Every finding on record at Tacoma Nursing and Rehabilitation Center

Based on observation and interview, the facility failed to ensure food was safely stored and prepared and dishes were sanitarily washed when reviewed for kitchen. This failure placed residents at risk of consuming contaminated foods, foodborne illness, a decline in condition, and a diminished quality of life. Findings included.Observation on 06/16/2026 at 8:57 AM showed the dry storage area had a canned food rack with one dented can of mandarin oranges and two dented cans of apples. Observation on 06/16/2026 at 9:01 AM showed the kitchen handwashing sink had a trash can with a lid that was not operatable via foot. Observation showed the lid needed to be lifted by hand to dispose of used paper towels. Observation on 06/17/2026 at 11:17 AM showed the facility's walk-in freezer showed 10 degrees Fahrenheit (F) and freezer items such as small single serve ice cream and hot dogs buns were soft to the touch and not frozen. Observation on 06/17/2026 at 11:20 AM showed Staff M, Dietary Manager, completed hand hygiene and carried a used paper towel across to the kitchen to a trash can with a hole in the top near the tray line. Observation on 06/17/2026 at 11:24 AM showed Staff O, Dietary Aid, completed hand hygiene and carried a used paper towel across to the kitchen to a trash can with a hole in the top near a prep station. Observation showed the trash can was overflowing, the lid could not sit flush with the can, and trash was sitting on top of the trash can. Observation on 06/17/2026 at 11:26 showed the washing machine's drain became clogged causing a large puddle in the dishwashing area. Observation showed a pack of cigarettes floating in the puddle and Staff N, Dishwasher, picked up the cigarettes from the puddle with gloved hands, opened to check the cigarettes, and put them aside. Observation showed Staff N returned to loading dirty dishes, moved to the clean dish area and began unloading clean dishes, and did not perform a glove change at any point. Observation on 06/17/2026 at 11:28 AM showed the overflowing trash can near the prep station contained used paper towels, gloves, and an empty, dented can which showed it had previously contained apples. Observation showed a dented can of apples next to the industrial can opener on the prep station. Observation on 06/17/2026 at 11:35 AM showed Staff M, Dietary Manager, performed hand hygiene and walked the used paper towel across the kitchen to a trash can with a hole in the lid near the tray line. Observation on 06/17/2026 at 11:36 AM showed Staff N, Dishwasher, unload a dietary cart of dirty dishes, pushed the cart across the kitchen into the back, took a rag from a sanitation bucket and wiped down the cart, returned to the dishwashing area, and unloaded clean dishes from racks without performing a gloves change at any point. Observation on 06/17/2026 at 11:45 AM showed Staff N, Dishwasher, sprayed and loaded dirty dishes and moved to unload clean dishes into the plate warmer without performing a glove change. Observation on 06/17/2026 at 11:48 AM showed Staff O, Dietary Aid, performed hand hygiene and moved across the kitchen to throw the used paper towel into the overflowing trash can, which laid on top of the garbage on top of the lid. Observation on 06/17/2026 at 11:48 AM showed Staff N, Dishwasher, loaded dirty dishes, moved to unload clean dishes, handed a tray of cups to another staff, and unloaded clean silverware without performing a glove change. Observation on 06/17/2026 at 11:49 AM showed a nursing staff bring a lunch tray back to the kitchen for replacement as it contained rice, which the resident did not like. Observation showed Staff O, Dietary Aid, took the tray, returned it to the tray line, and began loading trays without performing hand hygiene. Observation on 06/17/2026 at 12:21 PM showed the facility walk-in freezer showed 10 F on the internal thermometer. Observation showed some items continued to be soft to the touch and not frozen. Observation on 06/17/2026 at 12:36 PM showed the facility's walk-in freezer continued to show 10 F on the internal thermometer. Observation on 06/17/2026 at 12:40 PM showed the trash can near the tray line had started overflowing and used paper towels had fallen out onto the tray line. Observation and interview on 06/17/2026 at 12:44 PM showed the facility's walk-in freezer contained large ice cream buckets which showed signs of being melted and then refrozen. Observation showed a large brown paper bag with popsicles which were sticky to the touch. Staff P, Director of Operations, stated the single served ice creams were soft to the touch and should not have been. Staff P stated the large buckets of ice cream and paper bag of popsicles belonged to the activity department. During a joint interview on 06/17/2026 at 1:07 PM, Staff P, Director of Operations, stated facility dishwashers should remove gloves, perform hand hygiene, and don new gloves when moving between working with dirty and clean dishes. Staff P stated the observations of staff not changing gloves or performing hand hygiene when moving between dirty and clean dish sides did not meet expectations. Staff A, Administrator, stated the facility needed to re-wash all kitchen items to ensure they were not contaminated. Observation on 06/17/2026 at 2:46 PM showed the dry storage can rack contained two dented cans of mandarin oranges. During an interview on 06/22/2026 at 12:46 PM, Staff M, Dietary Manager, stated the facility put dented cans of food product in a separate area to be thrown away. Staff M stated dented cans would be used if they were not too damaged, which was when a can was dented in too far compared to a minor dent. Staff M stated the trash can at the handwashing sink could be used to dispose of used paper towels if the lid to the can was slid over a little bit, and, if it was not, staff could use a paper towel to slide it open. Staff M stated the facility's freezer had not been cooling correctly on 06/17/2026. During an interview on 06/22/2026 at 1:57 PM, Staff A, Administrator, stated the observation of stored and used dented cans did not meet expectations. Staff A stated the kitchen's handwashing sink should have a foot operated trashcan to avoid cross contamination when throwing away paper towels. Reference WAC 388-97-1100(3), -2980

Based on observation, interview, and record review, the facility failed to use measured spoons when serving and provide foods listed on the menu for 2 of 2 sampled days (06/17/2026 and 06/22/2026) reviewed for kitchen. This failure placed residents at risk of receiving reduced portions, receiving inadequate nutrition, avoidable weight loss, and a diminished quality of life. Findings included.Observation on 06/17/2026 at 11:33 AM showed Staff M, Dietary Manager, was serving rice with a gray handled scoop, vegetable medley with a green handled scoop, and carrots (the alternative to the vegetable medley) with an unmeasured silver slotted spoon. Review of the menu for 06/17/2026 lunch showed a half cup of vegetable medley, a half cup of rice, and did not show carrots included as an alternate. Review showed that residents with soft and bite size, minced, and pureed diets received altered rice. Review showed chocolate cake with peanut butter was to be served for dessert. Observation on 06/17/2026 at 12:29 PM showed the facility served cinnamon apples (the previous day's lunch dessert) for dessert. Observation and interview on 06/17/2026 at 12:32 PM showed there was no rice prepared for residents with soft and bite size, minced, and pureed diets. Staff M, Dietary Manager, stated residents with soft and bite size, minced, and pureed diets were served mashed potatoes instead of rice. Review of the menu for 06/22/2026 lunch showed teriyaki pot roast, snap peas, steamed rice, dinner roll, and peach short cake was to be served. Observation on 06/22/2026 at 11:49 AM showed the rice and snap peas were being served using unmeasured silver slotted spoons. During an interview on 06/22/2026 at 11:50 AM, Staff M, Dietary Manager, stated unmeasured silver slotted spoons were being used to serve rice and snap peas. Staff M stated no altered texture rice was prepared and mashed potatoes were being served in its place. Observation on 06/22/2026 at 11:57 AM showed facility staff prepared an order of two cheeseburgers that used slices of white bread in lieu of hamburger buns. During an interview on 06/22/2026 at 12:46 PM, Staff M, Dietary Manager, stated the facility ensured portion sizes were correct by using measured scoops when serving, and the unmeasured silver slotted spoons were for cooking. Staff M stated the menu would specify the correct amount to be provided. Staff M stated the facility did not follow the menu when it specified altered textured rice and instead would provide mashed potatoes. During an interview on 06/22/2026 at 1:57 PM, Staff A, Administrator, stated kitchen staff ensured portions sizes were correct by following the menu specified portions and using measured spoons and the observations of staff using unmeasured or incorrect measured spoons did not meet expectations. Reference WAC 388-97-1160(1)(a)(b), -1120(3)(c)(4)

Based on observation, interview, and record review, the facility failed to follow infection control practices related to enhanced barrier precautions (EBP, infection control measures used in nursing homes to prevent the spread of resistant organisms) and hand hygiene for 1 of 2 sampled residents (Resident 12) when reviewed for activities of daily living and catheter (thin flexible tube inserted into the body to withdraw urine). These failures placed the residents at risk of infection, preventable illness, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 12 was readmitted to the facility on [DATE] with diagnoses to include heart failure, end of life care (hospice), and compression fracture in the lumbar (low back) area. Resident 12 was able to communicate needs. <Enhanced Barrier Precautions> Review of the care plan, initiated on 01/19/2026, showed Resident 12 was to have EBP (staff to wear gown and gloves [PPE, personal protective equipment] when completing high contact care) related to the use of a catheter. Observation on 06/17/2026 at 01:26 PM showed Staff H, Certified Nursing Assistant (CNA), answered Resident 12's call light and provided incontinence care without wearing an isolation gown, only gloves. During the care, Staff H touched the bed linen, privacy curtain, and Resident 12's gown with their uniform. Resident 12 was laying on full size bed and Staff H was leaning on to the bed to reach Resident 12's body. <Hand Hygiene> Observation on 06/17/2026 at 1:28 PM showed Staff H, CNA, removed the front part of Resident 12's incontinent brief and wiped loose stools with wipes, then Staff H touched the privacy curtain, bed linens, and pillow that was on the chair next to bed with the soiled gloves. Staff H did not change gloves or perform hand hygiene after touching stools and wiping. A second unidentified CNA came into the room with gown and gloves and assisted Staff H with turning Resident 12 and continued with wiping loose stools from the back. The second CNA changed gloves and did not perform hand hygiene. Observation on 06/17/2026 at 1:40 PM showed Staff J, Registered Nurse (RN), entered Resident 12's room and applied ointment. Staff J stated Staff H should not have provided care without proper PPE and hand hygiene. During an interview on 06/22/2026 at 12:43 PM, Staff B, Director of Nursing Services, stated the staff were to perform hand hygiene before putting on gloves when changing gloves and after using gloves. Staff B stated staff not following EBP and lack of hand hygiene did not meet expectations. Reference WAC 388-97 -1320 (1)(c) (2)(a)

Based on observation, interview, and record review, the facility failed to provide oxygen therapy and hearing support in accordance with professional standards for 2 of 19 sampled residents (Residents 47 and 5) reviewed for quality of care. These failed practices placed the residents at risk for unmet needs and an inaccurate medical record. Findings included . Resident 5 Review of the electronic health record (EHR) showed Resident 5 readmitted to the facility on [DATE] with diagnoses to include anxiety disorder, personal history of other diseases of the respiratory system, and anemia (lack of healthy red blood cells to carry adequate oxygen to the body). Resident 5 was able to make needs known. Observations on 06/16/2026 at 12:07 PM and 06/17/2026 at 12:53 PM showed Resident 5 had an oxygen concentrator (medical device that provides supplemental oxygen) hooked to a nasal canula (devise used to deliver oxygen through a tube into the nose) in their room not in use. During an interview on 06/16/2026 at 12:07 PM, Resident 5 stated they used oxygen at night when they slept or if they were to take a nap. Review of the minimum data set assessment (MDS) dated [DATE] showed Resident 5 received oxygen therapy. Review of Resident 5's smoking care plan with an intervention initiated on 03/07/2024 showed, Patient is not on oxygen while out of bed, and no other mention of oxygen use was found in the resident's care plan. Review of Resident 5's EHR on 06/17/2026 showed no active orders for oxygen therapy. Observation on 06/18/2026 at 8:43 AM showed Resident 5 was not in their room; however, next to the resident's bed was an oxygen concentrator turned on at 4 liters (the flow of oxygen being delivered per minute) hooked to a nasal canula on the floor in the room. The oxygen tubing was dated 06/15/2026 and the plastic bag hanging off the oxygen concentrator had Resident 5's name written on it. During an interview on 06/18/2026 at 8:48 AM, Staff L, Certified Nursing Assistant (CNA), stated Resident 5 had told them that they used oxygen at night; however, they had not seen the resident use it during the day. During an interview on 06/18/2026 at 9:03 AM, Staff G, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated Resident 5 had an oxygen concentrator in their room. Staff G stated if Resident 5 stated they used oxygen at night, then they believed it was being used at night. Staff G stated Resident 5 should have had oxygen orders in place and care planned if they were receiving oxygen therapy; however, there were no orders and oxygen therapy/use had not been care planned. During an interview on 06/18/2026 at 9:17 AM, Staff B, Director of Nursing Services (DNS), stated if Resident 5 stated they used oxygen at night and the equipment was in their room then it was likely that the resident received oxygen at night. Staff B stated if Resident 5 required oxygen therapy there should have been an assessment, provider orders, implemented equipment, care planned, and oxygen saturation (SATs, measuring the percentage amount of oxygen in the blood) monitored. Staff B stated Resident 5's nightly oxygen usage did not meet their expectations. Resident 47 Review of the EHR showed Resident 47 admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms affecting memory). The resident was able to make needs known. During an interview and observation on 06/16/2026 at 1:40 PM, Resident 47 stated I can't hear you and smiled. There was no hearing aids noted in the resident's ears. During an interview and observation on 06/17/2026 at 11:28 AM, Resident 47 sat in their room watching the television, and no hearing aids were observed in the resident's ears. Review of the current plan of care on 6/17/2026 showed interventions for staff to place hearing aids in the morning and remove them to be charged in the evening. Review of the provider orders showed licensed nurses were to apply the hearing aids in the morning and remove them to charge at night, with a start date of 03/13/2024. Observation on 06/18/2026 at 9:09 AM showed Resident 47 with no hearing aid in place. During an interview on 06/18/2026 at 9:09 AM, Resident 47's roommate (Resident 78) stated [Resident 47] does not wear the hearing aids. They do not help. I think their son took them home a while ago. Review of the EHR showed staff documented in the medication administration record (MAR) from 06/01/2026 through 06/18/2026 that Resident 47 had their hearing aids placed in the mornings and removed to charge in the evening. During an interview on 06/18/2026 at 9:31 AM, Staff D, LPN, stated Resident 47's hearing aids did not work and maybe their son took them. Staff D stated they use a whiteboard to communicate. During an interview on 06/18/2026 at 9:34 AM, Staff E, CNA, stated Resident 47 did not like wearing the hearing aids. During an interview on 06/18/2026 at 9:37 AM, Staff B, DNS, stated this did not meet their expectations for Resident 47. Staff B stated Resident 47 did not wear the hearing aids and their son took them home because they do not help. Reference WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i)

Based on observation, interview, record review, the facility failed to ensure all planned and provided services were included in residents plans of care for 2 of 19 sampled residents (Residents 34 and 9) reviewed for comprehensive care plans. Failure to include Resident 34's denture use and Residents 34 and 9's oxygen use placed residents at risk of unprovided care, decline in clinical condition, and diminished quality of life. Findings included .Resident 34 Review of the electronic health record (EHR) showed Resident 34 readmitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, lung disease that causes restricted airflow and breathing problems), diabetes (high blood sugar), and anxiety disorder. Resident 34 was able to make needs known. Review of the quarterly minimum data set assessment (MDS) dated [DATE] showed Resident 34 received oxygen (O2) therapy and had broken or loosely fitting full or partial dentures. <Dentures> During an interview on 06/16/2026 at 12:40 PM, Resident 34 stated they had dentures; however, the bottom dentures did not fit right. Resident 34 stated the dentures were taken a few weeks ago to get fixed and had not got them back. Review of Resident 34's progress note dated 04/07/2026 showed, Resident received new dentures 4/6/2026. Review of the focused care plan for activities of daily living (ADL) self-care performance deficit, initiated on 01/30/2026, showed Resident 34 was independent with oral care; however, it did not show dentures. Review of the focused care plan for oral/dental health problems, initiated on 04/06/2026 showed Resident 34 had no teeth; however, it did not show dentures. During an interview on 06/18/2026 at 11:37 AM, Staff G, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated Resident 34's dentures should have been care planned when they were received. During an interview on 06/18/2026 at 12:21 PM, Staff B, Director of Nursing Services (DNS), stated Resident 34's care plan should have been revised when the resident received dentures and should reflect the resident's current oral/dental status. <Oxygen> Observations on 06/16/2026 at 9:37 AM and 12:56 PM, 06/17/2026 at 1:11 PM, and 06/18/2026 at 10:27 AM showed Resident 34 with O2 set to 2 liters (L, the flow of O2 being delivered per minute) via nasal canula (NC, devise to deliver O2 through a tube into the nose) connected to an O2 concentrator (medical device that provides supplemental O2). Review of the June 2026 MAR showed Resident 34 had an order with a start date of 05/27/2026 for continuous O2 at 2L/minute via NC to keep oxygen saturation greater than 90% and to monitor saturation every shift for COPD. Review of the focused care plan for COPD showed Resident 34 was on O2 therapy; however, it was not initiated/created until 06/15/2026. During an interview on 06/18/2026 at 10:33 AM, Staff G, RCM/LPN, stated Resident 34 was on O2 therapy; however, the care plan was not initiated until 06/15/2026 and this did not meet their expectations. Staff G stated O2 therapy care plan should have been initiated when Resident 34 was readmitted from the hospital on [DATE]. During an interview on 06/18/2026 at 10:59 AM, Staff B, DNS, stated Resident 34's care plan for O2 therapy did not meet their expectations. Resident 9 Review of the EHR showed Resident 9 admitted to the facility on [DATE] with diagnoses of pneumonia (a lung infection), diabetes, and congestive heart failure (CHF, when the heart can no longer pump enough blood). The resident was able to make needs known. Review of the EHR showed Resident 9 had a provider order for oxygen at two liters per minute with a start date of 11/19/2025. Review of the minimum data set assessment (MDS) showed Resident 9 was receiving oxygen during their stay. Review of the current plan of care on 06/17/2026 for Resident 9 showed oxygen was not included. During an interview on 06/18/2026 at 10:28 AM, Staff C, RCM/LPN, stated Resident 9 should have had a care plan in place for the use of oxygen. During an interview on 06/18/2026 at 10:35 AM, Staff B, DNS, stated it was their expectation that residents with CHF who received oxygen had it included in their comprehensive care plan and this did not happen for Resident 9 but should have. Reference WAC 388-97-1020(1)(2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 of 3 sampled residents (Resident 114) reviewed for dental services. This failure placed the resident at risk for continued dental problems and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 114 admitted to the facility on [DATE] with diagnoses to include heart failure, diabetes (the body's inability to regulate blood sugar), and dysphagia (difficulty swallowing). Resident 114 was able to make needs known. During an interview and observation on 06/16/2026 at 1:03 PM, Resident 114 stated they would like to have dentures because they had no teeth and staff were aware; however, they still had no dentures. Resident 114 had no upper or lower teeth and no visible dentures in their room. Review of the annual minimum data set assessment (MDS) dated [DATE] showed Resident 114 had no natural teeth or tooth fragments. Review of Resident 114's EHR showed a focused care plan for activities of daily living self-care performance deficit, initiated on 09/27/2023, with an intervention for Oral Care: The resident has missing teeth. Upper/lower dentures not with [Resident 114]. The resident requires oral inspection. Report changes to the nurse. Set up assist with oral cavity cares, initiated on 09/27/2023 and revised on 06/14/2024. It showed a focused care plan for potential oral/dental health problems related to edentulous [no natural teeth]. Resident is waiting for dentures initiated on 10/05/2023 and revised on 05/29/2026. Review of Resident 114's dental/dentures visit/exam form dated 05/22/2024 showed the provider recommended new upper and lower dentures. It showed handwritten on the form, Pt. [patient] said dentures lost a few weeks ago. Pt. would like new dentures. Review of Resident 114's dental/dentures visit/exam forms, dated 09/16/2024 and 01/23/2025, showed the provider recommended new upper and lower dentures. Review of Resident 114's Washington State Heath Care Authority Denture/Partial Appliance Request For Skilled Nursing Facility Client, form dated 01/29/2025 showed it was signed by the provider on 02/14/2025 and had handwritten on the form Emailed 2/17/25 @ 10:06 AM. Review of Resident 114's dental/dentures visit/exam forms dated 06/09/2025 and 03/16/2026 showed the provider recommended new upper and lower dentures. During an interview on 06/18/2026 at 12:40 PM, Staff G, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated they were not sure if Resident 114's denture request had been denied or not. Staff G stated that Staff Q, Central Supply/Transportation, would work with the denturist and the authorization process. Staff G stated that they should have been notified if the request had been denied and they had not been informed. Staff G stated on 05/05/2026 there was another request for Resident 114's dentures completed and it was emailed on 05/06/2026; however, this issue should have been addressed a lot sooner and this did not meet expectations. During an interview on 06/18/2026 at 1:06 PM, Staff Q, Central Supply/Transportation, stated they were not aware of Resident 114's denture request had been denied but could find out. Staff Q then called and spoke to the dental operations manager. Staff Q stated the dental operations manager stated that Resident 114's January 2025 denture request was denied due to needing additional information. Staff Q stated that Resident 114's denture request should have been addressed sooner, and this did not meet expectations. During an interview on 06/18/2026 at 1:57 PM, Staff A, Administrator, stated Resident 114's request for dentures should have been addressed sooner and this did not meet their expectations. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure 3 of 5 staff (Staff E, R, and G) immdiately reported abusive violations to the State Agency (SA) and facility administration. This failure placed residents at risk for abuse, potential for harm, and diminished quality of life. Findings included . Review of the facility Inicident Report (IR) dated 06/18/2024, showed Staff C, Certified Nursing Assistant (CNA), filmed two unauthorized videos of Resident 1 on their personal cellular device and posted the videos on a social media site. The first video showed Staff C lie to Resident 1 about another resident hitting them and encouraging Resident 1 to go beat the other resident up. In the video, Staff C used Resident 1's name and vulgar language. The second video showed Resident 1 lying on their bed, and Staff C asked Resident 1 how it felt to go viral. The IR conclusion substantiated abuse ocurred and that Staff E, CNA, and Staff F, CNA, failed to timely report the violations to the SA and facility administration. Review of the faciltiy IR witness statement by Staff E, Certified Nursing Assistant (CNA), dated 06/18/2024, showed they were in the room providing care to Resident 1's roommate with the curtain drawn and overheard the conversation Staff C had with Resident 1. Staff E stated they should have reported the conversation right after it happened but did not. Staff E stated they were unaware the video was taken until they saw it appear on the social medial site sometime in the previous week. Staff E, a mandated reporter, failed to report the converstaion they overheard immediately after it occurred and failed to report the video the observed (prior to 06/18/2024) to the State Agency (SA) and facility administration to protect the residents. Reveiw of the facility IR witness stated by Staff F, CNA, dated 06/18/2024, showed they observed the video at the nurse station during the day shift on 06/17/2024 while other staff were giggling about something. Staff F asked Staff C if Resident 1 was aware of the video and Staff C replied Resident 1 gave persmission to post the video, so Staff F thought nothing more of it. In an interview on 06/20/2024 at 12:30 PM, Staff C, Registered Nurse-Consultant, stated Staff E and Staff F should have reported the violation immediately to the State Agency as a mandated reporter and to facility administration and did not. Refer to F600 Reference WAC 388-97-0640 (2)(b)(5)(a)(b)(7)(b)(i)(ii).

Based on interviews and record review the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident 1) reviewed for abuse. Resident 1 experienced harm when staff failed to implement and comply with facility abuse prohibition and social media policies that violated their right to privacy and resulted in substantiated mental abuse. This failed practice also placed residents at risk for humiliation, resident-to-resident altercations, and diminished quality of life. Findings included . Review of the facility's Abuse, Neglect, and Exploitation policy, undated, showed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing their abuse prohibition policy and procedures. The policy showed possible indicators of abuse included verbal abuse of a resident overheard, psychological abuse of a resident observed, and evidence or photographs/videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent, and regardless of the resident's cognitive status. The policy indicated mental abuse included (but was not limited to) humiliation, harassment, threats of punishment, or abuse that was facilitatied or caused by nursing home staff taking or using photos/videos in any manner that would demean or humiliate a resident. Review of the facility's Social Media Policy-Residents, undated, showed the facility mandated all employees would maintain residents right to privacy, professional boundaries in the use of electronic media, and promptly report any identified breach of policy (including resident abuse). The facility mandated no: identification of any resident by name, sharing/posting/publishing of images or any resident-related information that was reasonably anticipated to violate resident rights or otherwise degrade/humiliate the resident, refer to any resident in a disparaging manner (even if they were not identified), and no photos/videos of residents on personal devices (including personal cell phones). <Resident 1> Review of the 05/08/2024 modified Quarterly Minimum Data Set (MDS-assessment tool) showed Resident 1 had some cognition problems, indicators of depression, and diagnoses included stroke, high blood pressure, and alcohol dependence. Review of the trauma informed care plan (CP), revised 01/30/2024, showed Resident 1 reported past traumatic events that included significant personal loss. Staff were directed to provide supportive care and report any signs or events of potential traumatization. Review of a Social Service Progress Note (SSPN), dated 06/18/2024 at 1:18 PM, showed a facility staff member took two videos of Resident 1 without their knowledge or permission and posted them on social media. Resident 1 recalled Staff D, Certified Nursing Assistant, entered their room about a week earlier and told Resident 1 another resident hit them. Resident 1 reported they were upset at first because they though Staff D truely was hurt. Resident 1 said they were later told by Staff D it was just a joke. Resident 1 state on the day prior (06/17/2024) Staff D asked Resident 1 how they felt about going viral, but did not know what that meant. That was when Resident 1 learned they were filmed and the videos were put on the internet. Resident 1 stated they were not asked, nor did they give permission for the videos to be recorded. In an interview on 06/20/2024 at 11:50 AM, Staff C, Registered Nurse (RN)-Consulting Nurse, stated they viewed the videos and described the content as aggregious, mentally abusive, and disheartening. Staff C stated the only person in the video was Resident 1 and heard Staff D (who was holding the phone), and Staff E, CNA, who was providing care to Resident 1's roommate at the time, behind the curtain, saying No. Staff D lied to Resident 1 about being hit by another resident and asked Resident 1 What are you going to do about it? - inciting violence, encouraging Resident 1 to defend Staff D and kick their ass. Staff C stated a group of staff were overheard giggling and talking about a viral video on 06/17/2024 at the nurse station. It was at that time that Staff F, CNA, viewed the video, but did not report the violation. Staff G, CNA, stated they heard about a video but never saw the video or who was in the video. Staff H, Maintenance Director, overheard their discussion of a viral video but did not know it contained a resident and they were in the middle of a task. Observation of a recording of the first video, on 06/26/2024 at 11:20 AM, showed the shoulder of Staff D while they walked into the room and stated [Resident 1], theres this resident out there -he just smacked me .what are you going to do? [NAME] replied Want me to beat his [a**]? Then a voice in the background that said No at the same time Staff D stated Yeah he just smacked me. [NAME] stated Where's he at? Staff D stated he's right outside. Come whoop his a** right now. How are you going to beat him up? Then a male walks into the picture and the video stopped. Observation of a recording of the the second video, on 06/26/2024 at 11:22 AM, showed Resident 1 lying on thier bed. Staff D asked Resident 1 how it felt to go viral?. In an interview on 06/26/2024 at 11:08 AM, Staff B, Director of Nursing, stated abuse was substantiated and Staff E and Staff F, who became aware of the video, should have reported the violation as soon as they obtained knowledge but did not. Refer to F-609 Reference WAC 388-97-0640 (1)(2)(3)(a)

Based on observation, interview, and record review, the facility failed to ensure 2 of 2 medication storage room refrigerators were secured (Medication Rooms Front and Back) when reviewed for medication storage. In addition, the facility failed to ensure diagnostic testing medication (PPD, purified protein derivative - a diagnostic skin test used to detect tuberculosis) were stored and dated properly. The facility failed to ensure the medication storage rooms were free of staff personal belongings, food, and drink. These failures had the potential for access to unsecured narcotics, an increased risk of drug diversion, and residents/staff to receive an expired diagnostic medication. Findings included . A document titled, Medication Storage, undated, showed that it was the facility's policy to ensure all medications housed on the premises would be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All drugs and biologicals would be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). Controlled medications were to be stored within a separately locked permanently affixed compartment when other medications were stored in the same area, such as in a refrigerator. Medication Room Back Observation on [DATE] at 8:14 AM showed the medication storage room refrigerator, which stored controlled substances, was unlocked. Observation showed a clear plastic container box located within the refrigerator was unsecured/unlocked, which contained lorazepam (a controlled substance used in the treatment of anxiety). The refrigerator also stored a vial of PPD which was open and undated. The storage room had a cabinet that stored a large purse, two medium sized food containers labeled ramen noodles, one plastic water bottle labeled purified water, which contained a light reddish colored liquid. A cabinet stored a container of instant coffee, one medium bottle of sweet relish, a bottle of thick dark molasses like substance (unlabeled), a container labeled cassia torae semen, (a Chinese medicinal herbal medicine) and a container labeled, cinnamon powder. Medication Room Front Observation on [DATE] at 8:25 AM showed the medication storage room had an unlocked medication refrigerator. Observation showed a clear plastic container stored within the unlocked medication refrigerator unsecured (unlocked) with two vials of a lorazepam. The refrigerator stored a vial of PPD which was open and undated. During an interview on [DATE] at 8:25 AM, Staff E, Licensed Practical Nurse/Staff Development Coordinator (LPN/SDC), stated the medication should have been locked and secured while in the refrigerator, and that the PPD medication vials should be labeled with an open date and discarded upon the expiration date. Staff E stated no personal items, food, or liquid should be stored within the medication storage rooms. During an interview on [DATE] at 8:58 AM, Staff B, Director of Nursing Services, stated the medication storage refrigerators should be locked along with the lorazepam narcotics within the refrigerators. Staff B stated the PPD vials, once opened, should have been dated to ensure that they would not be expired upon use. Staff B, stated no staff personal belongings, food and/or beverages should be stored in the medication storage rooms. Reference WAC [DATE] (2), -2340

Based on observation, interview, and record review, the facility failed to provide foods to accommodate residents needs and preferences for 2 of 4 tray audit opportunities when reviewed for kitchen and 1 of 1 sampled resident (Resident 45) reviewed for food choices. This failure placed residents at risk of not receiving preferred foods, decreased nutritional intake, unplanned weight loss, and a diminished quality of life. Findings included . Tray Audit A tray audit of four trays was conducted at the facility's lunch service on 03/27/2024. Observation showed the menu card had instructions to provide double portions, but normal portions were provided. Observation of the final tray showed instructions to provide a nutritional drink supplement, but there was no supplement on the tray. These two errors resulted in two of four of trays to be inaccurate from the menu card. During an interview on 03/28/2024 at 12:06 PM, Staff K, Dietary Manager, stated staff working on the tray line should provide all items written on the menu cards and that the tray audit on 03/27/2024 did not meet expectation. During an interview on 03/28/2024 at 12:44 PM, Staff A, Administrator, stated that kitchen staff should follow menu trays to ensure that resident food preferences and needs were honored. Staff A stated two of four trays being inaccurate to the menu card did not meet expectation. 46067 Resident 45 Resident 45 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs), respiratory failure (when the lungs can't get enough oxygen into the blood) and muscle weakness. During an interview on 03/25/2024 at 11:03 AM, Resident 45 stated they continued to be served foods that were on their dislike list. Resident 45 gave the example that they did not like pork; however, they had been served ham and bacon. Observation and review of Resident 45's breakfast tray on 03/27/2024 at 8:31 AM showed a slice of wheat toast, yogurt, milk, cranberry juice, and scrambled eggs and the tray card showed Dislikes and listed Fish group, Pork Group, Peas, Vegetables, Milk, OJ and scrambled eggs. During an interview on 03/27/2024 at 10:54 AM, Resident 45 said, I got scrambled eggs again for breakfast. Not sure why they ask my preferences if they are not going to listen. It is frustrating. It happens at least three times per week. During an interview on 03/27/2024 at 12:16 PM, Staff A, Administrator, stated they had been working with the kitchen on these types of issues and had recently hired a new dietary manager. Staff A stated the expectation was that resident preferences were adhered to. Reference WAC 388-97-1120 (2)(a), -1100(1), -1140 (6)

Based on observation and interview, the facility failed to ensure necessary maintenance of resident rooms for 2 of 4 sampled halls (Halls C and D) when reviewed for environment. This failure placed residents at risk for injury, lack of privacy, and diminished quality of life. Findings included . <Blinds> Observation on 03/28/2024 at 9:42 AM showed rooms 55, 57, 61, 65, 69, 70, 71, 72, 76, 82, 83, 84, 89, 91 and 96 had broken, bent or missing vinyl blinds. Numerous rooms had a window that faced the front of the building, the parking lot, and/or a busy street. <Fans> Observation on 03/25/2024 at 12:45 PM showed rooms 78, 80, 81, 82, 83, 84 and 90 had either circular or box fans labeled with the facility name in use by the resident. The fans were coated with dust and lint and some loose hanging particles could be seen moving while the fan was in operation. <Resident Countertops> Observation on 03/28/2024 at 9:42 AM showed rooms [ROOM NUMBER] had a raised screw approximately two inches sticking up on the left corners of the resident bathroom sink. During an interview on 03/28/2024 at 10:40 PM, Staff L, Maintenance Supervisor, stated they relied on staff or residents to inform them of blinds that needed to be repaired. Staff L stated they planned to replace broken blinds with a new vertical blind as they became available instead of replacing the current blinds. Staff L stated the raised screws were a safety hazard, but they were only aware of one room that still had the raised screws. Staff L stated they did not know who was responsible for cleaning the resident fans but they had their assistant start cleaning them in the last few days. During an interview on 03/28/2024 at 11:52 AM, Staff A, Administrator, stated they were aware that many rooms had broken blinds and they were in the process of converting to new blinds. Staff A stated it was an issue for resident privacy and did not meet their expectation. Staff A stated maintenance was responsible for making sure resident rooms did not have safety issues and there should not have been any sharp objects sticking up that could injure staff or residents. Staff A stated no staff had been designated to clean the resident's fans, but if visibly soiled housekeeping or maintenance should clean them. Reference WAC 388-97-3220 (1)

Based on interview and record review, the facility failed to develop and/or implement individualized comprehensive care plans for 3 of 24 residents (Residents 89, 38 and 45) whose care plans were reviewed. Failure to develop and implement care plans that were individualized and accurately reflected resident care needs related to Resident 89's enteral tube (a method of feeding that used the gastrointestinal [GI] tract to deliver nutrition and calories) and an esophagostomy (spit fistula, an opening in the neck or chest created and connected to the upper esophagus to allow spit to leave the body safely), Resident 38's epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), or Resident 45's diagnosis of chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs), respiratory failure (when the lungs can't get enough oxygen into the blood), and heart failure (when the heart doesn't pump enough blood for your body's needs) placed residents at risk of unmet care needs and potential negative outcomes. Findings included . Resident 89 Resident 89 was readmitted to the facility on [DATE] with diagnoses to include postprocedural complications and disorders of digestive system. Review of the electronic health record (EHR) showed Resident 89 had a percutaneous enteral jejunostomy tube and a surgically placed esophagostomy. Resident 89 was able to make their needs known and required assistance with activities of daily living (ADLs). Review of Resident 89's care plan showed the facility did not include any self-maintenance care of either the enteral feeding tube or the esophagostomy. During an interview on 03/27/2024 at 1:51 PM, Staff H, Licensed Practical Nurse/Residential Care Manager (LPN/RCM), stated that Resident 89 should have had their care plan updated to reflect the feeding tube and spit fistula self-maintenance care program. During an interview on 03/27/2024 at 2:06 PM, Staff B, Director of Nursing Services (DNS), stated that it was their expectation the care plan was updated to show that Resident 89 had a self-maintenance program for the care of their spit fistula and feeding tube. 46148 Resident 38 Resident 38 admitted to the facility on [DATE] with a diagnosis of epilepsy. Review of Resident 38's care plan showed the facility did not include the diagnosis or interventions related to epilepsy. Resident 45 Resident 45 admitted to the facility on [DATE] with diagnoses including COPD, respiratory failure, and heart failure. Review Resident 45's care plan showed the facility did not include the diagnoses or interventions related to COPD, respiratory failure, or heart failure. During an interview on 03/27/2024 at 9:04 AM, Staff F, Minimum Data Set/LPN, stated if a resident had a diagnosis included in the comprehensive assessment it should also be included in the resident's care plan. During an interview on 03/28/2024 at 11:08 AM, Staff B stated that it was their expectation that Residents 38 and 45 would have a comprehensive care plan that included their significant medical diagnosis such as epilepsy, COPD, respiratory failure, and heart failure. Reference WAC 388-97 -1020(1), (2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 24 sampled residents (Residents 89, 104, and 3) reviewed. The facility failed to ensure Resident 89's enteral tube (a method of feeding that used the gastrointestinal [GI] tract to deliver nutrition and calories) and an esophagostomy (spit fistula, an opening in the neck or chest created and connected to the upper esophagus to allow spit to leave the body safely) were managed, Resident 104's peripherally inserted central line catheter (PICC, a long flexible catheter [tube] placed into a vein in the upper arm and into a large vein in the chest) was monitored, and Resident 3's provider order to monitor hours slept were documented. These failures placed residents at risk of medical complications, unmet needs, and a poor quality of life. Findings included . According to the [NAME] Manual of Nursing Practice, Tenth Edition ([NAME], [NAME] & [NAME], 2014, page 16), The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable. According to [NAME], Duell & [NAME], Clinical Nursing Skills, 6th Edition, page 4, Nurse Practice Act identified skills and functions that professional nurses perform in daily practice included, in part, to administer treatments per physician's orders. The Washington State Nurse Practice Act, WAC 246-840-710(2)(d), states nurses violate standards of practice by, Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards. <Enteral Tube/Esophagostomy Fistula Maintenance> Review of the electronic health record (EHR) showed that Resident 89 readmitted to the facility on [DATE] with a diagnosis of postprocedural complications and disorders of digestive system. The documentation showed that the resident had a percutaneous enteral jejunostomy tube (J-tube, a tube surgically inserted through the abdomen directly into the small intestine to give medications, liquids, and liquid food to the resident) and a surgically placed esophagostomy. THe EHR showed Resident 89 was able to make their needs known and required assistance with activities of daily living (ADLs). Observation and interview on 03/25/2024 at 11:55 AM showed Resident 89 laid in bed. An IV pole next to the resident's bed had a tube feed bag 3/4 empty and was not attached or was infusing into the resident. Resident 89 stated they had recently disconnected themselves from the J-tube feed and they would start the feed later in the day. The tube feed bag was unlabeled and untimed, and, when asked what type of tube feed (liquid nutrition) was in the bag, the resident was unable to verbalize the name or type of liquid nutrition. An esophageal spit fistula was observed on the resident's left upper chest area with a stoma (surgical opening) affixed along with a drain bag. The resident stated that they did all their own care for the esophageal spit fistula and the J-Tube. Review of Resident 89's providers order summary, dated 01/18/2024, showed licensed staff were to administer the resident [NAME] Farms 1.4 tube feed at 65 milliliters (ml)/hour (a plant based nutritionally advanced formula) started at 3:00 PM and to disconnected at 11:00 AM, and to provide water flushes 30 ml for pre and post medication administration. Additional orders showed that licensed nurses (LNs) were to change the resident's wafer (a thin disk device used to enclose a medication or to separate two structures from one another) and drainage bag every Friday. The order summary did not show the resident was to conduct any self-care related maintenance to the tube feed or the spit fistula. Review of Resident 89's care plan, revised on 01/04/2024, showed that the resident had actual skin impairment for a spit fistula to the left upper chest and a feeding tube to the lower middle abdomen. No interventions on the care plan showed Resident 89 was to conduct self-care of the esophageal spit fistula or feeding tube. During an interview on 03/27/2024 at 1:18 PM, Staff J, Licensed Practical Nurse (LPN), stated that Resident 89 was on a self-medication program and that the resident was to conduct all care and services to the spit fistula, tube feeding and administer their own medication after the LNs crushed up the resident's medication. During an interview on 03/27/2024 at 1:51 PM, Staff H, LPN/Residential Care Manager (RCM) stated Resident 89 had a self-medication assessment conducted; however, it did not specify that tube feed care and services or esophageal fistula was to occur. Staff H stated that the self-management of the tube feed and spit fistula should have been on the medication administration record (MAR) and/or the treatment administration record (TAR) for the LNs, but the order must have dropped off after the resident's last hospitalization and subsequent readmission. During an interview on 03/27/2024 at 2:06 PM, Staff B, Director of Nursing Services (DNS), stated that it was their expectation that the orders for self-maintenance and management of the tube feed and spit fistula should have been ordered and placed on the MAR and/or TAR and the care plan updated accordingly. <PICC> Review of a document titled, Peripherally Inserted Central Line Catheter (PICC), date 08/2021, showed considerations were needed prior to starting (administering) the infusion. A written report of the line placement was required of the tip (intravenous line) verification, measurement of the external length of the PICC catheter (catheter only - not the hub, extension set or needleless connector) at insertion, with each dressing change, and when clinically indicated if catheter dislodgement was suspected. Staff were directed to compare the measurement obtained at insertion prior to the start of the infusion. Review of the EHR showed that Resident 104 admitted to the facility on [DATE] with diagnoses to include septic arthritis (infection in the joint fluid and tissues) and osteomyelitis (inflammation of bone or bone marrow usually due to infection) to the right hip and was admitted for long term intravenous (IV, into the vein) antibiotic treatment. Resident 104 had a PICC line inserted into their right arm. Review of Resident 104's care plan, dated 02/29/2024, showed Resident 104 was on IV antibiotic therapy related to septic arthritis and osteomyelitis. An additional care plan focus, dated 03/01/2024, showed that the resident was on the IV medication related to bacteremia (presence of bacteria in the blood). Several interventions were documented for the LN to monitor the IV site for complications; however, no care plan documentation showed for the LNs to measure the PICC line catheter length prior to administering the IV antibiotic medication infusion. Review of Resident 104's MAR orders showed an order for ceftriaxone (an antibiotic used in the treatment of bacterial infections) to be administered intravenously one time a day. The resident's TAR had several IV protocol orders that directed LN staff to change the IV dressing every week (Thursday) and as needed and to monitor the insertion site every shift. Observation and interview on 03/25/2024 at 2:14 PM showed Resident 104 laid in bed with an empty antibiotic bag labeled ceftriaxone along with IV tubing. The resident stated that they had been admitted for antibiotic therapy for an infection and that the LNs administered the antibiotic every day into their PICC line; however, the resident was unaware of whether LN staff measured the PICC catheter prior to administering the IV antibiotic. During an interview on 03/27/2024 at 10:03 AM, Staff J, LPN, stated that the PICC line dressing was changed the evening of 03/26/2024 and that the insertion site was assessed for infection and monitored for possible infiltration every day; however, they were unaware and did not ensure the correct measurements were in place or recorded prior to infusion of the resident's IV antibiotics. During an interview on 03/27/2024 at 11:21 AM, Staff B, DNS, stated that it was the expectation that the LNs to ensure the correct placement/measurements of the PICC line catheter prior the administration or infusion of the antibiotic medications and at each catheter dressing change for Resident 104. 38344 <Sleep Monitoring> Review of the EHR showed that Resident 3 readmitted to the facility on [DATE] with diagnoses to include depression and insomnia (persistent problems falling and staying asleep) and was able to make needs known. Review of the order dated 03/22/2023 showed that Resident 3 was prescribed melatonin (used to treat sleep problems) two tablets at bedtime related to insomnia. Review of the behavioral administration record (BAR) from 03/01/2024 - 03/26/2024 showed that Resident 3 had a provider order with a start date of 08/30/2023 to monitor hours of sleep related to melatonin use, every shift, for insomnia. It showed for staff to document the number of hours Resident 3 slept; however, all opportunities were recorded as an X. During an interview on 03/27/2024 at 2:08 PM, Staff C, LPN, stated that Resident 3's March 2024 BAR was missing documentation of hours the resident slept and this did not meet expectations. Staff C stated there was no documentation in the progress notes to show hours Resident 3 slept each shift. During an interview on 03/27/2024 at 2:23 PM, Staff B, DNS, stated that there was no numerical documentation for hours slept in Resident 3's March 2024 BAR and there should have been. Reference WAC 388-97-1620 (2)(b)(i)(ii), (6)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure activities of daily living assistance for a dependent resident was provided for 1 of 3 residents (Resident 59) reviewed for activities of daily living. The facility failed to ensure upper and lower denture placement was provided for Resident 59 which placed the resident at risk for decreased self-worth, depression, and a diminished quality of life. Findings included . Review of Resident 59's electronic health record (EHR) showed the resident readmitted to the facility on [DATE] with diagnoses to include muscle weakness, no natural teeth or tooth fragments, right and left-hand muscle contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and was able to make needs known. Observations on 03/25/2024 at 1:00 PM, 03/26/2024 at 9:06 AM, and 03/27/2024 at 9:20 AM, 12:20 PM, 12:40 PM, and 12:52 PM showed Resident 59 with no upper or lower dentures in place. During an interview on 03/25/2024 at 1:00 PM, Resident 59 stated they got new dentures about two months ago; however, they did not know where they were and had told staff, but nothing had been done about it. Observation and interview on 03/25/2024 at 1:09 PM showed Resident 59 with fingers of both hands curved inward toward the palms and the resident was unable to straighten their fingers. Resident 59 stated their hands had been that way before coming to the facility and needed staff assistance to assist them with denture placement. During an interview on 03/27/2024 at 12:20 PM, Resident 59 stated they had been offered to wear their dentures in the past and could not recall when staff stopped offering to put them in but that the resident wanted to wear their dentures. During an interview on 03/27/2024 at 12:40 PM, Staff D, Certified Nursing Assistant, stated they were familiar with Resident 59 and that the resident did not wear dentures and had never known Resident 59 to wear dentures. Staff D looked in Resident 59's closet, drawers, and was unable to locate any dentures. During an interview on 03/27/2024 at 12:52 PM, Staff C, Licensed Practical Nurse, stated Resident 59 had upper and lower dentures. Staff C located Resident 59's dentures and stated they were not sure why they were not in place and showed the dentures to Resident 59. Resident 59 said, Okay, there they are. During an interview on 03/27/2024 at 1:22 PM, Staff B, Director of Nursing Services, stated they were not aware that Resident 59 was not being offered to wear upper and lower dentures and that this did not meet expectations. Staff B stated Resident 59's care plan showed that the resident had upper and lower dentures and to provide oral and denture care; however, it did not include for denture placement to be offered in the AM (morning) and removed in the PM (evening) or to encouraged to wear during meals, and it should have. Reference WAC 388-97-1060 (2) (b)

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received the necessary services to maintain their level of functioning and/or prevent decline for 1 of 4 sampled residents (Resident 50), reviewed for limited range of motion (ROM). This failure placed the resident at risk for decreased ROM, increased pain, and diminished quality of life. Findings included . Review of a document titled, Restorative Nursing Programs, undated, showed that it was the facility's policy to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. In addition, the document showed that residents may receive restorative nursing services when not a candidate for specialized rehabilitation services or upon discharge from therapy. Furthermore, the document showed that the discharge therapist would communicate to the appropriate restorative aide, the provisions of the resident's restorative plan, providing any necessary training to carry out that plan. Review of the admission minimum data set assessment dated [DATE] showed Resident 50 admitted on [DATE] with a diagnosis of fracture of the right femur (a bone in the leg extending from pelvis to the knee). The resident was able to make needs known and was dependent or required substantial/maximal assistance with activities of daily living (ADL). During an interview on 03/25/2024 at 11:58 AM, Resident 50 stated they had received physical therapy previously for about a month but had been taken off the list and not had any additional therapy. Resident 50 stated they had rarely been assisted in getting out of bed and wanted to receive continue therapy. Review of Resident 50's progress note dated 02/08/2024 showed therapy services were reviewed and that the resident would receive therapy for five days a week from both physical therapy (PT) and occupational therapy (OT) and that therapy reviewed goals such as sitting balance, grooming, taking a few steps, transfer training and safety awareness. In addition, the resident's length of stay was to be for approximately two to three weeks and that discharge date was unknown as the resident lived in an apartment on the 3rd floor with 25 steps to get up to the apartment. Furthermore, Resident 50 was unable to walk and had agreed to stay at the facility until medically discharged . Review of a care plan revised on 02/06/2024 showed that Resident 50 had an ADL self-care performance deficit related to a fracture and immobility. The resident's goal would be to increase current level of function in all ADLs through the review date. Interventions included to monitor/document and report, when necessary, any changes, any potential for improvements, reasons for self-care deficits, expected course and decline in function. In addition, PT/OT was to evaluate and treat as per providers orders. During an interview on 03/27/2024 at 12:50 PM, Staff G, Physical Therapy Assistant (PTA), stated Resident 50 had been provided a lot of encouragement, had plateaued (remained at a stable level of achievement; leveled off), was discharge from PT/OT and was referred to a restorative nursing program from PT and a functional maintenance program from OT. Review of a document titled, Physical Therapy Discharge Summary, signed on 03/13/2024 showed that a physical therapist had a discharge recommendation of 24-hour care, restorative nursing program (RNP, a program that focuses on maximizing an optimal level of function that enables residents to retain their independence following the effects of an illness or injury). An additional document, titled, Occupational Therapy Discharge Summary, signed by an occupational therapist registered on 03/01/2024 show the resident's prognosis was to maintain current level of functioning (CLOF) and would be good with consistent staff follow-through. The discharge recommendation was to refer to functional maintenance program (FMP, a clinical program designed to augment or maintain a resident's functional status and well-being). During an interview on 03/27/2024 at 2:29 PM, Staff B, Director of Nursing, stated that they had never received the discharge documents from the PT/OT department but would start the program accordingly. Reference WAC 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to follow prepared menus for 2 of 4 halls (Halls C and D) and historically when reviewed for kitchen. This failure placed residents at risk of receiving nonpreferred food, decreased nutritional intake, and a diminished quality of life. Findings included . Kitchen Observation Review of the menu for 03/27/2024 showed meatloaf, potatoes au gratin, peas, dinner roll, and upside-down cake. Observation on 03/27/2024 at 11:58 AM showed the facility ran out of prepared meatloaf and started preparing hamburger patties topped with gravy. Observation on 03/27/2024 at 12:35 PM showed the facility ran out of dinner rolls and began serving biscuits with lunch trays. Observation on 03/27/2024 at 12:45 PM showed the facility ran out of biscuits and stopped serving a bread item with lunch trays. Observation on 03/27/2024 at 1:07 PM showed the facility provided test tray had two hamburger patties with gravy, potatoes au gratin, peas, and upside-down cake and there was no bread item (two of five items deviated from published menu). Resident Council Review of the resident council minutes for January 2024 showed that the resident council had concerns that food served in the facility deviated from the menu at least once a week. Review of the minutes for February 2024 did not show that this concern was considered or resolved. During an interview on 03/27/2024 at 10:47 AM, the resident council stated the menus continued to not be followed at least weekly. The resident council stated they had discussed this concern during resident council, but nothing was done. During an interview on 03/28/2024 at 12:06 PM, Staff K, Dietary Manager, stated the facility had run out prepared meatloaf on 03/27/2024 because the cook had not prepared enough, but hamburger patties were served instead. Staff K stated the facility had run out of prepared dinner rolls on 03/27/2024, but that biscuits were served instead. Staff K stated they were not aware that the biscuits had run out and lunch trays were prepared without a bread item. Staff K stated the expectation was for the facility to follow the prepared menu. During an interview on 03/28/2024 at 12:44 PM, Staff A, Administrator, stated whatever was posted on the menus should be provided and that the facility had not met that expectation on 03/27/2024. Reference WAC 388-97-1160 (1)(a)(b)

Based on interviews and record review, the facility failed to implement their Abuse, Neglect, and Exploitation policy and procedures and to act timely to ensure residents were free from sexual abuse and mistreatment for 3 of 5 sampled residents (Resident 1, 2 & 3) reviewed for abuse. This caused harm to Resident 1 when they experienced being inappropriately touched in a sexual manner without their consent. This failure placed residents at risk for sexual and physical abuse, psychological harm, feeling uncomfortable and a diminished quality of life. Findings included . Review of the facility's policy entitled, Abuse, Neglect and Exploitation, undated, defined sexual abuse as any type of non-consensual sexual contact with a resident. Review of the 12/26/2023 quarterly Minimum Data Set assessment, dated 12/26/2023, showed Resident 1 was alert and oriented, had no memory problems or behaviors, required assistance with toileting care/hygiene and was incontinent. Review of Resident 1's Activities of Daily Living (ADL) care plan, dated 10/18/2023, showed they required one person to help with toileting care. The incontinence care plan, dated 10/18/2023, directed care staff to apply protective barrier ointment after incontinence episodes. Review of the facility's investigation, dated 02/27/2024, showed Resident 1 alleged Staff D, Certified Nursing Assistant (CNA), inappropriately touched their outer and upper thigh over the course of two weeks. In one instance, Staff D reached for Resident 1's breast but they blocked Staff D from completing the act. Resident 1 reported the non-consensual sexual conduct to Staff F, CNA, on 02/25/2024 and to Staff E, CNA, on 02/26/2024. The investigation showed facility administration were not notified of the allegation until 02/27/2024. On 02/27/2024, Staff D, Staff E, and Staff F were suspended from duty pending investigation. During resident interviews, the facility found two female residents (Residents 2 and Resident 3) who reported concerns which did not rise to the level of Resident 1's allegation but were inappropriate conduct. Resident 2 reported they preferred not to have Staff D provide them care because Staff D called them [NAME] and told them you are cute which they were not comfortable with. Resident 3 reported they were okay with Staff D providing them care, but Staff D did display inappropriate conduct by raising eyebrows, made kissing actions with their mouth to be flirtatious, and would say I like you a lot. Neither Resident 2 nor Resident 3 ever reported this to anyone. The investigation showed another state investigative agency conducted their own investigation and notified the facility Staff D had other previous allegations, one of which was substantiated and was in the appeal process. The facility substantiated abuse more than likely occurred. Review of Staff D's employee file showed they were hired on 08/24/2022. The file contained a Background Check Inquiry (BCI), dated 12/15/2022. The facility was unable to provide a BCI that was conducted upon hire. There was no Character, Competence, & Suitability Review (CC&SR) attached to the 12/15/2022 BCI report as required. The facility was unable to provide a CC&SR. Review of the Application for employment showed only one previous employer, but no other previous Nursing Home (NH) employment. There was no education information entered on the application. The employee file did not contain any employee Reference Checks (RC). In an interview on 02/28/2024 at 2:38 PM, Resident 1 stated Staff D repeatedly caressed the outer part of their upper thigh during personal cares and attempted to grab their breast. Resident 1 stated they reported Staff D's conduct to Staff F on 02/25/2024 sometime during the day shift and told Staff E during the day shift on 02/26/2024. In an interview on 02/28/2024 at 5:00 PM, Staff A, Administrator, stated Staff D should have had a timely BCI conducted upon hire, and they were unaware the CC&SR was required for the BCI conducted on 12/15/2022. Staff A stated Staff C, Human Resources/Payroll, forwarded any BCIs requiring a CC&SR. Staff A stated they documented the CC&SR on the SA form and attached to the BCI report after completion. Staff A stated the BCIs and RCs should have been completed prior to Staff D having unsupervised access to vulnerable residents but was not. Refer to F-607 and F-609 Reference WAC 388-97-0640 (1)(2)(3)(a)

Based on interview and record review, the facility failed to implement their Abuse Policy and Procedures to ensure all residents were free from abuse, failed to conduct timely criminal Background Check Inquiry (BCI) upon hire; failed to perform timely Character, Competence, and Suitability Reviews (CC&SR-a determination made by facility administration to ensure the applicant can work in a position where there is unsupervised access to vulnerable adults by evaluating and analyzing the applicants various historic factors, document their decision, and attach to the BCI report) when indicated to be required by the BCI; and failed to obtain Reference Checks (RC) as part of the hiring process for 6 of 8 sampled residents (Staff D, E, F, G, I & K) reviewed for following and implementing written policies and procedures to prevent abuse and neglect. These failures placed residents at risk for abuse, neglect, exploitation, misappropriation of property, and diminished quality of life/quality of care. Findings included . Review of the facility's undated Abuse, Neglect, and Exploitation policy, showed the abuse prohibition plan included applicant screening of new employees for a history of abuse by conducting background checks, reference checks, and credential checks of all potential employees, contracted staff, students, consultants, volunteers, and maintain documentation of proof the screening occurred. <BCIs and CC&SRs> 1) In an interview on 02/28/2024 at 5:15 PM, Staff C, Human Resources / Payroll, stated Staff D, Certified Nursing Assistant (CNA), was hired on 08/24/2023. Review of Staff D's BCI report showed it was completed on 12/15/2023 and required a CC&SR to be completed. The BCI check was done 113 days after they were hired and provided unsupervised access to residents. The BCI report did not have a CC&SR attached. The facility was unable to provide a CC&SR for Staff D. In an interview on 02/28/2024 at 4:30 PM, Staff C stated if a CC&SR was completed it would be with the BCI report. Staff C said the BCI was performed late, there was no CC&SR attached to the BCI and could not verify a CC&SR was done. In an interview on 03/07/2024 at 5:15 PM, Staff D stated they did not know what a CC&SR was and did not recall a time where they talked with facility administration to explain the circumstances of the information provided by the BCI report. 2) Review of the employee file for Staff E, CNA, showed they were hired on 06/06/2023. Review of Staff E's employee time clock detail showed they began working on 06/12/2023. Review of Staff E's BCI report showed it was completed on 06/15/2023 and a CC&SR was required. The CC&SR, dated 06/26/2023, attached to the BCI showed it was completed 14 days after Staff E started working and 11 days after the BCI report was received. 3) Review of the employee file for Staff F, CNA, showed they were hired on 01/24/2023. Review of Staff F's employee time clock detail showed they began working on 01/23/2023. Review of Staff F's BCI report showed it was completed on 03/09/2023, 45 days after they began working. In an interview on 03/06/2024, Staff A, Administrator, stated conducting the BCI timely was important to protecting the residents' rights to be free from abuse. Staff A stated they expected Staff C to provide them with any BCI reports that required CC&SR, and all staff were to complete a BCI and CC&SR (if required) prior to having unsupervised access to any residents in the facility. Staff A said the BCIs for Staff D, Staff E, and Staff F were not conducted timely. The CC&SR for Staff D was not available in the employee file, and the CC&SR for Staff E was not completed timely but should have been done prior to unsupervised access to vulnerable residents. <RCs> 1) A review of the State Agency database, dated 02/28/2023, showed Staff D was employed and named as the Alleged Perpetrator (AP) in multiple similar allegations, at different Nursing Homes (NH), in two different counties including: NH-1, NH-2, NH-3 in King County and NH-4 in [NAME] County. Review of Staff D's Nursing Assistant Registry Inquiry (NARI), provided by Staff D on 02/28/2024, showed they were previously employed at NH-1 (from 10/21/2019 to 6/02/2020) and at NH-2 (from 4/01/2020 to 06/01/2023). Review of Staff D's employee file showed an 07/18/2023 Employment Application (EA) which was incomplete and only showed one previous employer, an Adult Family Home (AFH), where they worked from January 2016 to June of 2023. The application did not contain previous employment information for any other NHs or AFHs. There were no RCs completed as part of Staff D's EA and hiring process. In an interview on 02/28/2024 at 4:30 PM, Staff C stated they were made aware Staff D had been employed at NH-1 and NH-2 after they first submitted the NARI, and it came back with no previous NH employment. Staff C stated they asked Staff D about previous employment. Staff D provided the employment dates for NH-1 and NH-2 and Staff C submitted to the NAR. Staff C stated Staff D never reported employment for NH-3 or NH-4. Staff C stated they should have inquired with Staff D regarding the inconsistencies with the previous employment information provided on the EA and what they provided during the NARI but did not. Staff C stated they must not have done the RRFs or RCs for Staff D but should have. In an interview on 02/28/2024 at 4:55 PM, Staff C stated their hiring process included attempting to obtain three RCs, but to move forward with hiring the applicant, they were expected to have two RC's. Staff C stated they documented the RC information on the Performance Evaluation section of the Reference Request Form (RRF), which evaluated the applicant's reliability, relationship to others, attitude toward supervision, skill proficiency, overall performance, length of employment, reason for leaving, rehire ability, and positions held. In an interview on 03/07/2024 at 5:30 PM, Staff D said they worked at NH-1, NH-2, NH-3, and NH-4 but was unsure of the exact hire dates or dates they left the NHs. Staff D stated they always made sure they provided a complete EA with all their previous employment history to any potential employers, and they were unsure why they did not on the 07/18/2023 EA. 2) Review of employee file for Staff E showed no RRFs or RCs were completed upon hire. 3) Review of employee file for Staff F showed no RRFs or RCs were completed upon hire. 4) Review of the employee file for Staff G, CNA, showed no RRFs or RCs were completed upon hire. 5) Review of the employee file for Staff I, Registered Nurse, showed two RRFs initiated with two of Staff I's previous employers name, address, phone number, and position Staff I held during their employment. The Performance Evaluation sections of both RRFs were blank and not completed upon hire. 6) Review of the employee file for Staff K, Licensed Practical Nurse, showed two RRFs initiated with two of Staff K's previous employers name, address, phone number, and position Staff I held during their employment. The Performance Evaluation sections of both RRFs were blank and not completed upon hire. In an interview on 02/28/2024 at 4:58 PM, Staff A stated at least two RCs should be completed for each applicant upon hire and kept in the employee file but was not. Refer to F600 Reference WAC 388-97-1800 (2)(a-b)(3)(a)(b)(5)(a) -0640 (2)(a) .

Based on interview and record review, the facility failed to ensure abuse allegations were reported timely to the State Agency (SA) and facility administration by 2 of 5 sampled staff (Staff E and F) reviewed reporting alleged violations. This failure placed residents at risk for abuse, potential for harm, and diminished quality of life. Findings included . In an interview on 02/28/2024 at 2:38 PM, Resident 1 stated Staff D repeatedly caressed the outer part of their upper thigh during personal cares and attempted to grab their breast. Resident 1 stated they reported Staff D's conduct to Staff F on 02/25/2024 sometime during the day shift and told Staff E during the day shift on 02/26/2024. Review of the facility investigation, dated 02/27/2024, showed facility administration were made aware of the allegation on 02/27/2024. The investigation showed Staff E and Staff F were suspended pending investigation due to failure to report Resident 1's allegation timely to the SA and Administration. In an interview on 03/06/2024, Staff B, Director of Nursing Services, stated Staff F denied Resident 1 reported the allegation to them on 02/25/2024. Staff B stated when Resident 1 reported to Staff E on 02/26/24, Staff E asked Resident 1 if they reported it to anyone else, and Resident 1 stated they told Staff F the day prior. Staff B said Staff E assumed Staff F had reported it, so they did not report it on 02/26/2024. Staff E said when they came to work the next day (02/27/2024), Staff E told the Staffing Coordinator (SC) and the SC reported it immediately. Staff B stated they suspended Staff E and Staff F because they did not follow the abuse reporting requirements to report allegations immediately to the SA and to facility administration. Refer to F600 Reference WAC 388-97-0640 (2)(b)(5)(a)(b)(7)(b)(i)(ii)

Based on observation and interview, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. This failure placed residents at risk of foodborne illness and a deminished quality of life. Findings included . Observation on 02/26/2023 at 9:23 AM showed a box of frozen meat opened with the meat in a plastic bag set inside a metal tray sitting near the facility stove thawing. Further observation showed two mobile phones placed on the tray line with one attached to a charging cable. Observation showed Staff Y, Kitchen Staff, unloaded clean cups from a dishwashing rack and a cup fell to the floor. Further observation showed Staff Y picked up the cup from the floor, placed it on the food preparation table where the staff was unloading, and returned to unloading the clean cups without performing hand hygiene. Observation on 02/26/2023 at 9:36 AM showed a scraping tool with debris on the blade placed on a food shelf in dry storage near bag of powdered vanilla pudding. Observation on 02/26/2023 at 9:39 AM showed that the bag of meat continued thawing near the facility stove, the cup which had fallen to the ground continued on the table near the clean cups and the mobile phones continued to be placed on the tray line. Observation on 03/01/2023 at 11:03 AM showed Staff Y stood on the tray line with the dietary menu cards and then dropped approximately ten menu cards on the floor. Observation showed Staff Y and Staff V, Kitchen Staff, retrieved the menu cards from the floor, replaced them to the stack of menu cards, and returned to the tray line without performing hand hygiene. Further observation showed that the menu cards were placed on individual trays and placed in the food cart. Observation on 03/01/2023 at 11:47 AM showed Staff W, Kitchen Staff, entered the kitchen, went to the back room, removed outside clothing, brought a food serving scoop to Staff X, Kitchen Staff, who was serving food, and then performed hand hygiene. Observation on 03/01/2023 at 11:49 AM showed Staff X serving food from the steam table wearing a name badge which hung from the staff's clothing. Further observation showed Staff X leaned over the steam table and the name badge entered the rice pilaf being served. Observation on 03/02/2023 at 9:42 AM showed that the scrapping tool continued to be placed on a food shelf in the dry storage. Observation on 03/02/2023 at 9:48 AM showed that the resident food refrigerator for the back halls contained a blue lunch bag containing food which did not have a resident name or date label. Further review showed a plastic bag with two plastic food containers containing food without resident name or date label. During an interview on 03/02/2023 at 9:59 AM, Staff U, Dietary Manager, stated that the expectation was for staff to follow the food safety code. Staff U stated that resident refrigerators should only contain resident foods and should have the resident's name and a date label. Staff U stated that the blue lunch bag and plastic bag in the resident food refrigerator in the back hall did not meet expectation. Staff U stated that meats should be thawed in the kitchen's refrigerator and should not be left out at room temperature to thaw. Staff U stated that the food left out to thaw at room temperature did not meet expectation. Staff U stated that staff personal belongings, such as mobile phones, should not be in the food preparation area and that the mobile phones left out did not meet the expectation. Staff U stated that staff who retrieved items from the floor should perform hand hygiene. Staff U stated that the cup which fell to the floor should have been taken to the dishwashing area and the staff should have performed hand hygiene before continuing to unload clean cups and the menu cards should have been replaced with clean copies and staff should have performed hand hygiene. Staff U also stated that this did not meet expectation. Staff U also stated that tools should not be left in the dry storage area, and this did not meet expectation. Staff U stated that staff should perform hand hygiene prior to touching any items in the kitchen and that Staff W providing a food scoop to Staff X did not meet expectation. Staff U stated that staff clothing items should not enter food and that Staff X's name badge entering food did not meet expectation. During an interview on 03/02/2023 at 10:32 AM, Staff A, Administrator, stated that the expectation was for kitchen staff to follow the food safety code. Staff A further stated that the food placed in the resident refrigerator without name/date label, raw meat thawed at room temperature, mobile phones placed on tray line, staff retrieved items from floor without hand hygiene, scrapping tool left in dry storage on food shelf, staff provided food scoop prior to hand hygiene and staff name badge entered food did not meet expectation. Reference WAC 388-97-1100 (3), -2980

Based on observation, interview and record review, the facility failed to address identified risk factors for compromised nutritional status and/or monitor and accurately document weights for two of seven residents (Resident #s 78 and 95) reviewed for nutrition. This failure placed the residents at risk for continued weight loss and unmet needs, and resulted in actual harm to Resident #78 related to significant weight loss, continued psychological fear of choking/vomiting, medical complications [REDACTED]. Findings included . Refer to F686 for additional information. Review of the facility's policy and procedure titled, Nutrition Recommendations, dated (MONTH) 2019, showed that the Registered Dietitian will send their recommendations to the interdisciplinary team (Administrator, Director of Nursing Services, Resident Care Managers, and Dietary Services Manager) within 24 hours of their visit. Review of the facility's policy and procedure titled, Weight Monitoring and Documentation dated (MONTH) 2012, showed that the facility was to monitor nutrition parameters, including weights. It further showed that re-weighs would be obtained within 24 hours if a weight variance of plus or minus three pounds. RESIDENT #78 Refer to F686 for additional information related to Resident #78. Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 02/22/19, showed that Resident #78 admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS showed that Resident #78's most recent weight was 200 pounds (lbs.) and care areas that would be addressed in the resident's care plan included nutritional status. The MDS showed that Resident #78's mental status was moderately impaired. During an observation and interview on 04/22/19 at 12:28 PM, Staff BB, Nursing Assistant Certified (NAC), assisted Resident #78 with drinking 100 percent of an eight ounce container of a supplemental drink, by holding the container close to the mouth while Resident #78 drank through a straw. Staff BB, NAC, stated that Resident #78 had refused lunch. Resident #78 stated that the reason she was not eating was because she was afraid she might choke. She further stated that she choked twice at home prior to coming to the facility. When asked if she has had swallowing tests conducted, Resident #78 stated, No. Review of the document titled, Preliminary Care Plan dated 02/15/19 showed that Resident #78 had no care plan for nutrition. Review of Resident #78's comprehensive care plan on 04/10/19 and on 04/29/19, showed no nutrition care plan had been developed. Review of the Medical Nutrition Therapy Admission assessment dated [DATE] showed that Resident #78 was on a regular diet with regular texture, had independent dining ability, intact skin and the resident reported poor appetite. The Meal/Supplement Intake, portion of the assessment showed, No breakfast intakes documented. Resident reported eating this morning (02/21/19), average percentage lunch intake was 26 to 50 percent, and no supper intakes were documented due to resident had been refusing meals. It further showed, Per staff notes, resident has been relying primarily on supplements for the past 1-2 months due to fear of vomiting after meals. Recommendations included small portions as resident feels the meals are too big and healthshakes twice a day until meal intakes improve. The assessment showed, MD (medical doctor) saw resident on 02/20 and recommended [MEDICATION NAME] (medication to prevent nausea and vomiting) before meals. Additionally, the assessment showed, (MONTH) benefit from SLP (Speech Language Pathologist) evaluation to rule out dysphagia (difficulty swallowing). Review of Resident #78's current physician orders [REDACTED].#78's Medical Nutrition Therapy Admission assessment dated [DATE]). Progress note dated 02/28/19 showed that Staff DD, RDN, documented that Resident #78 continued to have poor intake. It further showed that Resident #78 complained of choking and that the resident may benefit from a swallow evaluation to rule out any chewing/swallowing deficits. Review of Resident #78's medical record from 02/15/19 through 04/29/19 showed no swallow evaluation had been conducted by Speech Therapy. Review of the medical record showed Resident #78's weight on 03/08/19 was 210 pounds (lbs.). Review of the discharge MDS dated [DATE] showed that Resident #78 discharged to the hospital on [DATE] with return anticipated. Review of the Readmission Nutrition assessment dated [DATE] showed Resident #78 weighed 175 lbs. on admit (03/21/19) per admission note. Review of the medical record showed Resident #78's weight on 04/11/19 was 163 lbs. compared to admit weight of 175 lbs. which was a difference of -6.86 percent (12 lbs.) in 21 days. However, the five day MDS dated [DATE] showed Resident #78's most recent weight was 210 lbs., compared to weight of 163 lbs. on 04/11/19 which would be a difference of -22.38 percent (47 lbs.). Review of physician orders [REDACTED].#78 was on a physician's orders [REDACTED]. Review of the five day MDS dated [DATE], showed that Resident #78 readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS showed that Resident #78 was on antibiotic therapy and resident's mental status was severely impaired. Review of Resident #78's physician's progress note dated 03/28/19 showed, Nutritional compromise is severe and driven by lack of appetite or interest by the resident, apparently. Would consider changing antidepressant to [MEDICATION NAME], if interested trying to reverse some of the health decline. Review of the physician order [REDACTED].#78 was prescribed [MEDICATION NAME] for an appetite stimulant (29 days after the initial physician's suggestion for the medication). Review of Resident #78's Medical Nutrition Therapy Admission assessment dated [DATE] showed, Resident has been refusing most foods. RDN spoke to resident's father over the phone. (Family member) stated resident had a couple of episodes of vomiting in the morning after breakfast and since then has been afraid to eat. Additionally, the assessment showed, Per resident's (family member), resident has fear of vomiting after meals which has been going on since 12/2018. It further showed that Resident #78 usually saw a psychiatrist as an outpatient; however, had not seen one since December. In addition, the assessment showed, Given resident's hx (history) of [NAME]D (obsessive-compulsive disorder, a mental disorder in which a person has unwanted and repeated thoughts, feelings, ideas, sensations, and behaviors that drive them to do something over and over) and [MEDICAL CONDITION], recommend mental health referral or follow up appointment with residents psychiatrist to assist with overcoming her fear of eating. During an interview on 04/29/19 at 4:15 PM, Staff L, Registered Nurse/Resident Care Manager (RN/RCM), stated that she was not aware of the initial suggestion by the physician for the appetite stimulant [MEDICATION NAME]; however, thought that it should have been reviewed right away and or at least within a couple days and she (Resident #78) should have been put on the psych list (psychiatrist list to be seen). Staff L, RN/RCM, looked at Resident #78's medical record and stated, I don't know if she has been seen by psych. When asked to be provided behavior monitoring documentation, Staff L, RN/RCM stated that they were supposed to be located in a book at the nurse's station; however, she had not seen behavior monitoring for Resident #78. During an interview on 04/29/19 at 5:22 PM, Staff B, Director of Nursing Services (DNS), stated that Resident #78 should have had a care plan for nutritional status on her initial care plan. When asked if Resident #78's care plan for refusal of care dated 04/19/19 was developed timely, Staff B, DNS, stated, No, and that Resident #78 should have had a care plan created when the refusals were identified. When asked to show behavior monitoring and discussion/review of the appetite stimulant [MEDICATION NAME] documentation for Resident #78, Staff B, DNS stated that she would have to look for that. No documentation was provided for review. RESIDENT #95 Review of the admission MDS dated [DATE], showed that Resident #95 admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS showed that Resident #95 weighed 88 pounds (lbs.), required supervision of one assist with eating and care areas that would be addressed in the resident's care plan included nutritional status. Resident #95 was able to make needs known. During an interview and observation on 04/18/19 at 9:16 AM, Resident #95 stated that she was not on a special diet and that she had lost some weight because she had been exercising a lot. She further stated that she had not been eating at the hospital prior to coming to the facility; however, her appetite was slowly coming back and she would like to gain weight. Resident #95 appeared thin. Review of the Medical Nutrition Therapy Admission assessment dated [DATE] showed that Resident #95 was on a regular textured diet with no added salt, thin liquids and had an admit weight of 88 lbs. Review of Resident #95's weights in the medical record showed an invalidation dated 04/25/19, of a weight that was obtained on 04/05/19 of 88 lbs. The reason for the invalidation showed Incorrect data and Weight out of range for resident; not validated. Other weights documented included 77.8 lbs. on 04/18/19 and 77.4 lbs. on 04/25/19. Weight on 04/05/19 was 88 lbs. and on 04/25/19 was 77.4 lbs., which was a difference of -12.05 percent (10.6 lbs.) in 20 days. During an interview on 04/25/19 at 4:11 PM, Staff L, RN/RCM, stated that her last weight was close/similar to her current weight so she made the 88 lbs. invalid. When asked why she waited until now (04/25/19) to invalidate a weight obtained on 04/05/19, Staff L, RN/RCM, stated that the weight of 88 lbs. was not validated; however, since the other two weights were so similar, that information was used to invalidate the 88 lbs. During an interview on 04/26/19 at 12:43 PM, when asked if the invalidation of Resident #95's weight of 88 lbs. met her expectations, Staff B, DNS, stated, It did not. She further stated that Resident #95's weight of 88 lbs. needed to be reactivated. Reference WAC 388-97-1060 (3)(h)

Based on observation, interview and record review, the facility failed to ensure pain management was provided for one of six residents (Resident #197) when reviewed for pain. Failure to renew a prescription of narcotic medication in a timely manner and provide treatment alternatives when awaiting the arrival of the medication, placed the resident at risk for unmanaged pain, worsening mood, unwanted behaviors and decreased quality of life. Findings included . RESIDENT #197 Review of the admission Minimum Data Set (MDS, a required assessment tool), dated 04/16/19, showed Resident #197 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented, had adequate memory recall, and able to make all needs known. The MDS further showed that Resident #197 stated she experienced pain occasionally, and averaged a four out of a scale of 10. Review of the care plan dated 04/19/19 showed Resident #197 had complaints of chronic pain related to back pain and [MEDICAL CONDITION] (widespread muscle pain and tenderness). The goal was for the resident to verbalize an acceptable level of pain (did not identify what level was acceptable). Interventions/approaches included acknowledging the resident that her pain was unique and believable, assess the effects of pain on the resident (disturbances in sleep, activity, appetite, etc.), and monitor/record any complaints of pain to include location, frequency, effect on function, intensity, alleviating factors and aggravating factors. Review of the admission pain assessment dated [DATE], showed Resident #197 experienced aching/dull pain in her legs and back within the last five days. The resident was able to describe her pain intensity in a numeric scale from 1-10, and stated her pain was well managed with her current med regime. The pain assessment further showed that repositioning helped reduce the pain. The pain assessment did not describe what pertinent [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. In an observation and interview on 04/18/19 at 9:53 AM, Resident #197 stated she was not having a good morning, and her pain level was at an 8. When asked why it was a bad morning, the resident stated her pain patch (facility staff) should have been changed two days ago, and took it off this morning and did not put one back on. I really hurt. A normal pain level is 4-5. They told me it (the pain patch) is out. There is nothing I can do but wait. Resident #197 further stated that she also had [MEDICATION NAME] for pain, but that was out too, and they were only offering her [MEDICATION NAME] ([MEDICATION NAME]). When asked what her pain felt like, Resident #197 stated it was pins and needles and stabbing pain, in both her legs. The resident clenched her fists off and on, and closed her eyes periodically during the conversation. The resident apologized for closing her eyes and stated that she was in so much pain I am having a hard time focusing. The resident further stated that she had [DIAGNOSES REDACTED], which affected her whole body, and [MEDICAL CONDITION] (nerve damage), which she used to be prescribed [MEDICATION NAME] (a medication used for nerve pain), but was eventually discontinued because of her poor kidney function. In an interview on 04/18/19 at 10:09 AM, when asked if Resident #197 was prescribed a [MEDICATION NAME] for pain, Staff OO, Licensed Practical Nurse (LPN), stated that she was, but noticed that there was not any in the medication cart drawer. Staff OO, LPN, further stated that yes, the patch should have been changed two days ago on 04/16/19, and today is 04/18, so yes, it has been 3 days. I was not informed about it on shift change this morning. Staff OO, LPN, stated that she had [MEDICATION NAME] PRN, which was also not available, and the Resident Care Manager (RCM) was aware. When asked what she was doing for Resident #197 to help with pain management in the meantime, Staff OO, LPN, stated that she could give her [MEDICATION NAME], but yes, it may not be effective. In addition, Staff OO, LPN stated she thought that they were working on a script from the doctor and would follow up on Resident #197's status. In a follow-up interview on 04/18/19 at 11:01 AM, Resident #197 stated that Staff D, LPN/RCM, followed up with her and was asked to choose between the [MEDICATION NAME] and the [MEDICATION NAME], and she chose the [MEDICATION NAME]. When asked if the nursing staff were working with her and talked to her about her pain regarding what made it better or worse, Resident #197 stated that they did not and just brought/offered her [MEDICATION NAME]. Resident #197 stated, It ([MEDICATION NAME]) is not working and I am beside myself. I hope they get the patch by tonight. The resident also asked, What about my breakthrough pain? In an interview on 04/22/19 at 2:02 PM, Staff D, LPN/Resident Care Manager (LPN/RCM), stated that Resident #197's [MEDICATION NAME] was to be changed on Tuesday, 04/16/19, but did not get a new [MEDICATION NAME] until the order was received Thursday, 04/18/19, and pulled from the E-kit in the late morning (two days without the [MEDICATION NAME]). The resident received her last dose of [MEDICATION NAME] on 04/12/19. The doctor did not renew the scripts (prescription) as he stated he would not prescribe [MEDICATION NAME] and [MEDICATION NAME], so she had to pick one. The resident chose the [MEDICATION NAME], but worried about breakthrough pain. Staff D, LPN/RCM, further stated that when she called the doctor, she found out there was a miscommunication and it was not ordered. In the meantime, the resident's pain was being monitored and a pain assessment had not been done yet as the resident did not report pain until 04/18/19 that she was aware of. In addition, Staff D, LPN/RCM, stated she also did an audit on the medication carts to find out if there was a sufficient amount of medication until the scripts needed to be renewed for the residents, to be more proactive, as the facility tended to be more reactive, and didn't identify that the medication was out until the day it was out. Staff D, LPN/RCM, stated education was also done with the nurses. When asked the expectation of when a comprehensive pain assessment was performed, Staff D, LPN/RCM, stated that it was done on admission, quarterly and change of condition. Staff D, LPN/RCM further stated, This is a change of condition. In an interview on 04/23/19 at 8:59 AM, Resident #197 stated that her pain had been intense, at about a level 8. The resident stated that the nurses did not ask for her pain level and she forgot to ask for her pain medication, They are not sensitive to my needs. I have been on the patch since (MONTH) (YEAR), and was on Hospice then. The patch works for me. I also keep the location of the patch on my leg. I had it on my chest before, but it didn't seem to work as well. Then they (Hospice) started to put it on my thigh. It worked better. The last nurse tried to put the patch on the same leg that the patch was already on, but I told them you have to put it on a different location. Resident #197 further stated she wanted [MEDICATION NAME], but had not received her medication yet that morning. In an interview on 04/23/19 at 9:17 AM, Staff OO, LPN, stated that pain monitoring documentation was scheduled for once a shift. Staff OO, LPN, further stated Resident #197 was correct, and that she had not received her medications yet that morning, but was in her room earlier to do a nebulizer treatment and blood sugar check with her. When asked if she asked the resident if she was in pain, Staff OO, LPN, stated she did not ask, and that she focused on the nebulizer and blood sugar at that time. Staff OO, LPN, stated she would go ask if she was in pain now. In an interview on 04/25/19 at 8:42 AM, Staff QQ, Nursing Assistant Certified (NAC), stated she had worked with Resident #197 since her admission, and that she recalled the time when the resident didn't have her pain medication ordered. Staff QQ, NAC, further stated that the resident complained of pain more than usual those days. Reference WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to address identified risk factors for the development of pressure ulcers for one of five residents (Resident #78) reviewed for pressure related wounds. This failure caused actual harm resulting in the development and worsening of a pressure injury, medical complications, and diminished quality of life. Findings included . Refer to F692 for additional information. The National Pressure Ulcer Advisory Panel (NPUAP) describes/defines a suspected deep tissue injury as: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury can result from prolonged pressure and may either resolve or develop into further tissue loss. Review of the facility's policy and procedure titled, Skin at Risk/Skin Breakdown, dated (MONTH) 2013, showed that a resident who entered the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable and a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 02/22/19, showed that Resident #78 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS showed that Resident #78 had no pressure ulcers (PU); however, was at risk of developing PUs and care areas that would be addressed in the resident's care plan included pressure ulcer and nutritional status. The MDS showed that Resident #78's mental status was moderately impaired. During an observation and interview on 04/25/19 at 10:57 AM, Resident #78 was lying in bed on her left side. Resident #78 stated that she was not sure if her wounds were getting better or not. Review of the document titled, Preliminary Care Plan dated 02/15/19 showed that Resident #78 was Not at risk for skin breakdown with a goal of Skin Doesn't Break down, and for Interventions: See In room Care Plan. This care plan did not address Resident #78's admitting [DIAGNOSES REDACTED]. Review of the In Room Care Plan dated 02/15/19 showed Resident #78 was to be positioned for comfort and pressure relief with care provided, had occasional incontinence (no control over urination) of the bladder, able to control bowels and required two person assist with bed mobility/positioning and transfers. Review of Resident #78's Treatment Administration Record (TAR) dated 02/15/19 through 02/28/19, showed that weekly skin checks were the only documented treatment being provided. Review of the progress note dated 03/03/19 showed that Staff CC, Nursing Assistant Certified (NAC), reported to the nurse of open areas to Resident #78's buttocks and left heel. Review of the document titled, Event & Occurrence Report, dated 03/03/19, showed that an investigation related to Resident #78's wounds was conducted. It further showed that on 03/01/19 and on 03/02/19 Staff CC, NAC, observed Resident #78's bottom with a red/purple, unopened, wrinkly area and applied A&D ointment two to three times a day. On 03/03/19, Staff CC, NAC, observed the skin opened and draining and applied A&D ointment. Staff CC, NAC observed skin issues for two days without reporting it to a nurse until day three (03/03/19). In addition the report showed, Root cause: Resident's skin breakdown is reasonably related to non-compliance with cares, refusals to be repositioned and poor nutrition. During an interview on 04/29/19, when asked to show documentation of Resident #78's refusals of care to include incontinence and repositioning between the dates of 02/15/19 and 03/03/19, prior to the development of PUs, Staff B, DNS, stated that she would have to look into Resident #78's medical record in order to provide that information. On 05/01/19 Staff B, DNS, provided Point of Care History, (electronic documentation) flow sheets dated 02/28/19 that showed a onetime refusal for Resident #78, in regards to transfer, eating and personal hygiene during the evening shift. Review of Resident #78's progress note dated 03/06/19 showed, Resident is not participating in therapy very much, is not eating well and declined shower today. Review of the progress note dated 04/04/19 showed that Resident #78's fear of falling and choking persists, and was the reasoning behind refusals. Review of the care plan, Problem Start Date: 03/06/2019, showed Resident #78 was at risk for and had actual alteration in skin integrity with sacral area (the bottom of the spine) and left heel pressure ulcers. The care plan had interventions with approach start dates from 03/06/19 to 04/18/19 documented, three days after wounds had been reported on 03/03/19. This care plan did not include Resident #78's fear of falling in relation to turning/repositioning or transfers. Review of Resident #78's progress notes showed that the resident refused to be repositioned and/or provided incontinent care on 03/22/19, 04/06/19, 04/08/19, 04/12/19, 04/13/19, 04/14/19, 04/15/19, 04/16/19 and 04/18/19 (all documented prior to the development of Resident #78's care plan for Resident Frequently Refuses Care dated 04/19/19). Review of the care plan Problem Start Date: 04/19/2019, showed Resident #78 frequently refused care. This care plan had interventions with a start date of 04/19/19, 47 days after PUs were identified on 03/03/19. Review of Resident #78's physician order [REDACTED]. Ordered four days after wounds were reported on 03/03/19. Review of the discharge MDS dated [DATE] showed that Resident #78 discharged to the hospital on [DATE] with return anticipated. Review of Resident #78's History and Physical form dated 03/24/19 showed that the resident readmitted after hospitalization secondary to sacral ulcer causing systemic (affecting the entire body) infection that was treated with surgical debridement (the removal of damaged tissue) and intravenous (IV) antibiotics. Review of the 5-day MDS dated [DATE], showed that Resident #78 readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS showed that Resident #78 had one stage two PU (broken skin/sore or a blister), one stage four PU (a deep sore that can expose muscle or bone), a surgical wound, required IV medication and was provided antibiotic therapy. Resident #78's mental status was severely impaired. Review of Resident #78's Medical Nutrition Therapy Admission assessment dated [DATE] showed that Resident #78 had a stage four sacral pressure injury which required surgical debridement and IV antibiotics. It further showed that Resident #78 had an unstagable pressure injury to the right heel. During an interview on 04/29/19 at 10:28 AM, Staff L, Registered Nurse/Resident Care Manager (RN/RCM), stated that PUs should be care planned once they have been identified and there should be interventions in place. She further stated that Resident #78's PUs on her sacrum and left heel were identified on 03/03/19. During an interview on 04/29/19 at 4:15 PM, when asked what interventions were put into place related to Resident #78's non-compliance with cares, refusals to be repositioned and poor nutrition (which was documented for the Root cause in Resident #78's Event & Occurrence Report, dated 03/03/19), prior to the development of Resident #78's PUs, Staff L, RN/RCM, stated that she did not see that there was one put into place for non-compliance for refusals of care. During an interview on 04/29/19 at 5:22 PM, Staff B, Director of Nursing Services (DNS), stated that Staff CC, NAC, should have reported Resident #78's discoloration to the skin immediately. She further stated that she did not necessarily agree that Resident #78 was low risk for skin breakdown as shown on the Preliminary Care Plan (dated 02/15/19). When asked if Resident #78's care plan for refusal of care dated 04/19/19 was developed timely, Staff B, DNS, stated, No, and that Resident #78 should have had a care plan created when the refusals were identified. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure physician ordered medications were administered to the correct resident causing actual harm for one of one resident (Resident #79) reviewed for medication errors. This failure resulted in low blood pressure, shock, abnormal laboratory and heart rhythm results, and required hospitalization for Resident #79. Findings included . Review of the facility's policy titled, Specific Procedures For All Medications, undated, showed that the nurses should identify the correct resident prior to administering medications. According to the National Coordinating Council for Medication Error Reporting and Prevention, undated, showed, medication error was defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. Refer to F609 for additional information related to resident #79 Review of the five day Minimum Data Set (MDS, a required assessment tool) dated 04/07/19, showed that Resident #79 was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. The MDS further showed that Resident #79 was alert and able to make needs known. During an interview on 04/17/19 at 2:01 PM, Resident #79 stated that a nurse gave him his roommate's medications a couple weeks ago, which caused him to become sick and he had to go to the hospital for a few days. Review of the facility's incident log showed that Resident #79's medication error was logged on 04/04/19; however, the incident occurred on 03/28/19 and resulted in an injury. It further showed that the facility had not notified the state hotline. Review of the progress note dated 03/28/19, showed, Patient received incorrect medications this morning, MD (medical doctor) notified and given information .continue to monitor. Review of the progress note dated 03/28/19, showed that Resident #79's blood pressure (BP) dropped to 80/42 millimeter of mercury (mmHg, a unit of pressure), oxygen saturation (the amount of oxygen that's in the bloodstream) had dropped to 88 percent. The note also showed that the facility called 911. The medics checked Resident #79's BP, and the result was 60/47mmHg. They also performed an electrocardiogram (EKG or ECG, a test that measures the electrical activity of the heartbeat) at the facility and the heart beat was irregular and Resident #79 was transferred to the hospital. Review of the hospital physician's note dated 03/28/19, showed that the reason for Resident #79's admission was shock secondary to wrong medication administration at nursing facility. It further showed that the wrong medications that Resident #79 had received were: [MEDICATION NAME] (all medications to treat high BP), and [MEDICATION NAME] (a diuretic medication that increases the passing of urine) of which Resident #79's received three times his normal dose. In addition, Resident #79 was administered [MEDICATION NAME] (medication used to treat the symptoms of an enlarged prostate and can cause sudden BP drop), [MEDICATION NAME] (an antidepressant medication), and [MEDICATION NAME] (a medication used to treat attention deficit [MEDICAL CONDITION] disorder, ADHD). The hospital physician's note also showed that Resident #79's BP was 56/19 mmHg at the lowest when he was in the emergency room . Review of Resident #79's [DIAGNOSES REDACTED]. Review of the progress note dated 03/31/19, showed that Resident #79 returned from hospital on [DATE]. Review of Resident #79's incident investigation report, undated, showed that Staff F, Licensed Practical Nurse (LPN), had administered medications to Resident #79 that were prescribed for his roommate due to Staff F, LPN, did not ask the resident to identify himself. The incident further showed that Staff F, LPN, was being oriented by Staff E, LPN at the time of the incident. During an interview on 04/23/19 at 11:25 AM, Staff E, LPN, stated that Staff F, LPN, was a new hire nurse with previous nursing home experience and had oriented on the floor with another nurse in the facility. Staff E, LPN, also stated that after working half of the shift with side-by-side supervision, she felt confident allowing Staff F, LPN, to prepare and administer medications to the residents independently. Staff E, LPN, further stated that Staff F, LPN, prepared the medications for Resident #79's roommate. In addition, Staff E, LPN, stated that before Staff F, LPN, took medications to the residents' room, she told Staff F, LPN, that the resident was the first bed in the room, and there was a picture in the Medication Administration Record [REDACTED]. Staff E, LPN, stated that she told Staff F, LPN, that the resident was alert and oriented, and was able to state his name when asked. Staff E, LPN, stated that while staff F, LPN, was in the residents' room, she prepared the medications for Resident #79 and brought the medications to the room. Resident #79 stated that he had already taken the medications from Staff F, LPN. Staff E, LPN, immediately spoke with Staff F, LPN, who admitted that Resident #79 had received the roommate's medications because he thought the first bed was the window bed. Staff E, LPN, notified the Resident Care Manager (RCM) and physician. Staff E, LPN, additionally stated that Resident #79's blood pressure kept dropping after receiving the wrong medications, so they sent him to the emergency room . During an interview on 04/23/19 at 12:00 PM, Staff D, LPN/RCM, stated that there were pictures of the residents in the computer on the MAR, and the nurses should check the pictures and ask patients for identification if they were alert and oriented which should be done with each medication administration. Staff D, LPN/RCM, also stated that Staff F, LPN, did not go through the required process to identify the resident prior to giving the medications to Resident #79. During an interview on 04/23/19 at 1:12 PM, Staff B, Director of Nursing Services (DNS), agreed that Staff F, LPN, had a medication error due to failure to identify the resident correctly, and there was a negative effect which may result in a serious consequence to Resident #79. Staff B, DNS, further stated that her expectation was that nurses should verify residents with the name and the picture in the MAR before administering medications. During an interview on 04/26/19 at 11:25 AM, Staff H, Staff Development Coordinator (SDC), stated that the nurses were expected to verify the residents before they administered medications by utilizing the Five Rights. Staff H, SDC, stated that the Five Rights included: the right patient, the right drug, the right time, the right dose, and the right route. In addition, Staff H, SDC, stated that Staff F, LPN, did not appropriately execute the Five Rights of medication administration. Reference WAC 388-97-1060 (3)(k)(iii)

Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services were provided for one of five residents (Resident #90) when reviewed for behavioral/emotional well-being. Failure to consistently monitor/evaluate the resident's status and underlying causes for changes in mood/behavior following a traumatic event, follow recommendations for a medication change, offer continuous resources and services to help cope with the trauma, and create an individualized treatment plan, resulted in psychosocial harm. Findings included . Review of the annual Minimum Data Set (MDS, a required assessment tool), dated 04/04/19, showed Resident #90 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented, had adequate memory recall and able to make all needs known. The MDS further showed that Resident #90 felt down/depressed, had difficulty sleeping, exhibited verbal outbursts and behaviors that could interfere with the resident's care, disrupt the living environment, and pose a risk for significant physical illness or injury. Resident #90 was coded as her behavioral status, deteriorated since last review. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the previous quarterly MDS dated [DATE] and 01/09/19, showed Resident #90 had no mood or behavioral indicators. Review of the Care Area Assessment (CAA) dated 04/04/19, showed Resident #90 triggered for alteration in psychosocial well-being, mood and behavior due to verbal behavioral problems, had a [DIAGNOSES REDACTED]. PBA occurs secondary to a neurologic disorder or [MEDICAL CONDITION]), and anxiety disorder; The CAA further showed that the resident had a mood/behavioral problem that impacted interpersonal relationships, and possible clinical issues that contributed to a mood problem to include a relapse of an underlying mental health problem. Staff will continue to offer support, and will offer education to assist resident as willing. A mental health referral would be made as needed. The CAA did not identify the [DIAGNOSES REDACTED]. Review of the care plan dated 04/16/19, showed that Resident #90 was at risk for complications related to alcohol/illicit drug history and use. The goal was for the resident to remain sober. Interventions included that a behavioral contract was in place and risks/benefits were discussed. In addition, the resident was at risk for alteration in psychosocial well-being. The goal was, Resident's psychosocial needs will be anticipated and met. Interventions included offering active listening and provide emotional support as needed. The care plan did not address recent changes in mood or behavior, to include a new [DIAGNOSES REDACTED]. Review of the Incident and Accident Log showed that Resident #90 had incidents dated 11/27/18, 04/03/19, and 04/23/19. Review of the investigation of the incident dated 11/27/18, showed Resident #90 was in the community alone at night, was assaulted by a stranger, which resulted in an injury above the right eye and fell out of her wheelchair. Review of psychiatry consult dated 12/14/18, showed Resident #90 was diagnosed with [REDACTED]. The bottom of the consult said, Agree, and was signed off by the physician. Review of physician progress notes [REDACTED].#90 was tearful during examination. The 11/28/18 progress note showed that the resident had a depressed mood after trauma. Review of the investigation dated 04/03/19, showed a needle was found under Resident #90's bed, and was suspected of illicit drug use. The report further showed that the resident signed a behavioral contract on 04/04/19 that stated she agreed not to consume nor store illicit drugs and/or alcohol on facility property or return to the facility intoxicated. In addition, Resident #90's urine tested positive for [MEDICATION NAME] (alcohol) and [MEDICATION NAME] ([MEDICATION NAME]/illicit drugs) on 04/05/19. Review of the investigation of the incident dated 04/23/19, showed Resident #90 returned to the facility intoxicated and admitted to drinking wine with her husband. In an interview on 04/25/19 at 1:18 PM, Staff K, Registered Nurse/Minimum Data Set (RN/MDS) stated she was not certain of the reason for the mood and behavioral decline since the last assessment, and that Social Services should know as they did those sections in the assessment. In an interview on 04/26/19 at 2:30 PM, Staff C, Social Services (SS), stated the MDS was coded worsened behavior due to capturing her verbal outbursts with staff, which was not previously observed. Staff C, SS, stated Resident #90 was normally social and cooperative with others and this was a change for her and not a trend that had been established. The resident was not generally belligerent or angry, but was generally social with the staff and residents. When asked why the resident resumed using drugs and alcohol to potentially identify the root cause, Staff C, SS, stated that the resident told her, It is my choice. Staff C, SS, further stated, that is as far as we are able to get with that. When asked about the psychiatry recommendations to increase the [MEDICATION NAME] and [MEDICATION NAME], Staff C, SS, stated she was not aware that there was a recommendation. In an interview on 04/29/19 at 9:36 AM, Staff EE, Rehabilitation Manager (RM), stated that Resident #90 talked to him frequently when she was on his case load in (MONTH) (YEAR), and continued to visit with him after she was no longer on the case load. Staff EE, RM, further stated that he noticed that she was less social with him in the last few months. In a follow-up interview on 04/26/19 at 3:30 PM, Staff C, SS, stated she found out that the physician's orders [REDACTED]. Staff C, SS, further stated that the next time the psychiatrist came in he would review the initial recommendations to increase of the antidepressant with the resident, four months after it was first recommended and approved. In an interview on 04/29/19 at 8:41 AM, Resident #90 stated that she talked to the psychiatrist after the incident in (MONTH) (YEAR), and that she had a hard time going out in the community; her stomach hurt, cried a lot and stayed in her room. Resident #90 was tearful at the time she shared the information. I wish someone would listen to me. I want my [MEDICATION NAME] increased. That would help me from being so tearful and anxious. Resident #90 further stated that despite being afraid going into the community, she had to go get her cigarettes, as that was part of being an independent smoker. Otherwise I would have to pay big bucks for someone to get them for me. The facility was aware of the recent traumatic event, [DIAGNOSES REDACTED].#90's psychosocial well-being. Reference WAC 388-97-1060(3)(e)

Based on observations, record review and interview, the facility failed to provide adequate supervision to ensure staff followed the plan of care to prevent accidents for 1 of 4 sampled residents (#1) reviewed for falls. Resident #1 fell from his bed that was not in the low position and the floor mattress was not in place next to the bed. This failure resulted in harm to Resident #1 who sustained a head injury that required treatment in the emergency room . Findings include: Review of a facility investigation dated 4/5/14 revealed Resident #1 was found on the floor, face down, next to his bed. Documented assessment by licensed nurse Staff D revealed "a large deep wound and bleeding to left side of forehead". Pressure and application of ice were completed prior to transfer to the emergency room for evaluation and treatment which included sutures and a head/neck scan which were negative for internal bleeding or fractures. Telephone interview with Staff D on 4/21/14 at 8:30 a.m. revealed she responded to Resident #1's call for help. Upon entering the room, she saw the resident face down on the floor, next to his bed. Staff D stated there was blood on the floor under the resident's head. She stated the head wound was approximately 3 centimeters long and irregularly shaped. Staff D stated staff provided first aid before transferring the resident to the emergency room . During interview, Staff D stated the mattress which was care planned to be on the floor next to the bed was not in place when she entered the room. The bed was not in the lowest position; Staff D stated it looked like the bed was at the level that would be used to transfer the resident from the bed to wheel chair. Record review revealed Resident #1 admitted during 5/2012 with multiple [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] revealed the resident was assessed as severely cognitively impaired and required two staff to assist with movement in bed and transfers. Review of care directives dated 1/7/14 and updated 4/7/14 revealed fall from bed preventive measures included keep bed in lowest position, mattress to the right of the bed with mat to the right of the mattress and scooped mattress. Telephone interview with Staff C (certified nursing assistant) on 4/17/14 at 2:00 p.m. revealed she provided Resident #1 morning care which included dressing him. She stated Resident #1 required two staff for transfer so she went to the door to look for her care partner. Staff C stated she went across the hall which she thought would just take a minute. She stated she assisted her partner with a resident transfer in that room and then heard Staff D call for assistance in Resident #1's room. Staff C stated when she left Resident #1's room the floor mattress was up against the opposite wall. The bed was not all the way down; it was at a height so the resident could transfer to the wheel chair. She had everything all ready for the transfer; she said she did not anticipate leaving the room and when she did leave, she thought it would be for just a few minutes. Staff D acknowledged responsibility for leaving Resident #1 in an unsafe position. During survey on 4/16/14 at 8:55 a.m., Resident #1 was observed in the main dining room sitting upright in a tilt-in-space wheel chair eating breakfast with assistance from staff. Observations of the resident while in bed were not possible due to timing of observations during a meal and activity. On 4/16/14 at 9:20 a.m., interview with Staff E (certified nursing assistant) assigned to care for Resident #1 revealed he was knowledgeable about fall prevention interventions for the resident while in bed and in the chair. Observations of the Resident's room earlier at 8:45 a.m. revealed fall prevention devices documented on care directives were available in the resident's room. Telephone interview with Staff A (director of nursing) at 1:30 p.m. revealed the resident's most recent falls occurred on 9/2013 and 11/2013 which involved the resident sliding from the wheel chair. Prior to those dates, a fall from the wheel chair was documented during 10/2012. There were no falls recorded from bed during the above time periods prior to 4/5/14. During exit interview on 4/16/14 at 1:15 p.m., administrative staffs A and B (director of nursing and administrator) discussed and provided evidence of individual and expanded staff training dated 4/5/14. Training emphasized following care directives and to always leave residents in safe position when leaving the bedside, including while doing tasks in the room.

Based on observation, interview and record review, it was determined that the facility failed to revise/or implement the plan of care for 1 of 3 residents (Resident # 67) reviewed for nutrition. Failure to implement multiple revisions to the care plan to encourage improved nutritional intake resulted in harm due to unplanned avoidable weight loss for this resident. Findings include: Resident #67 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review revealed in part, the following weights: 7/23/12, 81 pounds 8/20/12, 79 pounds 9/24/12, 78 pounds 10/15/12, 75 pounds 11/19/12, 73 pounds 12/19/12, 74 pounds 1/23/13, 71 pounds 2/20/13, 70 pounds The Registered Dieticians note dated 6/14/12 documented, the resident had a 6.8% weight loss in 30 days from the admitted [DATE] (which is "severe" weight loss). The note documented, "diet recently downgraded further to puree with nectar thick liquid related to increased swallowing difficulty, resident also with referral to dentist to eval fit of dentures." The Registered Dietician's note dated 8/2/12, documented the resident had an admission weight of 87 pounds on 5/16/12, and the Resident's weight on 8/1/12 was 79 pounds a 9.2% weight loss in 3 months (which is "severe" weight loss). The dietician's note suggest weight loss may be unavoidable related to Alzheimer disease. The Registered Dietician's note dated 12/29/12, documented Resident's weight to be 71 pounds on 12/24/12. The not documented, "suspect intake impacted by dementia." Record review revealed the resident's weight on 2/13/13 was 70 pounds, a 17 pound weight loss which is a severe weight loss of 19.5% since the admission date of [DATE]. Observations during meal time on 2/26/13 at 8:15 a.m., 2/27/13 between 8:10 a.m. and 8:26 a.m., and 3/1/13 at 8:20 a.m., revealed Resident #67 had multiple bowls of food placed in front of her/him at one time. Review of the record revealed a "Therapy Communication to Nursing" dated 7/2/12, which documented, in part, "Resident requires food items to be in bowls, please put one bowl at a time on the table in front of the resident." Further review of the record did not show evidence that the staff revised the care plan to direct staff to implement the dietician's recommendation to place one bowl of food at a time in front of Resident #67. Staff F stated staff had been in-serviced, although observations revealed the Resident continued to receive multiple bowls of food at one time. Staff F confirmed the care plan and care directive had not been revised to direct staff to place one bowl of food at a time in front of the Resident. On 3/1/13 at 9:00 a.m., interview with Staff F stated the dietary slip should go to the kitchen to inform the kitchen staff of any changes. Staff F confirmed the dietary slip requesting to have one bowl at a time placed in front of Resident #67 had not been sent to the kitchen. On 3/1/13 at 9:20 a.m., interview with the dietary manager (Staff P), confirmed she did not know of the request to have one bowl of food at a time served to Resident #67 for meals. Review of the record revealed a speech therapy note dated 6/18/12 documented, [MEDICAL CONDITION]- "not if caregivers providing patient with small portions at a time." FAILURE TO PROVIDE ASSISTANTS Observations during meal on 2/26/13 at 8:15 a.m., 2/27/13 between 8:10 a.m. and 8:26 a.m., and 3/1/13 at 8:20 a.m., revealed Resident #67 sat at the table with other residents and did not receive extensive to total assist from staff with eating. The resident sat at the table with other residents and fed her/himself. Unidentified staff members would approach the resident toward the end of the meal after Resident #67 had stopped eating, and would remind her/him to eat her/his meal, and the unidentified staff would then walk away. After the reminder, the resident would take a few more bites of the meal, and would again stop eating. The resident would say, "I want to go to my room," and the staff would take the resident out of the dining room before s/he finished the meal. Review of the facility's care plan documented the resident required the need of 1 person for assist with feeding to encourage adequate intake. The nursing care directive documented the resident required extensive to total assist for eating. On 3/4/13 at 2:48 p.m., interview with Staff X, confirmed that extensive to total assist with meal would be for staff to sit with the resident throughout the meal and assist the resident with eating. DENTURES Resident #67 observed during meal on 2/2/13 at 8:15 a.m., 2/27/13 at 8:10 a.m., and 3-1-13 at 8:20 a.m., to have dentures in while eating. On 3/1/13 at 9:12 a.m., interview with Staff NN reported she brushed Resident #67's dentures and put them in her mouth. Staff NN stated she did not know the Resident was not supposed to have the dentures in because when she last worked on 2/26/13, the Resident had the dentures in. Review of the record revealed a Speech Therapy note dated 5/20/12 documented, "Patient tolerating downgraded diet when wearing properly fitting dentures with adhesive." Review of the record revealed the resident had been seen by "Smile Seattle Dentures" on 6/13/12. According to the dental consult, the condition of Resident #67's dentures were loose or ill fitting, teeth were worn down, bite was off, incorrect, or slides class III bite, and dentures in poor shape. The dental consultant recommended for Resident #67 to have new upper and lower dentures. On 2/28/13 at 4:30 p.m., interview with Staff W stated she spoke with the dentist and the dentist said he never received the referral for dentures from the resident's physician. On 2/28/13 at 4:37 p.m., Staff F and Staff W, stated once a recommendation for dentures is made, the resident care manager (RCM) should submit the "denture/partial appliance request for skilled nursing facility client" to the resident's physician. Staff F confirmed the request for dentures had not been made for this resident. Review of the record revealed the resident continued to have problems eating with ill fitting dentures. Eight months after the request for dentures were made, a nursing note dated 2/19/13 documented, "Staff report resident's upper and lower dentures very loose, and collect food underneath even with use of adhesive. Also resident noted gagging and coughing, refusing to eat when dentures in, but when dentures out, will accept feeding assist better and has increased meal intake, care plan and care directive changed to leave dentures out at this time." Although the care plan and care directive documented to leave the dentures out, staff did not follow the care plan changes, and staff continued placing dentures in the Resident's mouth. The facility had multiple failures that prevented nutritional needs of Resident #67. Failures included, failure to provide 1:1 assistants with meals, failure to follow the plan of care and provide one bowl of food at a time to the Resident during meals, and failure to follow the plan of care and not place dentures to prevent problems with eating. These failures resulted in avoidable severe weight loss of 19.5% between 5/16/12 and 2/20/13. .

Based on observation, interview and record review it was determined that the facility failed to provide services to maintain the highest practicable levels for 4 of 29 Sampled Residents (#'s 100, 101,109 &143) reviewed for care and services of the 38 residents who were included in the Stage 2 review. These failures resulted in harm for Resident #101 due to unmet needs for pain issues and had the potential to place Resident (#s 100, 109 & 143) at risk to not have medical needs met and decline in condition. Findings include: RESIDENT #101 Resident #101 admitted to the facility in 2011 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) an assessment tool, dated 1/14/13, documented Resident #101 required extensive to total assistance with her activities of daily living. The MDS documented the resident had 6 days of walking sessions during the 7 day observation period. A care plan dated 2011, documented the resident was to participate in a restorative therapy program that included walking 30-50 feet in parallel bars and to stand in the standing frame up to 15 minutes as tolerated, 6 times a week. On 2/26/13 at 3:10 p.m., Resident #101 was observed lying in her bed. She said hello and stated she was resting. A "PRN (as needed) Medication Pain Management Flow Sheet" dated February 2013, documented "Rest" for non-pharmacological interventions to address pain. The flow sheet was blank for the month of February for any pain assessment completed. Record review of a "Restorative Flow Sheet" for February noted the following documentation: 2/02/13- "Resident complained of pain while on standing frame, tried to lower the bars and put table up. Resident still c/o (complained) put resident down. Attempted to walk resident at parallel bars and she stood up with knees bent and wouldn't take a step. LPN (nurse) notified." 2/03/13 - "Seems uncomfortable, without ambulation, difficult to stand at parallel bars." Between 2/06/13 and 2/10/13 documentation noted the resident could not or chose not to participate in the exercise program. 2/15/13- "Complained of pain to knees (during standing exercise)" 2/16/13 - "Resident crying when stood up on standing frame, Resident said, 'Oww' took four steps, knees bent. LPN notified." 2/18/13 - "Complained of pain in in knees. LPN notified." 2/22/13- "Resident complained of pain when up on standing frame. Resident only able to stand but keep knees bent." 2/23/13 & 2/24/13 - "Resident didn't want to ambulate, complained of pain in knees. LPN notified." 2/25/13-"Not able to stand at frame, became very agitated." The "Restorative Flow Sheet" had the letters "D/C" (discontinue) written on the sheet on 2/26/13 to stop the ambulation program and the standing frame exercise. Record review of Resident #101's progress notes and Medication Administration Records (MARs) found no assessment for pain regarding the 9 documented entries of pain and 4 refusals during the exercise program for the month of February 2013. No "as needed" pain medication was administered during this time frame. On 2/26/13 at 11:00 a.m., Staff BB said no one had reported Resident #101 having any pain during her rehab exercises. Staff BB said the restorative staff usually talked to her directly if a resident had pain. On 2/26/13 at 11:30 a.m., Staff Z said Resident #101 had not been ambulating in a "long time." Staff Z said Resident #101 could not fully extend her legs to stand. Staff Z said, "We report if residents have pain when they do their exercise program. We had to discontinue (Resident #101's nursing rehab) because she had pain when standing. Her knees are bent." At 11:40 a.m., Staff I said staff had reported to her several times during the month when Resident #101 had pain during standing or trying to walk in her exercise program, "So we discontinued it on the 26th." Staff I acknowledged there was no pain assessment completed and the physician was not notified when the resident complained of pain over the month time frame. At 11:50 a.m., Staff B said she would expect nurses to do an assessment and give pain medication if the resident had an order whenever they complained of pain on an ongoing basis. Resident #101 was not assessed for pain after 18 sessions of rehab therapy during the month of February 2013, when she was made to stand and ambulate while complaining of pain to the point of crying during her exercise sessions. RESIDENT #109 Resident #109 was admitted to the facility in 2011 with multiple medically disabling conditions. A Minimum Data Set (MDS) an assessment tool, dated 1/15/13, documented Resident #109 required extensive assistance with activities of daily living including transfers into and out of her electric wheelchair. The resident was independent with eating after staff assisted her with set up. A care plan dated January 2013, documented Resident #109 had [DIAGNOSES REDACTED]. On 2/28/13 at 12:40 a.m., Resident #109 had covered cup of coffee with a plastic lid and straw on her over bed table. Resident #109 was able to maneuver her electric wheelchair to the nurses' station where staff would hand her a cup of coffee. She was not able to get coffee on her own from the coffee dispenser. Resident #109 stated she was given coffee two days before which spilled on her leg causing a burn. Resident #109 said the staff person may not have put the lid on correctly and the coffee burned her upper thigh. Resident #109 said the burn was very painful at the time of the incident. Resident #109 also said she was having trouble with her electric wheelchair control making it hard to move the chair. Resident #109 was known to move about the facility in her electric wheelchair holding a cup of coffee on a daily basis. Record review of a chart note dated 2/26/13 at 8:45 p.m., found Staff N documented Resident #109 had a burn to her upper left thigh that measured 5 cm (centimeters) by 4.6 cm that was "reddish." The note documented the resident said she had spilled coffee on her leg. The note indicated Staff N had notified the physician. Staff N documented he gave the resident a narcotic pain pill for the pain caused by the burn. Staff N documented on a Treatment Administration Record (TAR) dated 2/26/13, "Monitor bruise on left thigh until healed." On 2/28/13 at 1:20 p.m. Staff K, who was on duty and in charge of doing the resident's treatments on 2/27/13, said she had not monitored the burn area on 2/27/13. Staff K said she needed to circle her initials for the treatment on the TAR as "not" monitored on 2/27/13. On 2/28/13 at 1:16 p.m., Resident #109 was observed in her bed. The resident had two burn areas measuring 5.0 x 9.0 cm and 4.5 x 2 cm. Both areas were bright red in appearance. On 2/28/13 at 1:16 p.m., Staff G said she first looked at the burn on 2/28/13. Staff G said she could not find any information in the chart regarding what Staff N had done such as a treatment plan for the burn including notifying the physician. Staff G did not know why Staff N had documented the burn as a bruise on the TAR dated 2/26/13. Staff G said Staff D looked at the burn on 2/27/13. At 2:00 p.m., Staff D said she had not looked at Resident #109's burn on 2/27/13. Staff D said she would place Resident #109 on the skin rounds check for the next week (3/07/13). At 3:07 p.m., Staff F who was assigned Resident #109, stated he was told in a morning meeting by the Director of Nursing Services on 2/27/13, that Resident #109 had a burn area on her leg and needed to be assessed that day. Staff F said he never "technically" looked at the resident's burn on 2/27/13. Staff F said, "No one saw it yesterday because she was up all day. I saw it this morning (2/28/13) and it is a burn." At 4:00 p.m., Staff E said Staff N did not did not fill out an incident report on the burn incident as required by the facility policy and he "misquoted" when he documented the burn as a bruise. On 3/04/13, Staff E stated Staff N never talked to the physician on the evening the burn was discovered. Staff E said Staff N had decided (on his own) the burn did not need any type of treatment because it was "after the fact" and there were no blisters observed. On 3/04/13, Staff E said the Director of Nursing Services notified the physician on 3/01/13. The physician could not verify if Staff N left him a voice mail on 2/26/13 regarding the burn. Facility staff failed to re-assess, observe, monitor and report to the physician regarding Resident #109 for over 36 hours after staff was aware she sustained a burn. Refer to F-157 RESIDENT #100 Resident #100 admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of the minimum data set (MDS), an assessment tool dated 2/4/13 identified the resident required [MEDICAL TREATMENT] treatment (a blood-cleansing procedure). Review of the record revealed the resident received [MEDICAL TREATMENT] treatment from an outside [MEDICAL TREATMENT] center. Further review did not show evidence Resident #100 received adequate post [MEDICAL TREATMENT] monitoring or that the resident had an emergency kit readily available for possible post [MEDICAL TREATMENT] complications related to the fistula (a connection between vein and artery for [MEDICAL TREATMENT] treatments). Review of the facility's "[MEDICAL TREATMENT] Protocol" dated March 2012 documented, in part, the following: ? Nursing staff will assess the resident's [MEDICAL TREATMENT] site, obtain vitals, perform a mini skin assessment, offer a snack if indicated and keep the resident under observation for the next eight hours ? Emergency dressing supplies will be kept in each resident's room in case of complications with their fistula/shunt On 2/27/13 at 1:51 p.m., interview with Staff F stated there should be a [MEDICAL TREATMENT] flow sheet in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the record did not reveal a completed [MEDICAL TREATMENT] flow sheet in the MAR indicated [REDACTED]. Staff F confirmed Resident #100 did not have a completed [MEDICAL TREATMENT] flow sheet in the MAR indicated [REDACTED]. Review of the record revealed a "[MEDICAL TREATMENT] Information Sheet" which included communication from the [MEDICAL TREATMENT] center and post [MEDICAL TREATMENT] assessment (vital signs, weights, mini skin assessment to include assessment of fistula site) to be completed by staff upon the Residents return to the facility. Review of the record revealed Resident #100's post [MEDICAL TREATMENT] assessments were incomplete. During the month of February 2013 up until the survey date, there were 11 days the residents weights were not monitored, and six days when the resident's vital signs were not monitored and six days when the fistula site did not have monitoring upon return from the [MEDICAL TREATMENT] center. Staff F confirmed the "[MEDICAL TREATMENT] Information Sheets" were incomplete. Review of the record revealed the resident had two sites for [MEDICAL TREATMENT] access, a port-a-cath (an implanted venous access device under the skin) and a fistula. Staff were unaware of which site the [MEDICAL TREATMENT] center accessed for treatment, and observations of the room did not reveal there was an emergency kit available for possible post [MEDICAL TREATMENT] complications related to the fistula. On 2/27/13 at approximately 1:05 p.m., Staff F reported the resident did not have a fistula, and Staff K reported she assessed the fistula site for bleeding whenever the resident returned from [MEDICAL TREATMENT]. On 2/27/13 at approximately 1:15 p.m., Staff F called the [MEDICAL TREATMENT] center to confirm which site the [MEDICAL TREATMENT] center accessed for [MEDICAL TREATMENT] treatement, and according to Staff F, the [MEDICAL TREATMENT] center reported they used the port-a-cath when the fistula did not work. On 2/28/13 at 12:27 p.m., interview with Resident #100 stated the [MEDICAL TREATMENT] center accessed both sites, stating when the fistula does not work the [MEDICAL TREATMENT] center will use the port-a-cath for [MEDICAL TREATMENT] treatment. On 2/27/13 at approximately 2:00 p.m., staff F reported he would provide the resident with an emergency kit for possible post [MEDICAL TREATMENT] complications related the fistula. Failure to consistently monitor Resident #100 for possible post [MEDICAL TREATMENT] complications, and failure to provide an emergency kit for possible post [MEDICAL TREATMENT] complications related to the fistula had the potential for staff not to readily identify and act upon possible post [MEDICAL TREATMENT] complications/emergencies. RESIDENT #143 An admission nursing assessment dated [DATE] documented Resident #143 had a purple area on the left great toe that measured 0.8 cm by 0.2 cm, soft and mushy heels and an open area on the right shin that measured 1.3 cm by 0.6 cm. A "Preliminary Care Plan" dated 2/20/13 identified the resident was at high risk for skin breakdown. The goal documented included "skin doesn't break down." On 3/1/13 at 1:15 p.m. Staff Q and the surveyor reviewed a February 2013 Treatment Flowsheet for Resident #143. The treatment flowsheet documented for staff to conduct a weekly skin check on Tuesdays. A box on the treatment record marked the date one week later on 2/26/13 for staff to conduct the skin check but the box was left blank. The treatment flowsheet also identified for staff to cleanse and dress the area on the right shin daily until resolved. Staff did not document they monitored, cleansed and dressed the area on 2/21/13 and 2/22/13; 2/24/13; 2/27/13 and 2/28/13 after initial discovery on 2/20/13. Another separate area on the treatment flowsheet identified for staff to monitor the purple discoloration on the left great toe weekly and marked the date 2/26/13 to be done. The record did not contain evidence staff conducted monitoring on 2/26/13 or thereafter. Staff Q also reviewed two separate "Skin Grid Forms", one for the open area on the shin and one for the bruise on the left toe. These forms did not contain evidence staff monitored the purple discoloration on the great toe or the open area on the shin the following week after initial discovery. On 3/1/13 at 1:20 p.m. Staff Q assessed the condition of the Resident #143's heels, shin and left great toe to ensure they were healing without complication. At this time, Staff Q identified a different red raised area on the left side of the right toe and reported it must be new. Failure to monitor two non-pressure skin conditions as identified when needed and conduct a full weekly skin check had the potential for staff to not readily identify if skin conditions or "mushy heels" worsened in order to implement timely changes to the plan of treatment. .

Based on observations, record review and interview, the facility failed to provide adequate supervision and/or failed to ensure staff used an assistive device during transport to prevent accidents for 1 of 7 sampled residents (#1) reviewed for allegations of abuse/neglect. This failure resulted in harm to Resident #1 when her foot dropped during transport and resulted in a fractured ankle. Findings include: Review of a facility investigation dated 6/1/12 revealed on 5/27/12, Staff D (nursing assistant) transported Resident #1 to the dining room in a wheel chair. Staff D stated she was aware Resident #1 used footrests on her wheel chair; however, she was unable to locate them at the time. Staff D asked the resident to hold up her legs. While Staff D pushed the chair, Resident #1's left leg dropped to the floor and was caught under the wheel chair. Further review of the investigation and nursing progress notes dated 5/27/12 revealed an initial nursing assessment by Staff E (licensed nurse) showed no visible signs of injury. Review of nursing progress notes dated 5/28/12 at 5:15 p.m. revealed Resident #1 complained of pain in her ankle; assessment revealed it was warm and painful to touch. Review of x-ray results dated 5/28/12 revealed a non-displaced fracture of the ankle. Resident #1 was transferred to the emergency room for further evaluation and treatment. On 5/29/12 at 12:45 p.m. , Resident #1 was observed in bed. During interview, the resident was able to tell the investigator her ankle was hurt; the resident was unable to recall how it happened. Interview with Staff C (nursing assistant) assigned to care for Resident #1 on 5/29/12 revealed she also cared for Resident #1 prior to the above incident. Staff C stated Resident #1 always used foot rests on the wheel chair because "she dragged her feet". Record review revealed Resident #1 admitted to the facility during 2009 with multiple medical [DIAGNOSES REDACTED]. The resident was dependent on staff for transfers and wheel chair mobility. Review of the facility's investigation summary revealed the facility was able to substantiate Staff D failed to use foot rests while pushing Resident #1 in the wheel chair. Investigation summary included reference to the resident's medical history including stroke with chronic left-sided weakness, which was the same side in which the injury occurred.

Based on observations, record review and interview, the facility failed to provide adequate supervision to ensure the immediate environment was safe for 1 of 6 residents (former Resident #1) reviewed for falls. Resident #1 had a non-injury fall from bed when the resident's head missed the mat and came into contact with the bare floor. Resident #1 had a second fall and missed the mat, resulting in harm related to nasal fractures and facial injuries sustained as a result of the fall. Findings include: Closed record review revealed former Resident #1 admitted during 4/2010 with multiple [DIAGNOSES REDACTED]. Review of the resident's most recent quarterly assessment dated [DATE] revealed the resident was totally dependent on staff for all activities of daily living. Further record review revealed documentation in a fall committee review dated 7/16/11 (after the resident's first fall) indicated Resident #1 had constant movement of limbs, head, and trunk when awake. Review of fall committeee review following the resident's second fall on 7/26/11 revealed the resident was known to have broad random movements of her head, limbs, and trunk, causing her to move. Review of a facility investigation dated 7/26/11 revealed staff found Resident #1 lying face down on the floor on the right side of her bed with blood around her head. The investigation revealed the floor mat was next to the bed with approximately 18 inches between the head of the bed and the wall. The resident's head was observed in the area not covered by the mat. A witness statement indicated if the resident had rolled straight out of bed, the resident would have landed fully on the mat; the resident's head was even with the head board and in the space between the wall and the top of the floor mat. Review of a facility investigation dated 7/16/11, ten days earlier than the above incident, revealed Resident #1 was found partially on the floor mat with her feet on the bed and her head just over the edge of the mat in contact with the bare floor. The facility's investigation concluded the fall was reasonably related to broad, continuous movements of the resident's head, trunk, and limbs with a tendency to move her head and trunk diagonally off the bed to the right side. The facility's plan to prevent recurrence included replacing a scoop mattress to define the edges of the bed that was previously ordered on [DATE] following a fall from bed. There was no evidence of a care plan change related to the floor mat to further protect the resident from falls related to the facility's assessment of the resident's increased involuntary movements in bed and potential to move diagonally off the bed on the right side. During interview on 8/10/11 at 1:40 p.m., Staff B (care manager) and the investigator observed Resident #1's former room environment. Prior to the second fall, Resident #1 was in a middle bed in a three bed room. A thin gel foam mat was positioned to the right of the resident's bed and a thicker foam mat on the left side of the bed. Staff B explained the thin mat, which was flatter and narrower than the foam mat, was used on the right to avoid a tripping hazard for the resident in the next bed. Staff B stated following Resident #1's first fall in which the resident's head was off the mat and in contact with the bare floor, there was no change to the placement and/or type of protective mat on the floor because of the potential tripping hazard for the roommate. Observations showed following the second fall with injury, Resident #1 was moved into the first bed which had since become available. The first bed position allowed sufficient room to make changes to further protect the resident from injury related to falls from bed. During telephone interview on 8/16/11 at 9:40 a.m., Staff A (director of nursing) stated the facility replaced the scoop mattress after the resident's fall on 7/16/11. Staff A indicated staff felt the mats on both sides of the bed and the scoop mattress provided the safety needed by the resident at that time.

Based on observations, record review, and interview, the facility failed to provide sufficient staff supervision to ensure the plan of care was followed for 1 of 4 residents (#1) reviewed for falls and/or injuries. This failure resulted in actual harm to Resident #1 who sustained a fractured arm when staff did not follow the resident's plan of care during a transfer. Findings include: Resident #1 admitted to the facility during 6/2011 with multiple medical [DIAGNOSES REDACTED]. Review of the resident's record revealed care directives (care instructions for staff providing daily care for the resident) dated 6/14/11 informed staff the resident required two people and the use of a gait belt to transfer the resident safely. During interview on 6/28/2011 at 9:20 a.m., Resident #1 informed the investigator her arm was broken; the resident's right arm was observed immobilized in a sling. The resident was not able at that time to provide details of how her arm was injured. Interview with Staff C (Investigation nurse) on 6/28/11 at 1:20 p.m. revealed during her interview with Resident #1 on 6/15/11, the resident stated her arm was hurt when a male staff transferred her from her wheel chair to bed that afternoon. The resident stated she told the staff not to use her arms but he did anyway and he did not use a belt. During that interview, Resident #1 told Staff C the staff stood in front of her and placed each of his hands on her mid-forearms and proceeded to transfer her to bed by using her arms. The staff that did not follow the plan of care was subsequently identified as Staff B, certified nursing assistant. Review of an X-ray report for Resident #1 dated 6/15/11 revealed evidence of an acute humeral neck fracture with mild displacement. The resident was sent to the emergency roiagnom on [DATE] for further evaluation and treatment of [REDACTED].

Based on observations, interviews and record review, the facility failed to ensure an emergency generator started and transferred power to the facility within the allotted ten seconds. Failure to ensure the emergency generator was functional put all residents' safety in jeopardy related to care and services within the facility. Findings include: Refer to: CFR 483.70, K-146: The facility failed to equip the temporary emergency generator to automatically transfer the power to functions that are minimum requirements in the 200 Life Safety Code existing. Failure to equip and maintain the emergency generator to transfer loads automatically in a power outage and relying on manual starting of the emergency generator could delay activation, leaving the facility without functioning egress lighting, illumination of exit directional signs, nurse call systems, suction machines, oxygen concentrators and breathing treatments. Observations on 2/2/11 at about 2:00 p.m. revealed a temporary generator placed in a parking lot outside the facility close to an exit door centrally located on the facility grounds. Observations by the Fire Marshal on 2/2/11 at approximately 8:30 a.m. revealed the temporary generator functioned properly when started manually and provided emergency power for required functions. At this time, Staff A, Staff H and Staff J were interviewed and were asked what facility staff members would start the emergency generator when the power was out. The above staff confirmed when there was a power outage, facility staff would contact maintenance initially and maintenance staff would come to the facility and start the generator. During the same interview on 2/2/11 at 8:30 a.m. Staff A, Staff H and Staff J were asked who at the facility other than the maintenance person knows how to start the temporary generator in the event of a power outage. The response from the above staff was that there was no one else that had been trained to start the temporary generator during a power outage. Staff A, Staff H and Staff J, during the interview, were asked if a procedure was in place or if any training of facility staff had taken place since beginning the use of the temporary generator. Staff A, Staff H and Staff J confirmed at this time there were no written procedures and there had been no facility staff training as to how to manually turn on the temporary generator. The facility had been solely relying on calling in the maintenance person in an emergency, which means there would be no power until the maintenance person arrived and turned on the temporary generator manually. Another function of the emergency power system is to provide backup power to the nurse call system. In the course of the exchange of information, it was revealed the nurse call system does not have a reliable battery back up in the event of a power outage. The nurse call system, as well as oxygen concentrators and suction devices, would rely entirely on the temporary emergency generator to continue functioning. Observations on 1/31/11 during initial tour at 8:30 a.m. and during the noon meal the same day, revealed several residents throughout the building receiving oxygen by a concentrator (a machine that concentrates oxygen in the air and delivers the oxygen through a tube to a resident who has trouble breathing). The concentrators rely on electricity to function. During the noon meal, surveyors identified residents with swallowing difficulties residing on C and D halls. Administrative staff identified 63 residents at risk for falls, 19 residents with swallowing difficulties/at risk for aspiration and 12 residents that needed oxygen provided by a concentrator at the bedside. Further observations during the time of the survey revealed an oxygen storage room located in a hallway near an exit door at least 40 feet from the closest resident room in which resided a resident who required oxygen. Record review revealed 119 residents residing at the facility on 1/31/11. Review of the facility night shift staffing pattern from 1/17/11 to 1/31/11 revealed an average of 10 staff which included 2 licensed staff and 8 nurse aides. In the event of a power outage during evening hours or late at night, presence of an emergency power system that required manual start-up placed the residents in the facility at risk for harm and/or injury from medical complications [REDACTED]. .