daily care meetings, which would sometimes include resident and family concerns, but that it was not information that was brought into QAPI. Staff V stated they were involved in QAPI and attended the meetings, but they did not bring in data or information into QAPI from their department unless it was part of the PIP they were focusing on. Staff V stated the data that was gone over in QAPI was the CMS reports and that was the information utilized to develop the facility PIPs.During an interview on 01/30/2026 at 8:39 AM, Staff C, Infection Preventionist (IP), stated they were involved in QAPI and attended the meeting. Staff C stated that during the meetings CMS reports data was reviewed. Staff C stated they did not bring infection control data into the QAPI meetings. Staff C stated they did not bring in or present information on trends/patterns regarding antibiotics or the facility's surveillance listing of infections throughout the facility.During an interview on 01/30/2026 at 9:04 AM, Staff B stated they were not able to show how the facility incorporated a thorough collection/analysis of resident/RR feedback data and information from all departments was brought into QAPI. Staff B stated that CMS data reports were reviewed during the QAPI meeting and previous PIPs. Staff B stated the facility had multiple avenues of data and information collection within the facility, like resident/RR feedback data. The information was not brought into or discussed during QAPI meetings, since the data or information was previously talked about within other facility meetings. Staff B stated that different department heads attended QAPI but did not bring in data or information from their department. Staff B stated the IP used to bring in and discuss infection control data and trends but was no longer completing that. Staff B stated the correct process was not being followed for QAPI and the meetings should have included information from all resident care departments, including resident/RR feedback information. During an interview on 01/30/2026 at 10:20 AM, Staff A, Administrator, stated they would attend the QAPI meetings and bring in data/information on CMS reports. Staff A stated they reviewed the QAPI meeting documentation and that it did not incorporate a thorough collection/analysis of resident data and information from all departments which was not the correct process for QAPI. Reference: WAC 388-97-1760(1)(2)Cross Reference: F868, F585 for more information.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee included the required members and met at least quarterly (once every quarter of the year or every three months) for 2 of 4 quarters (Q2 and Q3) reviewed for QAA. The failure to meet quarterly increased the facility's risk of unrecognized quality deficiencies, the facility's ability to effectively correct identified issues and ongoing unmet care needs regarding residents' quality of life.Findings included .Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) Policy and Procedure, dated January 2023 showed, the facility's QAA committee would collect and obtain data from several areas including staff/resident input, critical incidents and patterns which would then be reviewed to .identify problems. Additionally, the policy stated the committee would conduct a meeting at least quarterly.Review of the facility's policy titled, QAA- Quality Assurance Performance Improvement Plan, dated January 2020 showed, the committee member would include the facility's Administrator, Director of Nursing Services (DNS), a physician, three other staff members and the Infection Preventionist (IP).Record review of the quarterly QAPI meeting documents, from the facility's last annual recertification survey on 10/29/2024 through to 01/29/2026, showed the facility conducted quarterly QAA/QAPI meetings on: 03/24/2025, which included the Administrator, Medical Director, DNS and at least three other members (one from a leadership role) from the facility's staff. No documentation of the IP attending the committee meeting for March 2025. 11/03/2025, which included the required members.During an interview on 01/29/2026 at 4:55 PM, Staff B, DNS, stated they were the QAA/QAPI coordinator for the facility and conducted the quarterly meeting with the required members and Staff A, Administrator, oversaw them. During an interview on 01/29/2026 at 5:09 PM, Staff A stated the DNS headed up the QAA/QAPI committee meetings, arranged the quarterly meetings and had the QAPI meeting information/documents. During an interview on 01/30/2026 at 9:04 AM, Staff B stated the facility's process was to have QAA/QAPI meeting quarterly and included the Administrator, Medical Director, IP, other facility staff and a representative of the facility's governing body (a group or entity with the authority to make decision, establish policies and oversee operations) and themself. When reviewing the QAA/QAPI meeting documentation with the surveyor, Staff B stated they had documentation of two quarterly QAA/QAPI meetings, sign in sheets for two out of the four quarters in 2025 and the 03/04/2025 meeting did not show the IP attending the meeting. Staff B stated they had thought another meeting had been conducted but was unable to present additional documentation. Staff B stated they were not following the correct process, the committee meeting should have been conducted quarterly and included the required members. During an interview on 01/30/2026 at 10:20 AM, Staff A stated they had reviewed the QAA/QAPI information/documentation that was presented to the surveyor and the committee meetings did not have the required members along with not being conducted quarterly. Staff A stated the correct process was not being followed regarding QAA/QAPI. Reference: WAC 388-97-1760(1)(2)Cross Reference: F865

Based on observation and interview the facility failed to provide a safe and sanitary (relating to the conditions that affect hygiene and health) environment for 1 of 1 Laundry room (LR 1), reviewed for a functional environment. This failure placed residents and staff at an increased risk of cross-contamination (the harmful spread of diseases). Findings included.Observations of LR 1, accompanied by Staff R, Environmental/Maintenance Director, on 01/28/2026 from 2:05 PM to 2:44 PM showed:Washing machine (WM) number one was positioned next to a wall within LR 1, and behind the WM was a one foot (ft, a unit of measure) long by 1/2 ft wide puddle of water, directly underneath the machine, on the concrete floor. The water was noted to be coming from a metal plate attached to the bottom of the WM, with the leak somewhere inside the WM, dripping down to the bottom floor and wall (Staff R stated the WM's would sometime get clogged up with lint during the laundered cycle and water had been known to leak out before). The bottom of the white drywall (a name for a type of board, made from plaster and other materials, used to cover walls) by the WM was noted to have a brown discoloration/cracking, from prior exposure to water, and the puddled water was in contact with a 1/2 inch (a unit of measure) of gap filling material (a type of foam that can be used to fill gaps and cracks) in-between the drywall/concrete floor. Surveyor noted the foam was wet to the touch and water had been seeping (a slow flow of a liquid through a material's small holes) through the foam material. The puddle of water had a black sludge (a soft, wet mixture of liquid), resembling mold, noted within the water and within the foam in between the drywall and concrete floor. WM number 2 had one ft long, by 1/2 ft wide, by three-inch-tall pile of rubbery black shavings underneath, that were likely from the grinding of a rubber belt that was part of the WM used during its operation. During a concurrent interview with LR 1's observations on 01/28/2026 from 2:05 PM to 2:44 PM, Staff R stated they were unaware of water dripping or leaking from behind WM number 1. Staff R stated the bottom of the wall/foam material was wet and they would be spraying a disinfectant chemical, in the water and around the wall/concrete in case the black sludge, resembling mold, was spreading. Staff R stated the leak needed to be fixed and cleaned up. When Staff R noted the pile of rubbery black shavings, they stated the WM belt was likely torn up and the pile was from the rubber belt, which needed to be replaced. During an interview on 01/28/2026 at 3:23 PM, Staff A, Administrator, reviewed photographic documentation of LR 1 environment and stated the water leak/possible broken WM belt needed to be fixed. Staff A stated they agreed the Staff R and the water leak needed to be cleaned and disinfected. Reference: WAC 388-97-3220(1)

Based on interview and record review the facility failed to ensure 1 of 5 sampled residents (Resident 5) were fully informed of their care in language they could understand. This failure placed the resident at risk of poor understanding in their health care decisions and a diminished quality of life. Findings included . Per the 04/20/2025 admission assessment, Resident 5's vision was severely impaired, and they did not use corrective lenses. Review of the 04/16/2025 care plan showed Resident 5 had a left eye prosthetic (medical device that replaces a missing body part) and was legally blind in their right eye. Review of the 05/06/2025 Notice of Medicare Non-Coverage (NOMNC; official document issued as a formal notice about termination or denial of coverage for specific healthcare services or items) showed it was signed by Resident 5. Per the form, if the resident wished to appeal the decision to end their skilled nursing facility services, they were required to do so by noon the following day, 05/07/2025, by calling a phone number listed on the form. In an interview on 06/11/2025 at 9:21 AM, Resident 5 stated facility staff did not adequately explain paperwork given to them to sign. Resident 5 stated they were blind, and staff did not allow them to ask questions about their paperwork. The resident further stated they had to have a family member talk to facility staff about their lack of comprehension regarding the NOMNC. In an interview on 06/16/2025 at 1:41 PM, Staff E, Social Services, stated they reviewed paperwork such as NOMNCs with visually impaired residents, and if the resident requested, they would reach out to their representative and would document who was included. Staff E stated Resident 5 was cognitively intact and initially did not want to review their NOMNC without their representative. Per Staff E they attempted to reach the resident's representative and were unsuccessful, after which the resident agreed to proceed with the paperwork without their representative. Review of the June 2025 progress notes for Resident 5 showed an entry on 05/06/2025 that the resident was served a NOMNC by social services staff that day. There were no entries documenting attempts to reach the resident's representative on or before the date the NOMNC was served. Reference: (WAC) 388-97-0300 (3)(a)

Based on record review and interview, the facility failed to ensure services provided met professional standards of practice related to nursing assessments for 1 of 5 residents (Resident 1), reviewed for quality of care. This failure placed the resident at risk for injury and adverse outcomes. Findings included . Per the Washington State Board of Nursing Frequently Asked Questions (https://nursing.wa.gov/practicing-nurses/frequently-asked-questions#NA-FAQ) assessments requiring the use of the nursing process must be completed by an individual with a nursing license (licensed practical nurse or registered nurse). Per the facility's policy titled, Resident Fall Prevention Protocol, revised August 2024, showed nursing staff were to complete fall risk assessments following a fall, and were to assess the level of injury present. Review of the March 2025 progress notes for Resident 1 showed on 03/29/2025 the resident had a fall in their bathroom and had been assisted up into their wheelchair before the nurse assessed them for injury. Per the note, the resident had pain and swelling to their ankle and required ice and further diagnostics to determine the extent of the injury. In an interview on 04/28/2025 at 4:41 PM Staff C, Registered Nurse, stated nursing assistants should let the nurse know prior to moving a resident who has fallen so the resident could be assessed for injuries to ensure it was safe to move them and prevent new/further injury. Staff C stated they were not notified of Resident 1's fall on 03/29/2025 until after the nursing assistant had already put the resident back into their wheelchair. In an interview on 05/23/2025 at 2:11 PM Staff F, Nursing Assistant, stated Resident 1 fell while their assigned nurse (Staff C) was on their lunch break. Staff F stated a nurse was available on another hallway, but they did not request their assistance in assessing the resident for injury prior to getting them up as Staff C was to return shortly. In an interview on 04/28/2025 at 4:18 PM Staff B, Director of Nursing, stated Staff F worked with the facility for four years and should know the facility policy to not get a resident up after a fall without waiting for the nurse to assess the resident. Reference: (WAC) 388-97- 1620(2)(b)(i)(ii),(6)(b)(i)

Based on interview and record review, the facility failed to ensure that direct care staffing information was accurate upon submission to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2024 (July 1, 2024 through September 30, 2024) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure caused CMS to have inaccurate data related to facility staffing levels and had the potential to impact resident care and services. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) PBJ Staffing Data Report showed the facility reported data for Quarter 3, 2024 at a level lower than required by mandated staffing levels. In an interview on 04/28/2025 at 3:43 PM Staff D, Payroll, verified the staff hours for Quarter 3, 2024. Staff D stated resident census data was pulled from the MDS (Minimum Data Set, a federally mandated process for clinical assessment of all resident in Medicaid- and Medicare-certified nursing homes) assessments, which were not current at the time the PBJ was initially submitted. Per Staff D the census data error was previously discovered and appeared to already be corrected when they logged in to view the PBJ. In an interview on 06/18/2025 at 11:22 AM Staff A, Administrator, stated the facility had corrected the census data related to Quarter 3, 2024 several months prior when they corrected census data for a previous quarter.

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist met the qualifications for experience, education, training and/or certification for the role to assume responsibility of the facility's Infection Prevention and Control Program for 1 of 1 sampled staff (Staff C), reviewed for infection preventionist qualifications. This failure placed all residents, staff, and visitors at risk of contracting communicable diseases, unmet infection control issues, and lack of oversite of the facility staff's infection control practices. Findings included . In an interview on 10/21/2024 at 9:03 AM, Staff A, Administrator, stated Staff C was the facility's infection preventionist. Documentation of Staff C's completion of specialized infection prevention and control training was requested at that time. No documentation was provided. Review of the 10/21/2024 staff list showed Staff C was identified as the facility's only infection prevention and control staff. In an interview on 10/24/2024 at 4:06 PM, Staff B, Director of Nursing, stated Staff C was the facility's infection preventionist since March 2024 but Staff C was still in the process of completing the infection preventionist training. In an interview on 10/25/2024 at 10:19 AM, Staff E, Admissions Registered Nurse, stated Staff C was the facility's infection preventionist, and should refer infection control questions to them. In an interview on 10/28/2024 at 11:26 AM, Staff C, Infection Preventionist, stated they were new to the infection preventionist role and were still learning. In an interview on 10/28/2024 at 3:17 PM, Staff A, Administrator, stated Staff C was the facility's infection preventionist but was still in the process of completing the infection prevention and control training. Staff A further stated they expected the infection preventionist to have sufficient training in infection prevention and control to perform the role. No associated WAC. Refer to F880, F881, F883, F887, and WAC 1480 for additional information.

Based on observation, interview, and record review the facility failed to review policies and/or procedures yearly as required, perform hand hygiene when indicated, and store soiled laundry in a manner to prevent the spread of infection. In addition, the facility failed to implement, follow, and discontinue transmission-based precautions when indicated for 2 of 3 sampled residents (Resident 23 and 135), reviewed for infection control. This failure placed all residents, staff, and visitors at risk of development of a multi-drug-resistant organisms (MDRO), communicable diseases, and diminished quality of life Findings included . POLICIES Review of the facility policy titled, Vaccination of Residents, showed the policy was revised November 2012. No documentation was found to show the policy had been reviewed yearly as required. Review of the facility policy titled, Influenza Vaccine, showed the policy was revised November 2012. No documentation was found to show the policy had been reviewed yearly as required. Review of the facility policy titled, Pneumococcal Vaccine, showed the policy was revised October 2014. No documentation was found to show the policy had been reviewed yearly as required. Review of the facility policy titled, Antibiotic Stewardship, showed the policy was revised July 2016. No documentation was found to show the policy had been reviewed yearly as required. Review of the facility policy titled, COVID-19, showed the policy was reviewed/revised March 2022. No documentation was found to show the policy had been reviewed yearly as required. Review of the facility policy titled, COVID-19 Vaccine Policy showed the policy was implemented December 2020. No documentation was found to show the policy had been reviewed yearly as required. Review of the undated facility policy titled, Transmission Based Precautions showed no documentation the policy had been reviewed yearly as required. In an interview on 10/28/2024 at 10:57 AM, Staff H, Charge Nurse, was unsure what the facility process was for reviewing policies, how often policies were reviewed, or where documentation on policies reviewed was located. In an interview on 10/28/2024 at 11:26 AM, with Staff C, Infection Preventionist (IP), and Staff B, Director of Nursing (DNS). Staff C was unsure what the facility process was for reviewing policies, how often policies were reviewed, or where documentation on policies reviewed was located. Staff B stated policies were to be reviewed yearly and documented on the policy itself when it was reviewed. Staff B acknowledged policies were being reviewed and/or updated as needed and some policies might not be up to date. In an interview on 10/28/2024 at 3:17 PM, Staff A, Administrator, stated policies were reviewed yearly and documented through the facility's quality assurance and performance improvement program. The State Survey Agency requested documentation that showed policies were reviewed yearly as required, at that time and again on 10/29/2024 at 3:04 PM. No documentation was provided. HAND HYGIENE Review of the facility policy titled, Handwashing/Hand Hygiene revised August 2015, showed hand hygiene was the primary means to prevent the spread of infections. The policy instructed staff to perform hand hygiene by using alcohol-based hand rub (ABHR) or wash their hands with soap and water before and after direct contact with residents, before preparing or handling medication, before and after handling an invasive medical device, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site, after contact with a resident's intact skin, after handling used dressings or contaminated equipment, after contact with objects in the immediate vicinity of a resident, after removing gloves, before and after entering an isolation precaution setting, and after removal of personal protective equipment (PPE). The policy specified staff were to wash their hands with soap and water when visibly soiled and after contact with a resident with infectious stools. Glove use and routine hand hygiene was the best practice for preventing healthcare-associated infections. The policy further showed all staff were to perform hand hygiene when indicated to help prevent the spread of infections to other personnel, residents, and visitors. The website CDC.gov - in which CDC refers to Centers for Disease Control and Prevention- with regard to hand hygiene showed, hand hygiene protects both healthcare personnel and patients. Hand hygiene means handwashing with water and soap or antiseptic hand rub (alcohol-based foam or gel hand sanitizer) . gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning [applying] gloves and touching the patient or the patient's surroundings recommendations for hand hygiene in healthcare settings . immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal cleaning hands at key times with soap and water or hand sanitizer that contains at least 60% alcohol is one of the most important steps you can take to avoid getting sick and spreading germs to those around you. The website CDC.gov - with regard to standard precautions showed, standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene, use of gloves, gown, masks, eye protection, or face shield, depending on the anticipated exposure The application of Standard Precautions during patient care is determined by the nature of the HCW [health care worker]-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. During observation on 10/22/2024 at 8:40 AM, Staff I, Nursing Assistant (NA), assisted a resident reposition in bed, exited the room without performing hand hygiene, pushed a black rolling cart down the hall that contained black cups with lids and straws, then delivered a cup to a resident in a different room, without performing hand hygiene. During observation on 10/22/2024 at 8:47 AM, Staff I, NA, exited a resident room while actively removing a pair of green gloves, did not perform hand hygiene, walked down the hall to the clean linen cart to obtain a pair of yellow socks, and returned to the resident room, without performing hand hygiene. During observation on 10/22/2024 at 9:31 AM, Staff I, entered a resident room without performing hand hygiene, adjusted the resident's bedside table and privacy curtain, and exited the room without performing hand hygiene. During observation on 10/23/2024 at 1:45 PM, Staff J, NA, put on a pair of green gloves without performing hand hygiene. During observation on 10/24/2024 at 8:11 AM, Staff K, Registered Nurse (RN), dispensed medications for a resident, did not perform hand hygiene prior to entering the resident room, placed items on the resident's bedside table, adjusted the bedside table, and administered an injection without performing hand hygiene or applying a pair of gloves. In an interview on 10/24/2024 at 8:19 AM, Staff K, stated they never wore gloves when administering injections. Staff K acknowledged they should have used ABHR prior to entering the resident room. In an interview on 10/25/2024 at 2:35 PM, Staff L, NA, stated hand hygiene should be performed when entering and exiting a resident room, before applying and after removal of PPE. Staff L was unable to specify other instances when hand hygiene was indicated. In an interview on 10/25/2024 at 3:00 PM, Staff N, Licensed Practical Nurse, stated staff should perform hand hygiene when indicated to prevent the spread of germs. In an interview on 10/28/2024 at 10:57 AM, Staff H, Charge Nurse, stated staff should wear gloves when administering injections. Staff H further stated staff should perform hand hygiene when indicated to prevent the spread of germs or infection and prevent others from getting sick. In an interview on 10/28/2024 at 1:31 PM, Staff C, IP, explained hand hygiene was cleansing hands with ABHR or washing with soap and water when visibly soiled or after contact with a resident with infectious stools. Staff C stated hand hygiene should be performed when entering and exiting a resident room, before and after removal of PPE, and after staff ate or used the restroom. Staff C was unable to specify other instances when hand hygiene was indicated. Staff C stated staff were expected to perform hand hygiene when indicated to prevent the spread of germs and/or infection. Staff C further stated staff should wear gloves when administering injections because of the potential risk of contact with blood. In an interview on 10/28/2024 at 3:17 PM, Staff A, Administrator, stated they expected staff to perform hand hygiene when indicated. <Resident 135> According to a 10/04/2024 admission assessment, Resident 135 was alert and made their needs known. The document further showed Resident 135 had diagnoses which included diabetes, heart failure (an impairment of the hearts ability to fill and pump blood, which can cause swollen legs) and peripheral vascular disease (a disorder of the blood vessels, that can cause impaired circulation to the legs and feet.) On 10/21/2024 at 11:50 AM, observed as Staff X, Registered Nurse (RN) changed the dressing on Resident 135's right lower leg. The resident had a bulky dressing wrapped from below their knee to just above the ankle. Staff X wore a gown and gloves into the room when they brought in the new dressing supplies. They set the unopened supplies on the resident's bed. The resident then moved their wheelchair so they could prop their right foot on the bed, leaving the right calf free. Staff X unwound the fluffy gauze roll (kerlex) and absorbent pads (ABD pads), which were saturated and heavy with clear drainage, and discarded them in the trash. Staff X then pressed around on the resident's leg, to evaluate the extent of the swelling and where all the drainage was coming from. Staff X did not change their gloves or perform hand hygiene, after handling the soiled dressing or touching the resident's skin. Staff X then opened the new kerlex roll packaging and ABD package, and set the opened ABD's on their lap (covered with a gown) and redressed the leg, used bandage scissors, all while wearing the same gloves they removed the soiled dressings with. When asked how often the dressing changes were done, Staff X responded that it was ordered as needed. Staff X removed their gown and gloves, and used hand sanitizer when they left the room. During an interview on 10/25/2024 at 2:41 PM, Staff N, LPN, stated that they should clean your hands and put on clean gloves, after removing an old dressing during wound care. So basically, when you went from a dirty task to a clean. During an interview on 10/25/2024 at 3:04 PM, Staff Q, RN, stated should change gloves after they removed the old dressing and cleansed the wound and before they put the new dressing on. They further stated it could cause an infection, if hand hygiene not done. During an interview on 10/25/2024 at 3:35 PM, Staff B, Director of Nursing stated their expectation of staff performing a dressing change was to do hand hygiene and change gloves after removing soiled dressing, anytime they went from a dirty task to a clean task. Not doing so was an infection control issue. Staff B acknowledged the description of the dressing change for Resident 135 did not meet their expectations. SOILED LINEN STORAGE During observation on 10/21/2024 at 9:10 AM, two large waist high barrels were observed in the common milieu area, one barrel lid was labeled as soiled linen with biohazards stickers, the second was labeled as garbage. Similar observations were made on 10/22/2024 at 9:31 AM, 10/23/2024 at 8:44 AM, and on 10/28/2024 at 10:27 AM. In an interview on 10/28/2024 at 10:33 AM, Staff O, NA, stated the soiled linen and trash barrels were always stored in the common milieu instead of behind closed doors and acknowledged it could be a potential infection control issue. In an interview on 10/28/2024 at 10:57 AM, Staff H, Charge Nurse, stated soiled linen and garbage was stored in different locations on the units based on NA preference and had seen them stored in the common milieu area. Staff H further stated storing soil linen and garbage in the common milieu area could be a potential infection control issue if residents tried to access them. In an interview on 10/28/2024 at 1:31 PM, Staff C, IP, stated the large soiled linen and garbage barrels should be stored in the shower room, not in the common milieu area, because that could be a potential infection control issue. TRANSMISSION BASED PRECAUTIONS Review of the undated facility policy titled, Transmission Based Precautions showed transmission of infection required a source of infection, a mode of transmission, and a vulnerable host. The policy categorized transmission-based precautions (TBP) into contact precautions, droplet precautions, airborne precautions, and enhanced barrier precautions (EBP). Clear signage would be posted on the resident door or wall outside of the resident room indicating the type of precaution implemented and required PPE. Contact precautions were designed to reduce the transmission of microorganisms by direct or indirect contact. Direct contact transmission involved the physical transfer of microorganisms to a susceptible host from an infected person and indirect contact transmission involved contact of a susceptible host with contaminated hands, objects, or surfaces. The website CDC.gov - with regard to TBP showed, Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use contact precautions for patient with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning [applying] PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of the undated facility policy titled, Enhanced Barrier Precautions showed EBP referred to the use gloves and gown during high-contact resident care activities for residents know to be colonized or infected with a MDRO or at increased risk of MDRO acquisition. The policy showed a provider order would be obtained for EBP for resident with chronic wounds and/or indwelling medical devices. High-contact care activities included dressing, bathing, transferring, providing hygiene, changing linens, and indwelling medical device care. The policy showed staff were expected to know which residents should be placed on EBP, appropriate PPE to wear and when to wear it. The website CDC.gov - with regard to EBP showed, Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities . Examples of high-contact resident care activities requiring gown and glove use include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line [venous catheter inserted into the neck, chest, or groin to provide access to the bloodstream], urinary catheter [flexible tube that drains urine from the bladder into a collection bag], feeding tube [flexible tube that provides nutrition, fluids, and medicine when unable to eat or drink safely], tracheostomy [surgical opening that creates an opening into the neck to provide alternative airway for breathing]/ventilator [machine that assists with breathing when unable to do so independently]), and wound care for any skin opening requiring a dressing . EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. <Resident 23> According to the admission assessment, dated 07/13/2024, showed Resident 23 admitted to the facility on [DATE]. The assessment further showed Resident 23 had a colostomy, had surgical wounds, did not require isolation or quarantine for active infectious disease, did not have intravenous (IV) access or a MDRO infection. Resident 23 was cognitively intact and able to verbalize their needs. Review of the 07/09/2024 clinical admission assessment showed Resident 23 had a colostomy, had an abdominal surgical incision, was not on isolation precautions for active infections, and did not have IV access. Review of the 07/10/2024 care plan showed Resident 23 was on EBP related to having a colostomy and instructed staff to follow precaution signage, perform hand hygiene per protocol, monitor for signs and/or symptoms of infection, and notify the provider of changes of condition. The 07/10/2024 care plan showed Resident 23 was at risk for impairment to skin integrity related to bruising, moisture associated skin damage and fungal skin conditions. The care plan instructed staff to perform treatments per provider orders, float heels, and therapy for positioning and mobility. Review of August 2024 through October 2024 weekly head to toe assessments showed Resident 23 had a small skin tear to their right wrist, no chronic skin issues were documented. Review of September 2024 through October 2024 nursing progress notes showed Resident 23's abdominal surgical incision healed on 09/28/2024. During observation on 10/21/2024 at 8:47 AM, EBP signage was posted right outside Resident 23's room with a plastic tote full of PPE supplies. Similar observations were made on 10/21/2024 at 9:41 AM and 2:37 PM, on 10/22/2024 at 8:50 AM and 3:36 PM. Review of provider orders as of 10/22/2024 showed no order for Resident 23 to be on EBP for their colostomy. During an interview on 10/23/2024 at 2:18 PM, Resident 23 stated their surgical incisions were healed but they still had a colostomy. In an interview on 10/24/2024 at 10:01 AM, Staff M, NA, stated Resident 23 had a colostomy but no other wounds or indwelling medical devices. In an interview on 10/24/2024 at 10:25 AM, Staff K, RN, stated Resident 23's surgical incisions had healed, did not have chronic wounds or indwelling medical devices. In an interview on 10/24/2024 at 11:50 AM, Staff B, DNS, reviewed Resident 23's medical record. Staff B stated Resident 23 did not have wounds or indwelling medical devices. In an interview on 10/28/2024 at 11:51 AM, Staff C, IP, and Staff B, DNS. Staff C stated EBP required the use of gloves and a gown when providing resident care. Staff B stated if staff were entering an EBP room they were not required to put on PPE if they were not coming into contact with the resident or their environment. Staff B explained EBP were implemented to protect the resident from potential MDRO acquisition because they were at higher risk compared to contact precautions that protected staff from MDROs. Staff B further stated EBP should be removed as soon as the indwelling medical device was removed or if discontinuation was ordered by the provider. Both Staff B and C reviewed Resident 23's medical record. Staff C stated Resident 23 was on EBP because they had a colostomy. Staff C further stated Resident 23 did not have wounds or long-term IV access. <Resident 135> According to the admission assessment, dated 10/04/2024, showed Resident 135 admitted to the facility on [DATE] with diagnoses including a MDRO infection. The assessment further showed Resident 135 had surgical wounds, had IV access, and was not on isolation or quarantine for active infectious diseases. Resident 135 was cognitively intact and able to verbalize their needs. Review of 09/30/2024 hospital discharge paperwork showed Resident 135 was to be on contact precautions for an active MDRO infection. Review of the 09/30/2024 clinical admission assessment showed Resident 135 had a surgical incision to their chest and long-term IV access. The assessment further showed Resident 135 was to be on contact isolation precautions related to a MDRO bladder infection. Review of the 10/03/2024 care plan showed Resident 135 was at risk for infection related to long-term IV access and instructed staff to completed dressing changes weekly, monitor lung sounds, and inspect the insertion site for signs and/or symptoms of infection. The 10/03/2024 urinary care plan showed Resident 135 had a MDRO bladder infection and instructed staff to administer medications per provider orders, encourage fluids, and monitor urine. Special instructions on the care plan showed Resident 135 was on contact precautions for a MDRO bladder infection. During observation on 10/21/2024 at 10:59 AM, a Contact Precaution sign was posted outside Resident 135's room. The sign instructed persons entering the room to perform hand hygiene and wear a gown and gloves prior to entering. Similar observation was made on 10/22/2024 at 8:38 AM. During observation on 10/21/2024 at 12:47 PM, Staff M, NA, entered Resident 135's room without putting on a gown or gloves, moved a breathing machine and placed it on a chair, placed a meal tray on the bedside table, adjusted the table and opened up the tray, then used ABHR when exiting the room. At 12:49 PM, Staff M returned to Resident 135's room, did not perform hand hygiene, did not put on gloves or a gown, entered the room to hand Resident 135 butter, moved the call light within reach, and used ABHR when exiting the room. At 12:54 PM, a male visitor was sitting on Resident 135's bed without wearing a gown or gloves. At 12:56 PM, the male visitor exited Resident 135's room without performing hand hygiene. In an interview on 10/28/2024 at 11:51 AM, Staff C, IP, stated if TBP were not followed it could cause the spread of infection and cause an infection outbreak. Staff C further stated they expected staff to follow TBP when implemented. In an interview on 10/28/2024 at 3:17 PM, Staff A, Administrator, stated they expected staff to follow TBP when implemented. Reference WAC 388-97-1320 (1)(a), (2)(b), (1)(c ), (3) Refer to F882 for additional information. 42802

Based on interview and record review the facility failed to not request or require residents to waive their rights to retain personal property including items of value to admit to the facility for 4 of 4 sampled residents (Resident 23, 76, 184, and 185), reviewed for resident rights. This failure placed all residents at risk of inability to exercise their resident rights, unmet needs, and diminished quality of life. Findings included . Review of the facility policy titled, Resident Rights revised February 2018, showed residents had the right to keep and use their personal belongings and property as long as it did not interfere with the rights, health, or safety of others. The facility was to protect resident property from theft. The policy further showed residents had the right to manage their own money, choose a trusted person to do so, or may deposit funds into a personal resident account (trust fund) with the facility. The facility must allow residents access to their bank accounts, cash, and other financial records. <Resident 23> According to the admission assessment, dated 07/13/2024, showed Resident 23 admitted to the facility on [DATE] with diagnoses including adjustment disorder with depressed mood. The assessment further showed it was very important for Resident 23 to care for their belongings and somewhat important to have a place to lock items for safety. Resident 23 was cognitively intact and able to verbalize their needs. Review of the 07/09/2024 facility admission agreement showed the resident had the following responsibilities to assist the facility protect their personal belongings: DO NOT bring valuables to the facility. This includes jewelry, money, credit cards. The admission agreement showed a resident/resident representative signature indicated the agreement was read, understood, and agreed to abide by all aspects of the agreement. The form was electronically signed by Resident 23 on 07/09/2024. Review of Resident 23's personal effect inventory sheet showed they brought in a wallet that was sent home with their child. The bottom of the form included the statement I certify that this is a correct list of my belongings which I wish to retain in my possession and for which I take ENTIRE RESPONSIBILITY and showed it was signed by the resident or their representative on 07/09/2024. Review of the 07/30/2024 resident preference evaluations showed it was very important for Resident 23 to care for their personal belongings. In an interview on 10/22/2024 at 9:43 AM, Resident 23 stated the facility told them they were not allowed to bring money or personal items into the facility because it was not safe. Resident 23 explained that prior to being at the facility they managed their own finances but since they admitted to the facility, they had to rely on their child to bring them money if or when needed. Resident 23 further stated they would prefer to have their insurance and debit cards on their person, if allowed by the facility. In an interview on 10/24/2024 at 10:01 AM, Staff M, Nursing Assistant, stated staff filled out a resident personal possession inventory sheet upon admission. Staff M explained residents were allowed to bring personal items but if money and/or debit cards were brought into the facility, it was inventoried, removed from the resident, and secured in a facility safe. Staff M further stated the safe was in the front office and was unsure if it could be accessed after hours. In an interview on 10/24/2024 at 10:25 AM, Staff K, Registered Nurse (RN), stated the facility completed a resident possession inventory sheet upon admission. Staff K explained residents were discouraged from bringing wallets, purses, or items of value into the facility but could bring items in if adamant. Staff K further stated the facility had a safe, but they were unsure where it was located or how to access it. In an interview on 10/24/2024 at 10:42 AM, Staff D, Social Service Director, stated resident were allowed to bring personal items into the facility but discouraged items of value because the facility did not want items to get lost. Staff D explained resident could bring items of value in if they were adamant and had a safe in the front office to secure items. Staff D further stated the admissions nurse was the only staff that had a key to the safe and was unsure how the safe was accessed after business hours or on Sundays. Staff D reviewed the admission agreement and acknowledged the verbiage appeared as if residents were not allowed to bring items in. In an interview on 10/24/2024 at 11:32 AM, with Staff E, Admission RN, and Staff F, Admission RN, they explained residents were allowed to bring personal items into the building and items inventoried on a personal possession sheet. Both Staff explained that if a resident brought in a significant amount of cash, it would be inventoried, removed and stored in the office safe because residents do not need money at the facility. They further explained the safe was in a closet in their office (behind 3 closed doors), they were the only two staff with keys to access the safe and they did not work on Sundays. Both Staff acknowledged if a resident wanted to access items in the safe after hours or on Sunday, they would have to at least wait until the next day. Both Staff E and Staff F reviewed Resident 23's admission agreement. Both staff acknowledged every resident signed the admission agreement, the verbiage on the admission agreement appeared to take away a residents right to have personal possessions as a condition of admission, and safeguarding resident personal items in a place that could not be easily accessed by a resident was similar to them not being allowed to bring items in. <Resident 184> According to the admission assessment, dated 07/29/2024, showed Resident 184 admitted to the facility on ,d+[DATE]/. The assessment further showed it was somewhat important for Resident 184 to care for their belongings. Resident 184 was cognitively intact and able to verbalize their needs. Review of the 07/25/2024 facility admission agreement showed the resident had the following responsibilities to assist the facility protect their personal belongings: DO NOT bring valuables to the facility. This includes jewelry, money, credit cards. The admission agreement showed a resident/resident representative signature indicated the agreement was read, understood, and agreed to abide by all aspects of the agreement. The form was electronically signed by Resident 184 on 07/25/2024. Review of Resident 184's personal effect inventory sheet showed no items of value were brought into the facility. The bottom of the form included the statement I certify that this is a correct list of my belongings which I wish to retain in my possession and for which I take ENTIRE RESPONSIBILITY and showed it was signed by the resident's spouse on 07/25/2024. Review of the 08/05/2024 resident preference evaluation showed it was somewhat important for Resident 184 to take care of their personal belongings. <Resident 185> According to the admission assessment, dated 09/30/2024, Resident 185 admitted to the facility ion 09/26/2024. The assessment further showed it was very important for Resident 185 to care for their personal belongings. Resident 185 had severe cognitive impairment, had short term and long term memory problems, no speech, and sometimes understood others. Review of the 09/26/2024 facility admission agreement showed the resident had the following responsibilities to assist the facility protect their personal belongings: DO NOT bring valuables to the facility. This includes jewelry, money, credit cards. The admission agreement showed a resident/resident representative signature indicated the agreement was read, understood, and agreed to abide by all aspects of the agreement. The form was electronically signed by the severly cognitivley impaired Resident 185 on 09/26/2024, not the resident representative. Review of Resident 184's personal effect inventory sheet showed no items of value were brought into the facility and unable to tell me anything related to personal items written. The bottom of the form included the statement I certify that this is a correct list of my belongings which I wish to retain in my possession and for which I take ENTIRE RESPONSIBILITY and showed unable to sign written in the resident/representative signature section on 09/26/2024. <Resident 76> According to the admission assessment, dated 09/20/2024, Resident 76 admitted to the facility on [DATE]. The assessment further showed Resident 76 was cognitively intact and it was somewhat important for them to take care of their personal belongings. Review of the 09/16/2024 facility admission agreement showed the resident had the following responsibilities to assist the facility protect their personal belongings: DO NOT bring valuables to the facility. This includes jewelry, money, credit cards. The admission agreement showed a resident/resident representative signature indicated the agreement was read, understood, and agreed to abide by all aspects of the agreement. The form was electronically signed by Resident 76 on 09/16/2024. Further review of Resident 76's record showed no personal effect inventory sheet was found. In an interview on 10/24/2024 at 11:50 AM, Staff B, Director of Nursing, reviewed the facility admission agreement and acknowledged the verbiage appeared to violate a resident rights to bring personal belongings into the facility. Reference WAC 388-97- 0040 (2)(a)(b), -1080 (4)(i)(ii)

Based on interview and record review the facility failed to routinely provide education on benefits and potential side effects of vaccinations, offer pneumococcal (bacteria that could cause respiratory infections) and influenza (flu, contagious viral respiratory illness) vaccinations when indicated, and document in the resident's medical record accordingly for 3 of 5 sampled residents (Resident 4, 52 and 78), reviewed for immunizations. These failures placed residents at risk of being unable to make informed decisions regarding immunizations, acquiring communicable diseases, and diminished quality of life. Findings included . Review of the facility policy titled, Vaccination of Residents revised November 2012, showed all residents would be offered vaccinations to aid in the prevention of infectious diseases. Residents and/or their representatives would be provided information and education regarding benefits and potential side effects of vaccinations. The policy further showed education provided would be documented in the resident's medical record. Residents and/or their representatives could refuse vaccinations for any reason, vaccine refusals would also be documented in the resident's medical record. Review of the facility policy titled, Influenza Vaccine revised November 2012, showed all residents and staff without medical contraindications would be offered the influenza vaccine annually between October 1 and March 31. The policy showed the facility would provide pertinent information about the significant risks and benefits of vaccines to staff and residents/representatives prior to vaccination with documentation of education in the resident and/or employee's record. The policy further showed a resident and/or staff vaccination refusal would be documented on the influenza informed consent form. Review of the facility policy titled, Pneumococcal Vaccine revised October 2014, showed all residents would be offered pneumococcal vaccines within 30 days of admission unless medically contraindicated or if the resident had already been vaccinated. The policy showed the facility would provide information and education regarding the benefits and potential side effects of pneumococcal vaccine prior to vaccination with documentation of education in the resident's record. The policy further showed a residents and/or their representatives could refuse vaccination and vaccine refusals would be documented in the resident's medical record. <Resident 4> According to the admission assessment, dated 09/13/2024, Resident 4 admitted to the facility on [DATE] with diagnoses including respiratory failure (serious condition that made it difficult for a person to breathe on their own). The assessment further showed Resident 4 received the influenza vaccination outside of the facility and was offered and declined the pneumococcal vaccination. Resident 4 was cognitively intact and able to clearly verbalize their needs. Review of Resident 4's immunization record showed no documentation Resident 4 was educated, offered, or administered an influenza vaccine for the October 2024-May 2025 flu season. The immunization record further showed Resident 4 refused the pneumococcal vaccination on 09/10/2024 and immunization education provided was documented as no. Review of September 2024 through October 2024 nursing progress notes showed no documentation Resident 4 was educated, offered, or administered influenza or pneumococcal vaccinations. <Resident 78> According to the admission assessment, dated 09/24/2024, Resident 78 admitted to the facility on [DATE] with diagnoses including cancer, malnutrition, and failure to thrive. The assessment further showed Resident 78 received the influenza vaccine outside of the facility and pneumococcal vaccine was up to date. Resident 78 was cognitively intact and able to clearly verbalize their needs. Review of Resident 78's immunization record showed no documentation Resident 78 was educated, offered, or administered an influenza vaccine for the October 2024-May 2025 flu season. Review of September 2024 through October 2024 nursing progress notes showed no documentation Resident 78 was educated on, offered, or administered an influenza vaccine for the October 2024-May 2025 flu season. <Resident 52> According to the admission assessment, dated 10/17/2024, Resident 52 admitted to the facility on [DATE]. Review of Resident 52's immunization record showed no documentation Resident 52 was educated or offered an influenza vaccine for the October 2024-May 2025 flu season. Review of October 2024 nursing progress notes showed no documentation Resident 52 was educated or offered an influenza vaccination for the October 2024-May 2025 flu season. In an interview on 10/28/2024 at 1:17 PM, Staff C, Infection Preventionist, stated they reviewed resident immunization records to determine which vaccinations were needed. Staff C further stated the facility offered residents pneumococcal vaccinations if they qualified and influenza vaccines during the flu season. Staff C acknowledged they did not document education on risks versus benefits of vaccinations when vaccines were offered and refused. In an interview on 10/28/2024 at 3:17 PM, Staff A, Administrator, stated they expected residents to be educated on vaccinations offered. Reference WAC 388-97-1340 (1),(2),(3) Refer to F641 and F882 for additional information

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the undated facility policy titled, Record of Food Temperatures showed the dietary department would check food temperatures on all items prepared by the dietary department, hot foods should be held at 135 degrees Fahrenheit (F), and potentially hazardous cold food kept at or below 41 degrees F. The policy instructed staff to measure and record food temperature on a temperature log every meal. Hot food temperature should be checked when placed on the steam table. Food that did not meet food code standard temperature were not to be served. Cold menu items were to be placed in an ice bath pan for holding until served. The policy instructed staff to clean, sanitize and calibrate the food thermometer used to verify food temperatures. Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised [DATE], showed hot foods should be kept at 135 F or above and cold foods should be kept at 41 F or below prior to serving. Food Preparation and Service During observation of tray line service on [DATE] at 11:35 AM, Staff CC, Dietary Cook, began to serve the lunch meal (Swiss steak, baked potato, Normany vegetables, roll, apple walnut chicken salad with gorgonzola, sweet onion dressing, fruit cup) at the steam table. Staff CC placed a baked potato on the plate, sliced it open and then added the Swiss steak on the plate. Staff CC passed the plate to their right side to Staff DD, Dietary Cook, to add more food items. Prior to serving. No staff checked the food temperatures of the food resting in the steam table. This surveyor prompted Staff CC and Staff DD to check the temperatures of all food items at the steam table. Both Staff CC and Staff DD stated they were unsure food temperature ranges that food items were required to be at prior to serving and had to ask another staff member. At 11:42 AM, Staff CC began to temp all food items with a digital food thermometer at the steam table, except the salads, which were placed in the holding fridge located underneath the steam table. During an observation on [DATE] at 11:43 AM, Staff CC used the digital food thermometer to check the temperature of the soup being served. The soup being served was stored in cardboard cups with a lid (approximately 20) stacked against the end of the right side of the steam table. The temperature for the soup was 154 F. During observation and interview on [DATE] at 11:50 AM, Staff EE, Dietary Aide, was placing cold items including fruit cups on the trays and putting them in the meal carts. Staff EE was prompted to temp the diced peaches in hard plastic cups after Staff EE stated they had not checked the temperature of the fruit being served. The regular texture fruit temperature was 54.3 F and the pureed fruit temperature was 54.5 F. In an interview on [DATE] at 11:58 AM, Staff EE, acknowledged cold food items needed to be at a temperature of at least 41 F and should have been kept in an ice bucket to keep the items cold to keep bacteria from growing. During observation during tray line on [DATE] at 12:10 PM, Staff CC did not temp two salads prior to serving and placed the salads on the steam table shelf for Staff EE to receive it on the opposite side. They stated that they did not temp the salads and were prompted again to provide the temperatures. The following temperatures were noted: the first salad at 50.2 F and the second salad at 50 F. In an interview on [DATE] at 12:35 PM, Staff U, Registered Dietician, confirmed line staff should have temped the food prior to serving during tray line and the temperature of the cold food items should have been at least 41 F. Staff U stated that this was important for food palatability and to reduce foodborne illness. In an interview on [DATE] at 12:39 PM, Staff T, Dietary Services Director, stated the soup should have been served at 160 F prior to being placed on a meal tray. Review of the kitchen temperature logs from [DATE] through [DATE] only showed the final cooking and holding temperatures, did not include temperature checks before tray line or mid service. There was no documentation on final holding temperatures for breakfast items served on [DATE]. In an interview on [DATE] at 11:05 AM, Staff T, stated the temperatures of food should be checked and monitored at the following times: final cooking, before tray line starts, mid service break and at the end of tray line. Staff T stated temperatures should have been checked throughout the meal servicing process and is important to make sure safe food temperatures are maintained. Food Storage During a kitchen observation on [DATE] at 8:50 AM, the walk-in refrigerator had one metal pan of uncovered and undated cooked bacon. The bacon was on the middle rack of the cooling shelf directly in front of the refrigerator entrance door with pans above and next to. At 9:16 AM, the bacon was still uncovered and undated. In an observation and interview on [DATE] at 2:37 PM, Staff T, acknowledge that the bacon cooling in the refrigerator should have been covered. During a kitchen observation on [DATE] at 9:34 AM, the walk-in freezer had a package of frozen shrimp sliced open at the top with an expiration date of [DATE] and an opened resealable bag of chicken wings (,d+[DATE] full) with an expiration date of ,d+[DATE]. In an observation and interview on [DATE] at 2:34 PM, Staff T was shown the expired food items in the walk-in freezer. More food items on the shelf were discovered and determined to be expired, chicken strips in a resealable plastic bag labeled with an expiration date of ,d+[DATE] and potato wedges in a resealable plastic bag labeled with an expiration date of ,d+[DATE]. Staff T acknowledged that all expired freezer items should have been discarded due to food safety regulations. Reference: WAC [DATE] (2) (3); [DATE]

Based on observation, interview, and record review the facility failed to routinely implement a system with sufficient detail to enable an accurate reconciliation of all controlled drugs, including the facilities emergency medication supply in 1 of 1 sampled medication rooms (Victorian Rose) reviewed for medication storage. This failure placed the facility at increased risk for potential controlled substance drug diversion and detracted from the facility's ability to promptly identify drug diversion. Findings included . Review of the facility policy titled, Medication Storage in the Facility reviewed January 2020, showed medication storage conditions were monitored on a monthly basis by the consultant pharmacist or the pharmacy designee. Controlled substances that required refrigeration were to be stored within a locked box, attached to the inside of the refrigerator. The policy further showed controlled substances were subject to special handling, storage, disposal and record keeping. Medications subject to abuse or diversion were to be stored in permanently affixed, double locked compartments separate from all other medications. At each shift change, or when keys were transferred, a physical inventory of all controlled substances, including refrigerated items was to be conducted by two licensed nurses and documented. During observation and interview on 10/23/2024 at 2:30 PM, with Staff Q, Registered Nurse (RN), the Victorian [NAME] medication room refrigerator was observed. The refrigerator contained a clear removable box with three separate locking compartments. The first compartment was empty, the middle compartment contained two 30 milliliter (ml) bottles of liquid Ativan (controlled substance typically used to treat anxiety or symptoms of air hunger, the feeling of being unable to breathe deep enough or running out of air, during end of life) and three different vials of insulin, the third compartment contained suppositories, a vial of insulin, and an enzyme used to break up clogs in intravenous catheters. Staff Q stated the liquid Ativan was part of the facility's emergency medication supply and tracked in the electronic medication dispensing machine. Staff Q explained that if Ativan was removed from the emergency medication supply for a specific resident the Ativan would then be logging into a controlled substance book, counted and tracked there. Staff Q further stated they were unsure how often the pharmacy checked or tracked the Ativan in the refrigerator. During observation and interview on 10/23/2024 at 2:44 PM, Staff R, RN, the Victorian [NAME] medication room refrigerator was observed. Staff R stated the liquid Ativan was part of the facility's emergency medication supply and tracked in the electronic medication dispensing machine. Staff R was unable to access the electronic medication dispensing machine to verify the Ativan count or balance. Staff R acknowledged facility nursing staff would not be aware if the Ativan count was accurate or not because it was tracked by the pharmacy. During observation and interview on 10/23/2024 at 2:58 PM, Staff B, Director of Nursing, the Victorian [NAME] medication room refrigerator was observed. Staff B removed the clear removable box containing Ativan and other medications out of the refrigerator. Staff B stated the Ativan was part of the emergency medication supply and tracked via the electronic medication dispensing machine at least twice monthly by pharmacy staff. Staff B acknowledged they would have no knowledge of potential medication drug diversion if the Ativan was not stored in a permanently affixed compartment or routinely tracked. During observation and interview on 10/23/2024 at 3:45 PM, with Staff S, Pharmacist, and Staff B, Director of Nursing. Staff S stated insulin was placed in the same locking compartment as the emergency Ativan supply to help minimize or prevent potential insulin errors. Staff B told Staff S that staff could log into the electronic medication dispensing machine to access insulin and remove Ativan without facility or pharmacy knowledge. The State Survey Agency requested documentation that showed when the emergency Ativan supply was stocked and tracked. Review of the 10/24/2024 activity transaction report, the 10/24/2024 inventory replenishment report, and an undated transaction log did not show sufficient detail to enable an accurate reconciliation of the facility's emergency Ativan medication supply. During an interview on 10/28/2024 at 3:17 PM, Staff A, Administrator, stated they expected staff to store controlled drugs in a manner that would prevent potential drug diversion and maintain records for all controlled drugs in sufficient detail to enable an accurate reconciliation. Reference WAC 388-97-1300 (1)(b)(ii), (c )(ii-iv)

Based on interview and record review the facility failed to routinely encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 7 of 7 sampled residents (Residents 6, 7, 8, 25, 48, 50, and 53), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 revised October 2023, showed the RAI consisted of three basic components: the MDS, the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three component of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. When the transmission file was received by iQIES, the system performs a series of validation edits to evaluate whether or not the data submitted met the required standards. MDS records were verified to ensure clinical responses were within valid ranges and were consistent, dates were reasonable, and records were in the proper order with regard to records that were previously accepted by iQIES for the same resident. The provider was notified of the results of this evaluation by error and warning messages on a Final Validation Report. <Resident 6> Review of the discharge assessment, dated 08/15/2024, showed Resident 6 admitted to the facility on [DATE] and discharged to the community on 08/15/2024. The assessment further showed the assessment observation end date was 08/15/2024 and was signed as completed on 10/23/2024. Review of August 2024 through October 2024 nursing progress notes showed Resident 6 discharged the facility on 08/15/2024. <Resident 7> Review of the discharge assessment, dated 08/30/2024, showed Resident 7 admitted to the facility on [DATE] and discharged to the community on 08/30/2024. The assessment further showed the assessment observation end date was 08/30/2024 and was signed as completed on 10/22/2024. Review of August 2024 through October 2024 nursing progress notes showed Resident 7 discharged the facility on 08/30/2024. <Resident 8> Review of the discharge assessment, dated 08/06/2024, showed Resident 8 admitted to the facility on [DATE] and discharged to the community on 08/06/2024. The assessment further showed the assessment observation end date was 08/06/2024 and was signed as completed on 10/23/2024. Review of August 2024 through October 2024 nursing progress notes showed Resident 8 discharged the facility on 08/06/2024. <Resident 25> Review of the discharge assessment, dated 08/07/2024, showed Resident 25 admitted to the facility on [DATE] and discharged home with services on 08/07/2024. The assessment further showed the assessment observation end date was 08/07/2024 and was signed as completed on 10/23/2024. Review of August 2024 through October 2024 nursing progress notes showed Resident 25 discharged home on 08/07/2024. <Resident 48> Review of the discharge assessment, dated 09/11/2024, showed Resident 48 admitted to the facility on [DATE] and discharged to an unknown location on 09/11/2024. The assessment further showed the assessment observation end date was 09/11/2024 and was not signed as completed as of 10/29/2024. Review of September 2024 through October 2024 nursing progress notes showed Resident 48 discharged home on 09/11/2024. <Resident 50> Review of the discharge assessment, dated 08/13/2024, showed Resident 50 admitted to the facility on [DATE] and discharged to the community on 08/13/2024. The assessment further showed the assessment observation end date was 08/13/2024 and was signed as completed on 10/23/2024. Review of August 2024 through September 2024 nursing progress notes showed Resident 50 discharged the facility on 08/13/2024. <Resident 53> Review of the discharge assessment, dated 08/06/2024, showed Resident 53 admitted to the facility on [DATE] and discharged home with services on 08/06/2024. The assessment further showed the assessment observation end date was 08/06/2024 and was signed as completed on 10/23/2024. Review of August 2024 through October 2024 nursing progress notes showed Resident 53 discharged the facility on 08/06/2024. Review of the facility MDS batch report #1032 showed 62 assessment were accepted on 10/28/2024. The batch included assessments dated 07/24/2024 through 10/23/2024, including a 07/24/2024 and a 08/13/2024 assessment for Resident 50. Review of the 10/28/2024 iQIES MDS validation report showed 62 files were submitted and accepted with 49 warning messages. The warning messages showed the following: - Resident 8, 08/06/2024 MDS assessment completed late and was more than 14 days after the assessment reference dated. - Resident 50, 07/24/2024 MDS assessment completed late and was more than 14 days after the assessment reference dated. The 08/13/2024 MDS assessment completed late and was more than 14 days after the assessment reference dated. - Resident 25, 08/07/2024 MDS assessment completed late and was more than 14 days after the assessment reference dated. - Resident 53, 08/06/2024 MDS assessment completed late and was more than 14 days after the assessment reference dated. - Resident 6, 08/15/2024 MDS assessment completed late and was more than 14 days after the assessment reference dated. - Resident 7, 08/30/2024 MDS assessment completed late and was more than 14 days after the assessment reference dated. Review of the facility resident discharge list from 08/22/2024 through 10/21/2024 showed 97 residents discharged the facility in 60 days. Review of the 10/21/2024 facility Matrix (used to identify pertinent care categories) for new admissions showed 30 residents admitted the facility in the last 30 days. In an interview on 10/29/2024 at 11:04 AM, Staff G, MDS Coordinator, explained the MDS process. Staff G stated MDSs needed to be completed and submitted to CMS per the required time frames, discharge MDS should be completed with 14 days of the event occurring. Staff G further stated a MDS validation report would be received when a MDS was submitted that would flag errors to fix and/or warnings including late submissions. Staff G acknowledged as the only MDS coordinator, they struggled to keep up with the MDS workload and had late MDS submissions, including the batch that was submitted on 10/28/2024. In an interview on 10/29/2024 at 11:22 AM, Staff A, Administrator, stated they expected MDS to be completed within the required time frames according to the RAI manual. Staff A acknowledged some MDSs were submitted late. Reference WAC 388-97- 1000 (4)(b), (5)(b)

Based on observation, interview and record review, the facility failed to consistently provide bathing for 2 of 4 sampled residents (Resident 28 and 234), reviewed for activities of daily living (ADLs). This failure placed residents at risk for poor personal hygiene, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living reviewed October 2024, showed the facility would ensure a resident's abilities in ADLs did not deteriorate unless deterioration was unavoidable. The policy further showed care, and services would be provided to include bathing, dressing, grooming, and oral care. A resident who was unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. <Resident 28> According to the comprehensive assessment, dated 10/05/2024, Resident 28 admitted to the facility on [DATE] with diagnoses including heart failure, malnutrition and anxiety disorder. The assessment further showed Resident 28 required substantial/max assistance from staff to complete showering and/or bathing. Resident 28 was cognitively intact. Review of the 10/01/2024 care plan showed Resident 28 needed assistance with showers and instructed staff to provide showers (including shampoo and nail care) per the resident's schedule. During an interview on 10/22/2024 at 9:27 AM, Resident 28 stated they had only received showers once a week and did not like the facility's organizational approach for providing showering/bathing. In a follow-up interview on 10/23/2024 at 3:58 PM, Resident 28 stated that they had not received a shower that week. Review of the shower schedule book showed Resident 28 was to receive showers twice a week on Tuesdays during the day and Friday evenings. Review of the bathing documentation from 10/1/2024 through 10/22/2024, showed Resident 28 received 2 out of 7 scheduled showers, one on 10/8/2024 and the second on 10/15/24. The record further showed N/A documented 35 times. In an interview on 10/28/2024 at 10:01 AM, Staff Y, Nursing Assistant, stated residents were scheduled for showers twice a week according to the schedule in the shower book. Staff Y further stated residents scheduled showers were heavily missed due to the lack of staff. Staff Y explained when staff was unable to perform resident baths due to staffing it was documented as N/A in their record. In an interview on 10/28/2024 at 3:33 PM, Staff B, Director of Nursing (DON), stated that staff should reapproach/reattempt to provide showers if initially refused. Staff B stated that bathing refusals were documented in the resident's electronic health record and on a shower refusal form submitted to the DON. Staff B acknowledged residents may not get showered if/when the assigned shower aide was reassigned to provide care on the unit. Staff B reviewed the shower refusal forms. Staff B acknowledged Resident 28 did not receive showers as scheduled and should have. <Resident 234> According to the admission assessment, dated 10/07/2024, Resident 234 admitted to the facility on [DATE]. Review of October 2024 nursing progress notes showed Resident 234 had diagnoses including knee fracture, required assistance with transfers, was cooperative with cares, and was occasionally incontinent. The notes further showed showers were very important to Resident 234. During an interview on 10/21/24 at 10:30 AM, Resident 234's child stated Resident 234 had not been bathed since 10/13/2024, eight days, and was instructed by staff to bathe Resident 234 themselves. Resident 234's child further stated when a scheduled shower was missed it was not guaranteed to be given at a later day or time. During an interview on 10/22/2024 at 10:22 AM, Resident 234 stated they still had not had a shower since 10/13/2024 and was still waiting to receive one as requested. Review of the shower schedule book showed Resident 234 was to receive showers twice weekly on Sunday and Wednesday evenings. Review of the shower record from 10/7/2024 through 10/23/2024 showed Resident 234 received 2 out of 5 scheduled showers. The record further showed N/A documented 27 times. No documentation was found to show Resident 234 refused to bathe or alternative bathing was offered. In an interview on 10/28/2024 at 3:33 PM, Staff B, stated the facility did not staff a bathe aide for evening shift even though residents were scheduled to bathe on evening shift and the bathe aide was often pulled to provide direct resident care on the floor. Staff B reviewed the bathing refusal documentation forms. Staff B acknowledged Resident 234 had no shower refusals and should have received showers as scheduled. Reference : (WAC) 388-97-1060 (1)(2)(a)(i)

Based on observation, interview, and record review, the facility failed to effectively implement actions to contain the spread of COVID-19, a highly contagious virus, by: 1). Failure to cohort residents appropriately (placing residents who tested positive for COVID-19 on a separate unit during infectious outbreaks), in order to prevent transmission to residents without COVID-19; 2). Failure to change personal protective equipment (PPE) (protective clothing - including gown, gloves, and goggles, used to protect the wearer and reduce the risk of spreading infectious pathogens) between residents; and 3). Failure to ensure a communicable disease/outbreak was reported to the State Survey Agency, as required. These failures placed all residents and staff at risk for contracting COVID-19, during a global pandemic and facility outbreak. The facility's failure to cohort residents with COVID-19, and change PPE between COVID and non-COVID residents, constituted a situation of an immediate jeopardy (IJ). On 01/07/2021 at 4:30 PM, the facility was notified of the IJ related to CFR 483.80 F 880, Infection Prevention and Control. On 01/13/2021 at 3:26 PM, removal of the IJ occurred through observations, interviews, and review of records, to include policies and procedures, and medical records. Findings included: COHORTING Per the CDC document titled Responding to Coronavirus (COVID-19) in Nursing Homes dated April 30, 2020, nursing homes should ensure physical separation of confirmed positive COVID-19 residents from negative residents (separate floor, wing, or cluster of rooms), to minimize the risk of [MEDICAL CONDITION] spreading to non-infected residents. In an interview on 01/06/2021 at 10:40 AM, Staff B, Infection Prevention Nurse, stated she had been in communication with the Local Health Jurisdiction (LHJ) regarding how to cohort and contain COVID by designating the units as Red, 'Yellow, and Green. Staff B provided an email communication confirming their plan with the LHJ which showed the following: Red COVID Unit o Don't change N-95 between residents - greater chance of exposure to staff if continually changing them o Once on the unit, can only enter and exit through the outside door - no going back through the building o PPE - N-95, goggles/shield, gowns, gloves - Hand Hygiene Yellow Quarantine Unit o PPE - N-95, goggles/shield, gowns, gloves - Hand Hygiene o Change mask between residents to prevent possible spread o (LHJ clarified with Staff B - the masks could be replaced every day, and goggles/shields should be wiped down between resident cares) Green Negative Unit o PPE - N-95, goggles/shields, gowns, gloves as necessary - Hand Hygiene In an interview 01/06/2021 at 10:30 AM, while standing outside the Victorian unit, a Red COVID unit, (designated to cohort residents who tested positive for COVID-19), when asked if they had any non-COVID residents on that unit, Staff B stated, yes. When asked why those residents hadn't been moved to the Yellow quarantine unit, (designated for new admissions and/or residents who had been exposed to COVID-19), Staff B stated because those residents had been more directly exposed and will get it, referring to COVID. She further stated she didn't want to increase exposure on the Yellow units by moving them. Review of the Resident Census report dated 01/06/2021, showed seven residents resided on the COVID unit who were negative for COVID-19. Further review of the census showed 13 beds were available on the two Yellow quarantine units. On 01/06/2021 at 12:18 PM, a representative of the LHJ stated she had communicated to the facility that it was not recommended to have COVID negative and COVID positive residents residing on the same unit, if at all possible. In an interview on 01/06/2021 at 12:45 PM Staff A, Administrator, confirmed the facility had chosen to leave the residents where they were, rather than risk increased exposure by moving them to the Yellow quarantine unit as recommended by the LHJ. PPE (Personal Protective Equioment) In an observation and interview on 01/06/2021 at 11:00 AM, an unnamed staff was observed on the Victorian Unit, a Red COVID Unit, changing his N-95 mask and putting on a reusable gown, prior to entering a resident room. Staff B, also present during the observation, stated there were positive and negative residents on that unit, so she had the staff change their mask and gown, so those residents wouldn't be more exposed to COVID. When asked about increasing staff exposure, per her communication with the LHJ, Staff B, shook her head in agreement. In an observation and interview on 01/07/2021 at 2:40 PM on the Serenity Unit, a Yellow quarantine unit, staff were observed to be wearing the same PPE without changing gowns or wiping down goggles between residents, as recommended by the LHJ. There were no signs posted outside resident rooms to designate which isolation precautions were in place. When asked about their process, Staff D, Registered Nurse, stated the process had completely changed from the previous day, stating they were instructed to remove the signs, and to treat all residents the same. When asked where the directive came from, Staff D stated she wasn't sure. In an observation and interview on 01/07/2021 at 3:45 PM on Victorian Unit, a Red COVID unit, staff were observed to be wearing the same PPE from one resident to the next, only changing gloves and performing hand hygiene. When asked if the non-COVID residents had been moved off the unit, Staff C, Nursing Assistant, replied, no. There were no isolation signs on the resident rooms, showing which residents were positive for COVID-19. When asked about this, Staff C shook his head, and stated they were told to remove the signs and treat them all the same. When asked who gave the directive for the change, the staff on the unit were unsure. On 01/07/2021 at 3:00 PM, a representative from the LHJ stated extended use gowns were not recommended on a quarantine unit, and could spread COVID when a facility was in outbreak status. In an interview on 01/07/2021 at 4:10 PM, when asked about the new PPE process Staff A, Administrator, stated they were treating all residents as though they had COVID. REPORTING Review of the Nursing Home Guidelines - The Purple Book, dated October 2015, showed the facility must report any communicable disease/outbreak to the State Survey Agency, and the local Department of Health. According to the facility policy Infection Control Measures during Pandemic Event, dated August 2020, showed if a pandemic pathogen was detected, notification of the local or state health officials should be completed if a case of the suspected illness was identified. On 01/04/2021, the facility made three separate calls to the Complaint Resolution Unit (CRU - the State Survey Agency reporting system), reporting positive COVID-19 residents and staff: - The first intake reported three employees who had tested positive for COVID-19 in December 2020; the first employee had tested positive on 12/15/2020 (reported 20 days after receiving positive results), the second on 12/17/2020 (reported 18 days after receiving positive results), and the third on 12/29/2020 (reported six days after receiving positive results). - The second intake reported one employee who tested positive for COVID-19 on 12/28/2020 (reported seven days after receiving positive results). - The third intake reported 10 residents and five employees who tested positive for COVID-19 on 12/31/2020 (reported four days after receiving the results). Follow-up information on the intake showed the facility called with additional information on 01/05/2021 at 1:39 PM, listing 12 additional residents had tested positive on 01/04/2021, and on 01/05/2021, seven residents and three staff had tested positive for COVID-19. In an interview on 01/06/2021 at 10:15 AM, Staff B, Infection Prevention Nurse, stated the results kept coming in, so she decided to call them all in at once instead of daily, as required. Reference: WAC 388-97-1320(1)(a)(2)(a)

Based on observation, interview, and record review, the facility failed to ensure one of four sample residents (#1), reviewed for medication administration, was free from a significant medication error. Failure to ensure medications were administered to the right resident resulted in actual harm to Resident #1, who required invasive treatment to reverse the effects of the medication error. Findings included . According to the facility's policy titled, General Policy and Procedure for Medication Administration, revised 12/23/03, staff would identify the resident when giving medication. No further guidance on how to properly identify a resident was included. Per the 09/16/19 admission assessment, Resident #1 had [DIAGNOSES REDACTED]. Additionally, the assessment showed the resident had a moderate cognitive impairment. According to a facility incident report dated 09/18/19, Staff C, Licensed Practical Nurse (LPN), administered Resident #5's ordered medications to Resident #1 that morning, after asking the resident his first name only (Resident #5 had the same first name). Included were three medications to treat high blood pressure ([MEDICATION NAME], and [MEDICATION NAME]) which Resident #1 did not use. Resident #1 also received three units of a short-acting insulin, two laxative medications, and Aspirin, all of which he did not use. Staff C discovered the error when a nursing assistant brought Resident #5 to her, and requested his morning medications. Staff C reported the insulin error only to the Advanced Registered Nurse Practitioner (ARNP). Review of the ARNP's 09/18/19 progress note showed no issues related to the insulin medication error were anticipated, as the resident had an elevated blood sugar level, was eating when the medication was delivered, and would have additional blood sugar testing later in the day. An addendum to the note showed the resident went out to a scheduled cardiology appointment (a doctor who treats disorders of the heart), where he received intravenous fluids for a low blood pressure of 64/40, before being sent to the hospital for evaluation of possible causes of the low blood pressure. According to the 09/18/19 hospital records, Resident #1 arrived with a stable blood pressure, and remained stable throughout his short stay. The additional medication errors were reported, and the doctor determined the low blood pressure was a result of the medication errors. The resident did not require additional intervention, and returned to the facility with orders for close monitoring. Review of the nursing progress notes for 09/18/19 showed the resident's vital signs were taken frequently throughout the afternoon and evening, and he had no further issues with his blood pressure. In an interview on 09/26/19 at 4:52 PM, Staff D, Registered Nurse, confirmed Resident #1 and #5 resided on the same unit, and had the same first name. Per Staff D, nurses could identify residents by their picture in the computer system, asking the nursing assistants, and/or asking the resident his or her name. Staff D stated the facility did not have a system to alert staff to residents with the same name, but there were residents with same names on other units in the facility who had not suffered a wrong patient medication error. On 09/27/19 at 10:19 AM, Resident #1 was seated in a wheelchair at a table in the middle of the unit he resided on, and offered his first name only when asked who he was. The resident provided his last name when specifically asked for it. Per the resident, when he was at his cardiology appointment he felt so awful he had to lay down, and neither he nor his family member knew why his blood pressure was so low (at the time). The resident stated he currently felt well, and had no concerns for his safety. In an interview on 09/27/19 at 12:00 PM, Staff A, Director of Nursing, confirmed Staff C, LPN, had not identified the correct resident prior to providing the medication, resulting in a significant medication error requiring medical intervention. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to ensure one of seven sample residents (#1), reviewed for medication administration, received an antidepressant medication, as ordered. As a result of the error, Resident #1 experienced psychosocial harm, as evidenced by increased symptoms of anxiety and depression. Findings included: Per the State Operations Manual, (MONTH) (YEAR) (Appendix P, Section IV, E, Psychosocial Outcome Severity Guide, Severity Level 3) shows noncompliance resulting in actual harm, can include but may not be limited to clinical compromise, decline, or the resident's inability to maintain and/or reach his/her highest practicable well-being. Examples of negative psychosocial outcomes, as a result of the facility's noncompliance, may include but are not limited to: tearfulness, persistent depressed mood, anxiety, thoughts of impending doom, and suicidal ideation (without an intent to act). Per review of Resident #1's medical record, she admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the admission orders [REDACTED]. In an interview with an interested party on 12/04/18 at 3:15 PM, she/he stated Resident #1 had a [AGE] year history of treatment with [MEDICATION NAME] for depression. The interested party stated she/he communicated and visited with Resident #1, at different times during her stay at the facility (from 11/08/18 through 11/13/18). As the days passed, the interested party noticed an increase in Resident #1's depression symptoms. On Resident #1's fourth night at the facility (11/11/18), she expressed lack of joy, was tearful, and looked depressed. Per the interested party, she looked like she was in a deep, dark hole. Review of Resident #1's nursing progress notes, dated 11/09/18 at 3:30 PM, showed an order to increase Resident #1's [MEDICATION NAME] (antianxiety medication) from 7.5 milligrams (mg.) twice a day, to 10 mg. twice a day, and administer Lorazapam (a second antianxiety medication), 1.0 mg every 12 hours as needed, for anxiety. On 11/10/18, the nursing progress notes at 12:22 PM showed Resident #1 stated, (I'm) just very emotional . On 11/11/18, the nursing progress notes at 2:06 PM showed Resident #1 had multiple complaints to loved ones, and s/s (signs/symptoms) and behaviors associated with increased anxiety and depression, panic, uneasiness, and tearfulness. The nursing progress notes on 11/11/18 at 11:38 PM showed Resident #1 was given [MEDICATION NAME] (antianxiety medication) at 6:53 PM, for thoughts of impending doom and anxiety. The note showed the resident expressed a general feeling of wanting to hurt herself, and was tearful, sad and emotional. At that time, a registered nurse found [MEDICATION NAME] was missing from the medication cart, and the resident was notified. The note showed the resident expressed concern about medications, and discussed leaving the facility against medical advice (AMA). The note showed family arrived around 8:30 PM, and were able to provide home medication ([MEDICATION NAME]), per order. Resident #1 was more relaxed and calm, and family stayed with the resident through the night. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. According to the MAR, Resident #1 missed a total of three [MEDICATION NAME] doses (on 11/08/18, 11/09/18, and 11/10/18). In an interview on 12/12/18 at 12:30 PM, Staff B, Pharmacist, confirmed it was possible for a resident, with a [AGE] year history of treatment with [MEDICATION NAME], to experience target behaviors, such as those experienced by Resident #1, if one or more doses were missed. In an interview on 12/12/18 at 1:45 PM, Staff C, Director of Nursing, confirmed Resident #1's order for the [MEDICATION NAME] was due for administration at bedtime on 11/08/18 (the date the resident admitted to the facility), and was not administered until bedtime on 11/11/18 (i.e., three missed doses). Staff C stated the Medication Administration Policy and Procedure was reviewed with all licensed nursing staff, following the discovery of the medication error for Resident #1. The facility failed to provide Resident #1 with [MEDICATION NAME] (an antidepressant medication) as ordered. As a result, Resident #1, experienced symptoms of anxiety and depression, that caused psychosocial harm. (For additional information see F-658-Services Provided Meet Professional Standards, and F-755-Pharmacy Services) Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to ensure a licensed nurse (Staff C), provided appropriate care and services, in accordance with professional standards, to 1 of 1 residents (#2), reviewed for a change in condition. This failure resulted in actual harm to the resident, who experienced a significant decline in his respiratory status, and overall condition. Findings include: According to the Lippincott Manual of Nursing Practice, Tenth Edition (Lippincott, Williams & Wilkins, 2014, page 16), The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practioners are accountable. Per the record, Resident #2 was readmitted to the facility, after a hospitalization , in [DATE]. [DIAGNOSES REDACTED]. He was also receiving oxygen. The medical record noted a [DATE] POLST (Physician order [REDACTED]. The [DATE] care plan goal, related to respiratory status, was for the resident to be free of signs of respiratory distress. Staff were directed to monitor the resident for labored breathing, wheezing, coughing, and congestion. On [DATE], Staff C, a licensed practical nurse, worked from 6 a.m. to 10 p.m., providing care to Resident #2. According to documentation in the physician reporting log (information provided to the physician, for review at his/her on-site visit to the facility), Staff C made two entries dated [DATE], which were untimed: One entry documented the resident was becoming confused and was sounding worse, extra lung sounds. An additional entry documented Resident #2 had a decreased level of consciousness, his lungs were worse, and he had increased confusion. Per a [DATE] facility investigation, the decline in the resident's condition, along with a thorough assessment, were not documented in the nursing progress notes. The investigation also indicated the physician was not notified/consulted per phone, and the registered nurse on duty was not asked to assess the resident (as per facility policy). In statements written by Staff D and E, nursing assistants, both had expressed concern related to Resident #2's condition to Staff C, and said the resident should have been sent to the hospital. Staff C refused, asked Staff E to get the resident's vital signs, and told her the physician would not be called. Although Staff C recognized the significant change in condition of Resident #2, he did not take appropriate actions, or act within professional standards of practice. The resident continued to decline, and died the evening of [DATE], of acute [MEDICAL CONDITION]. Staff C was terminated.

Based on record review and interview, the facility failed to provide timely and appropriate care and services, for 1 of 1 residents (#2), reviewed for a change of condition. Failure to adequately assess the resident, and notify/consult with the physician, resulted in actual harm to Resident #2, who experienced a continued deterioration of his respiratory status. Findings include: Review of the medical record revealed Resident #2 was initially admitted to the nursing facility in [DATE], from an acute care hospital, with multiple [DIAGNOSES REDACTED]. On [DATE], he was transferred back to the hospital from the nursing facility, because of increased shortness of breath/difficulty breathing. He returned to the nursing facility on [DATE], with additional [DIAGNOSES REDACTED]. The [DATE] care plan directed staff to: monitor the resident for symptoms of respiratory distress, including labored breathing, wheezing, coughing, and congestion. The care plan goal, related to respiratory status, was for Resident #2 to be free from signs of respiratory distress. The medical record noted a [DATE] POLST (Physician order [REDACTED]. Record review of the [DATE] physician orders [REDACTED].) Additionally, the resident had oxygen administered via a nasal cannula (flexible tubing, placed in the nose), to help with breathing difficulties. On [DATE], Staff C, a licensed practical nurse, worked a double shift (6 a.m. - 10 p.m.), and was assigned to provide nursing care tor Resident #2. Staff C documented he administered two breathing treatments to Resident #2 (at 2:00 p.m. and 8:00 p.m.). At 9:15 p.m., Staff C documented the 8:00 p.m. treatment was effective. Record review of the physician reporting log (written communication for nursing to convey non-emergent resident needs, to be reviewed by the physician when conducting a facility visit), listed two separate entries by Staff C (both dated [DATE], but not timed): - (Resident#2) is becoming confused and sounding worse, extra lung sounds. -(Resident #2) decreased LOC (level of consciousness). Lungs worse. Increased confusion. Per a facility investigation, dated [DATE], the decline in the resident's condition was not documented in the nursing progress notes, and the physician was not notified by phone which is the facility policy for significant changes in condition. Per the investigation, Staff C also did not request a registered nurse (who was also on duty) assess the resident. Further review of the investigation included witness statements by nursing assistants assigned to Resident #2 on the evening of [DATE], which documented: Staff D, a nursing assistant, said the resident hadn't been breathing well for several days, and did not look good. At approximately 8:00 p.m. on [DATE], Resident #2 was wheezing, and his eyes were rolling back. Per the statement, Staff D and another nursing assistant, went to the resident's room several times during the shift, and requested the resident get sent to the hospital; Staff C refused. Staff E, a nursing asssistant, reported Resident #2 had increased shortness of breath and confusion, and requested Staff C send the the resident to the hospital; Staff C refused. Staff E said she was instructed to get vital signs, and Staff C said he was not going to call the physician. Even though Staff C recognized the significant change of condition, and nursing assistants reported concerns over his continued deterioration, the physician was not notified regarding the worsening respiratory function or decreased level of consciousness. A thorough physical assessment of the resident was not completed, or the assistance of a registered nurse requested. The resident died the evening of [DATE], of acute [MEDICAL CONDITION]. In an interview on ,[DATE] /17 at 2:15 p.m., with Staff A, the administrator, and Staff B, the director of nursing, both confirmed the investigation results, said Staff C did not report the change of condition to the physician as expected of a nurse (and per facility policy), and was terminated. Per Staff A and B, immediately after the incident, all nursing staff were provided an in-service related to recognizing and intervening when a resident has a change in condition, following facility protocol, and physician notification.

Based on interview and record review, it was determined the facility failed to ensure interventions to prevent injury were implemented as planned for 1 of 6 sample residents (#1). The failed practice resulted in actual harm to the resident, who fell during a transfer, and sustained a fracture. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident required total assistance for all activities of daily living, and was a full mechanical lift transfer, due to non weight-bearing status on the right leg. She utilized a wheelchair for mobility. According to the record, the resident's right leg fracture was due to osteoporosis (or brittle bones), and because of this, the resident was at high risk for injury. The resident's care plan directed staff to use a mechanical lift to transfer the resident out of bed, and to maintain non weight-bearing status on the right leg. Review of a facility investigation documented the following: On the morning of 11/7/14, Staff #B and #E were assisting the resident to get out of bed for therapy. When they attempted to assist the resident to turn in bed, so they could place the mechanical lift sling under her, the resident insisted she could transfer to the wheelchair by herself - from a sitting position on the bed. Staff #B then assisted the resident to sit at the side of the bed. Staff #F reported that she brought the resident's breakfast tray to the room, while the resident was sitting up at the side of the bed. Staff #F reported that she told Staff #B the resident's care plan directed staff to transfer her out of bed using the mechanical lift. Staff #F said she then directed Staff #B to transfer the resident using the lift, and offered to stay and assist with the transfer. Staff #B said she did not need help. According to the investigation, after Staff #F left the room, Staff #B assisted the resident to stand on the left leg. The resident could not maintain her balance, and started to slide to the floor. Staff #B and #E assisted the resident to the floor, where she landed on her bottom. Per record review, staff then assisted the resident to bed using the mechanical lift. Afterwards, the resident complained of pain in her right knee. The physician ordered an immediate x-ray of the right leg, which revealed an additional leg fracture. When interviewed on 10/14/14 at 4:00 p.m., Staff #A stated the resident remained in the facility until 11/10/14, when she was transferred to the hospital for surgery to repair the fracture. During a telephone interview on 11/24/14/ at 10:35 a.m., Staff #D, the resident's physical therapist, said the resident was unable to stand on her left leg, and remained non-weight bearing on the right leg. She verified the resident required a mechanical lift to safely transfer. The facility's failure to ensure the resident was safely transferred resulted in significant injury to the resident, who fell and sustained a second fracture to her right leg. Surgical intervention and hospitalization were required to stabilize the fracture.

Based on interview and record review, the facility failed to ensure that its policies and procedures regarding reporting allegations of abuse were implemented. At least 6 different nursing assistants (Staff #F, G, H, I, J, K) and 1 licensed nurse (Staff #B) had direct observation and/or knowledge of alleged physical or verbal abusive acts by one licensed nurse (Staff #A) toward 11 of 14 residents reviewed for abuse (#6, 22, 46, 52, 55, 92, 95, 97, 100, 108,127) in a sample of 44 residents. These 6 different nursing assistants (Staff #F, G, H, I, J, K) and the licensed nurse supervisor (Staff #B) failed to immediately report different observations or knowledge of Staff #A's alleged abusive acts to the facility Administrator, the Director of Nursing, and the State Hot Line per facility policy and procedure for abuse prevention. This failure by multiple staff to report allegations of abusive behavior as required demonstrated the facility's Abuse Prevention Program was ineffective. The failure to ensure that a thorough Abuse Prevention Program was developed and implemented constituted immediate jeopardy for 11 identified residents and potentially all current residents. Findings include: Policies and Procedures: The facility's policy and procedure for abuse and neglect prevention included a clear description of who staff should report abuse allegations to. However, their Abuse Prevention Program did not evidence what administration was doing to ensure that staff were correctly implementing the information on which they were trained. There was no evidence that the facility's prevention program focused on administration responsibility to include such factors as ensuring supervision of staff providing care, particularly on the evening and night shifts, when there were lower numbers of personnel in the building. Nursing Assistants' Observations of Abuse 1. On 3/17/11 at 11:40 a.m. Staff #F, who worked the day shift on Alpine Hall, asked to speak to the surveyor. He reported an allegation that Staff #A, the evening licensed nurse on Alpine Hall, forcibly tried to get residents to drink by holding their nostrils closed. He stated he did not work the evening shift but Staff #G witnessed the alleged abuse while working the past weekend and reported the allegation to Staff #B. Resident #52 and other dependent residents residing on Alpine Hall were at risk. He stated Staff #A was still scheduled to work the evening shift on 3/17/11 and did not think Staff #B had investigated the allegation. He stated there have been concerns about Staff #B's treatment of [REDACTED]. The surveyor took action immediately report the allegation as required. During an interview on 3/23/11 at 10:00a.m., Staff #F stated Staff #A forced Resident #55 to eat by holding her arms down when she tried to push the food away. Resident #55 would tell Staff #A, "No," but Staff #A would keep feeding her. 2. During an interview on 3/21/11 at 10:00a.m., Staff #G said she would report allegations of abuse to her supervisor or administration and would call the Hot Line. She said she recently had to write a statement related to a nurse force feeding residents. Staff #G said she observed Staff #A commit alleged abusive behavior while on evening shift on 3/13/11 toward 3 residents (#46, 127, 100). Staff #G stated she normally did not work the evening shift and had not worked with Staff #A prior to this shift. Staff #G did not report the alleged abuse to the on-call manager in charge that evening. Staff #G reported the incident to Staff #B on 3/14/11. Staff #G said she should have called the State Hot Line and should have told someone that evening, but did not know who was in charge. During the above interview, Staff #G said she witnessed Staff #A putting bite after bite of food into Resident #46's mouth. Staff #G stated Staff #A said "I don't care if you like it, you are going to eat it." Per Staff #G, Resident #46's eyebrows were raised and mouth full, she looked like she did not know what to do and could not get away from Staff #A. Staff #G said this particular observation bothered her the most. She said Resident #46 was very sick and was on comfort measures. Staff #G said she witnessed Resident #127 eat 75% of her meal and drink most of her fluids. Staff #G said when this resident was done eating and her tray was removed Staff #A shook her finger and said "no no no, you are going to eat that!" Staff #A grabbed the rest of the resident's milk and went over to the resident and pushed it against her mouth and moved her head back while she poured it in. Staff #G said she assisted Resident #100 during the dinner meal on 3/13/11. Resident #100 told Staff #G she did not like the meal and just wanted to eat her jello and drink her ensure. Staff #A said, "don't give her any jello or ensure until she finishes her meal." Staff #G continued to give her the jello and ensure. Staff #G said there was some arguing between Staff #A and Resident #100. Staff #G said she asked the other nursing assistants who worked on 3/13/11 if that was how Staff #A always acted toward residents and they said yes that was her normal behavior. Staff #G said the staff did not want to make waves by saying anything because they had to work with Staff #A. Staff #G said she knew what happened was not okay and could not believe it was normal behavior. She said, she reported it because "I don't have to work with that nurse all the time so I don't care." She also said, from her experience that evening Staff #A "talks to us (referring to the nursing assistants) like she talks to the residents." Staff #G said she knew another nursing assistant (Staff #K) requested to move to another station because of Staff #A and how she treated residents. Staff #G said when she reported the concern to her, Staff #B said she would "take care of it". Staff #G said Staff #B wrote a few notes on a piece of paper, called her at home later on in the week (week of 3/14-3/18/11), and asked her to write a statement. 3. In an interview on 3/21/11 at 11:30 a.m., Staff #B stated on the morning of 3/14/11 Staff #G reported she observed Staff #A force feed Residents #46, #100, and #127 on Alpine Hall during dinner on 3/13/11. Staff #A allegedly gave Resident #46 bites of food with her mouth already full. Resident #100 and #127 were allegedly being fed the same way. Staff #B stated she documented the allegations from Staff #G. She showed the surveyors a single sheet of paper with a statement about residents being force fed and the 3 resident names listed. She stated her plan to investigate was to interview Staff #A about the allegations on 3/17/11 at 1:15 p.m., before the evening shift started at 2:00 p.m., which was the licensed nurse's next scheduled day to work. However administration received the allegation earlier in the day on 3/17/11 when reported by the surveyors, placed the licensed nurse on administrative leave, and started the investigation. She confirmed she did not report the allegation immediately and did not take any measures to protect residents beyond her plan to interview Staff #A on the next day she was scheduled to work. Regarding reporting abuse, she stated, "We are to report abuse. If the resident says ok, then we don't go further." During the interview, Staff #B stated there had been other reports of concerns about Staff #A. Nursing assistants reported Staff #A was "pretty hard" on them. Nursing assistants also reported Staff #A was "hard" on Resident #97 when she gave the resident suppositories. Nursing assistants told her the treatment was "making the resident depressed." Staff #B interviewed the resident and asked her directly if Staff #A was rough. The resident stated no, Staff #A was doing what she had to do. Staff #B stated she received this report before Christmas. She stated she did not document an investigation, did not complete any other interviews, but she did observe Staff #A feeding residents and observed no forced feeding at that time. She did not report the allegations at the time they were received and did not take any other measures to protect residents from possible further abuse. 4. During an interview on 3/21/11 at 3:30 p.m., Staff #H said she would report allegations of abuse to her supervisor and call the Hot Line. She said she never called the Hot Line before because she wanted to follow the chain of command and thought the staff at the facility could take care of concerns. Staff #H stated she worked with Staff #A on a regular basis. Staff #H said she witnessed residents being forced to eat; it was not out of the ordinary. Staff #H said what she witnessed Staff #A do to residents she considered abuse. Staff #H said she worked with Resident #46 a lot in the past and witnessed Staff #A make the resident get out of bed when she did not want to get up. Resident #46 would tell the nursing assistants including Staff #H she did not feel well enough to get up and wanted to stay in bed. Staff #A would get upset when staff informed her the resident did not want to get up and Staff #A would "huff and puff" and tell the resident "you are going to get up." Staff #H said she told the resident she did not have to do anything she did not want to do and the resident would say "I don't want to get you guys in trouble, I will get up." Staff #H said this happened numerous times, the resident was not doing good and just wanted to rest. Staff #H said she witnessed Staff #A doing nail care on Resident #6. The resident's foot wiggled because she was ticklish. Staff #H said Staff #A was irritated and said, in a mean tone, "stop moving your foot!" Staff #A then picked up the resident's leg and slammed it down, to let her know she needed to stop moving her foot. Staff #H said she and the other nursing assistants would talk about it and they would normally not say anything about her behavior because if "we did she would make work miserable for us." Staff #H said her understanding was that Staff #A had been suspended for her behavior before, saw that she continued to work at the facility and continued the behavior, so she did not think anything would be done if brought up again. 5. In an interview on 3/21/11 at 3:30 p.m., Staff #K stated she worked with Staff #A on Alpine Hall until just the last few days, when she was re-assigned to a different hall. She stated Staff #A did care about residents and could encourage them to eat. She would also force them. She stated she witnessed Staff #A make Resident #95 and #108 take both food and medication through their clenched mouths. Staff #K stated about 4 months ago, Resident #97 had "bad" hemorrhoids. Staff #A applied hemorrhoid cream and inserted her finger in the resident's rectum to apply the cream. The resident was uncomfortable, so Staff #A asked the nursing assistants to assist. The resident was in distress during the treatment and became depressed. She stated she couldn't even look at the resident, she felt so badly. She told Staff #B and stopped assisting with the treatment. She thought the resident's hemorrhoids got better. Several days ago administration asked her to submit a written statement about Staff #A's treatment of [REDACTED].#B about her concerns about the resident, so she asked Staff #B what had been determined. Staff #B told her she had forgotten about the concerns and gave her no additional information. During the interview, Staff #K stated mandatory reporting was reporting to the supervisor. If the allegation was about the licensed nurse, you reported to the Resident Care Manager (RCM). If the allegation was about the RCM, then you talked to the Director of Nursing (DNS). When asked when she would call the State Hot Line, she stated if the facility didn't do what they should do, then she would call the State Hot Line. 6. During an interview on 3/21/11 at 3:45 p.m., Staff #I said she would report allegations of abuse to her supervisor or administration and call the Hot Line. Staff #I said she worked with Staff #A for approximately 4 years. Staff #I stated she witnessed residents being force fed by Staff #A and said other nursing assistants force fed residents at Staff #A's direction, including her. Staff #I stated Staff #A cared about nutrition of residents even if they did not want to eat, it didn't matter. Staff #I said Resident #92 slept a lot and was declining. Staff #I said the resident did not want to get out of bed, did not want to eat and was sleeping. Staff #A made the resident get up and eat. Staff #A held the resident's head up for 20 minutes while she was sleeping. Staff #A instructed another nursing assistant to feed the resident while she slept and Staff #A held her head up. Staff #I stated the resident would wake up long enough to swallow every once in a while. Staff #I said Staff #A did not care if residents wanted to get up or not, eat or not or when they wanted their cares it was "her way or the highway." Staff #I said Staff #A had been doing these types of things on and off for the last 4 years. Staff #I said she forgot to put a draw sheet (the small sheet that goes over the top sheet and under the resident) on Resident #22's bed. Staff #A called Staff #I into the resident's room, while the resident was in the room in her bed. Staff #A told Staff #I "I am going to kick your ass" and told her to fix the resident's bed. Staff #I said she was scared of Staff #A and said she was not kidding when Staff #A said that to her. During an interview on 3/22/11 at 3:45 p.m., Staff #I said Staff #A would feed Resident #95 even though the resident would say "no" over and over. Resident #95 would spit her food at Staff #A, and Staff #A would put the resident's dentures back in and start feeding her again. 7. During an interview on 3/22/11 at 3:50p.m., Staff #H and Staff #J confirmed the above incident with Resident #95, and Staff #H said this kind of thing happened with all the residents on the unit where Staff #A worked. 8. During an interview on 3/22/11 at 3:55p.m., Staff #J stated Resident #97 hated getting her hemorrhoid cream. Staff #J said the resident would scream when Staff #A put the cream on the resident and she could be heard up and down the hallway. Staff #H confirmed this and Staff #I said the resident would yell "no, I don't want that." Nursing Assistants' and Licensed Nurse's Failure to Report Abuse 1. Staff #F reported knowledge of multiple allegations of physical abuse to a surveyor 5 days after they occurred, but did not report to administration and the State Hot Line for reporting abuse when they occurred. 2. Staff #K reported multiple observations of alleged physical abuse to her immediate supervisor (Staff #B), but did not report to administration and the State Hot Line for reporting abuse when they occurred. 3. Staff #B did not report allegations about Resident # 46, #97, #100, and #127 to administration and the State Hot Line for reporting abuse when they occurred. 4. Staff #G did not report the three occurrences of alleged verbal and physical abuse to her immediate supervisor when she observed it or to the State Hot Line. 5. Staff #H did not report the ongoing observations of alleged verbal and physical abuse to her immediate supervisor when she observed them or to the State Hot Line. 6. Staff #I did not report the ongoing observations of alleged verbal and physical abuse to her immediate supervisor when she observed it or to the State Hot Line. 7. Staff #J did not report the ongoing observations of alleged verbal and physical abuse to her immediate supervisor when she observe it or to the State Hot Line. 8. When the above NAs who failed to report multiple observations of possible physical and verbal abuse were asked why they did not report what they had seen and heard, reasons given included fear of Staff #A, perception that previously reported allegations concerning Staff #A were not dealt with, perceptions that Staff #A was a good nurse and had good intentions, and that by reporting to the immediate supervisor (Staff #B), administration would protect the residents and report to the State Hot Line for reporting abuse. 9. During interviews on 3/22/11 at 3:10 p.m. and 3/24/11 at 1:30 p.m., the Administrator and Director of Nursing stated that all staff were trained that they were mandatory reporters and responsible for immediately reporting alleged abuse to administration and to the State Hot Line for reporting abuse. They stated they had no knowledge of the multiple observations of possible physical and verbal abuse toward the 11 sample residents until notified by the surveyors on 3/17/11 at which time they initiated an investigation and began interviewing staff who worked on Alpine Hall. The number of staff members who were witnesses to or had knowledge of alleged abusive acts and failed to intervene to protect residents or immediately report this knowledge, demonstrated that the facility failed to have an effective abuse prevention program, resulting in actual harm for 1 resident (#97) and potentially placing all residents at risk for ongoing abuse.

Based on interview and record review, the facility's governing body/administration failed to ensure implementation of policies and procedures related to reporting allegations of abuse for 11 of 44 sample residents (#6, 22, 46, 52, 55, 92, 95, 97, 100, 108, 127) by one licensed nurse (Staff #A). Six nursing assistants (Staff #F, G, H, I, J, K) and 1 licensed nurse (Staff #B) had direct observations and/or knowledge of the alleged abuse and failed to take responsibility for reporting the allegations. This constituted Immediate Jeopardy for 11 sample residents and potentially all current residents. Findings include: See F226 for additional details On 3/17/11 at 11:40 a.m. Staff #F reported an allegation to a surveyor that Staff #A forcibly tried to get Resident #52 to drink by holding her nostrils closed. He stated he did not work the evening shift but Staff #G witnessed the alleged abuse while working the past weekend and had reported the allegation to Staff #B. He stated Staff #A was still scheduled to work the evening shift on 3/17/11 and he did not think Staff #B had investigated the allegation. He stated there were concerns about Staff #A's treatment of [REDACTED]. The survey team reported the allegations to the Director of Nursing on 3/17/11 at 12:10 p.m. and an investigation was initiated into the allegations of abuse. The Director of Nursing said there were previous complaints about Staff #A being "forceful," but only in relation to forcing staff to do their work. Staff #A was suspended and an investigation began. In an interview on 3/21/11 at 11:55 a.m. Staff #B stated that Staff #G reported to her on 3/14/11 that Staff #A was force feeding 3 residents (#46, 100, 127). Staff #B did not investigate for 4 days, since Staff #A was not working. Staff #B said she was going to talk to Staff #A on 3/17/11 when she came to work, but the survey team reported the allegations to the Director of Nursing on 3/17/11 and a full investigation began. In an interview on 3/21/11 at 3:45 p.m., the survey team reported to the Director of Nursing Resident #100's statement from an interview that "someone crammed food" in her mouth. The resident was unable to name the staff or when it occurred. The Director of Nursing said she would look into the allegation. Additional interviews with Staff #G, H, I, J, and K on 3/21/11, 3/22/11, and 3/23/11 revealed more allegations of abusive treatment of [REDACTED].#A. The interviews also revealed that staff would only call the State Hot Line if their supervisor or the facility did not take care of the allegations. Nursing assistants interviewed thought the facility dealt with the allegations somehow, but never reported back to them. In a meeting on 3/22/11 at 10:55 a.m., the Director of Nursing stated that she got written statements from Staff #F, H, I, J, and K related to the allegations of abusive treatment of [REDACTED]. The Director of Nursing confirmed the facility requested a written statement from Staff #G, but could not find it. In a meeting on 3/22/11 at 3:10 p.m., the Administrator and the Director of Nursing stated they were unaware of previous allegations of abuse by Staff #A as reported by Staff #F, G, H, I, J, and K. The Administrator and the Director of Nursing stated Staff #B had not reported any allegations regarding abuse towards Residents #46, 97, 100, and 127. The Administrator and the Director of Nursing never received reports from 6 nursing assistants or 1 licensed nurse related to direct observation and/or knowledge of allegations of abusive treatment of [REDACTED]. The Administrator and Director of Nursing confirmed all staff were educated and aware they were mandatory reporters and should have immediately reported the allegations. If staff were afraid of their supervisor, there was a "chain of command" through which they could report. Staff could always call the "on-call" supervisor or administrator to report allegations. At the conclusion of the survey on 3/24/11, the written statement from Staff #G was still unavailable. Failure to ensure implementation of the facility's policies for reporting and investigating allegations of abuse for 11 sample residents and failure to ensure staff took responsibility for reporting all allegations of abuse placed all residents in Immediate Jeopardy.

Based on interview and record review, the facility failed to provide the necessary care and services for 1 of 2 residents reviewed for bowel incontinence (#97) in a sample of 44 in accordance with the comprehensive assessment and plan of care related to management of hemorrhoids. Resident #97 suffered harm when she verbalized pain and verbally and physically resisted when Staff #A administered repeated hemorrhoid treatments. Findings include: Resident #97 had [DIAGNOSES REDACTED]. Per record review, the resident had memory problems and required limited assistance with most activities of daily living. The resident had a regular bowel pattern with no bowel medications needed. Review of the resident's treatment records revealed the resident had physician orders [REDACTED]. The resident received no hemorrhoid treatment in October 2010, 19 treatments on 16 days in November 2010, 8 treatments in December 2010, and one treatment in January 2011. In an interview on 3/21/11 at 3:30 p.m., Staff #K stated about 4 months ago, Resident #97 had bad hemorrhoids. Staff #A applied hemorrhoid cream. The resident was in distress with the treatments and Staff #A asked the nursing assistants to assist her during the treatment by holding the resident. Review of Staff #K's written statement included in the facility investigation of 3/17/11 revealed the following regarding Resident #97's response to treatments. "...At first (Resident #97) was cooperative with this but (Staff #A) would put her finger in rectum so (Resident #97) would fight. So then (Staff #A) would tell us to hold her while (Staff #A) would pull (Resident #97) pants down while (Resident #97) was screaming and crying and fighting for her to stop...which she did not stop. Per record review, there was no information on the November 2010, December 2010, and January 2011 behavior monitors that the resident was exhibiting any behaviors. Other than the treatment records, the resident's hemorrhoid treatments were not documented, including the resident's response of distress and the effectiveness of the treatment. There was no information to indicate the facility notified the physician and the family of the resident's level of distress with treatment, evaluated the treatment, and offered additional measures that would treat the hemorrhoids and alleviate the resident's pain and distress.

Based on interview and record review, the facility failed to ensure 2 of 14 residents reviewed for abuse (#92, 97) in a sample of 44 were provided medical treatment and assistance with eating in a manner that was free from abuse. Resident #97 verbalized pain and verbally and physically resisted when Staff #A administered repeated hemorrhoid treatments. Resident #92 was repeatedly forced to get up and forced to eat bites of food while staff held her head in an upright position. Resident #97 suffered harm. Resident #92 was placed at risk for harm related to aspiration, and potentially all 17 residents residing in Alpine Hall were placed at risk for harm. Findings include: 1. Resident #97 had [DIAGNOSES REDACTED]. Per record review, the resident had memory problems and required limited assistance with most activities of daily living. The resident had a regular bowel pattern with no bowel medications needed. Review of the resident's treatment records revealed the resident had physician orders [REDACTED]. The resident received no hemorrhoid treatment in October 2010, 19 treatments on 16 days in November 2010, 8 treatments in December 2010, and one treatment in January 2011. In an interview on 3/21/11 at 11:30 a.m., Staff #B stated prior to Christmas the nursing assistants reported Staff #A was hard on the resident when administering suppositories and the treatments were making the resident depressed. Staff #B stated she interviewed the resident and asked her directly if Staff #A was rough. The resident stated no, she was doing what she had to do. Staff #B stated based on the resident's verbal response, she did not investigate further. In an interview on 3/21/11 at 3:30 p.m., Staff #K stated she used to work the evening shift on Alpine Hall with Staff #A. About 4 months ago, Resident #97 had bad hemorrhoids. Staff #A applied hemorrhoid cream and inserted her finger inside the resident's rectum to apply the cream. The resident was in distress with the treatments and Staff #A asked the nursing assistants to assist her during the treatment by holding the resident. She stated she couldn't even look at the resident during the treatment and she thought the resident got depressed. She stated she reported her concerns to Staff #B and stopped assisting during the treatments. She thought the resident's hemorrhoids got better after that. She stated a few days ago the facility asked her to write a statement about what she witnessed. Review of Staff #K's written statement included in the facility investigation of 3/17/11 revealed the following regarding Resident #97's response to treatments. "...At first (Resident #97) was cooperative with this but (Staff #A) would put her finger in rectum so (Resident #97) would fight. So then (Staff #A) would tell us to hold her while (Staff #A) would pull (Resident #97) pants down while (Resident #97) was screaming and crying and fighting for her to stop...which she did not stop. I reported this to (Staff #B) because it was very wrong. (Resident #97) was a lot more depressed and weepy when this was going on." During interviews on 3/22/11 at 3:55 p.m., Staff #J stated the resident "hated" getting her hemorrhoid cream. She stated the resident would "...scream when (Staff #A) put the cream on the resident and she could be heard up and down the hallway." Staff #I stated the resident would yell "I don't want that." In an interview on 3/23/11 at 10:30 a.m., the surveyor asked the resident if she was ever handled roughly during care. The resident responded "sometimes." The surveyor asked the resident what she did when that happened and the resident did not respond. The surveyor asked her if she could tell someone when that happened and she shrugged her shoulders and stated "I sleep." Review of the Activity Program Report dated 2/11/11 revealed "this resident has had a decline related to medical issues." Review of social services quarterly notes dated 2/17/11 revealed the resident had no decline and appetite and sleeping was stable. Review of the Mental Health Care Conference Notes dated 3/11/11 revealed the resident "seemed" to be declining and recommended further assessment and re-evaluation in 30 days. There was no information available to indicate the facility evaluated the resident for psychosocial outcomes related to repeatedly receiving painful treatments she did not want. The facility failed to recognize the nursing assistants' reports as allegations of physical abuse with possible psychosocial harm. Other than the treatment records, there was no information available to determine the date the facility staff reported the allegations to Staff #B and the date Staff #B interviewed the resident. There was no information to indicate the facility took any additional measures to protect the resident from additional treatments. As a result, the resident suffered pain and mental anguish. 2. Resident # 92 had [DIAGNOSES REDACTED]. The resident required extensive assist with most activities of daily living and was no longer able to feed herself. The resident had memory problems and needed assistance with decision-making. Per the social service progress note dated 9/29/10, the resident and legal representative wanted comfort measures only and no artificial nutrition. The resident was very sleepy because of her medical condition. Per the social service notes dated 10/14/10 and 11/27/10, the resident continued to be very sleepy and difficult to arouse. Nursing assistants reported to social service staff that the resident had progressively gotten worse physically since admission. The nutrition assessment dated [DATE] noted the resident's diet was changed to pureed due to weakness and being too tired to chew. The resident was discharged to the hospital on [DATE] with aspiration pneumonia. Once the resident returned on 12/26/10, the resident received speech therapy services secondary to swallow problems. Per the nutrition assessment dated [DATE], the resident continued to have poor intake of food and was declining. It also noted the resident was "unable/unwilling" to improve intake and weight loss was expected and unavoidable. Per record review, Staff #A documented on 2/11/11, "resident weak, hanging head, held her head up and assisted her with intake." Staff #A documented the resident was more alert after she ate. During an interview on 3/21/11 at 3:45p.m., Staff #I stated she observed Staff #A force feed Resident #92 on 2/11/11. Staff #I said the resident was sleeping at dinner and "out of it" that day. Staff #I stated Staff #A refused to allow the resident to "not eat." Staff #A held the resident's head up for twenty minutes, while the resident slept in her wheelchair and instructed one of the nursing assistants to feed the resident. Staff #I watched Staff #A hold the resident's head as another aide put food in her mouth, Staff #I stated the resident would wake up long enough to swallow every now and then. During an interview on 3/23/11 at 2:40p.m., the Director of Nursing confirmed comfort care meant not forcing residents to eat. The resident was placed at risk for aspiration.

Based on observation, interview, and record review, the facility failed to ensure that allegations of physical abuse regarding 4 of 14 residents reviewed for abuse/neglect (#46, 97, 100, 127) in a sample of 44 were reported, thoroughly investigated, and that residents were protected from the possibility of further abuse, mistreatment, or neglect during the investigation as required by 42 CFR 483.13 (c)(2)(3)(4). Although alleged incidents of physical abuse were reported, there was no immediate action taken, such as protecting residents from potential further physical abuse, immediate reporting, and investigating. The failure to thoroughly investigate and protect residents after receiving allegations of physical abuse resulted in actual harm to Resident #97, who suffered pain and experienced mental anguish, and placed the identified residents and potentially all 17 residents residing in Alpine Hall at risk for abuse. Findings include: 1. Resident #97 had [DIAGNOSES REDACTED]. Per record review, the resident had memory problems and required limited assistance with most activities of daily living. The resident had a regular bowel pattern with no bowel medications needed. Review of the resident's treatment records revealed the resident had physician orders [REDACTED]. The resident received no hemorrhoid treatment in October 2010, 19 treatments on 16 days in November 2010, 8 treatments in December 2010, and one treatment in January 2011. In an interview on 3/21/11 at 11:30 a.m., Staff #B stated prior to Christmas the nursing assistants reported Staff #A was hard on the resident when administering suppositories and the treatments were making the resident depressed. Staff #B stated she interviewed the resident and asked her directly if Staff #A was rough. The resident stated no, she was doing what she had to do. Staff #B stated based on the resident's verbal response, she did not investigate further. In an interview on 3/21/11 at 3:30 p.m., Staff #K stated she used to work the evening shift on Alpine Hall with Staff #A. About 4 months ago, Resident #97 had bad hemorrhoids. Staff #A applied hemorrhoid cream and inserted her finger inside the resident's rectum to apply the cream. The resident was in distress with the treatments and Staff #A asked the nursing assistants to assist her during the treatment by holding the resident. She stated she reported her concerns to Staff #B and stopped assisting during the treatments. She thought the resident's hemorrhoids got better after that. She stated a few days ago the facility asked her to write a statement about what she witnessed. Review of Staff #K's written statement regarding the resident's response to treatment revealed the resident was "screaming and crying." During interviews on 3/22/11 at 3:55 p.m., Staff #J stated the resident "hated" getting her hemorrhoid cream. She stated the resident would "...scream when (Staff #A) put the cream on the resident and she could be heard up and down the hallway." Staff #I stated the resident would yell "I don't want that." In an interview on 3/23/11 at 10:30 a.m., the surveyor asked the resident if she was ever handled roughly during care. The resident responded "sometimes." The surveyor asked the resident what she did when that happened and the resident did not respond. The surveyor asked her if she could tell someone when that happened and she shrugged her shoulders and stated "I sleep." During interview on 3/22/11 at 3:10 p.m., the Administrator and Director of Nursing stated staff did not report the allegations to them at the time they occurred. Per record review, there was no information available to determine the date the facility staff reported the allegations to Staff #B and the date Staff #B interviewed the resident. There was no information to indicate the facility took any additional measures to protect the resident from additional treatments. The resident suffered harm as a result. 2. Resident #46 did not reside in the facility after 3/17/11. The resident had [DIAGNOSES REDACTED]. Per record review, the resident required total assistance with eating. She ate a regular diet with nectar thick liquids. Staff was directed to position her 90 degrees upright with all oral food and fluids and to feed her at a slow rate. Review of the Resident Care Conference notes dated 3/10/11 revealed family was present at the conference. The resident's medical status and weight loss was reviewed and the family stated "No force feeding" and "no tube feeding." A physician order [REDACTED]. On 3/17/11 at 11:40 a.m., Staff #F, who worked the day shift on Alpine Hall, asked to speak to the surveyor. He reported an allegation that Staff #G witnessed alleged abuse by Staff #A toward residents while working the past weekend and had reported the allegation to Staff #B. He stated Staff #A was still scheduled to work the evening shift on 3/17/11 and did not think Staff #B had investigated the allegation. Action was taken by the surveyor to immediately report the allegation as required. During an interview on 3/21/11 at 10:00 a.m., Staff #G said she recently had to write a statement related to a nurse force feeding residents. Staff #G stated she observed Staff #A commit alleged abusive behavior while on evening shift in the Alpine Hall on 3/13/11 toward 3 residents (#46, 147, 100). Staff #G stated she normally did not work the evening shift and had not worked with Staff#A prior to this shift. Staff #G reported the incident to Staff #B on the morning of 3/14/11. Staff #G said she should have called the State Hot Line for reporting abuse and should have told someone that evening but did not know who was in charge. During the interview, Staff #G said she witnessed Staff #A putting bite after bite of food into Resident #46's mouth. Staff #G stated Staff #A said "I don't care if you like it, you are going to eat it." Per Staff #G, Resident #46's eyebrows were raised and mouth full, she looked like she did not know what to do and could not get away from Staff #A. Staff #G said this particular observation bothered her the most. She said Resident #46 was very sick and was on comfort measures. In an interview on 3/21/11 at 11:30 a.m., Staff #B stated on the morning of 3/14/11 Staff #G reported she observed Staff #A force feed Residents #46, #100, and #127 on Alpine Hall during dinner on 3/13/11. Staff #A allegedly gave Resident #46 bites of food with her mouth already full. Resident #100 and #127 were allegedly being fed the same way. Staff #A stated she documented the allegations from Staff #G. She showed the surveyors a single sheet of paper with a statement about residents being force fed and the 3 resident names listed. She stated her plan to investigate was to interview Staff #A about the allegations on 3/17/11 at 1:15 p.m., before the evening shift started at 2:00 p.m., which was the licensed nurse's next scheduled day to work. However administration received the allegation from the surveyors earlier in the day on 3/17/11, had already placed Staff #A on administrative leave, and had already started the investigation. She confirmed she did not report the allegation immediately, initiate a timely investigation, and had no information to show the measures she took to protect residents. During interview on 3/22/11 at 3:10 p.m., the Administrator and Director of Nursing stated staff did not report the allegations to them at the time they occurred. 3. Resident #127 had [DIAGNOSES REDACTED]. She ate a diet of pureed texture food with pudding thick liquids and had been evaluated in March 2011 by the physician and the facility for continued weight loss. In an interview on 3/21/11 at 10:00 a.m., Staff #G stated she witnessed the resident eat 75% of her meal and drink most of her fluids. Staff #G said when the resident was done eating and her tray was removed Staff #A shook her finger at the resident and said "no no no, you are going to eat that!" Staff #A "grabbed" the rest of the resident's milk and went over to the resident and "pushed it against her mouth and moved her head back while she poured it in." Staff #G stated she reported this to Staff #B on the morning of 3/14/11. In an interview on 3/21/11 at 11:30 a.m., Staff #B confirmed she received an allegation from Staff #G on 3/14/11 about Staff #A force feeding the resident. She stated she did not immediately report the allegation and did not initiate an investigation until 3/17/11 when the surveyors notified the facility. During an interview on 3/22/11 at 3:10 p.m., the Administrator and Director of Nursing stated staff did not report the allegations to them at the time they occurred. 4. Resident #100 had [DIAGNOSES REDACTED]. In an interview on 3/21/11 at 10:00 a.m., Staff #G stated she assisted the resident during the dinner meal on 3/13/11. The resident told Staff #G she did not like the meal and just wanted to eat her jello and drink her ensure. Staff #A said, "don't give her any jello or ensure until she finishes her meal." Staff #G continued to give her the jello and ensure. Staff #G said there was some arguing between Staff #A and the resident. Staff #G stated she reported this to Staff #B on the morning of 3/14/11. In an interview on 3/21/11 10:40 a.m. with the resident in her room, the resident tired easily while talking. The surveyor asked the resident if she received the assistance she needed with eating. The resident replied "they cram food in me." The resident was unable to respond to additional questions other than to respond "happened at night." The surveyors informed the facility of the allegation on 3/21/11. In an interview on 3/21/11 at 11:30 a.m., Staff #B confirmed she received an allegation from Staff #G on 3/14/11 about Staff #A force feeding the resident. She stated she did not immediately report the allegation and did not initiate an investigation until 3/17/11 when the surveyors notified the facility. During interview on 3/22/11 at 3:10 p.m., the Administrator and Director of Nursing stated staff did not report the allegations to them at the time they occurred.

Based on record review and interview, the facility failed to ensure beverages were served at safe temperatures for 1 of 5 sample residents (#1). The failed practice resulted in actual harm to the resident who sustained second degree burns. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per the record, the resident had cognitive impairments and required extensive assistance of two for transfers. Per record review, on 10/22/10 the resident sustained [REDACTED]. The facility investigation determined staff heated the mug of cider in the microwave prior to placing it on a bedside table near the resident. A housekeeping staff member bumped the table while mopping the floor, causing the hot cider to spill onto the resident. The temperature of the hot cider was unknown as staff had not checked it. During an interview on 10/25/10 at 12:15 a.m., an administrative staff member stated that at the time of the incident, the facility did not have policies and procedures in place for heating foods or beverages in the microwave. Rather than take temperatures, staff just felt the container to see if it was too hot. The administrative staff member further stated that because the resident was in his recliner, staff was unable to remove the resident's clothing quickly enough to prevent prolonged contact with the hot liquid. As a result of the incident, the facility put policies and procedures in place requiring staff to check the temperature of all foods and liquids heated in the microwave to ensure they are under 145 degrees, and to seat residents at the table when eating or drinking. The facility's failure to put a system in place for monitoring the temperatures of foods/liquids heated in the microwave, resulted in actual harm to the resident who sustained second degree burns to his left thigh that measured 10 x 14.5 centimeters and 14 x 8 centimeters and required medical treatment.