Every finding on record at The Broadview Center

Based on interview and record review, the facility failed to perform daily weight monitoring, and failed to notify the medical provider about repeated low blood pressure readings associated with use of a diuretic (a medication that helps the body get rid of extra fluid) for 1 of 4 residents (Resident 1), reviewed for quality of care. These failures placed the resident at risk for unrecognized medical complications, unmet care needs, and a diminished quality of life.Findings included.Review of a face sheet showed that Resident 1 was admitted to the facility on [DATE] with diagnoses that included fluid overload (the body has too much fluid) and left ventricular failure (Heart Failure - a condition where the left side of the heart cannot pump blood effectively) from a recent hospitalization.Review of Resident 1's hospital document titled, Skilled Nursing Facility or Acute Rehabilitation Form, dated 07/18/2026 showed an order for a diuretic medication to be administered twice daily. It further showed nursing instructions included, Weight patient 3X [three times] a week and call MD [Medical Doctor] to adjust diuretics if weight increasing by 3 [three] pounds in a week or 5 [five] pounds total and that Resident 1's weight was 142 pounds.Review of Resident 1's physician orders, printed on 08/07/2026, showed a twice-daily order for a diuretic medication beginning 07/18/2026, and a separate order for daily weight monitoring once per day beginning 07/19/2026. Further review showed an order for assessment of Resident 1's vital signs (measurement of the body's most basic functions) every shift beginning on 07/18/2026.Review of Resident 1's care plan for diuretic use, dated 07/18/2026, showed that Resident 1 has a diuretic medication requirement with increased risk for electrolyte imbalance [the body has too much or too little of important minerals], dehydration [the body does not have enough water], hypotension [low blood pressure], dizziness. The care plan also outlined nursing interventions directing staff to observe for signs and symptoms of fluid imbalance including dehydration or fluid overload and notify MD as needed.Review of Resident 1's electronic health records (EHR) including the Medication Administration Record (MAR), nursing progress notes, and vital-sign documentation did not show recorded daily weights for 07/19/2026, 07/21/2026, 07/22/2026, 07/23/2026 and on 07/24/2026. Further review showed that Resident 1's weight was 136 pounds on 07/20/2026 (six pounds less than Resident 1's recorded weight on 07/18/2026).Review of Resident 1's MAR showed recorded blood pressure (BP) readings as follows:-BP 104 over 62 was recorded on 07/20/2026 -BP 96 over 66 was recorded on 07/21/2026 -BP 105 over 62 was recorded on 07/22/2026-BP 92 over 68 was recorded on 07/23/2026 -BP 80 over 38 was recorded on 07/24/2026Review of Resident 1's EHR including nursing progress notes did not show documentation of provider notification and/or nursing intervention related to low BP readings on 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026 and on 07/24/2026.Review of Resident 1's late entry nursing progress note dated 07/29/2026 showed, This nurse went to assess resident, and it was noted that [Resident 1] was hypotensive [low blood pressure] with a BP of 80/38 [80 over 38] manually. [Resident 1] was more confused than usual and was not making sense.Attempted to notify provider, provider did not answer. Per nursing judgement, called 911 [Emergency services] to send [Resident 1] to hospital.Review of Resident 1's document titled, SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated 07/25/2026 showed that Resident 1 had a change in condition and was transferred to the hospital at 2:49 PM on 07/25/2026. It further showed that Resident 1's BP of 80/38 was recorded on 07/24/2026 at 11:40 PM.Review of Resident 1's document titled, ED [Emergency Department] Provider Note, dated 07/25/2026, showed that Resident 1 presented to the ED with decreased level of consciousness and hypotension and that Resident 1 was recorded to have a BP of 94/50.Review of Resident 1's hospital History and Physical, dated 07/25/2026, showed that Resident 1 had recently been diagnosed with heart failure during a prior hospitalization and had been newly started on several medications, including a diuretic. Further review showed that Resident 1 was hypovolemic (when the body does not have enough fluid or blood) on admission and that suspect over diuresis [someone has been given too much diuretic medication, causing the body to lose more fluid than it should].Review of Resident 1's hospital Discharge summary, dated [DATE], documented that Resident 1 was assessed as unlikely to tolerate the prescribed diuretic medication and that not looking like he will tolerate [diuretic medication]. Further review showed the provider noted that He should have daily weights monitored and frequent metabolic panels checked [a blood test].In an interview and joint record review on 08/19/2026 at 1:28 PM with Staff B, Resident Care Manager, stated that the facility's process for monitoring residents prescribed a diuretic medication included observing for potential side effects such as hypotension and dehydration. Staff B stated that the facility monitored vital signs, including blood pressure and weights, as part of this process. Staff B stated that we monitor for rapid and excessive weight loss and weight gain, and that we do this by monitoring weights daily. A joint record review of Resident 1's EHR showed a twice-daily order for a diuretic medication, a separate order for daily weight monitoring once per day and an order for assessment of Resident 1's vital signs every shift. Further review did not show Resident 1's recorded daily weights for 07/19/2026, 07/21/2026, 07/22/2026, 07/23/2026 and on 07/24/2026. Staff B stated that Resident 1's weight was not recorded as ordered and that It's [it is] not documented in the MAR and PCC [Point Click Care - EHR system]. Further joint record review of Resident 1's July 2026 MAR showed low BP readings were recorded for the evening shift on 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026 and on 07/24/2026. When asked what was indicated in Resident 1's BP readings, Staff B stated, That [Resident 1 was] hypotensive and that I would have notified the provider and pushed fluids [increase fluid intake]. When asked where documentation of nursing follow-up interventions related to Resident 1's low BP readings would be recorded, Staff B stated, In the progress notes usually. A joint record review of Resident 1's progress notes did not show documentation of provider notification and/or nursing intervention related to low BP readings on 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026 and 07/24/2026. Staff B stated, I don't [do not] see provider notification for the other days. When asked if Resident 1 was adequately monitored related to diuretic medication use, Staff B stated, I would say no, because the provider was not made aware of the hypotension. Staff B further stated that they expected Resident 1's daily weights would have been monitored and recorded.In an interview on 08/19/2026 at 2:05 PM, Staff A, Director of Nursing, stated that residents prescribed a diuretic were monitored both for effectiveness of the medication and for potential side effects. Staff A explained, Monitor for fluid retention and monitor weight per provider orders and direction. Staff A further stated that they would expect Resident 1 to have been appropriately monitored for diuretic use in accordance with standards of practice. Reference: (WAC) 388-97-1060 (1).

Based on observation, interview, and record review, the facility failed to ensure hand hygiene/glove use practices and/or Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) practices were followed for 5 of 6 Staff (Staff G, H, J, K, & L), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk of infection and related complications. Findings included.Review of the facility's undated policy titled, Hand Hygiene, showed, The facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene. The policy showed, All staff are responsible for following hand hygiene procedures: . b. Before and after having direct contact with a resident's intact skin. c. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. e. When hands move from a contaminated-body site to a clean body site during resident care f. Before and after wearing gloves. The policy further showed an alcohol-based hand sanitizer should be used, Before moving from work on a soiled body site to a clean body site on the same resident iv. After touching a resident or the resident's immediate environment v. After contact with blood, body fluids or contaminated surfaces vi. Immediately after removing gloves.Review of the Centers for Disease Control and Prevention (CDC) online document titled, Implementation of Personal Protective Equipment (PPE [gown and gloves]) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, showed, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. The document further showed, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:.Changing briefs or assisting with toileting.Device care or use:.urinary catheter [flexible tube inserted into the bladder that drains urine].Review of Resident 9's physician orders printed on 06/24/2026 showed an order for Enhanced Barrier Precautions r/t [related to] indwelling urinary catheter, bilateral [both] lower leg wound. Ensure precautions in place, educate resident/visitors of infection control.Observation on 06/24/2026 at 9:30 AM, showed an EBP signage outside Resident 9's room.<STAFF G>In an observation on 06/24/2026 at 9:47 AM, Staff G, Certified Nursing Assistant (CNA), entered Resident 9's room wearing a gown and gloves. Staff G cleaned Resident 9's kidney basin (kidney-shaped tray used to catch bodily fluids) that contained oral secretions from their oral care, Staff G then removed their gloves and applied new gloves. Staff G touched Resident 9's belongings including their bed, control, and cables, removed their gloves and applied new gloves. Staff G did peri-care (cleaning of private parts) on Resident 9's front side including catheter care, then they removed their gloves and applied new gloves to clean Resident 9's bowel movement (BM). Staff G removed their gloves and applied new gloves and then touched Resident 9's pillow and blanket, and assisted Resident 9 with putting a new gown on. Staff G did not do hand hygiene in between glove use. On 06/24/2026 at 10:18 AM, Staff G stated that they would do hand hygiene before and after a task. Staff G stated that they would change their gloves in between tasks and it was a part of hand hygiene. When asked if hand hygiene should be performed after glove removal, Staff G stated, I may need to be guided. Staff G stated hand hygiene was important to avoid spreading diseases and for infection control.<STAFF H>In an observation on 06/25/2026 at 9:57 AM, Staff H, CNA, entered Resident 9's room wearing a gown and gloves. Staff H unfasted Resident 9's brief and performed peri-care on Resident 9 using wet wipes. Staff H assisted Resident 9 to roll towards them and held onto Resident 9's hand. Staff H applied barrier cream to Resident 9's skin and then applied a new brief to Resident 9. Staff H touched Resident 9's bedding, bedside table, and their gown. Staff H did not change their gloves after performing peri-care on Resident 9 or do hand hygiene.On 06/25/2026 at 10:34 AM, Staff H stated that hand hygiene was performed before and after care, removing gloves, between meal trays, and before removing or applying PPE. Staff H stated gloves should be changed between dirty to clean tasks. Staff H further stated they should have changed their gloves in between dirty to clean tasks for Resident 9's care and done hand hygiene in between glove use.On 06/25/2026 at 11:13 AM, Staff I, Licensed Practical Nurse (LPN), stated hand hygiene should be performed after glove removal. Staff I further stated (Staff H) should have removed their gloves after peri-care on Resident 9 and done hand hygiene and applied a new pair of gloves. <STAFF J>In an observation and interview on 06/29/2026 at 10:04 AM, Staff J, CNA, entered Resident 9's room wearing a gown and applied two pairs of gloves inside the room. Staff J unfastened Resident 9's brief, did peri-care and then removed their top gloves. Staff J then cleaned Resident 9's BM, and removed the soiled brief and then their gloves. Staff J applied new gloves and continued to wipe Resident 9 and applied a new brief. Staff J assisted Resident 9 get positioned in bed and touched their bed control, sheets, and pillow. Staff J then grabbed the dirty trash bag and removed their gloves and applied new gloves to empty Resident 9's catheter bag (used to collect urine). Staff J removed their gown and gloves and then touched Resident 9's bedside table to move it next to their bed. Staff J did not do hand hygiene in between glove use. Staff J stated hand hygiene should be performed after cleaning a resident's BM, after using gloves, and when leaving a resident's room.<STAFF K AND STAFF L>In an observation on 06/29/2026 at 10:32 AM, Staff K, LPN, and Staff L, CNA, entered Resident 9's room and applied gloves. Staff K unfasted Resident 9's brief and positioned them on their side and applied gel medication to Resident 9's back. Staff K removed their gloves, applied new gloves and applied skin prep (used to protect skin) to Resident 9's bottom. Staff L cleaned Resident 9's BM and then performed peri-care and catheter care on Resident 9. Both staff did not wear a gown while performing care for Resident 9. Staff K did not do hand hygiene in between glove use. Staff L did not remove their gloves after cleaning Resident 9's BM or do hand hygiene prior to performing catheter care on Resident 9.On 06/29/2026 at 10:46 AM, Staff K stated that Resident 9 was on EBP due to their catheter. Staff K stated that gloves were important when providing care and that a gown could also be worn according to the precaution. Staff K stated that hand hygiene should be done before and after caring for a resident, and after removing their gloves. Staff K further stated that Staff L should have removed their gloves and done hand hygiene before doing catheter care on Resident 9.On 06/29/2026 at 11:00 AM, Staff L stated that they should have followed EBP signage for Resident 9 and worn a gown while performing care. Staff L stated that they performed hand hygiene when exiting a resident room. Staff L stated that wiping Resident 9's BM first and then performing catheter care with the same pair of gloves put Resident 9 at risk of a urinary tract infection.On 06/29/2026 at 11:30 AM, Staff B, Director of Nursing, stated they expected staff to follow their hand hygiene policy and follow EBP signage outside a resident's room.Reference WAC 388-97-1320(1)(a)(c).

Based on interview and record review, the facility failed to prevent physical abuse for 2 of 6 residents (Resident 3 and 5), reviewed for abuse investigations. These failures placed the residents at increased risk of injury, emotional distress and a diminished quality of life. Findings included .Review of the facility's policy titled, Abuse, reviewed on 10/20/2022, showed This organization recognizes and respects that each resident has the right to be free from abuse. It further showed that abuse was defined as the willful infliction of injury.Instances of abuse of all residents, irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.<RESIDENT 3>Review of an incident investigation report dated 06/01/2026, showed that nursing staff heard [a] commotion in [the] dining room and witnessed [Resident 4] having an argument with [Resident 3] and that Resident 4 moved her hand toward [Resident 3]'s face making contact.Review of the nursing progress note dated 06/01/2026 showed that Resident 3 and Resident 4 had resident to resident physical incident.In an interview on 06/11/2026 at 2:37 PM, Resident 3 stated, Yes when asked if they had an altercation with a resident. Resident 3 stated that they could not remember the resident's name but she hit me like this [with an open hand to their right temple area]. She was bragging about something but then she hit me.In an interview on 06/11/2026 at 3:01 PM, Resident 4 stated that they had an argument with Resident 3 when they were in the dining room. Resident 4 stated that Resident 3 was picking with everybody and that they asked Resident 3 if they [want to] get slapped? Resident 4 stated that Resident 3 raised her hand and when she raised her hand, I slapped her.In an interview on 06/12/2026 at 9:08 AM, Resident 7 stated that they were sitting with Resident 3 and Resident 4 in the dining room. Resident 7 stated that Resident 4 and Resident 3 were arguing with each other and that Resident 4 stood up and slapped Resident 3.In an interview on 06/12/2026 at 9:37 AM, Staff D, Registered Nurse, stated that they were in the hallway when they heard noises coming from the dining room. Staff D stated that when they got to the dining room, they saw Staff C, Certified Nursing Assistant, trying to intervene between Resident 3 and Resident 4. Staff D stated that Staff C told them that Resident 4 slapped Resident 3. In an interview on 06/12/2026 at 9:43 AM, Staff C stated that they heard a commotion in the dining room and saw Resident 4 swung her hand and smacked her [Resident 3]. Staff C further stated, I saw the altercation as it happened and I separated them. <RESIDENT 5>Review of an incident investigation report dated 06/03/2026, showed that Residents 5, 6 and 8 were in the dining room talking to each other. The investigation report showed that Staff E, Certified Nursing Assistant (CNA) heard Resident 5 with an elevated voice and witnessed Resident 6 grabbed Resident 5's right forearm. The investigation report further showed that Resident 5 sustained two new superficial (outer skin) bruises on her right arm.red/purple in color.Review of the nursing progress note dated 06/03/2026, showed Resident 5 had a bruise and complained of pain to their right forearm.An observation and interview on 06/11/2026 at 4:44 PM, showed Resident 5 was propelling around the unit in their wheelchair. When asked to be interviewed, Resident 5 stated, I have no time for that. Come back next time.In a follow-up interview and observation on 06/12/2026 at 11:42 AM, Resident 5 stated, Oh, I am going to tell you something when asked to show their right forearm. Resident 5 pulled up their right sleeve and showed a pale bluish discoloration on their right forearm. Resident 5 stated, Someone grabbed my arm so tight and it turned blue. When asked if they knew the person who grabbed their right arm, Resident 5 stated, I don't remember but he grabbed my arm and I screamed.An observation and interview on 06/12/2026 at 8:48 AM, showed Resident 6 had difficulty speaking and used gestures/nodding to communicate. Resident 6's facial expression showed their eyebrows drawn together and declined further questions when asked related to the altercation with Resident 5.In an interview on 06/12/2026 at 11:12 AM, Resident 8 stated that they were in the dining room with Resident 6 when Resident 5 yelled at them and said that we were going to jail because we were holding hands. [Resident 6] then wheeled over to [Resident 5] and grabbed her arm, and she screamed like bloody murder. And people came over. In a phone interview on 06/23/2026 at 11:04 AM, Staff E, CNA, stated that they were in the dining room and saw the incident. Staff E stated that Resident 5 said something and [Resident 6] took a swing, [and] he hit her in the right arm. He was like holding her [right] arm. It happened really fast and I separated them. In an interview on 06/23/2026 at 11:42 AM, Staff B, Director of Nursing, stated that they investigated two separate resident-to-resident altercations that resulted to physical abuse for Resident 3 and Resident 5. Staff B stated that Resident 5 sustained superficial bruises on their right forearm. Staff B further stated that they considered resident-to-resident altercation as a form of abuse and that they expected residents to be free from abuse. Reference WAC: 388-97-0640(1).

Based on interview and record review, the facility failed to develop a plan for discharge and to notify a resident and/or their representative of a discharge in writing for 1 of 3 residents (Resident 1), reviewed for discharge process. This failure placed the resident and their representative at risk of not having an opportunity to make an informed decision about the discharge and about their rights to appeal the discharge. Findings included.Review of the facility's policy titled, Discharge Planning, dated 10/01/2021, showed that The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care.The facility's discharge planning process must be consistent with the discharge rights for all individuals, including skilled and long-term care residents, regardless of source of payment.Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnosis that included sepsis (a life-threatening reaction to an infection), a history of repeated falls, and abnormality of gait (the way a person walks) and mobility.Review of Resident 1's care plan for rehabilitation, revised on 01/14/2026, showed that [Resident 1] has been admitted to the facility to rehabilitation and requires assistance with activities of daily living [ADL] due to recent hospitalization for sepsis with altered mental status [confusion] and overall decline in functional abilities. Further review of Resident 1's comprehensive care plan did not show a care plan or goals related to discharge planning. Review of Resident 1's comprehensive care plan also showed a closed (retired) date of 02/03/2026 due to discharge from the facility.Review of Resident 1's Electronic Health Record (EHR) under the census section showed his discharge date of 01/30/2026. Further review showed private pay as Resident 1's billed primary payer from 01/24/2026 through 01/29/2026.Review of a medical provider progress note dated 01/21/2026 showed that Resident 1 was documented to have discharge planning issues and that He is currently min [minimal] to max [maximal] assist with most ADL, not able to stand without breaks, continuing confusion. Recommendation is 24-hour assistance.Review of a document titled Notice of Medicare Non-Coverage, signed by Resident 1's representative on 01/22/2026, showed that Resident 1's skilled services were scheduled to end on 01/24/2026. Further review indicated that financial liability would begin on 01/25/2026 and that Resident 1 had the right to file an appeal the termination of skilled services.Review of a progress note dated 01/23/2026 showed that Resident 1 filed an appeal. Further review showed that the note was authored by Staff F, Social Worker.Review of a progress note dated 01/24/2026, authored by Staff F, showed Received notice [Resident 1] lost his appeal, LCD [last covered day] remains 01/24/2026.Review of a progress note dated 02/09/2026 showed documentation that Resident 1 won his redetermination appeal.Review of a scanned document in Resident 1's EHR, dated 02/07/2026, showed that An independent reconsideration peer reviewer determined that termination of skilled services 01/24/2026 was issued incorrectly. Further review showed that The determination was based on the following information:- [Resident 1 required] complete assistance to move from bed to a chair. - [Resident 1 was] unable to walk-The plan for your care after leaving the skilled nursing facility is not documented in your medical record.In an interview on 06/10/2026 at 2:31 PM, Resident 1's representative was asked the circumstances of Resident 1's discharge from the facility on 01/30/2026, Resident 1's representative stated, We were told that Medicare would stop paying [Name of Resident 1's health insurance] within three days and so we just had to scramble to find an adult family home [AFH - a house in the community staffed by caregivers who provide 24-hour support], we hardly knew what that was.we had to do it in a very big hurry and then they said we had to pay [the facility]. Resident 1's representative further stated, He wasn't [was not] ready to leave, we felt rushed. We felt like we had no choice, and that We wouldn't [would not] have chosen to go to the AFH, we felt like he wasn't [was not] ready at that time.In an interview and joint record review on 06/11/2026 at 1:27 PM, Staff F was asked if residents and/or their representatives were issued a notice when the facility transferred or discharged residents out of the facility, and that Staff F stated, We don't [do not] have documents that state the purpose of the discharge or any kind of notice. I usually just notify them verbally. A joint record review of a facility document titled Nursing Home Transfer or Discharge Notice showed that Written notice of transfer or discharge, and the reasons for the move, must be provide to the resident and the resident's representative, in a language and manner they understand. Further review of the document showed Appeal Rights - You have the right to appeal this discharge or transfer by making a request for a hearing.You have the right to remain in the facility until the appeal is decided, if the hearing request is received on or before the proposed date of transfer/discharge, or the day you are actually transferred/discharged . Staff F stated Yes, it [Notice of transfer or discharge form] does look familiar, I have not been completing this. A joint record review of Resident 1's EHR did not show a completed notice of transfer or discharge issued to Resident 1 and/or their representative. Staff F stated, I do not see one for him, and that I would expect to see it in [Resident 1's EHR] if it was completed.In an interview on 06/11/2026 at 2:03 PM, Staff B, Director of Nursing, stated that the facility's process for issuing notices of transfers or discharge to residents was that there is a written notice. For non-emergency discharges we do provide that written notice.In a follow-up interview on 06/23/2026 at 12:05 PM, Staff B stated, There should have been a discharge notice issued [to Resident 1 and his representative] and that it would have informed the resident of their right to appeal that discharge.In an interview on 06/23/2026 at 12:13 PM, Staff A, Administrator, stated that the facility followed the process of issuing written notices of transfer or discharge to residents, and that these notices inform residents of their right to appeal. When asked about the facility's policy, Staff A stated, Every discharge or transfer would have that notice issued. Whether that's [that is] happening or not, I don't [do not] know if that's been happening. When asked how resident care and services were continued during an ongoing appeal, Staff A stated, We keep them on skilled services until we know that they have exhausted all of their chances to appeal.Reference: (WAC) 388-97-0120 (2) (a-c).

Based on interview and record review, the facility failed to prevent physical abuse for 1 of 8 residents (Resident 1), reviewed for abuse investigations. Resident 2 initiated physical aggression towards Resident 1 by grabbing her left wrist causing unwanted physical contact, swelling and bruising. This failure placed residents at an increased risk of injury, emotional distress and a reduced quality of life.Findings included.Review of the facility's policy titled, Abuse, reviewed on 10/20/2022, showed This organization recognizes and respects that each resident has the right to be free from abuse. It further showed that abuse was defined as the willful inflection of injury.Instances of abuse of all residents, irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to infect injury or harm.Review of an incident summary, dated 04/19/2026 at 7:15 PM, showed that nursing staff witnessed [Resident 2] agitated and initiated physical aggression to [Resident 1] by grabbing her left wrist causing a superficial bruise.It further showed documentation of Resident 1's statement which showed, [Resident 1] was in the middle of the hallway and I was not able to go through so I asked her politely to move so that we can go through.[Resident 2] then got upset and grabbed/pulled my left wrist. It further showed that the incident between Resident 1 and 2 was witnessed by staff.Review of Resident 1's document titled, Skin Observation Weekly (Licensed Nurse, dated 04/16/2026, showed that Resident 1 was assessed to have no bruises, or other skin conditions four days before the incident.Review of Resident 1's skin observation weekly document, dated 04/23/2026, showed that Resident 1 was assessed to have left dorsal bruise fading four days after the incident.Review of Resident 1's Treatment Administration Record dated April 2026, showed an order to Monitor bruise to left dorsal hand until resolved, every shift skin monitoring until resolved, and that this order was initiated on 04/20/2026.In an interview on 05/08/2026 at 12:51 PM, Resident 1 was asked about the 04/19/2025 incident involving her and Resident 2, and Resident 1 stated, My friend and I take the wheelchair up and down the hallway sometimes just to exercise on our own.[Resident 2] was sitting in the middle of the isle and I asked her to please move and she told me to move and then she grabbed my left wrist by her bare hands.This [Resident 1's left wrist] was swollen, big, black and blue. Resident 1 further stated that the swelling and bruising to her left wrist was painful in the beginning.In an interview on 05/14/2026 at 12:55 PM, Staff C, Licensed Practical Nurse, stated that staff were trained on abuse and neglect, including physical abuse. Staff C further stated that resident-to-resident altercations can constitute abuse, noting that there are two kinds, sometimes verbal and even physical contact.In an interview on 05/14/2026 at 1:10 PM, Staff D, Certified Nursing Assistant, stated she was trained on abuse and neglect, including physical abuse. Staff D further explained that an example of physical abuse included somebody hitting another person.In an interview on 05/14/2026 at 1:38 PM with Staff A, Administrator, and Staff B, Director of Nursing, Staff B stated that the facility's policy on abuse defined what was considered physical abuse. Staff A stated that physical abuse was unwanted touch from one person to another. Staff A further stated that the facility followed the Purple Book, Nursing Home Guidelines [a guidance manual for nursing homes focused on abuse and neglect prevention, incident identification, investigation procedures, and reporting requirements]. When asked if Resident 1 sustained a physical injury as a direct result of the resident-to-resident incident involving Resident 2 on 04/19/2026, Staff B stated, Yes. Staff B further stated, I don't [do not] think it was intentional, rather it was a reaction by [Resident 2].Reference: (WAC) 388-97-0640(1).

Based on interview and record review, the facility failed to ensure bathing/showers were consistently provided for 1 of 3 residents (Resident 1), reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, and a diminished quality of life.Findings included .Review of the facility's policy titled, Activities of Daily Living (ADLs), dated 10/01/2021, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy showed if a resident refused care the resident and/or representative would be informed of the risks and benefits, offered an alternative intervention to minimize further decline, and the refusal and information would be documented in the resident's clinical record. The policy further showed each resident would receive a tub or shower baths as often as needed, but not less than twice weekly or as required by law.Review of the annual Minimum Data Set (MDS-a required assessment tool) dated 02/11/2026 showed Resident 1 did not have impaired memory or thinking and was dependent on staff for assistance with showers/baths.Review of Resident 1's care plan for rehabilitation initiated on 02/12/2025 showed Resident 1 had been admitted to the facility and required assistance with their activities of daily living. The care plan was revised on 06/30/2025 and showed Resident 1 was dependent on staff for bathing.Review of Resident 1's Electronic Health Record (EHR), under task- ADL Bath/Shower, showed Resident 1 was scheduled for a shower/bath every Tuesday evening and as needed. The 30-day look back period from 03/25/2026 to 04/08/2026 showed bed baths were documented as provided on 03/25/2026 and 04/08/2026, which reflected two bed baths in a 30-day period.Review of Resident 1's EHR under nursing progress notes dated 03/25/2026 to 04/16/2026 showed no documented refusal of showers/baths.In an interview on 04/08/2026 at 12:16 PM, Resident 1 stated, I would love to have two showers a week, I would be happy just to get one shower a week, sometimes I get a bed bath. It has even been a while since I had one of them. But that is nothing like getting a shower, I feel so much cleaner with a shower. I need help to take my showers; I can't take them by myself. I can't even get out of bed by myself.In an interview on 04/17/2026 at 1:37 PM, Staff B, Certified Nursing Assistant, stated the nurse would tell the assigned aide which resident was scheduled to be showered that day, if there was no shower aid scheduled for work, the assigned nursing assistant would give the resident the shower. Staff B stated that they help residents that could not do it by themselves and that they document under ADL Bath/Shower task after the resident received the shower/bed bath. Staff B further stated that if the resident refused, they would let the nurse know.In an interview on 04/17/2026 at 2:01 PM, Staff C, Resident Care Manager, stated that most of the residents were scheduled for showers/baths at least once a week, but most were scheduled twice a week and would receive the required assistance from staff to complete the shower/bed bath.A joint record review and interview on 04/17/2026 at 2:44 PM with Staff A, Director of Nursing Services, showed Resident 1's care plan in the EHR for rehabilitation, initiated on 02/12/2025, and revised on 06/30/2025, showed Resident 1 was dependent on staff for bathing. Staff A stated their expectation was for the residents to receive their showers/bed baths as scheduled and for staff to assist residents with showers/baths if the resident's required assistance. Staff A further stated that Resident 1 did not receive showers/bed baths as scheduled and was dependent on staff for showers/baths.Reference: (WAC) 388-97-1060 (2)(c).

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) was adequately monitored for a change in level of consciousness and decreased oxygen saturation (level of oxygen present in the blood), reviewed for quality of care. Additionally, the facility failed to promptly initiate oxygen therapy and to offer prompt transfer to a hospital for evaluation of change of condition. These failures placed the resident at risk of a delay with a higher level of care and associated complications.Findings included.Review of the facility's policy titled Change in a Resident's Condition, dated [DATE], showed that a significant change in the resident's condition was A deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. It showed that nursing staff would notify the medical provider of significant change in the resident's physical, mental or psychosocial status, need to transfer the resident to a hospital, and that prior to notifying the medical provider, the nurse will make detailed observations and gather relevant and pertinent information for the medical provider. It also showed that nursing staff would notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status and when it was necessary to transfer the resident to a hospital. It further showed, The nurse/designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition status.Review of a hospital Discharge summary dated [DATE] showed Resident 1 was hospitalized on [DATE] due to a fracture (broken bone) to her left leg and that Resident 1 was subsequently discharged to a skilled nursing facility for rehabilitation.Review of hospital nursing progress notes dated [DATE] through [DATE] showed Resident 1 was neurologically (related to the brain, nerves and nervous system) assessed to be alert and oriented x 4 [means a person is awake, aware, and able to correctly answer questions about four key things: person, place, time, and situation]. It further showed that Resident 1's oxygen saturation levels were read at room air (non-use of oxygen therapy):-96% (percent) on [DATE].-97% on [DATE].-98% on [DATE].-96% on [DATE].Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnoses that included subsequent encounter for closed fracture with routine healing, muscle weakness, and altered mental status.Review of an admission nursing progress note, dated [DATE] at 7:13 PM, showed Resident 1 was Alert and oriented x 4, able to verbalize needs clear. Reported mild pain up on movement.hears adequately. It further showed Resident 1 was Full Code [A medical term used in nursing homes to indicate the resident wishes for emergency treatments to include cardiopulmonary resuscitation, defibrillation (using electric shocks to restart the heart), and hospital transfer to be evaluated for intubation (putting a tube in the airway to help with breathing), ventilation (life support) and medications (drugs to restart or stabilize the heart)].Review of a document titled POLST (Portable Orders for Life Sustaining Treatment), showed it was completed and signed by Resident 1 on [DATE]. It showed their elected level of medical interventions was Full treatment [primary goal is prolonging life by all medically effective means], It further showed that full treatment included transfer to a hospital if indicated.Review of a nursing progress note dated [DATE] at 11:44 PM, showed Resident 1 was alert and oriented and able to make needs known.[Resident 1] states that she was given lots of medication prior to arriving and her stomach was bothering her.rating pain 4-5/10 [resident rated pain from a scale of one to ten], [Resident 1] refused offer of oxycodone [narcotic (controlled) pain medication]. It further showed an oxygen saturation reading of 96% on room air.Review of a medical provider encounter note dated [DATE] showed Resident 1 was seen by their attending medical provider after nursing reported a change in condition. It showed, Patient [resident] demonstrates significantly altered mental status with inability to respond appropriately to questions, excessive somnolence (sleepiness or drowsiness) and poor interaction. It also showed treatment plan for reduce sedating medications due to excessive drowsiness and altered mental status and monitor mental status closely. It further showed Resident 1's oxygen saturation reading on [DATE] at 3:42 PM was at 90% room air.Review of a nursing progress note dated [DATE] at 4:41 PM, written by Staff C, Registered Nurse (RN), showed Cognitive status assessed. Resident is cognitively impaired, and Behavior/mood evaluated and the resident is noted to be uncooperative.Review of a document titled, SBAR [Situation, Background, Appearance, Review and Notify] Communication Form, showed it was completed by Staff D, RN, on [DATE] at 5:50 PM. It showed that Resident 1 was noted to have altered level of consciousness, labored or rapid breathing, shortness of breath and other respiratory changes and an oxygen saturation level reading of 88% on room air. It further showed that the Primary Care Clinician was notified at 5:43 PM, and that they recommended to continue monitoring the patient condition. It did not show documentation of oxygen therapy initiation or follow-up assessments of Resident 1's oxygen saturation levels. Further review did not show documentation of initiation of transfer to the hospital for further evaluation.Review of a nursing progress note dated [DATE] at 6:21 PM, written by Staff F, Assistant Director of Nursing, showed Family called with concerns regarding sedation, this LN went to see [Resident 1], found with eyes closed, resp [respiration] even and unlabored, awakens easily but nods off while talking. It also showed, call placed to MD [medical provider] and that an order was received to change a sedating medication to as needed from a routine schedule of administration. It further showed Resident 1 was placed on alert to monitor for sedations. It did not show that Resident 1 was assessed for vital signs and/or that Resident 1 or their collateral contacts were offered a transfer to the hospital for further evaluation for change in condition. Further review of nursing progress notes did not show documentation of follow-up assessments of Resident 1's vital signs and/or mental status.Review of a nursing progress note dated [DATE] at 12:34 AM, written by Staff D showed [Resident 1] increase respiratory distress, oxygen given via nasal cannula [flexible tube used to deliver oxygen through the nostrils], 911 called, moved resident to floor and start CPR, 911 arrived and took over. It further showed that Resident 1 was pronounced dead on [[DATE]] at 9:47 PM.In an interview on [DATE] at 12:25 PM, Staff C stated that if close monitoring of a resident's mental status was indicated, they would check them, and I ask questions to assess for their orientation. Staff C stated that their process for monitoring a change of a resident's condition was that We document notes whenever we see the resident. Staff C further stated that oxygen therapy would be initiated for a resident if their oxygen saturation level reading was below 90%.In a follow-up interview on [DATE] at 3:24 PM, Staff C stated that they cared for Resident 1 on [DATE] and that she was not in a good shape. Staff C stated they reported Resident 1's change in condition to the medical provider who visited with her on [DATE] around 1:30 PM. When asked if Resident 1 was offered to be transferred to the hospital for a change in their condition, Staff C stated that they did not receive [physician] orders to send to the hospital and Staff C did not offer Resident 1 a transfer to the hospital because she just came [admitted to the facility]. Staff C stated that they questioned Resident 1's admission to the facility and that Resident 1 was not alert and oriented 100%, she was very much distended [means swollen or bloated], and that she didn't [did not] look ready for a nursing home to me.In an interview on [DATE] at 12:41 PM, Staff E, Resident Care Manager (RCM), stated that close monitoring of a resident with a change in mental status would include frequent visual/physical checks of the resident and would be reported to the medical provider along with checking the resident's vital signs.In an interview on [DATE] at 3:15 PM, Staff D stated Resident 1's oxygen saturation level reading of 88% prompted them to notify the medical provider for change in condition on [DATE] at 5:43 PM. When asked if oxygen therapy was started for Resident 1, Staff D stated, I did not get any order from the doctor. Staff D further stated he and Staff F notified Staff A, Medical Director, via the SBAR Communication Form and that we did not get orders to transfer to the hospital. Staff D stated that Staff A instructed him to continue to monitor [Resident 1].In an interview and joint record review on [DATE] at 1:22 PM, Staff F stated a resident's change in condition was monitored by checking vital signs and placing the resident on alert charting (process to ensure nursing staff from all work shifts monitor and document a resident's medical condition and/or status). Staff F stated that they received a call from Resident 1's collateral contact informing them that she wasn't [was not] her normal self, and that they wanted to know what was going on. Staff F stated they went to check on Resident 1 approximately one hour prior to writing a progress note on [DATE] at 6:21 PM. When asked how Resident 1 was assessed, Staff F stated, I just checked on her respiratory rate, she woke up and talked to me and that's [that is] as far as I went. Staff F stated, Yeah I guess I should have taken vital signs. Staff F stated that Resident 1 was responsive to voice, but fell asleep while talking to me, and that they called and informed Staff A of Resident 1's condition. A joint record review of Resident 1's nursing progress notes from [DATE] through [DATE] showed Resident 1 had a change in her mental status and oxygen saturation readings. Further joint record review showed a medical provider encounter on [DATE] with a treatment plan to closely monitor the resident's mental status. Staff F stated they expected checking on her frequently and doing vital signs would have been completed and that I don't [do not] see it in [Resident 1's] electronic health records [EHR]. When asked if a hospital transfer was offered to Resident 1 and/or their collateral contacts, Staff F stated, I didn't [did not] offer it.A joint record review and interview on [DATE] at 1:19 PM with Staff A, showed Resident 1's provider encounter note dated [DATE] and that Resident 1 was reported by nursing staff to have a change in condition. Further review showed the provider encounter note included a plan to closely monitor Resident 1's mental status. When asked how they expected a resident's mental status to be closely monitored, Staff A stated that documentation of a resident's condition/status would be done on an hourly basis instead of every work shift and that because the medical provider was suspecting [Resident 1 was] over-sedated and expected some meds [medication] to wear off, in which case, the resident would start to perk up, therefore checking on the resident closely every hour. When asked if oxygen saturation levels would continue to decrease if sedating medications were wearing off over time, Staff A stated, No, they would go up, if a somnolent residents starts to de-sat [decrease oxygen saturation levels], that's when you start oxygen therapy and if it doesn't [does not] go up, then the resident should have been transferred to the hospital. Staff A further stated an oxygen saturation level below 90% room air indicated the need for oxygen therapy. When asked if Resident 1's status of altered mental status along with decreasing oxygen saturation levels was a medical concern, Staff A stated, Absolutely. When asked if Resident 1's change in condition could have prompted a transfer to the hospital, Staff A stated, Yes. Staff A further stated, My first knowledge of this resident was when EMS [Emergency Medical Services/911 responders] was trying to revive the patient. When asked if Resident 1 could have benefited from a transfer to the hospital for further evaluation, Staff A stated, At some point, it's [it is] possible there could have been a missed opportunity to transfer the resident to a higher level of care.In an interview on [DATE] at 3:55 PM, Staff G, RCM, stated staff could initiate oxygen therapy for a resident and then notify the medical provider and that If the oxygen saturation is below 90%, I would start [oxygen therapy] or if there's respiratory distress or shortness of breath.A joint record review and interview on [DATE] at 4:36 PM with Staff B, Director of Nursing, showed Resident 1's EHR showed a completed POLST form and nursing progress notes from [DATE] through [DATE] that showed Resident 1 had a change in her mental status and oxygen saturation readings. Further joint record review showed a medical provider encounter on [DATE] with a treatment plan to closely monitor the resident's mental status. When asked if Resident 1's change in condition was known by nursing and medical providers on [DATE], Staff B stated, Yes, according to the notes. When asked if oxygen therapy could have been started when Resident 1's oxygen saturation fell below 90% room air, Staff A stated, Yes. When asked if Resident 1 and/or Resident 1's collateral contacts were offered a transfer to the hospital for a change in condition, Staff B stated, No. Staff B further stated, I had hoped they had looked at [Resident 1's] vitals [vital signs] more frequently, and making a decision then, and that staff could send them out and notify the doctor if that was necessary.Reference: (WAC) 388-97-1060(1)(3)(vi).

Based on observation, interview, and record review, the facility failed to provide adequate assessment and supervision for electronic cigarette use and ensure safe storage of smoking materials for 1 of 1 resident (Resident 7) that constituted an Immediate Jeopardy (IJ) and failed to supervise and restrain a pet (dog) for 1 of 1 staff (Staff F), reviewed for accident/hazards. Resident 9 experienced harm when they sustained a laceration (cut) on the back of their head when a staff member's dog was unleashed, wandered under the table in the dining room, startled the resident who fell backwards in their wheelchair hitting their head and required transport to the hospital for further evaluation. These failures placed the residents at risk for significant safety hazards including explosion and/or fire related to the electronic cigarette battery, avoidable accidents, bodily injury, and other negative outcomes. An IJ was identified, and the facility was notified of the noncompliance on 09/05/2025. The IJ was determined to have begun on 09/05/2025 when the facility failed to adequately assess Resident 7 for smoking and to ensure safe storage of smoking materials. The IJ was removed on 09/08/2025 when an on-site inspection confirmed the facility implemented their removal plan by removing the smoking materials in Resident 7's room for safe storage, completed a smoking assessment and updated Resident 7's care plan with the facility providing supervised vaping, completed interviews and observations of all residents and their rooms to ensure smoking materials were stored safely, and all residents and/or resident representatives, and staff were educated on the facility's non-smoking policy. Findings included . RESIDENT 7Review of the facility's policy titled, “Smoking Prohibited,” dated 10/01/2021, showed that smoking or vaping by residents was prohibited within the facility and on the grounds of the facility. It showed that vaping referred to the use of electronic nicotine delivery system or electronic smoking devices such as e-cigarettes [or E-cigar]. It further showed that residents may not keep smoking materials in their rooms and that if a resident had smoking materials, they were to be given to the “nurse” for secure storage. Review of a face sheet showed Resident 7 admitted to the facility on [DATE] with diagnosis that included stroke (caused by a blocked blood vessel in the brain), unsteadiness on feet and need for assistance with personal care. Review of a quarterly Minimum Data Set (MDS – an assessment tool), dated 08/25/2025 showed Resident 7 was cognitively intact (a person's thinking and memory are working well) with a Brief Interview for Mental Status (BIMS -a cognitive screening tool) score of 15 (highest possible score). Review of a document titled, admission Nursing Collection, dated 07/09/2025, showed that a “Smoking Safety Screen” was completed for Resident 7. It further showed that Resident 7 was identified to “use tobacco products” upon admission to the facility. Review of Resident 7's care plan titled, “Tobacco Use,” dated 07/14/2025, showed that Resident 7 “preferred” to smoke cigarettes, cigar, pipes, and via electronic delivery systems, including electronic cigarettes and vape pen. It showed that the care plan goal was, “The resident will smoke safely thru the review period.” It further showed a care plan intervention for the facility to complete a smoking assessment as needed. Review of Resident 7's Electronic Health Records (EHR) did not show documentation of a completed smoking assessment. Review of a nursing progress note dated 07/10/2025, showed that Resident 7 “request to smoke vapes, on routine nicotine (smoking cessation) patch” and that “Staff educate [Resident 7] that no smoking is allowed in the facility.” Review of July 2025 Medication Administration Record (MAR) showed that Resident 7 refused their nicotine patch on eight occasions from July 10, 2025, through July 31, 2025. Review of August 2025 MAR showed that Resident7 refused their nicotine patch every day from 08/01/2025 through 08/19/2025. It further showed that Resident 7 physician's order for routine nicotine patch was discontinued on 08/19/2025. An observation and interview on 09/05/2025 at 10:30 AM showed Resident 7 was lying in bed, holding a slim, rectangular device, which they raised to their mouth before exhaling a cloud of white, odorless vapor. When asked if Resident 7 was vaping, Resident 7 stated, “Yes” and that they were aware that residents were not allowed to use a vape within the facility. When asked if Resident 7 independently stored and charged the battery of their vape device, Resident 7 stated, “Yes.” Resident further stated that their vape device was a “Juul [brand name].” A follow up observation and interview on 09/05/2025 at 12:10 PM, showed Resident 7 was sitting upright on the side of their bed and used their vape pen while watching television. Resident 7 stated that the facility knew about their use of a vape device and that Resident 7 refused nicotine patches that were offered by the facility. When asked how often they vaped, Resident 7 stated, “not that often, I would say, three times a day,” and that they vaped unsupervised in their room. When asked if staff had ever seen Resident 7 used their vape inside the facility, Resident 7 stated, “Yes,” and that “They (Staff) don't [do not] pay attention to it, they're [they are] working.” In an interview and joint record review on 09/05/2025 at 12:19 PM, Staff D, Registered Nurse (RN), was asked if there were residents that smoked in the facility, Staff D stated, “I know [Resident 7] uses e-cigarettes.” Staff D stated that residents were not allowed to smoke within the facility and that they did not know if residents could vape within the facility. Staff D stated that they saw Resident 7 vaping in the facility “once in a while,” and that Staff D last saw Resident 7 vaping in the facility on 09/05/2025. When asked what their action was after observing Resident 7 vaping in the facility, Staff D stated that they “reminded [Resident 7] of the risks for “hypertension [high blood pressure] and heart problems.” When asked if they offered to safely store Resident 7's vape device, Staff D stated that Resident 7's vape was their “own supply” and that they had not been told “how to keep or safe keep those e-cigarettes.” When asked if residents were allowed to smoke outside of the facility, Staff D stated, “Yes, it's [it is] open, there's [there is] a patio.” Staff D then stated that they were not “aware” that Resident 7 needed to be supervised for smoking because Staff D did not “know about e-cigarettes.” Staff D further stated that they were “not sure” if the facility had a smoking policy that included vape devices. In an interview and joint record review on 09/05/2025 at 1:15 PM, Staff E, RN, Unit Manager, stated that the facility was a non-smoking facility, which meant that residents were not allowed to smoke within the facility and within the facility premises. Staff E stated that they were “not sure” if the facility's non-smoking policy included the use of vaping devices. When asked what the facility's process was when smoking materials were identified within the facility, Staff E stated that they would “clarify with the Director of Nursing [DON]” if they could “confiscate” the smoking materials and “keep in a safe place away from the resident.” A joint record review of Resident 7's EHR showed a Tobacco Use Care Plan, dated 07/14/2025, that listed an intervention to complete a smoking assessment as needed. Staff E stated that Resident 7 was screened for tobacco use on admission and that they did not see documentation of a completed smoking assessment. When asked what the purpose was of completing a smoking assessment, Staff E further stated that they had “no idea,” and that they had not completed a smoking assessment before because the facility was a “non-smoking facility.” When asked if Resident 7 should have been assessed for smoking, Staff E stated that they would “clarify it with the DON.” In an interview on 09/05/2025 at 1:32 PM, Staff B, DON, stated that the facility had a smoking policy and that they were “not sure” if the policy included the use of vape devices. When asked if vape devices were considered smoking materials, Staff B stated, “Yes,” and that they “believed” there were no residents that had vape devices “in-house.” Staff B stated that they expected that smoking materials would be “kept in the nurses' station” accessible only to staff. Staff B stated that vape devices posed “fire hazards” and that vape devices would be considered smoking materials. Staff B further stated that if a resident was observed using e-cigarettes and/or vape devices that they would expect staff to “right away” educate the resident on the associated risks, intervene to stop the activity, and secure any smoking materials. Staff B stated that the reason for removing the smoking supplies from a resident's procession was for “safety reasons, safe storage, and to keep everybody safe.” When asked if a smoking assessment should be completed for a resident identified on admit having used tobacco, Staff B stated that they expected there would be an “evaluation that is followed up on by nursing [staff].” When asked if Resident 7 should have been assessed for smoking, Staff B stated that they would “have to look into it.” In an interview on 09/05/2025 at 2:20 PM with Staff B, and Staff A, Interim Administrator, Staff B stated that they were “under the impression” that the facility had a designated smoking area in the “courtyard,” and that they would “get the determination of that.” Staff A clarified that the facility was a “non-smoking facility.” Record review of Resident 7's EHR showed a progress note signed by Staff D on 09/05/2025 at 3:11 PM, showed “This writer saw [Resident 7] has E-cigar in her room,” and that Staff B was notified. Record review of Resident 7's EHR showed a progress note signed by Staff B on 09/05/2025 at 3:41 PM, showed “Smoking Evaluation completed.” RESIDENT 9 Review of the Pet, Animal Policy, revised in January 2025 showed, Personal Pet Visits:The following rules and restrictions apply to personal pet visits:a. A staff member, volunteer, or other designated individual must always accompany animals at all times. b. Animals must be on a leash and/or restrained while in the facility. Safety Precautions: Animals will not be allowed in food preparation areas, dining areas, bathrooms or treatment areas. Review of the quarterly MDS dated [DATE] showed Resident 9 was admitted to the facility on [DATE] with a diagnosis list that included dementia (impaired memory) and required partial to moderate assistance for transfers and mobility. The MDS further showed the resident used a wheelchair. Review of the incident investigation dated 08/04/2025 showed Resident 9 was eating breakfast in the dining room when a dog entered the dining room and crawled under the table that Resident 9 sat at in their wheelchair to eat breakfast. The investigation showed Resident 9 was startled and they lifted both feet up which caused the wheelchair to tip backwards with Resident 9 in the wheelchair. A licensed nurse (LN) found Resident 9 on the floor, on their back. The LN assessed the resident and found a laceration (cut) on their head that measured 1.0 centimeters (cm-a unit of measurement) by 0.5 cm. Resident 9 complained of pain when the area was touched. First Aide was performed to clean the cut, and pressure was applied to the area to control the bleeding. Resident 9 required extensive assistance from staff to be transferred from the floor to their wheelchair. Resident 9 was transported to the local hospital for assessment and evaluation of their head and pain on 08/04/2025 and returned to the facility the same day. A computed tomography (CT-imaging to create detailed images of the body) scan was completed and was negative for any traumatic injury of the head or neck. The incident investigation dated 08/04/2025 further showed a LN (Staff M, Licensed Practical Nurse - LPN) observed the dog come into the dining room from the gym (therapy room) and go between Resident 9 and another resident that sat at the table, the dog then went under the table between the two residents, when Resident 9 screamed “help.” Staff M walked towards Resident 9's table, the dog barked and Resident 9's wheelchair flipped back, and Resident 9 was found on their back. The investigation then stated it seemed like the dog was stuck under the table and could not figure their way out from the table. In an interview on 08/15/2025 at 12:45 PM Staff F, Rehabilitation Director, stated, “the dog went into the dining room, he (the dog) was eating crumbs that fell on the floor under the table and got stuck in the wheelchair. He should have been on his leash; this accident would not have happened. They sent Resident 9 to the hospital. The rules were broken and Resident 9 got harmed because the dog was not on a leash. He (the dog) got tangled up in their wheelchair and tipped it over. Resident 9 would not have been hurt if he (the dog) was on a leash, we would have been able to stop him from going under the table, getting tangled up in the wheelchair and tipping it over. It was a broken policy, the policy said 100% the dogs need to be on a leash, always and he was not.” In an interview on 08/15/2025 at 1:29 PM, Staff L, Speech Therapist, stated that they went to the gym, the door was left open, and the dog went to the dining room from the gym, then they heard a loud bang that came from the dining room, and went to see what the noise was and saw Resident 9 on the floor, with the back of their head bleeding. The dog was not on a leash; he (the dog) smelled food that came from the dining room and went to get some food. The dog was not on a leash while he was in the gym or in the dining room. In an interview on 09/15/2025 at 11:59 PM Staff M stated, “I was in the dining room, Resident 9 was sitting in their wheelchair at the table eating breakfast when the dog went under the table, Resident 9 tried to move their legs away from the dog, fell backwards and hit the back of their head on the floor. There was blood from a cut on the back of their head, Resident 9 was frightened. The dog was not on a leash, the dog should not be in a resident area, especially not in the dining room when the residents eat. The dog was not on a leash when I saw the dog come from the gym (therapy) room. The dog was by itself. There was nobody with the dog when it entered the dining room. This accident could have been avoided if the dog had been on a leash with someone supervising and holding the leash to prevent the dog from going under the table. Resident 9 would not have fallen backwards in their wheelchair and cut the back of their head because the dog would not have been under the table.” In an interview on 09/15/2025 at 12:30 PM, Staff N, Registered Nurse, Unit Manager, stated, “all dogs were supposed to always be on leashes and supervised when they were in the facility. Staff N further stated if the dog had been on a leash, Resident 9 would not have been harmed on 08/04/2025 when the dog went under the dining room table and Resident 9 fell backwards in their wheelchair and cut the back of their head.” In interview on 09/15/2025 at 3:29 PM, Staff B stated Resident 9's accident on 08/04/2025 could have been avoided if the dog was on a leash, Resident 9 would not have injured the back of their head when they fell backwards in their wheelchair. In an interview on 09/15/2025 at 4:01 PM, Staff C, Administrator, stated, “I think the dog got in the way and tripped Resident 9. I am not sure about that, but per policy the dog should have been on a leash. This would not have happened if the dog was on a leash.” Reference: (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) included a completed facility-based and community-based risk assessment, the facility resources to include a list of medical and non-medical equipment description, and contracts, memorandums of understanding and other agreements with third parties to provide services or equipment to the facility both during normal and emergency situations. This failure placed the residents at risk for unmet care needs.Findings included .Review of the facility's policy titled, Facility Assessment, dated 10/01/2025, showed that A facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for the residents during day-to-day operations.Review of the facility's document titled Facility Assessment, dated 07/10/2025, did not show inclusion of a completed facility-based and community-based risk assessment, a list of medical and non-medical equipment description and contracts, memorandums of understanding and other agreements with third parties to provide services or equipment to the facility both during normal and emergency situations. It further showed that [Facility name] does not admit active COVID-19 patients. In an interview on 09/16/2025 at 4:15 PM with Staff A, Interim Administrator, and Staff C, Administrator, Staff C stated the facility could admit active COVID-19 residents and that the facility assessment needed to be updated to reflect that. Joint record review of the facility assessment dated [DATE] showed that a list of medical and non-medical equipment description was referred to be outlined in Appendix 1. It further showed that contracts, memorandums of understanding and other agreements with third parties to provide services or equipment to the facility both during normal and emergency situations were referred to be outlined in Appendix 2. Staff C and Staff A stated, No, we can't [cannot] find it [documentation of Appendix 1 and 2]. When asked if the facility assessment included a completed facility-based and community-based risk assessment, Staff C stated, No, but I can include it. No associated WAC.

Based on interview and record review, the facility failed to conduct a thorough investigation and/or include a corrective action to prevent reoccurrence of an incident for 3 of 4 residents (Resident 4, 1 & 2), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents and unidentified abuse.Findings included… Review of the facility's policy titled, “Abuse Investigation and Reporting,” dated 10/01/2021, showed that all reports of abuse, neglect and mistreatment were thoroughly investigated by “facility management.” Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events . Federal law requires the nursing home to do a thorough investigation of the incident. In order for a facility to provide evidence of the thoroughness of the investigation the information must be recorded.” It further showed that “the investigation is done to determine, as far as possible: what occurred; and to make necessary changes to the provision of care and services to prevent reoccurrence…The investigation should end with the identification of who was involved in the incident and what, when, where, why and how the incident happened during the probable or reasonable cause.” RESIDENT 4Review of a face sheet showed Resident 4 admitted to the facility on [DATE] with diagnosis that included anxiety disorder (feeling of constant worrying), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and dementia (impaired thinking and memory). Review of the facility's compiled documents titled, “Investigative Summary, [Resident 4], dated 08/26/2025, showed it was completed by Staff B, Director of Nursing. It showed that the facility was made aware of an allegation of abuse on 08/21/2025. The contents of the investigation included the investigation summary and staff statements from Staff U, Certified Nursing Assistant (CNA) and Staff V, CNA, did not show that the investigation ended with the identification of when the alleged incident happened. Further review of Resident 4's investigative summary documents showed resident interviews were completed on 08/26/2025 by Staff W, Social Worker. Review of interviews completed with Residents 8, 18, 19, 20, 21, 22 and 23 showed that these residents answered, “Yes,” to the question, “Do you have concerns about your safety?” It did not show documentation of Staff W completing a follow-up regarding residents' concern about their safety. In an interview and joint record review on 09/10/2025 at 3:52 PM, Staff B stated that Staff W did not “ask” the resident interview questions on 08/26/2025 correctly for Residents 8, 18, 19, 20, 21, 22 and 23. Staff B further stated that there was “follow-up” completed with residents who answered, “Yes” to having safety concerns. A joint record review of the documents provided by Staff B showed, “8/26 [2025] – f/u [follow-up] on safety concerns question. Resident had no safety concerns, [Staff B initials]” was documented on the back of the resident interview forms for Resident 8, 18, 19, 20, 21, 22 and 23. When asked who completed the follow-up with the residents, Staff B stated, “I asked either the [Nurse Unit Manager] or Social Worker, I don't [do not] remember.” When asked if they expected Staff W to have completed an immediate follow-up with the residents while conducting the interviews, Staff B stated “Yes.” When asked if they expected staff who were tasked with investigation interviews would be trained to conduct interviews correctly, Staff B stated, “Yes.” When asked if Staff W completed the investigation interviews correctly, Staff B stated, “based on this [resident interview forms], no.” Review of a quarterly Minimum Data Set (MDS – an assessment tool) dated 06/05/2025 showed that Resident 22 had a Brief Interview for Mental Status (BIMS – short test used to check how well a person's memory and thinking skills are working) score of four. This indicated severe cognitive impairment (major trouble with memory, thinking, and understanding). Review of a quarterly MDS dated [DATE] showed that a BIMS was not attempted with Resident 23 due to “resident is rarely/never understood.” In an interview on 09/11/2025 at 10:34 AM, Staff W stated that they were trained on the facility's process for investigating allegations of abuse and that, “I know how to do it and I've [I have] read the [facility] policies.” When asked how investigation resident interviews were conducted, Staff W stated that “Questions are printed on a document that is taken to the resident to be used for the interview, the resident is asked to sign the interview form afterwards.” Staff W stated that they wrote up the resident interview questions used for Resident 4's investigation on 08/26/2025. A joint record review of resident interview forms dated 08/26/2025 for Residents 8, 18, 19, 20, 21, 22 and 23 showed that these residents answered “Yes,” to the question, “Do you have concerns about your safety?” Staff W stated that they asked the question incorrectly. When asked if they were asked by Staff B to complete a follow-up for the resident interviews for Residents 8, 18, 19, 20, 21, 22 and 23. Staff W stated, “I didn't [did not] follow up because I didn't know I made the error. [Staff B] saw it and I don't [do not] know if [Staff B] followed up.” When asked how residents were selected for resident interviews, Staff W stated they selected residents based on their cognition (ability to remember and understand things) and those who have knowledge of the staff identified in an investigation. Staff W stated that residents who could not be interviewed due to poor cognition would require their representative to be interviewed. Staff W stated that they referred to the BIMS score in MDS assessments to determine a resident's ability to be interviewed. A joint record review of Resident 22 and 23's interview questionnaires completed on 08/26/2025 showed signatures from both residents. Staff W stated that they should have interviewed Resident 22 and 23's representatives and that these residents should not have been interviewed. In an interview on 09/15/2025 at 2:42 PM, Staff B stated that the facility referred to the BIMS score to determine a resident's cognition and ability to be interviewed. Staff B was asked if Resident 22 and 23 were appropriate to be interviewed [by Staff W] on 08/26/2025 and Staff B stated, “I don't [do not] have an answer for that.” Staff B stated that the facility followed guidance from the Purple Book for completing investigations. When asked if Resident 4's investigation determine the specific date and/or time of the alleged incident, Staff B stated, “I don't [do no] have an answer.” Review of the facility's policy titled, “Abuse,” revised on 10/20/2022, showed the organization would maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. This would include analysis of the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. The policy showed that if an alleged allegation was verified appropriate corrective action must be taken. The policy further showed that resident's plan of care would be revised to reflect interventions to minimize reoccurrence and to treat any injury or harm identified through assessment of the resident. RESIDENT 1 & RESIDENT 2 INCIDENTReview of Resident 1 and Resident 2's investigation dated 08/22/2025, showed a Resident-to-Resident Investigation was completed. The “Summary of Events,” showed that on 08/22/2025 administration was notified that Resident 1 was attempting to push another resident back to their room, when Resident 2 tried to intervene. The summary showed that “In intervening, [Resident 1] became agitated and scratched and hit [Resident 2's] arms.” The investigation showed that the residents were immediately separated. The investigation further showed witness statements that saw Resident 1 “holding (in squeeze form),” Resident 2's arm and stopped once they saw the staff member and “yelled” at them in sign language. Further review of the investigation showed a care plan for Resident 1 and Resident 2. The investigation and care plans did not show a new or revised intervention was addressed or evaluated to prevent reoccurrence from the incident that occurred between Resident 1 and Resident 2 on 08/22/2025. On 09/05/2025 at 9:47 AM, Resident 2 stated that a “deaf” person (Resident 1) grabbed their friend's wheelchair and yelled at them (Resident 2) and said, “no, no, no.” Resident 2 stated that they did not know that they (Resident 1) were “deaf,” and did not know what they were saying, and they grabbed Resident 2's arm. Resident 2 lifted her left sleeve up to show three circular shaped bruises on their left forearm, indicating where Resident 1 had grabbed them. Resident 2 stated, “she [Resident 1] makes me nervous.” Resident 2 stated that staff heard her and Resident 1 yelling and separated them. In an interview and joint record review on 09/15/2025 at 11:36 AM, Staff E, Registered Nurse Unit Manager, stated the purpose of an investigation was to determine the cause of the incident and make a plan to correct the incident to prevent reoccurrence. Staff E stated that on 08/22/2025, they were informed by a nurse that Resident 1 grabbed Resident 2's arm and that had caused bruising. When asked what corrective action was taken related to the incident, Staff E stated, “separate the residents,” and “more supervision I guess, and don't [do not] sit them next to each other in the dining room.” When asked how staff would know what corrective action was taken, Staff E stated staff would know through verbal nursing report and alert charting (communication tool used for monitoring a resident's change of condition). When asked if they would expect the resident's care plan to reflect their behaviors, Staff E stated, “Yeah I guess it should, at that time [Resident 2] preferred to eat in her room,” and that “[Resident 2] still didn't [did not] want to see [Resident 1] I guess.” Staff E stated that Resident 1 could get “easily agitated” if you did not understand them and had a history of grabbing staff. A joint record review of Resident 1's mood and behavior care plan revised on 06/28/2024, showed Resident 1 had a behavior of grabbing staff, pushing them and locking them in an office. When asked if there was anything in Resident 1's care plan that addressed grabbing other residents, Staff E stated that they did not see any and that grabbing another resident would be a behavior, and that Staff E “could add that.” Staff E further stated that it was important to add Resident 1's behaviors in their care plan so that staff were aware. A joint record review of Resident 2's care plan printed on 09/15/2025, showed no care plan monitoring or interventions that addressed how Resident 2 would be protected from potential reoccurrence of the 08/22/2025 incident with Resident 1. Staff E further stated that there were no interventions. On 09/15/2025 at 4:59 PM, Staff B stated on 08/22/2025 the immediate action was to separate Resident 1 and Resident 2. When asked what the corrective action was, Staff B stated to keep Resident 1 and Resident 2 separated. When asked how the staff were aware of this, Staff B stated the kitchen and nursing staff had been “told,” and there was no documentation of that. Staff B further stated that they would expect Resident 1's behavior of grabbing another resident to be in their care plan. When asked if they would expect there to be a care plan or intervention for Resident 2 to address what happened on 08/22/2025 and how the facility would protect Resident 2, Staff B stated, “I don't [do not] have an answer for that.” On 09/16/2025 at 2:00 PM, Staff C, Administrator, stated the purpose of an investigation was to keep residents safe, find out the root cause of why the incident occurred, and prevent it from happening in the future. When asked if abuse or neglect was substantiated on the investigation for the incident on 08/22/2025 between Resident 1 and Resident 2, Staff C stated that the abuse was physical. When asked what corrective action was taken based on the investigation, Staff C stated that Resident 1 and Resident 2 were placed on alert and separated and were interviewed on whether they felt safe. When asked if there were any new/revised interventions as part of the investigation for Resident 1 and Resident 2's care plan, Staff C stated, “I could not find any other interventions, other than being separated.” Reference: (WAC) 388-97-0640 (6)(a)

Based on interview and record review, the facility failed to ensure bathing/showers were consistently provided for 4 of 6 residents (Residents 2, 6, 3 & 5), reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, decreased self-esteem, and a diminished quality of life.Findings included . Review of the facility's policy titled, “Activities of Daily Living (ADLs),” dated 10/01/2021, showed, “Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.” The policy showed if a resident refused care the resident and/or representative would be informed of the risks and benefits, offered an alternative intervention to minimize further decline, and the refusal and information would be documented in the resident's clinical record. The policy further showed each resident would receive a tub or shower baths as often as needed, but not less than twice weekly or as required by law. RESIDENT 2Review of the ADL self-care needs care plan initiated on 04/14/2025, showed Resident 2 required extensive assistance by one staff with bathing/showering. Review of Resident 2's Electronic Health Record (EHR), under task- ADL Bathing/Showering, showed they were scheduled for a shower on Thursday evenings and as needed. The task showed a lookback of 30 days from 08/12/2025 to 09/10/2025. The task showed two showers were given during this time: one on 08/22/2025 and on 09/01/2025. The task further showed documentation for the remaining days were documented as, “Not Applicable,” and did not show whether Resident 2 was offered a shower or if they declined a shower. Review of Resident 2's progress notes from 08/12/2025 to 09/10/2025 did not show whether Resident 2 was offered a shower or if they declined a shower during the time. RESIDENT 6Review of Resident 6's face sheet printed on 09/05/2025 showed they admitted to the facility on [DATE]. Review of a care plan printed on 09/16/2025 did not show the amount of assistance Resident 6 required with their showers/bathing. Review of Resident 6's EHR, under task- “*GG- Shower/Bathe Self Every Thursday day shifts and PRN [as needed],” showed Resident 6 was scheduled for a shower on Thursday. The task showed a lookback of 30 days from 08/26/2025 to 09/04/2025. The task showed one shower was given during this time: on 09/03/2025 (11 days after their admission). The task further showed documentation for the remaining days were documented as, “Not Applicable,” and did not show whether Resident 6 was offered a shower or if they declined a shower. Review of Resident 6's progress notes did not show whether Resident 6 was offered a shower or if they declined a shower during the time from 08/22/2025 to 09/08/2025. A joint record review and interview on 09/10/2025 at 1:20 PM, with Staff E, Unit Manager Registered Nurse, showed Resident 2's EHR under task- ADL Bathing/Showering revealed two showers on 08/22/2025 and on 09/01/2025 were given during a lookback of 30 days from 08/12/2025 to 09/10/2025. The task further showed documentation for the remaining days were documented as, “Not Applicable.” When asked if there was documentation to show whether Resident 2 was offered or refused a shower on the remaining days, Staff E stated, “I don't [do not] see it here.” When asked if there was any documentation to show whether Resident 6 was offered or declined a shower Staff E stated, “If there is no documentation then it means that it was not done. They [staff] should have offered a shower.” Staff E further stated it was important for a resident to be offered or receive a shower/bath for their dignity and comfort. On 09/11/2025 at 3:19 PM, Staff B, Director of Nursing, stated they would expect staff to document whether a resident received or refused their shower, and that “Not Applicable” documentation did not show whether a resident was offered a shower. When asked when Resident 6 received their first shower, Staff B stated, “It looks like due to documentation,” on 09/03/2025. When asked how many days Resident 6 went without a shower Staff B stated, “From 08/22/2025 to 09/03/2025.” Staff B stated that Resident 6 should have been offered a shower/bath prior to 09/03/2025. RESIDENT 3Review of a care plan for “Activity of Daily Living,” revised on 01/07/2025 showed Resident 3 required limited assistance of one staff member with bathing/showering. The care plan further showed Resident 3 preferred to take bed baths. Review of Resident 3's EHR, under task- ADL Bathing/Showering, showed Resident 3 was scheduled for a shower/bath every Sunday and Thursday evening and as needed. The task further showed Resident 3 did not receive bed baths from 08/13/2025 to 08/25/2025. Review of Resident 3's progress notes did not show whether Resident 3 was offered a bed bath or if they declined a bed bath during the time from 08/13/2025 to 08/25/2025. In an interview and joint record review on 09/11/2025 at 2:43 PM. Staff E stated Resident 3 was scheduled to receive two bed baths a week. A joint record review of Resident 3's EHR under task did not show that Resident 3 received bed baths from 08/13/2025 to 08/25/2025. Staff E stated refusals should be documented. Further joint review of the task record dated 08/13/2025 to 08/25/2025 with Staff E showed no documented refusals of the bed baths and did not show that Resident 3 received bed baths during the time of 08/13/2025 to 08/25/2025. RESIDENT 5Review of a care plan for bathing, initiated on 08/13/2025 showed Resident 5 was dependent on staff for bathing. Review of Resident 5' s EHR, under task-ADL Bathing/Showering, showed Resident 5 was scheduled for a shower/bath every Monday evening and as needed. The task further showed Resident 5 received one shower on 08/26/2025 during the time frame of 08/12/2025 to 09/08/2025. Review of Resident 5' s nursing progress notes dated 08/12/2025 to 09/08/2025 showed no documental refusals of showers. In an interview and joint record review on 09/11/2025 at 2:58 PM, Staff E stated Resident 5 was scheduled to receive a shower once a week, on Monday. A joint record review with Staff E of Resident 5's EHR under task, showed that Resident 5 received one shower on 08/26/2025 during the time frame of 08/12/2025 to 09/08/2025. Staff E stated refusals should be documented, further joint review of the task record dated 08/12/2025 to 09/08/2025 with Staff E showed no documented refusals of the showers, Staff E then stated the documentation showed that Resident 5 received one shower during the time of 08/12/2025 to 09/08/2025. In an interview and joint record review on 09/11/2025 at 3:28 PM, Staff B stated the task record showed Resident 5 received a shower on 08/26/2025, and nothing else was documented about a shower for Resident 5 during the time frame of 08/12/2025 to 09/08/2025. In an interview on 09/15/2025 at 4:01 PM, Staff C, Administrator, stated, “If Resident 3 or Resident 5 refused care like bed baths or showers it should be documented as a refusal, otherwise the expectation was for Resident 3 and Resident 5 to receive bed baths and showers as scheduled, and as needed.” Reference: (WAC) 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift for 7 of 10 days (09/01/2025, 09/02/2025, 09/03/2025, 09/04/2025, 09/05/2025, 09/09/2025 & 09/10/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included .Review of the nursing staff posting forms dated 09/01/2025, 09/02/2025, 09/03/2025, 09/04/2025, 09/05/2025, 09/09/2025 and 09/10/2025 did not show actual nursing hours worked. In an interview on 09/16/2025 at 3:46 PM, Staff O, Receptionist stated the nurse staffing form was posted every morning for day shift and then the evening and night shift was added to the form in the afternoon. Staff O further stated, I never do the actual hours worked. I just put up the staff hours that the nursing staff were scheduled to work. I never seen the actual hours worked completed on the form. The nursing forms were given to the staffing coordinator to save and file.In an interview on 09/16/2025 at 3:52 PM, Staff P, Staffing Coordinator, stated that the previous administration staff would fill in the actual hours worked on the nursing staff posting forms the next day. It was never done on the same day, so you would not know the actual hours worked until the next day or later if they did not get filled out.In an interview on 09/16/2025 at 5:10 PM Staff C, Administrator, stated the actual nursing hours should be posted on the same day to inform visitors and residents of the actual nursing hours worked.No Reference WAC .

Based on observation, interview, and record review, the facility failed to ensure foods were served at proper temperature for 1 of 7 nursing units (Transitional Care Unit [TCU]), and 4 of 4 residents (Residents 3, 5, 6 & 16), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life. Findings included .FOOD TEMPERATURES-TCUDuring a joint observation and interview on 09/10/2025 at 12:11 PM, Staff Q, Dietary Manager, used the facility's kitchen thermometer to check the temperatures of the meal that was delivered to the TCU. The plate that had food on it was removed from a plastic tray; the serving plate sat on a round plate warmer and was covered with a round plastic top that covered the entire plate. Staff Q stated, the meal being served was baked beans, hamburgers, corn on the cob and chicken noodle soup. The following food items' temperature were noted as follows:-Baked beans temperature showed 133 degrees Fahrenheit (F-a unit of measurement),-Hamburger patty's temperature showed 124 degrees F-Corn on the cob's temperature showed 113 degrees F-Chicken noodle soup's temperature showed 105 degrees FInterview on 09/10/2025 at 12:18 PM, Staff Q stated the baked beans, hamburger patty, corn on the cob and the chicken noodle soup should have tested at 140 degrees F, and the temperatures were low for the food that was tested. Staff Q stated that when the food leaves the kitchen, the temperature should remain at 140 degrees F for up to forty minutes. Staff Q further stated the food did not hold the temperature for forty minutes and that the temperatures of the meal that was just tested left the kitchen less than ten minutes ago.FOOD TEMPERATURES AND PALATIBILITYRESIDENT 3Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 07/28/2025 showed the resident did not have impaired thinking or problems with their memory.In an interview on 09/08/2025 at 2:21 PM, Resident 3 stated, the food is always cold; to get a good meal I have to get it from outside of here and delivered to me. I haven't done it yet. I am trying to get all that figured out now.RESIDENT 5Review of the quarterly MDS dated [DATE] showed the resident did not have impaired thinking or problems with memory.In an interview on 09/09/2025 at 1:21 PM, Resident 5 stated that the food is cold, and it tastes terrible. I have chicken noodle soup with my lunch every day and it is always cold; I eat it anyway because it helps my stomach to feel better. I wish I could at least have it warm, the whole lunch would taste better if it was at least warm.RESIDENT 6Review of the admission MDS dated [DATE] showed the resident did not have impaired thinking or problems with their memory.In an interview on 09/09/2025 at 1:14 PM, Resident 6 stated, every meal is served lukewarm to cold, breakfast, lunch and dinner. A nice warm bowl of oatmeal in the mornings would be so nice. I sometimes don't eat because the food is always served lukewarm to cold.RESIDENT 16Review of the admission MDS dated [DATE] showed the resident did not have impaired thinking or problems with their memory.In an interview on 09/09/2025 at 1:16 PM, Resident 16 stated, the food should never be served cold, that is not right. Every meal is served cold. It tastes terrible.In an interview on 09/12/2025 at 12:23 PM, Staff Q stated, I am aware that there were some residents that complained of their meals being served cold and not tasting good. I thought the food being placed on a warm plate, covered with a lid and placed in a closed food cart for delivery to the nursing units would help the meals to keep the temperatures at 140 degrees F when brought to the nursing units and served to the residents.In an interview on 09/15/2025 at 3:29 PM with Staff B, Director of Nursing Services, stated they knew the previous Administrator and the dietary manager were working together to resolve the residents' complaints about cold food and the food not tasting good, and that they were not sure of the outcome.In an interview on 09/16/2025 at 5:03 PM, Staff C, Administrator, stated the residents should have meals served at the proper temperatures.Reference: (WAC) 388-97-1100 (2).

Based on interview and record review, the facility failed to employ a qualified social worker that met the educational requirements and supervised social work experience for one year in a health care setting for 4 of 4 social workers (Staff L, M, N & O), reviewed for social worker qualifications. This failure placed the residents at risk for unmet social services care needs, and a diminished quality of life.Findings included .Review of the Facility Assessment, updated on 07/10/2025, showed the facility was licensed to provide care for 211 residents.STAFF LReview of the facility staff list showed Staff L, Social Worker, was hired on 12/23/2024 and was employed per diem (works on an as-needed basis).STAFF MReview of the facility staff list showed Staff M, Social Worker, was hired on 08/04/2025 and was employed full time.On 09/16/2025 at 5:46 PM, Staff M stated that the facility was licensed to hold over 200 beds (or residents). When asked how many social workers were employed in the facility Staff M stated there were three full-time social workers, and that Staff L was per diem and was not at the facility every day. Staff M stated that they had a master's degree in theology (provides an advanced academic study of a religion from academic, historical, and philosophical perspectives, and can prepare individuals for various careers in ministry, teaching, and further doctoral studies). Staff M stated that they did not have a degree in social work or in a human service field. When asked if they met the qualifications for a social worker in a facility with over 120 licensed beds, Staff M stated, I guess not, further stating Theology dealt with Christian studies and was not a human service field.STAFF NReview of the facility staff list showed Staff N, Social Worker, was hired on 12/23/2024 and was employed full time.On 09/16/2025 at 6:24 PM, Staff N stated that they had been employed with the previous company and had worked at the facility for three years. Staff N stated that they had an associate's degree and did not have a bachelor's degree in social work or in a human services field. When asked if they met the qualifications for a social worker in a facility with over 120 licensed beds, Staff N stated, I do not have it at this time.STAFF OReview of the facility staff list showed Staff O, Social Worker, was hired on 08/19/2025 and was employed full time.Review of an email exchange with Staff C, Administrator, on 09/16/2025 (2:47 PM) showed a request for the facility's social workers' certifications/qualifications. Another email exchange on 09/16/2025 (7:08 PM) with Staff C, Staff A, Interim Administrator, and Staff B, Director of Nursing, showed an additional request for completed documents for the facility's social worker(s) certifications/qualifications.In an interview on 09/16/2025 at 7:29 PM with Staff A and Staff C, Staff A stated the facility was licensed for 211 beds. Staff A stated the facility employed three full time social workers and that Staff L was per diem or as needed/ on-call. Staff C stated that they would expect to have a qualified social worker that met the requirements for their facility. When asked if they were familiar with the required qualifications for a social worker for the facility, Staff C stated, well apparently not as well as I should be. Staff C stated that Staff M had a master's degree in theology and was not applicable to social work or a human service field. Staff C further stated that Staff N had certifications [was not provided], and that they had been reaching out to Staff O all day and had not got back to me.An additional email exchange with Staff C on 09/17/2025 (10:02 AM) showed a request for all the facility's employed social worker's certifications/qualifications/degrees, any resume showing at least one year experience working as a social worker in a healthcare setting, and the facility's job requirements and description or policy for a social worker. The facility did not provide qualifications for Staff L, Staff M, Staff N, or Staff O or a job description or policy for a social worker as requested.In a follow-up email on 09/17/2025 at 11:56 AM, from Staff A showed they were unable to get any information regarding the 3rd social workers [Staff O] qualifications.Reference: (WAC) 388-97-0960 (2)(a)(b).

Based on interview and record review, the facility failed to ensure shower preferences were reasonably accommodated for 2 of 6 residents (Residents 2 & 3), reviewed for preferences. This failure placed the residents at risk of unmet care needs and a diminished quality of life.Findings included… Review of the facility's undated policy titled, “Dignity,” showed, “The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.” The policy further showed residents were supported in exercising their rights and allowed them to choose when to sleep, eat and conduct activities of daily living (ADL). RESIDENT 2Review of Resident 2's “Shower Preference Questionnaire,” dated 07/03/2023 and another one dated 05/30/2024, showed Resident 2 preferred a shower in the morning twice a week. Review of Resident 2's care plan printed on 09/09/2025, did not show Resident 2's shower preferences. Review of Resident 2's Electronic Health Record (EHR), under task- ADL Bathing/Showering, showed Resident 2 was scheduled for a shower on Thursday evenings and as needed. The task further showed Resident 2 did not receive a shower twice a week in the morning per their preference. In an interview and joint record review on 09/10/2025 at 1:20 PM, Staff E, Resident Care Manager, stated a resident was asked about their shower preferences upon admission. A joint record review of Resident 2's “Shower Preference Questionnaire,” dated 07/03/2023 showed Resident 2 preferred a shower in the morning twice a week. Additional joint record review of Resident 2's EHR showed Resident 2 was scheduled for showers every Thursday once a week and as needed. Staff E stated that if the facility could accommodate the residents' preferences, they would try to honor them. When asked if the facility was currently honoring Resident 2's shower preferences, Staff E stated, “How it is does not reflect it now.” In an interview and joint record review on 09/15/2025 at 4:59 PM, Staff B, Director of Nursing, stated the facility was not honoring Resident 2's shower preferences and that they should have. Joint record review of Resident 2's “Shower Preference Questionnaire,” showed a new questionnaire was completed and dated 09/15/2025 with the same shower preferences. Staff B stated that Resident 2's shower schedule had been updated to Tuesdays and Thursdays during the day. On 09/16/2025 at 2:11 PM, Staff C, Administrator, stated they would expect to honor resident's shower preferences “within reason.” Staff C further stated that a shower twice a week seemed like a “reasonable” request. RESIDENT 3Review of Resident 3's care plan for preferences dated 12/02/2019 and revised on 01/07/2025 showed Resident 3 preferred bed baths. In an interview on 09/08/2025 on 3:27 PM, Resident 3 stated, “I prefer bed baths, and I prefer to get them two times a week. A long time ago I was asked if I would like to take showers or bed baths. I chose bed baths because I don't like getting out of bed to take a shower. I told the staff I would like to receive two bed baths a week in the evening. Review of Resident 3's EHR, under task- ADL Bathing/Showering, showed Resident 3 was scheduled for a shower/bath every Sunday and Thursday evening and as needed. The task further showed Resident 3 did not receive bed baths two times a week from 08/13/2025 to 08/25/2025. In an interview and joint record review on 09/11/2025 at 2:43 PM Staff E RCM stated, we recently went to interview and update all the residents shower preferences and care planned their choices, I know Resident 3 preferred bed baths. In a joint record review of Resident 3's EHR under task showed Resident 3 did not receive bed baths two times a week per Resident 3's preference from 08/13/2025 to 08/25/2025. Staff E also stated Resident 3 refused at times and that all refusals should be documented. Further joint review of the task record dated 08/13/2025 to 08/25/2025 with Staff E did not show documented refusals of the bed baths, Staff E then stated Resident 3 did not receive two showers per week during this time. In an interview and joint record review on 09/11/2025 at 3:20 PM with Staff B stated, the task record showed Resident 3 preferred bed baths two times per week and did not receive two times a week from 08/13/2025 to 08/25/2025. Staff B then stated Resident 3's preference for two bed baths per week was not honored. In an interview on 09/15/2025 at 4:01 PM Staff C stated, “I expect the Resident's preferences to be honored for showers and bed baths.” Reference: (WAC) 388-97 0860 (2) .

Based on observation, interview, and record review, the facility failed to develop care plans for 2 of 2 residents (Residents 8 & 4), reviewed for comprehensive care plans. The failure to develop care plans for assistive device use, independent community outings, and refusal of incontinent care (toileting assistance) placed the residents at risk for unmet care needs and a diminished quality of life. Findings included .Review of the facility's undated policy titled, Care Planning - Comprehensive Person-Centered, showed, A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. It showed that Comprehensive Care Plan meant an interdisciplinary communication tool developed after completion of a comprehensive MDS [Minimum Data Set - an assessment tool] and review of the Care Area Assessments. It showed, The resident will receive the services and/or items included in the plan of care, and any services that would otherwise be required but are not provided due to the resident's exercise of right to refuse treatment. It further showed that the comprehensive care plan will Incorporate identified problem areas.Incorporate risk factors associated with identified problems.promote resident safety.RESIDENT 8Review of a face sheet showed Resident 8 initially admitted to the facility on [DATE] with diagnosis that included generalized (not specific) muscle weakness and a history of person injured in unspecified motor-vehicle accident. It further showed that Resident 8 readmitted to the facility on [DATE].Review of an initial admission nursing progress note dated 07/01/2025 showed that Resident 8 Arrived in electric wheelchair. Review of the admission MDS dated [DATE] showed that Resident 8 was coded to have impairment (limitation that interfered with daily functions or placed resident at risk of injury in the last seven days) to both lower extremities and that Resident 8 used a motorized wheelchair as a mobility device. It further showed that Resident 8 was cognitively intact with a BIMS score of 15. In an interview and observation on 09/09/2025 at 1:04 PM, Resident 8 stated that they went out to the community un-supervised and that they used their motorized wheelchair to visit family and to get food. An observation of Resident 8's room showed a parked motorized wheelchair. In a follow-up interview on 09/11/2025 at 11:29 AM, Resident 8 stated that they independently used their motorized wheelchair outside of the facility 3 to 4 days out of the week. Review of a comprehensive care plan printed on 09/05/2025 did not show documentation of Resident 8's use of a motorized wheelchair. Further review did not show documentation of Resident 8's preference and/or ability for independent community outings. In an interview on 09/11/2025 at 11:47 AM, Staff J, Certified Nursing Assistant (CNA), did not identify Resident 8 when asked to identify Unit 700 residents who used a motorized wheelchair.In an interview on 09/11/2025 at 11:52 AM, Staff I, Licensed Practical Nurse (LPN), stated nobody used a motorized wheelchair in Unit 700. When asked if Resident 8 used a motorized wheelchair, Staff I stated, Oh yes, you're [ you are] right, and that most of the time [Resident 8 stayed in their] room and Resident 8 had not left their room lately. When asked if Resident 8 left the facility using their motorized wheelchair, Staff I stated [Resident 8] does, and that Resident 8 had not gone out in the last 3 weeks] due to an incident where Resident 8 bumped [themselves] in the store.In an interview and joint record review on 09/12/2025 at 11:20 AM, Staff H, LPN Unit Manager, stated that Resident 8 was alert and oriented and could sign in and out of the facility for community outings. Staff H stated that leaving the facility independently posed a risk to residents' safety to include cars, accidents, and falls. When asked if Resident 8 was identified by nursing to be at risk for falls and accidents, Staff H stated, Yes. A joint record review of Resident 8's comprehensive care plan did not show a care plan for Resident 8 leaving the facility independently and that Staff H expected there to be a care plan. When asked if assistive devices and equipment were important to be included in a resident's care plan, Staff H stated, yes, we include wheelchairs and walkers and that motorized wheelchairs were considered an assistive device. Joint record review of Resident 8's care plan did not show documentation of Resident's 8's use of a motorized wheelchair. Staff H stated that wheelchair was mentioned, but it doesn't [does not] say electric wheelchair. It should be there. When asked if Resident 8's safety interventions related to their use of a motorized wheelchair were identified and included in their care plan, Staff H stated, It should be there.In an interview on 09/12/2025 at 2:08 PM, Staff B, Director of Nursing, was asked if leaving the facility independently posed a risk to residents, Staff B stated, not necessarily if the resident was mobile. When asked if residents who were mobile could be at risk for accidents and hazards, Staff B stated, Yes. When asked if Resident 8's care plan included safety interventions related to leaving the facility independently, Staff B stated, Not everyone can go out independently, it depends on the situation, and that I have to see what [Resident 8's] particular situation is. Staff B further stated that they expected Resident 8's care plan would include their use of a motorized wheelchair and leaving the facility independently. RESIDENT 4Review of a face sheet showed Resident 4 admitted to the facility on [DATE] with diagnosis that included anxiety disorder (feeling of constant worrying), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and dementia (impaired thinking and memory). Review of the facility's compiled documents titled, Investigative Summary, [Resident 4], dated 08/26/2025, showed it was completed by Staff B. It showed, It appears [Resident 4] does not like to be bothered at times, leading to the allegations. However, leaving resident soiled will be detrimental to [Resident 4's] skin and general well-being.Staff educated to inform nurse if [Resident 4] refuses to be changed [incontinent care] and [Resident 4's representative] will also be called to try and encourage [Resident 4].In an interview and joint record review on 09/12/2025 at 12:00, Staff H stated staff would re-approach residents whenever residents refused any kind of care and that with the resident's initial refusal of care, staff would find out why, so that staff can accommodate the resident's needs. Staff H further stated that if the refusal of care was identified to be consistent [same way every time] for a resident, they would expect identified approaches to address the refusal of care to be included in the resident's care plan. Staff H stated that refusal of care posed a risk for residents. When asked if Resident 4 consistently refused care, Staff H stated that Resident 4 refuses medications and incontinent care, and that skin breakdown was a risk for refusing incontinent care. A joint record review of Resident 4's Electronic Health Record (EHR) did not show documentation of Resident 4's refusal of incontinent care included in their care plan. Staff H stated that Resident's refusal of incontinent care and intervention to notify Resident 4's representative was not included in their care plan. In an interview on 09/15/2025 at 2:42 PM, Staff B stated that they concluded that Resident 4 refused incontinent care at certain times from completing their investigation dated 08/26/2025. When asked if Resident 4's care plan included Resident 4's refusal of incontinent care and the intervention to notify Resident 4's representative, Staff B stated, I have to check. A follow-up joint record review and interview on 09/16/2025 at 2:39 PM, showed Resident 4's care plan did not include Resident 4's refusal of incontinent care and the intervention to notify Resident 4's representative, and Staff B stated, I don't [do not] see it. Reference: (WAC) 388-97-1020 (1) (2)(a)(b).

Based on observation, interview, and record review, the facility failed to ensure monitoring for latent (hidden or not active yet) signs of injury and prompt medical evaluation for treatment was provided in accordance with professional standards of practice for 1 of 1 resident (Resident 8), reviewed for change of condition. These failures disallowed an opportunity to promptly evaluate the resident for a change in condition, which resulted in a delay of medical services, and placed the resident at risk for adverse consequences, related complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Change in a Resident's Condition, dated 10/01/2021, showed that the facility will promptly notify the resident's physician/practitioner of changes in the resident's medical/mental condition and/or status.The nurse will notify the resident's Attending Physician/practitioner or physician on call when there has been an accident or incident involving the resident.The nurse/designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's policy titled, Charting and Documentation, dated 10/01/2021, showed that All services provided to the resident.or changes in the resident's medical, physical, functional, or psychological condition, will be documented in the resident's medical record.The following information is to be documented in the resident medical record.Events, incidents, or accidents involving the resident.Review of a face sheet showed Resident 8 initially admitted to the facility on [DATE] with diagnosis that included generalized (not specific) muscle weakness and cauda equina syndrome (medical condition that affects the bundle of nerves at the bottom of the spinal cord).Review of an admission MDS dated [DATE] showed that Resident 8 was cognitively intact with a Brief Interview for Mental Status (BIMS -a cognitive screening tool) score of 15 (highest possible score). It further showed that Resident 8 used a motorized wheelchair for mobility.In an interview on 09/11/2025 at 11:29 AM, Resident 8 stated that on 08/21/2025, they used their motorized wheelchair at a clothing store when they injured their right foot. Resident 8 further stated that the tip of their right Ankle-Foot Orthosis (AFO-type of brace designed to support the ankle and foot) got caught on a store display while maneuvering down a narrow isle, which caused their right leg to flip around. When asked if they returned to the facility independently after the incident, Resident 8 stated, Yes, and that they initially reported the incident to a Physical Therapist (PT) to take a look at my leg and that Resident 8 felt like they sprained their right ankle. Resident 8 further stated that a Certified Nursing Assistant (CNA) later helped them take off their right AFO which resulted in Resident 8 having pain. Resident 8 stated that the CNA notified the Nurse. Review of a nursing progress note dated 08/21/2025 at 8:00 PM, showed Resident 8 was given oxycodone (strong pain medication) 10 mg (milligrams-a unit of measurement) that was instructed to be given every six hours as needed for severe pain. Review of a nursing progress note dated 08/21/2025 at 8:54 PM, showed [Resident 8] reported pain at around 8 pm [8:00 PM] on right ankle and wants oxycodone, [Resident 8] stated, I pumped my right ankle on my power w/c [wheelchair] while out for shopping to [a clothing store] this morning. It showed, [Resident 8] unable to move [their] leg r/t [related to] paralyze. [Resident 8] placed on a/c [alert charting - communication tool used for monitoring a resident's change of condition] for monitor. It further showed that the medical provider was notified via communication book and that Report given to incoming nurse.Review of a nursing progress notes showed Resident 8 was given additional doses of oxycodone 10 mg for severe pain on the following dates and times:- On 08/21/2025 at 11:03 PM- On 08/22/2025 at 3:07 PMReview of Resident 8's nursing progress notes did not show documentation of alert charting and/or medical provider assessment of Resident 8's complaint of right ankle pain on 08/22/2025, 08/23/2025 and on 08/24/2025 [three days following Resident's 8 change of condition].Review of Resident 8's August 2025 Medication Administration Record showed that Resident 8 was documented to receive non-pharmacological pain interventions on the following dates and nursing shifts:-On 08/21/2025, Rest for all shifts and Cold/Ice during the evening and night shifts.-On 08/22/2025, Rest for all shifts and Cold/Ice during the day and evening shifts.-On 08/23/2025, Rest for all shifts and Cold/Ice during the day and evening shifts.-On 08/24/2025, Rest for the day and evening shifts and Cold/Ice during the day and evening shifts. -On 08/25/2025, Rest for the day and evening shifts.Review of a medical provider's encounter note dated 08/25/2025 showed Resident 8 was assessed for a chief complaint of right ankle sprain. It showed that mechanism for Resident 8's complaint of right ankle pain was that ankle twisted at [a clothing store] when [their AFO] brace caught on display edge. It further showed that Resident 8 reported a pain score of eight out of 10 when moved, and that right leg pain was reported as pretty bad. It further showed that an ankle x-ray [used to check for broken bones] was ordered. Review of a progress note dated 08/26/2025, written by Staff H, Licensed Practical Nurse (LPN), Unit Manager, showed X-ray result of fracture [broken bone] on right distal [lower part of] tibia [shinbone], and provider plan to send [Resident 8] to emergency [Emergency Room].Review of discharge MDS dated [DATE] showed Resident 8's discharge from the facility was unplanned and that return to the facility was anticipated.Review of Resident 8's hospital Discharge summary dated [DATE] showed that Resident 8 Presents several days after a mechanical incident, [Resident 8's] right leg got stuck on display at a store while [Resident 8] was using [their] motorized scooter.For pain [Resident 8] has been using as needed oxycodone in the hospital. [Resident 8] is needing higher doses than [Resident 8] was on previously. At this point, [Resident 8] would like to try oral Dilaudid (a very strong painkiller that is prescribed to someone experiencing severe pain, like after major surgery or a serious injury) to see if it is more effective.Review of a face sheet showed Resident 8 readmitted to the facility on [DATE] with diagnosis that included non-displaced fracture of right tibia, acute embolism (blood clot) and thrombosis (blood clot forms inside a blood vessel that can block the flow of blood) of unspecified deep veins of lower left extremity. Record review of a provider progress note titled, Provider Readmit Visit (72 hours) note, dated 09/01/2025 showed Resident 8 was assessed by Staff G, Nurse Practitioner. It showed that The patient initially sustained a right tibial fracture after twisting [their] foot while manipulating [their] wheelchair. An X-ray on August 26 [2025] confirmed the fracture. Subsequently [after that] [Resident 8] was admitted to the hospital where [they] were diagnosed with left leg DVT and acute pulmonary embolism. She was stabilized and discharged on August 31 [2025] for continued medical management and therapy. It further showed, Assessment/Plan included Acute embolism and thrombosis of other specified deep vein of left lower extremity Left leg DVT [Deep Vein Thrombosis] and acute pulmonary embolism - blood clot likely due to immobilization following tibial fracture.In an interview on 09/11/2025 at 11:52 AM, Staff I, LPN, stated, nobody used a motorized wheelchair in Unit 700. When asked about Resident 8 regarding the use of a motorized wheelchair, Staff I stated, Oh yes, you're [you are] right, and that most of the time [Resident 8 stayed in their] room and Resident 8 had not left their room lately. When asked if Resident 8 left the facility using their motorized wheelchair, Staff I stated, [Resident 8] does, and that Resident 8 had not gone out in the last 3 weeks] due to an incident where Resident 8 bumped [themselves] in the store. Staff I further stated that prior to that incident [08/21/2025], [Resident 8] was going out. In an interview on 09/11/2025 at 12:15 PM, with Staff F, Rehabilitation Director, and Staff K, PT, Staff K stated that Resident 8 had reported the incident on 08/21/2025 to them and that they performed passive range of motion [PROM-moving a person's body part for them, without them doing any of the work], of Resident 8's right leg. Staff K stated that [Resident 8 was not] on case load [therapy services], so I [did not] feel comfortable doing more than PROM. When asked if Staff K notified Nursing of Resident 8's reported 08/21/2025 incident, Staff K answered, No and that they typically [do not] touch [work] with residents who are not on case load. In an interview on 09/12/2025 at 10:31 AM, Staff G stated that they were notified of Resident 8's 08/21/2025 incident on 08/25/2025. Staff G stated that Resident 8 was assessed to have pain and difficulty with mobility to their right foot. Staff G stated that Resident 8 goes out [of the facility] frequently via their motorized wheelchair. Staff G then stated that Resident 8 was assessed at the Emergency Department following the x-ray result of Resident 8's right ankle fracture. When asked if Resident 8 had a tibial fracture before the 08/21/2025 incident, Staff G stated, No. When asked if the incident on 08/21/2025 caused Resident 8 to stay in bed or become immobile due to right ankle pain, Staff G stated, I believe so and that Resident 8 was personally deciding not to [get out of bed]. Staff G confirmed that they wrote the readmission visit note dated 09/01/2025. When asked if Resident 8's 08/21/2025 incident resulted in Resident 8's hospitalization and new diagnosis of right tibial fracture, left leg DVT and Pulmonary embolism, Staff G stated that Resident 8 was found to have them [new diagnosis] when Resident 8 was admitted to the hospital for the fracture. Staff G further stated that a DVT and pulmonary embolism can occur when a resident is immobile for long periods and not on blood thinners. When asked if this was the case for Resident 8, Staff G stated, It could have been and that because of previous injuries, [Resident 8] did not have great sensation to lower extremities.In a follow-up interview on 09/12/2025 at 10:52 AM, Staff F stated that the Therapy department was part of the interdisciplinary team that provided services to residents. When asked if Resident 8 should have communicated Resident 8's initial report of the 08/21/2025 incident to the Nursing department, Staff F stated that Staff K said that they did not notify nursing staff on 08/21/2025 and that Resident 8 was on case load at the time of the incident. Staff F stated that they expected Therapy to notify Nursing of the reported incident on 08/21/2025 and for myself to follow-up with the physician to ensure Resident 8 was assessed for pain. Staff F further stated that If it's [is not] documented, I can't [cannot] say it [communication between Therapy and Nursing] happened. Review of a facility document titled, [Facility Name] Therapy Minutes Report, dated 07/01/2025 through 08/26/2025, did not show that Resident 8 received therapy services on 08/22/2025, 08/23/2025 and 08/24/2025. Review of Resident 8's document titled, Occupational Therapy Treatment Encounter Notes, dated 08/25/2025, showed that Resident 8 refuses to get EOB [Edge of Bed] due to pain in ankle, and that Resident 8 performed therapy exercises while lying in bed. In a follow-up interview on 09/12/2025 at 11:05 AM, Resident 8 stated that they experienced pain and difficulty with movement following the 08/21/2025 incident and that I wasn't [was not] able to transfer, I wasn't able to move it [right leg], any movement of my body, even trying to roll side to side for brief changes was extremely painful. When asked if Resident 8 was able to perform activities out of bed after the incident to include participating in Therapy, Resident 8 stated, No, absolutely not. Resident 8 further stated that It was definitely hard, my main priority for choosing this facility is their therapy program and that I was very sad to not go to Physical Therapy. My goal is to go home. In an interview and joint record review on 09/12/2025 at 11:20 AM, Staff H stated that the facility placed residents on alert charting whenever there was a change of condition that required ongoing monitoring. When asked if a resident's new report of pain required ongoing monitoring, Staff H stated, Yes. A joint record review of Resident 8's nursing progress note dated 08/21/2025 showed that Resident 8 reported the 08/21/2025 incident to a nurse and that Resident 8 complained of right foot pain. Further joint record review of Resident 8's progress notes for 08/22/2025, 08/23/2025, and 08/24/2025 did not show documentation of alert charting for Resident 8's change of condition. Staff H stated, I don't [do not] see that, and that Resident should have continued to be monitored for signs and symptoms of changes related to their complaint of right ankle pain following the 08/21/2025 incident. In an interview on 09/12/2025 at 09/12/2025 at 2:08 PM, Staff B, Director of Nursing, stated the facility placed residents on alert charting if there was a change of condition and that included anything outside of the ordinary. Staff B stated that they expected residents placed on alert charting would have follow up documentation. A joint record review of Resident 8's nursing progress note dated 08/21/2025 showed Resident 8 reported an incident that resulted in a new complaint of right ankle pain. It did not show documentation of alert charting for 08/22/2025, 08/23/2025, and 08/24/2025. Staff B stated, Yes, I am aware of that situation, that was brought to my attention after the resident was in the hospital. Staff B stated that Resident 8 should have continued to be monitored for changes in signs and symptoms related to their right ankle pain and that the provider should have followed up promptly. Staff B further stated that they completed an internal investigation of the 08/21/2025 incident.Review of the facility document titled, Internal Investigation Summary, [Resident 8], dated 08/29/2025, showed it was completed by Staff B. It showed Internal Investigation due to [Resident 8] currently hospitalized and discharged from facility. Was informed by RCM [Resident Care Manager/Nurse Unit Manager] on 08/27 [2025] at clinical stand-up meeting that [Resident 8] was transferred to hospital yesterday, and this was due to a fracture of her right foot. Per RCM, [Resident 8] informed a nurse last week when [Resident 8] returned from outing that she had bumped her ankle, and that nurse called the on-call [provider] and also referred to provider. However, per RCM provider did not order any x-rays until day before yesterday [08/25/2025] and that upon results showing a fracture, instructed a transfer to hospital. RCM stated he was unaware of incident because the nurse did not place [Resident 8] on alert [charting]. It further showed, The nurse who was informed when resident returned from outing (08/21/2025) regarding bumping her foot and that this nurse failed to place resident on alert or 24-hour report which would have alerted other nurses to follow up. Although she documented referral to provider, there is no evidence of provider follow up. In follow-up interview and joint record review on 09/15/2025 at 2:38 PM, Staff B was asked if the 08/21/2025 incident caused Resident 8 to become immobile due to right ankle pain, Staff B stated, There weren't [were not] any changes to [Resident 8's] usual routine. Staff B stated that they gathered this information by asking the RCM When asked if there were documentation from nursing staff assessments related to Resident 8's no changes in routine following the incident, Staff B stated, No. A joint record review of Resident 8's provider readmission visit note dated 09/01/2025 showed Staff G documented, Blood clot likely due to immobilization following tibial fracture. Staff B stated, I [do not] have anything to say about it. In an interview on 09/16/2025 at 2:09 PM, Staff C, Administrator, stated that they expected Resident 8 would have been monitored for ongoing changes related to the incident on 08/21/2025 and their complaint of right ankle pain. Reference: (WAC) 388-97-1060 (1) .

Based on observation, interview, and record review the facility failed to provide/replace a pressure relieving bed mattress (Dolphin Mattress-a type of mattress that alternated fluid through the mattress) as recommended by the wound consultant to prevent and protect skin/wounds from further breaking down for 1 or 3 residents (Resident 3), reviewed for pressure ulcers. This failure placed the resident at risk for related medical complications, a decrease in healing potential, and a diminished quality of life.Findings included.Review of the National Pressure Injury Advisory Panel (NPIAP - leading expert in pressure injuries/wounds), dated February 2025, defined pressure injury stages as follows: -Stage 4 Pressure Injury is a full-thickness loss of skin and tissue with exposed or directly palpable fascia (layer of tissue covering the muscle), muscle, tendon (a cord or band of dense, tough, inelastic, white, fibrous tissue, serving to connect a muscle with a bone or part), ligament (a tough fibrous band of connective tissue that supports internal organs and holds bones together at the joints. It connects bones to other bones and helps hold organs in place), cartilage (a strong, flexible connective tissue that protects the joints and bones acting as a shock absorber throughout the body) or bone in the ulcer. Slough (is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and/or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible.Review of the facility's undated Pressure Injury and Prevention Management Policy showed, If a referral is made to a wound consultant, the wound consultant will provide timely and accurate information to the facility on the status of the pressure ulcer/injury and will provide recommendation for change in treatment and care of the pressure ulcer/injury.Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool) dated 07/28/2025 showed Resident 3 readmitted to the facility on [DATE]. Further review of the MDS dated [DATE] showed Resident 3 required assistance with bed mobility and transfers.Review of the Electronic Health Record (EHR) showed Resident 3 had history of pressure injuries that included Stage 4 pressure injuries to the right and left hip and Osteomyelitis (bone infection) of the right femur (leg), the EHR further showed the Stage 4 pressure injuries and Osteomyelitis had a chronic (long) history of healing and reopening.Review of a physician order in the EHR dated 03/20/2025 showed Resident 3 had orders to be followed by a wound care clinic outside of the facility.Review of a wound care clinic notes dated 08/28/2025, showed Resident 3's mattress was not sufficiently offloading pressure, and Resident 3 needed a Dolphin Mattress to prevent and protect skin/wounds from further breaking down.In an interview on 08/26/2025 at 12:13 PM, Collateral Contact 1 (CC1), stated, We made several phone calls and sent so many recommendations to the nursing staff at the facility to please arrange to get this Dolphin Mattress for Resident 3. We informed them that the current mattress that they replaced with when the Dolphin Mattress broke was not sufficient for offloading pressure. CC1 stated Resident 3 had a long history of pressure injuries and that they recommended this mattress to prevent and assist in healing of pressure injuries.Observation on 09/08/2025 at 2:21 PM, Resident 3 had a MATT-EASY AIR mattress [a type of mattress that alternated air through the mattress] on their bed that was not the Dolphin Mattress as CC1 recommended in the wound care note dated 08/28/2025.In an interview on 09/09/2025 at 11:36 AM, CC2 stated the difference between the two mattresses were that the Dolphin Mattress functioned by alternating fluid in the mattress to relieve pressure and MATT-EASY AIR mattress functioned by alternating air to relieve pressure. CC2 further stated that the Dolphin Mattress was highly recommended for pressure reduction, healing, and prevention of pressure ulcers.In an interview on 09/15/2025 at 1:37 PM, Staff E, Registered Nurse, Unit Manager, stated that when Resident 3 returned from the wound care clinic the orders and recommendations were faxed over and that they noted the new orders and recommendations and made sure all were taken care of. Staff E stated that the Dolphin Mattress broke, and they informed the previous administration staff about the recommendation for it. Staff E stated that the MATT-EASY AIR mattress was ordered and placed on Resident 3's bed on 08/05/2025 despite the wound care recommendations for Dolphin Mattress. Staff E further stated the Dolphin Mattress was never replaced and had informed the previous administration regarding Resident 3's multiple wound care notes that recommended the Dolphin Mattress.In an interview on 09/15/2025 at 3:29 PM, Staff B, Director of Nursing, stated, I know the previous Administrator was working with our corporation to get the Dolphin Mattress replaced, I am not sure, but I think they did not want to pay to fix or replace the bed, so another mattress was ordered for Resident 3.In an interview on 09/16/2025 at 5:11 PM, Staff C, Administrator, stated that the mattresses should function the same, if one worked by alternating fluid, the one that it was replaced with should also function by alternating fluid.Reference: (WAC) 388-97-1060(3)(b).

Based on interview and record review, the facility failed to ensure 2 of 2 residents (Residents 3 and 17) were free from significant medication errors. The failure to provide intravenous (IV- administered through a vein) antibiotic medications (to treat infection) placed the residents at risk for a decline in their medical condition, a life-threatening infection, and a diminished quality of life.Findings included .RESIDENT 3Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 07/28/2025 showed Resident 3 was readmitted to the facility on [DATE] and had intact thinking.In an interview on 09/08/2025 at 2:32 PM, Resident 3 stated, a few weeks ago I missed the antibiotic [medication] I was supposed to take for the infection in my wounds and bone, it was an IV the nurses told me they did not have it and that they were trying to get it delivered from the pharmacy. After I missed a few doses, I started to feel like I had a fever and chills. When the aides took my temperature, it was normal, but I still felt like I had a fever and chills from missing the antibiotics.Review of August 2025 Medication Administration Record (MAR) in the Electronic Health Record (EHR) showed orders for Meropenem (antibiotic-medication used to treat infection) 1 gram (gm-a unit of measurement) IV every 8 hours for Pelvic (hip) Osteomyelitis (bone infection) with a date to start on 07/28/2025 and a date to stop on 08/28/2025. Further review of the MAR dated 08/24/2025 at 2:00 PM and at 10:00 PM and on 08/25/2025 at 6:00 AM and at 2:00 PM, showed the medication was not administered. Medication Meropenem 1 gm IV was not administered four times from 08/24/2025 to 08/25/2025.Review of the nursing progress notes in the EHR dated 08/24/2025 showed Resident 4 missed doses of Meropenem 1 gm IV at 2:00 PM, 10:00 PM and on 08/25/2025 at 6:00 AM and 2:00PM.RESIDENT 17Review of the admission MDS dated [DATE] showed Resident 17 was admitted to the facility on [DATE].Review of a nursing admission progress note in the EHR dated 08/22/2025 showed Resident 17 admitted to the facility with right hip peri-prosthetic joint infection (an infection that occurred around the replaced right hip joint) and had a suspected joint infection and was admitted to the facility for intravenous antibiotic therapy.Review of the physician's orders in the EHR dated 08/23/2025 showed orders for Daptomycin (medication used to treat infection) IV 500 milligrams (mg-unit of measurement) at 10:00 AM for infection for 41 days and Ertapenem 1 gram IV at 10:00 AM for 6 weeks. Review of the MAR dated 08/23/2025 showed Daptomycin IV use 500 mg at 10:00 AM for infection or Ertapenem 1 gram IV at 10:00 AM was not administered to Resident 17.Review of a progress note in the EHR dated 08/23/2025 showed Resident 17 was transferred to a local hospital at 12:50 PM due to the pharmacy's inability to deliver the residents IV antibiotic medications.In an interview on 09/12/2025 at 1:31PM Staff D, Registered Nurse (RN), stated, we don't know where to get IV medications anymore, there has been a change, we don't know who to call. The pharmacy here doesn't do IVs anymore. They won't deliver IV medication here now. If I had a resident that had physicians orders for IV medication, I would have to ask the Director of Nursing Services (DNS) what to do. In an interview on 09/12/2025 at 1:46 PM Staff T, RN stated, the pharmacy does not do IVs, they will deliver all the other medications, just not the IVs. I don't know who to call if I get IV medication delivered here for the residents if they need it. I would have to ask the DNS; it's not the same pharmacy that we had for IVs, the pharmacy we have now will deliver all other medications, just not IVs.In an interview on 09/15/2025 at 1:07 PM Staff E, RN, Unit Manager stated, the previous pharmacy was called to deliver the IV antibiotic medication for Resident 3, and we were told they did not deliver IV medication to the facility anymore because their contract ended with the facility. Resident 3 missed three or four doses of their antibiotic IV. We informed the physician, and they wanted Resident 3 to be monitored here at the facility. I think Resident 17 was transported back to the hospital because we could not get their IV medication here. We have a new pharmacy that will bring IV medication to the facility now.In an interview on 09/15/2025 at 3:29 PM Staff B, DNS, stated there was an issue with the previous pharmacy when they stopped delivering IV medication to the facility. We notified the physician of Resident 3 when the IV antibiotic medication (Meropenem) was not administered, the physician ordered for the resident to be monitored in the facility. Staff B stated Resident 3 missed three or four doses of the IV antibiotic. Staff B stated there was another resident, Resident 17 was admitted to the facility and had to be transported back to the hospital the day after they were admitted because Resident 17 had physician orders for antibiotic IV's and they could not get the IV antibiotic medication delivered from the pharmacy to the facility. Staff B stated Resident 17 missed two doses of antibiotic medication before they were transported back to the hospital the day after admission. Staff B further stated those were significant medications that Resident 3 and Resident 17 missed, and now the facility had a pharmacy that would deliver IV medication to the facility.In an interview on 09/16/2025 at 5:16 PM, Staff C, Administrator, stated the previous pharmacy would not deliver the IV medications which caused Resident 3 and Resident 17 to miss those IV medications.Reference: (WAC) 388-97-1060(3)(k)(iii).

Based on observation, interview, and record review, the facility failed to ensure aerosol contact precautions (safety steps used to keep germs from spreading) that included keeping the door closed at all times and proper use of Personal Protective Equipment (PPE - gown, gloves, N95 [respirator -medical face mask that filters out at least 95% of tiny particles in the air] and face shield) were followed for 2 of 2 staff (Staff X & Z), reviewed for infection control. This failure placed the residents, staff, and visitors at risk for facility acquired or healthcare-associated infections and related complications.Findings included.Review of the facility's undated policy titled, Coronavirus Disease (COVID-19) [respiratory disease caused by a virus]-Infection Prevention and Control Measures, showed This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility, It further showed that IPC measures to address COVID-19 included identifying and managing ill residents.optimizing engineering controls [keeping isolation room doors closed] and indoor air quality.STAFF XReview of the facility document titled, admission Nursing Collection Tool, dated 09/12/2025, showed Resident 24 tested positive for COVID and required isolation precautions [or aerosol contact precautions] and appropriate PPE per policy. It further showed that Resident 24 admitted to the facility's Transitional Care [TCU, room [ROOM NUMBER]].Review of an admission Nursing Collection Tool, dated 09/13/2025, showed that Resident 25 tested positive for COVID and required isolation precautions and appropriate PPE per policy. It further showed that Resident 24 admitted to the Transitional Care [TCU, room [ROOM NUMBER]].Observation on 09/15/2025 at 3:32 PM, showed a sign posted on the closed double-door entrance to the TCU that indicated, All staff and visitors, N95 is required beyond this point. It further showed that an aerosol contact precaution sign was posted on room [ROOM NUMBER]'s door and that the door was not closed. In an interview and joint record review on 09/15/2025 at 3:37 PM, Staff X, Nursing Assistant Certified (NAC), stated that the double doors to the TCU were kept closed because Resident 24 and Resident 25 were positive with COVID-19. A joint record review of the aerosol contact precaution sign posted on room [ROOM NUMBER]'s door indicated that the door remains closed. Staff X stated, It [room [ROOM NUMBER]'s door] should be closed. In an interview on 09/15/2025 at 3:39 PM, Staff Y, Licensed Practical Nurse (LPN), stated that Resident 24 and 25 were on aerosol contact precautions for COVID-19. Staff Y stated that both residents were located in room [ROOM NUMBER] and that the door should be closed all the time. In an interview on 09/15/2025 at 4:35 PM, Staff N, Registered Nurse Unit Manager, stated that the facility admitted residents who tested positive for COVID-19 and that Residents 24 and Resident 25 were admitted to the facility with active COVID-19. Staff N stated that they expected staff to wear appropriate PPE and kept isolation door rooms closed when aerosol contact precautions were implemented. STAFF ZObservation on 09/16/2025 at 10:03 AM showed room [ROOM NUMBER]'s door was open and that Staff Z, NAC, was inside the room with a resident. It further showed Staff Z exited room [ROOM NUMBER] wearing a surgical mask. It did not show Staff Z used appropriate PPE according to aerosol contact precautions (N95, gown, mask, eye protection and gloves). In an interview on 09/16/2025 at 10:08 AM, Staff Z, NAC, stated that they entered room [ROOM NUMBER] to remove used glasses [for drinking]. A joint observation of the aerosol contact sign posted on the door of room [ROOM NUMBER] showed instructions to keep the door closed and for staff to wear appropriate PPE. Staff Z stated they should have worn appropriate PPE and kept room [ROOM NUMBER]'s door closed. In an interview on 09/16/2025 at 10:15 AM, Staff M, LPN, stated they expected staff would follow precautions indicated on the aerosol contact precaution sign when it was posted and that staff would wear N95 while working in the TCU. In an interview on 09/16/2025 at 3:30 PM, Staff B, Director of Nursing, stated that the facility admitted residents with active COVID-19 infection. Staff B stated that they expected staff would wear appropriate PPE to include N95 mask on the COVID Unit [TCU]. Staff B further stated that they expected room doors would remain closed as much as possible, when aerosol contact precautions were indicated. Reference: (WAC) 388-97-1320 1(a)2(a).

Based on observation, interview, and record review, the facility failed to ensure eight of eight staff members (Staff A, B, C, D, E, F, G, and H) consistently implemented written infection control policies and procedures and follow standards of practice related to hand hygiene/washing, donning (put-on) and doffing (take-off) of Personal Protective Equipment (PPE), and the required isolation/transmission-based precautions when providing care and services to residents with known or suspected COVID-19 infection. The facility failed to develop and implement an effective infection control program related to the handling and disposal of potentially contaminated and infectious materials (garbage, trash and other wastes from the COVID-19 unit) and maintain a sanitary environment to minimize the risk and spread of infection. Additionally, the facility failed to ensure Staff J followed and implemented written infection control policies and procedures, including the standards of practice related to hand hygiene/washing, use of PPEs (mask and face shield) including the need to secure and protect supplies from dirt, dust and other contaminants as required. These failures placed all the residents and staff of the facility in the likelihood of serious harm and for acquiring communicable diseases and serious infections, including COVID-19. The facility's failure to ensure that staff were following standards of practice when providing care and services to residents with known and/or suspected COVID-19 infection, the failure to properly secure, contain and dispose of potentially contaminated and infectious materials from the COVID-19 unit, and the failure to follow and implement written policies and procedures for infection control, constituted a situation of an Immediate Jeopardy (IJ). On 11/30/20 at 4:45 PM, the facility was notified of the IJ related to CFR 483.80 F880, Infection Prevention and Control. Findings included . According to the Centers for Disease Control (CDC), COVID-19 is an illness caused by [MEDICAL CONDITION] (coronavirus) that can spread from person to person and through contact with contaminated surfaces. The CDC also stated that a person can become infected from respiratory droplets when an infected person coughs, sneezes or talks. The CDC guidelines for COVID-19 included the following: Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (such as goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. A review of the facility policy titled, Special Droplet/Contact Precautions, dated 03/2020, showed that all facility staff, including visitors, doctors and staff, were expected to: a) Clean hands when entering and leaving the resident/isolation room; and b) Gown and gloves at the door. The policy showed these precautions would be used for respiratory viruses, including COVID-19. TRANSMISSION BASED PRECAUTIONS, PPE USE AND HAND HYGIENE UNIT 100 Observation on 11/30/2020 at 10:10 AM showed Staff A, Housekeeping Aide (HA) entered room [ROOM NUMBER] and provided housekeeping services. Staff A was wearing a mask, facial covering (face shield) and a pair of gloves. After cleaning the room, Staff A exited room [ROOM NUMBER] without removing the contaminated gloves and without performing any form of hand hygiene. Staff A entered and provided housekeeping services to rooms [ROOM NUMBER] using the same contaminated gloves and without performing any form of hand hygiene. At 10:35 AM, Staff A entered and provided housekeeping services in room [ROOM NUMBER] (an isolation room). room [ROOM NUMBER] had a sign posted at the doorway that showed, Special Droplet/Contact Precautions which directed staff to clean hands when entering and leaving the isolation room, and to don a gown at the door when entering the room. However, Staff A did not perform any type of hand hygiene, did not remove his contaminated gloves, and did not wear a gown prior to entering the isolation room as required. Staff A then exited room [ROOM NUMBER] without removing his contaminated gloves and without performing any hand hygiene. The resident in room [ROOM NUMBER], Resident #1, sneezed and coughed twice while Staff A was in the room close to the resident (approximately at an arm's length distance). During an observation and interview on 11/30/2020 at 10:45 AM, Staff A, HA, entered room [ROOM NUMBER] and performed housekeeping services using the same contaminated gloves (same gloves used in rooms 116, 115, 114, 113 and 112) and without performing any form of hand hygiene. Staff A was stopped and interviewed as he exited room [ROOM NUMBER] and attempted to enter another room (room [ROOM NUMBER]) without removing his contaminated gloves and without performing any form of hand hygiene. Staff A stated that he was aware that he should have removed his gloves and washed his hands before and after leaving each resident room, but stated that he just forgot. Staff A also stated that room [ROOM NUMBER] was an isolation room due to possible COVID-19, and he should have worn a gown when he entered the room as per the directions on the precautions sign at the room's doorway. UNIT 200 Observation on 11/30/2020 at 10:55 AM showed Staff B, HA, providing housekeeping services in unit 200. Staff B entered and provided housekeeping services, without wearing a gown, in several isolation rooms (205, 207, 209, 212 and 214) in which residents with known/suspected COVID-19 resided. The rooms had doorway signs titled Special Droplet/Contact Precautions that instructed facility staff to clean hands when entering and leaving the resident/isolation room, and to put on a gown and gloves at the door. However, Staff B provided housekeeping services to rooms 205, 207, 209, 212 and 214 using the same contaminated gloves, and had entered and exited each isolation room without performing any form of hand hygiene. Additionally, Staff B used the same towel to clean the doorknobs inside the resident rooms (bathroom and room doors) and to clean the handrails outside the rooms in the hallways. Staff B also went in and out of the 200 unit to gather housekeeping supplies while wearing the same contaminated gloves. An observation on 11/30/2020 at 11: 00 AM showed Staff C, Physical Therapist (PT) providing care to Resident #2 (room [ROOM NUMBER]). Resident #2 was on Special Droplet/Contact Precautions for known and/or suspected COVID-19. Staff C was not wearing a gown and did not wear gloves when she turned and repositioned the resident in bed, assisted the resident with blanket covers, and placed some items, including the bedside table and the call light, within Resident #2's reach. During an interview on 11/30/2020 at 11:05 AM, Staff C, PT stated that she was aware of what PPEs were required when entering an isolation room, including the room [ROOM NUMBER] for Resident #2. Staff C stated that she should have worn the required PPE, including gown and gloves, when she provided care to Resident #2. During an interview on 11/30/2020 at 11:10 AM, Staff B, HA, stated that she should have removed her contaminated gloves after contact with dirty surfaces and before leaving each isolation room. Staff B also stated that she should have performed hand hygiene before entering or exiting a resident room, and before and after she put on or removed her gloves. Staff B further stated, she just forgot to remove her contaminated gloves, to wash hands and to wear gowns when entering an isolation room. UNIT 300 Observation on 11/30/2020 at 11:15 AM showed that all resident rooms on Unit 300 had signs posted at the doorways that were titled, Special Droplet/Contact Precautions. During an observation and interview on 11/30/2020 at 11:20 AM, Staff D, HA, was providing housekeeping services in Unit 300. Staff D wore full PPE as she entered several isolation rooms (301, 303, 304, 306 and 308) in which residents with known/positive COVID-19 resided. However, Staff D entered and exited each isolation room without removing her contaminated gloves and gown, and proceeded to clean and enter other rooms in the unit using the same contaminated gloves and gown. Staff D also helped gather supplies for a newly admitted resident with COVID-19 to the unit (clean linens, oxygen concentrator and portable oxygen tank) while wearing the same contaminated gown and gloves. Staff D stated that she should have taken off and removed her gloves after touching dirty and contaminated surfaces. Staff D also stated that she should have removed the contaminated gown in between resident rooms to prevent and minimize the spread of infection. An observation on 11/30/2020 at 11:22 AM showed Staff D, HA, drop a clean glove on the floor, and instead of throwing it in the trash, Staff D put the soiled glove back on her cart where the clean gloves were. An observation on 11/30/2020 at 11:25 AM showed Staff E, Licensed Practical Nurse (LPN), providing care and services to Resident #5 (a newly admitted resident with COVID-19). Staff E was wearing full PPE including an N95 mask, face shield, gown and gloves when she assisted Resident #5 with transferring from wheelchair to bed, turning and reposition in bed, and with medication administration. However, Staff E did not remove her contaminated gown and gloves after providing care to Resident #5, left the room and then proceeded to the nurse's station while wearing the same contaminated gown and gloves. Then at 11:30 AM, Staff E went back into Resident #5's room to check on the resident after which Staff E then removed her contaminated gloves and performed hand washing. However, Staff E did not remove her contaminated gown and proceeded to provide direct care to another resident in the unit using the same contaminated gown. During an interview on 11/30/2020 at 11:35 AM, Staff E, LPN, stated that gloves should be removed before and after resident contact and/or after contact with dirty or contaminated surfaces. Staff E stated that her gown should have been removed between each resident. Staff E stated that most resident rooms did not have bins in which to place contaminated gowns, so sometimes staff removed gowns after leaving resident rooms and while in the hallway to dispose the contaminated gown using a bin located close to the unit entrance. An observation on 11/30/2020 at 11:40 AM showed Staff F, Registered Nurse (RN) enter a resident room, and provided care and services to Resident #3, a resident with known/positive COVID-19. Staff F wore full PPE, including an N95 mask, face shield, gown, and gloves. However, Staff F exited the room without removing the contaminated gloves and gown, and no hand hygiene was performed. Staff F continued to work in the unit's common area, including the nurse's station, and hallways wearing the same contaminated gown and gloves. During an observation and interview on 11/30/2020 at 11:45 AM, Staff G, Nursing Assistant Certified (NAC), entered a resident room and provided care and services to Resident #4, a resident with known/positive COVID-19. Staff G was wearing full PPE including an N95 mask, face shield, gown and gloves. However, Staff G exited the room without removing the contaminated gown. Staff G proceeded to walk in the hallway (near the entrance), removed the contaminated gown, and placed it on a bin/linen container. Staff G stated that the contaminated gown and gloves should be removed at each resident room to prevent and minimize the risk spread of infection. However, Staff F stated that most resident rooms in Unit 300 did not have bins or linen containers in which to place contaminated gowns. During an observation and interview on 11/30/2020 at 11:50 AM, Staff H, (NAC), entered a room and provided care to Resident #7, a resident with known/positive COVID-19. Staff H wore full PPE, including an N95 mask, face shield, gown and gloves. However, Staff H exited the room without removing the contaminated gown. Staff H proceeded to walk in the hallway, removed the contaminated gown, and placed it in a linen container. Staff H stated that contaminated gowns should have been removed at each resident's room to prevent and minimize the spread of infection. However, Staff H stated that most resident rooms in Unit 300 did not have containers to place contaminated gowns. During a joint observation on 11/30/2020 at 12:00 noon, Staff I, Infection Control Preventionist (ICP)/LPN, Staff I and the surveyors watched Staff F, LPN, Staff G, NAC, doff their contaminated gowns in the hallway (rather than doffing the contaminated gowns before exiting each resident room). Staff I stated that staff should be wearing clean gowns and gloves when entering each resident room, and should doff (remove) contaminated gloves and gown before leaving the room to prevent and minimize the spread of infection/cross contamination in between residents and staff. Staff I stated that the local public health and county health officials had recommended that staff not wear the same gowns in-between residents and should practice removing contaminated gowns at the door of each resident. During an observation and interview on 12/14/2020 at 11:47 AM, Staff E, LPN was washing her hands after providing care to Resident #3, a resident with known/positive for COVID-19. Staff E washed her hands for the duration of only 7 seconds. When asked why she washed her hands for only 7 seconds, Staff E stated, I was in a hurry, and then stated that she should have washed her hands for 15 seconds and not 7 seconds. UNIT 600 and UNIT 700 An observation on 12/14/2020 at 10:55 AM showed Staff J, Laundry Aide (LA)/HA delivering incontinent supplies (briefs and pull-ups) to the residents of Unit 600 and Unit 700 (2nd floor). Staff J wore an N95 mask that was improperly fitted (visibly oversized with the mask extending down to the lower neck area). Staff J was not wearing a face shield or goggles throughout the observation. Additionally, Staff J entered, delivered the supplies, and exited resident rooms 610, 611, 612, 613, 616, 617 and 618 without performing any hand hygiene in between resident rooms. Staff J also carried the incontinent briefs and supplies by holding the supplies close to her upper body in direct contact with her contaminated clothing/scrubs. The incontinent supply cart remained uncovered throughout the observation. During a joint observation on 12/14/2020 at 11:05 AM with Staff I, ICP/LPN, observation showed Staff J continue to deliver incontinent supplies to the rest of Unit 600 and Unit 700 resident rooms. Staff J carried the incontinent briefs and supplies by holding them close to her upper body in direct contact with her contaminated clothing/scrubs, and left the incontinent supply cart uncovered. Staff J entered and exited the resident rooms without performing any hand hygiene/washing in between. During a joint interview on 12/14/2020 at the time of the observation (11:05 AM) with Staff I, ICP/LPN and Staff J LA/HA, Staff J stated, No one educated her that she should wash her hands before going in/out of resident rooms. Staff J also stated that she was not wearing a face shield because it was hard for her to see. Staff J then showed her face shield that was not long enough to cover the lower part of her face, and stated this face shield had been cut and given to her by her supervisor. Staff J further stated that she should have covered the incontinent supply cart at times when not attended, and she should have held the briefs and clean supplies away from her clothing. Staff I ICP/LPN stated that she would immediately educate and train Staff J about hand hygiene, the importance of wearing a facial covering/face shield and other infection control policies and procedures. During a joint observation and interview on 12/14/2020 at 11:40 AM with Staff I, Staff J, LA/HA was again observed entering and leaving resident rooms without performing hand hygiene and without wearing a face shield. Additionally, Staff J was improperly wearing her N95 mask (nose not covered) when she entered resident rooms and delivered incontinent supplies from rooms 622 up to Unit 700. Staff J carried the clean incontinent briefs and supplies by holding them in direct contact with her contaminated clothing/scrubs. Staff J left the incontinent supply cart uncovered throughout this observation. An N95 mask was observed on the incontinent cart mixed with clean items and incontinent briefs. When asked about the mask, Staff J stated that it was her old mask she wore earlier during the day and she had no explanation on why she did not discard the contaminated mask or why she placed it together with clean incontinent briefs/supplies. During a joint interview on 12/14/2020 at 11:45 AM with Staff I, ICP/LPN and Staff J LA/HA, Staff J stated that it was difficult for her to see and perform her job when she wears a face shield. Staff J also stated that she did not understand why she needed to keep the clean incontinent briefs covered because they will get dirty anyway. Staff J further stated that she should only wash her hands when they are dirty, and not every time she entered and exited a resident room or before and after delivering supplies to the residents. Staff J was unable to provide an answer as to why her N95 mask was not covering her nose at the time of the observation. ENVIRONMENT/UNSANITARY CONDITIONS During a joint observation and interview on 11/30/2020 at 11:15 AM with Staff D, HA, Staff E, LPN, and Staff F, RN, piles of garbage bags (eight to ten bags) filled with potentially contaminated wastes/items and trash from the COVID-19 unit were lying on the floor in front of and next to the Unit 300 entrance/exit doors (just outside the unit). Several garbage bags were not secured and leaking a dark/yellowish substance and was dripping on the floor. Observed items that were not secured and contained within the bags included, soiled and used gloves and masks, soiled and used incontinent briefs-some with yellowish-brownish semi-solid substance leaking from them, food wastes, and trash from the residents on the COVID-19 unit (Unit 300). All these potentially contaminated items were intermixed right next to and/or in between clean items (clean linens that were uncovered, clean rolls of plastic bags, and other housekeeping supplies), food trays, and other personal items used by the resident in the unit, such as a personal wheelchair. Staff D, HA, Staff E, LPN, and Staff F, RN all stated that the facility management gave them instructions to just leave the garbage bags outside the unit, close to the Unit 300 entrance/exit doors, and that maintenance or other housekeeping staff would then collect and remove the garbage from the facility. Staff D HA, Staff E LPN, and Staff F RN all stated that the process for garbage collection and removal for unit 300 was unsanitary and a serious health concern to both residents and staff due to the environmental risk hazards of leaking garbage bags, and having clean items next to soiled items/garbage, and that it presented a risk to the health and well-being of everyone in the facility. Staff D then tied and secured some of the garbage bags and placed them at the housekeeping carts. During a joint observation and interview on 11/30/2020 at 12:05 PM, with Staff I, ICP/LPN, Staff I observed the piles of garbage bags and trash filled with potentially contaminated wastes/items and trash from the COVID-19 unit intermixed with clean items (clean linens that were uncovered, clean rolls of plastic bags, and other housekeeping supplies), food trays, and other personal items used by the resident in the unit, such as a resident's personal wheelchair. Staff I stated that she was not sure why there was a pile of garbage at the entrance/exit doors of the COVID-19 unit and why they were mixed together with clean linens and items. Staff I stated that this situation was embarrassing and she would immediately address the concern. During a telephone interview and meeting on 11/30/2020 t 4:50 PM, the facility's Chief Executive Officer (CEO) and Staff I, ICP/LPN were informed of the findings and concerns related to infection control as detailed above. Staff I stated that the facility would immediately educate and train staff related to infection prevention and control program, standards of practice including the areas of hand washing/hygiene, donning and doffing of PPE's, following the required transmission based precautions and reviewing/revising of the procedures in securing trash, garbage and other potentially contaminated materials/items from the COVID-19 unit. As of 11/30/2020, the facility had a total of 30 positive cases of COVID-19 for residents (all facility- acquired) with eight COVID-19 related resident deaths, and 35 staff members with positive test results for COVID-19. On 12/04/2020, the facility reported four (4) new cases of COVID-19 for residents (all facility acquired) and 5 additional staff members tested positive for COVID-19. (Testing conducted on 12/01/20). Reference: (WAC) 388-97-1320 (1)(a)(c)(2)(a)(3)(4)

Based on observation, interview and record review, the facility failed to consistently and timely implement their abuse/neglect policy and procedures during the provision of care and services by not identifying and protecting one of five Residents (#1) from abuse/neglect. Failure to identify potential abuse, intervene, and protect Resident #1, resulted in psychological harm. Findings included . The facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition, revised date of (MONTH) 2019, showed that each resident has the right to be free from verbal, sexual, physical, and mental abuse, .each resident also has the right to be free from mistreatment, and neglect. The facility's definition of verbal abuse: the use of oral, written or gestured language that includes disparaging and derogatory terms to resident or families, .examples of verbal abuse include, but not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The facility's policy under protection showed that necessary steps will be taken immediately to protect resident(s) from further abuse and/or neglect while that investigation is in process. When there is reason to suspect or believe abuse/neglect has occurred, the involved employee(s) should be sent home pending outcome of the investigation and or removed from the patient areas. The facility's policy form, Abuse Prohibition Policy Notification & Acknowledgement, dated (MONTH) (YEAR), showed that employees are oriented and educated on the facility's policies, processes, and reporting requirements. The form showed the alleged violation involving mistreatment, neglect, or abuse, . are reported immediately to the Administrator, Director of Nursing and to other officials in accordance with Federal and State law. RESIDENT #1 During an interview on 01/14/2020 from 11:15 a.m. to 11:43 a.m., Resident #1 stated that she had asked a staff member, a nursing assistant, (NAC A) to adjust her pillow under her knee to alleviate pain after knee surgery as she was having extreme pain in her knee. Resident #1 stated that NAC A would not adjust her pillow and NAC A just got mad at her, lectured and screamed at me. Resident #1 stated that NAC A treated her as if she was not important and refused to take me to the bathroom. Resident #1 stated that she experienced urinary incontinence due to not being assisted to the bathroom, and when NAC A refused to adjust my pillows, I suffered in pain, and stated that positioning the pillow under the leg/knee would have helped relieve the pain. Resident #1 stated that she had informed staff regarding NAC A being very abusive verbally and that she felt vulnerable, when NAC A stood over her, and felt afraid of her. Resident #1 stated that even though she had previously informed facility staff about NAC A's attitude, she again informed staff during a care conference on 01/02/2020 that NAC A would not do anything and would not listen and her attitude was so different. Resident #1 stated that you know when you're on the receiving end when staff were not doing what was asked of them. The facility's investigative report, dated 01/02/2020, showed that Resident #1 had reported that NAC A, a night shift staff, had yelled at her and was mean. Resident #1 informed the facility that NAC A had told her to 'do it herself' when Resident #1 had asked her to move pillows, and that NAC A told Resident #1 that she could not check on her every 5 minutes. The report showed that during the care conference on 01/02/2020, Resident #1 started to cry and informed staff that NAC A isn't very nice. The facility's investigation report showed that a night shift licensed nurse's (LN B) written statement for 01/02/2020 showed that NAC A was not being kind to resident and that another NAC had reported that NAC A was not talking well to residents. LN B's statement showed that she had spoken to NAC A, but had not recognized the incident as possible abuse toward the resident. Another staff's written statement, dated 01/03/20, showed that NAC C had noticed NAC A being rude and not very friendly with a patient, so NAC C helped Resident #1 and notified LN B. The facility's analysis/conclusion of the investigation showed that the night shift NAC (C) had reported to the LN (B) that NAC A was being unfriendly and rude to a resident.' The conclusion showed that Resident #1 was a credible witness, and that during a care conference on 01/02/2020 Resident #1 told staff that NAC A had yelled at her. The report showed that Resident #1 was distressed over NAC A's behavior; and showed that the type of injury that was checked on the report was 'psychological harm.' The facility's report showed that, based on Resident #1's interview, that NAC A refused to reposition the resident as requested, and that her co-workers considered NAC A's behavior as being rude. NAC A was terminated and the facility documentation showed that the allegation of verbal abuse/neglect to be substantiated. During an interview with NAC F, a night shift NAC on 02/07/20 at 5:00 a.m., when asked what abuse was, NAC F stated that abuse may include hitting a resident to be physical abuse and that mental abuse would be when a staff member refused to provide care, something a resident asks for and staff tell the resident that they can't have it. When asked what action would be taken if she observed physical and mental abuse, NAC F stated that she would tell the LN, talk to the NAC, supervisor, and Director of Nursing (DNS) . Additionally, NAC F stated that if it was really abuse, call state immediately and DNS. During an interview with NAC D, a night shift NAC on 02/07/20 at 5:45 a.m., she stated that neglect involved not providing care to a resident and that emotional or spiritual abuse would be when a staff member was rude to a resident, such as not going to change them or screaming at a resident. During an interview with LN E, a registered nurse, on 01/14/2020 at 11:13 a.m., she stated that if a NAC was rough with a resident, she would switch the NAC to a different section and talk to the NAC about the rough handling as the NAC may have just held on too strong and don't realize, and resident surprised by it. During an interview on 02/07/2020 at 5:20 a.m., NAC C stated that Resident #1 was very angry about NAC A not adjusting her pillows and that NAC A was rude. NAC C stated that she informed the night shift nurse (LN B) and told NAC A not to go back to Resident #1. During an interview with LN B on 02/07/2020 at 5:10 a.m., she stated that NAC A had been harsh with Resident #1 and during that shift she had spoken with NAC A and informed her that she had to be kind to residents. LN B stated that even though she was aware of NAC A's behavior toward Resident #1, NAC A completed the full shift and that she (LN B) had not initiated an incident report. When asked LN B about abuse, she stated that abuse may occur when a resident does not receive care, and that all residents' wishes should be respected. LN B stated that if one becomes aware of abuse, the allegation needs to be reported immediately. When asked if she had spoken to Resident #1 about NAC A's behaviors, LN B stated that she had not spoken to Resident #1. During an interview with the Director of Nursing (DNS) on 01/14/2020 at 3:25 p.m., she stated that NAC A was terminated, and that Resident #1 was alert and was accurate to report the verbal abuse of NAC A telling the resident that she could not keep coming back. The DNS stated that the facility had concluded that neglect of care for Resident #1 was clear and simple. Reference: (WAC) 388-97-0640 (2)(a)(b)

Based on interview and record review, the facility failed to ensure all residents were free from sexual abuse. Failure to ensure one of three residents (Resident #1) remained free from sexual abuse resulted in Resident #1 reporting to law enforcement incidents of sexual abuse while at a nursing home and providing videos of the reported sexual abuse by a facility caregiver during provision of personal care, and the resident being sent by law enforcement to a hospital to be evaluated for sexual abuse. Findings included . Review of the facility's policy titled, Abuse Prevention Policy and Procedure dated revised (MONTH) 2019, showed that each resident had the right to be free from verbal, sexual, physical, and mental abuse. The facility implemented policies and procedures so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents. The facility policy's definition of sexual abuse included but not limited to, unwanted or inappropriate touching, sexual harassment, sexual coercion, sexually explicit photographing, and sexual assault. The policy showed Reasonable cause to Believe: A mandated reporter thinks it is probable that an incident of abuse, abandonment, neglect, or financial exploitation happened. Probable means that based on information or evidence readily obtained from various sources, it is likely the incident occurred. RESIDENT 1 Resident 1 was admitted to the facility 09/10/2018 with a [MEDICAL CONDITION] disease. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident 1 was cognitively intact and required two person assistance with toileting and one person assistance with hygiene. The MDS showed that Resident 1 used a wheelchair for mobility. During an interview on 07/03/2019 at approximately 9:50 A.M., the Director of Nursing (DNS) and facility Administrator stated that on the evening of 07/02/2019, law enforcement had shown up at the facility and informed Licensed Nurse (LN A), a licensed practical nurse, that inappropriate touching had happened with Resident 1. Law enforcement had informed LN A that they had pictures of a facility staff (NA) regarding inappropriateness with Resident 1. The administrator stated that on 07/02/2019 at approximately 6:10 PM, LN A called her to report that law enforcement had visited the facility regarding inappropriate touching. The administrator stated that she had directed LN A to call the allegation into the state hot line and to start interviewing other residents. The administrator and DNS stated that law enforcement had informed LN A that a family member had installed a camera in Resident 1's room. During an interview on 07/03/2019 at 12:55 PM, LN A stated that on 7/2/19 at approximately 6:00 - 6:30 PM, law enforcement came to the facility. LN A stated that law enforcement informed her that a crime had been committed against Resident 1 by a staff member and that the incident was sexual in nature. Law enforcement also informed LN A that Resident 1 did not feel safe at the facility and would not be returning to the facility. Law enforcement showed LN A a photo which she then identified the person as being a nursing assistant (NAC B) who worked at the facility. LN A stated she then notified both the Administrator and DNS informing them that law enforcement had come to the facility regarding Resident 1 being sexually assaulted by NAC B. During a telephone interview with law enforcement on 07/03/2019 at 11:54 AM, she stated that law enforcement would be taking NAC B into custody today. During a telephone interview with law enforcement on 08/06/2019 at 11:50 AM, she stated that the resident's family member had provided the videos to law enforcement, several of which were criminal in nature. According to a law enforcement report, Offense Report form dated 07/02/2019, showed that Resident 1 was being sexually assaulted and suspect is known. Review of the online King County Correctional Facility (jail) documentation, dated 07/03/19, showed that NAC B was booked and charged with a sexual crime. Reference WAC 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to provide effective monitoring and supervision, and failed to implement adequate fall interventions to prevent Resident (97) from future falls, after the resident fell face forward after falling asleep in her wheelchair and sustained a head injury. This failure placed the resident at risk for falls with serious injuries or death, thus resulting in an immediate jeopardy (IJ) that was called on 12/06/18. This is a repeat citation from 8/20/18. Findings included: Resident 97 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Minimum (MDS) data set [DATE], the resident scored a 6 on the Brief Interview for Mental Status and was able to make her immediate needs known, but was otherwise had some confusion. Hospital records dated 01/15/18 showed the resident was found down, unresponsive after a syncopal (loss of consciousness) episode. A facility fall risk assessment reviewed dated 10/25/18 identified the resident as a high risk for falls. Review of the facility 's fall policy titled, Fall Reduction Guidelines dated 12/2011 showed the following: 1. History of falls prior to or during hospitalization shall be documented on the care plan. 2. Implement fall reduction guidelines as determined by the resident's assessed needs. 3. Refer to therapy, restorative program as appropriate for strengthening or other activities to improve or maintain activity and ambulation levels. Review of nursing progress notes dated 11/24/18 showed at 8:40 AM, stated Resident fell asleep in the dining room in her wheelchair(W/C) during meal time. The note stated the resident fell out of her wheelchair, hitting her forehead causing a bruise to her forehead 4 cm(centimeter) in length, 3 cm width, and ½ inch deep with 3 cm on side forehead. The note stated staff tried to catch the resident before the fall, but staff could not get to her in time. A progress note dated 11/25/18 showed the resident's forehead was very swollen and full of blood. The note also showed the resident had bilateral black eyes as the blood was making its way down her face. A progress note dated 11/26/18 showed the resident had a hematoma around both eyes (raccoon eyes), the nurse practitioner was called and ordered the resident to be sent to the emergency room for evaluation. The progress note did not state any possible causes for the fall or any immediate interventions placed to prevent another fall occurrence. Review of the facility investigation dated 11/24/18, showed the resident was assesed to have 5-10 pain level, non verbal sounds such as crying, moaning, gasping and facial expressions, such as grimacing or furrowed brows. The investigation showed the care plan was followed, but rehab was not notified as directed by the facility policy. The investigation showed actions taken were first aid and Other specified by progress notes. The facility investigation did not include a conclusion or summary to show possible causes or any immediate interventions in place to prevent another fall occurance. Review of the resident care plan, initiated on 01/30/18, identified the resident as a high risk for falls related to confusion, gait/ balance problems, incontinence, poor communication/comprehension and was unaware of safety needs. A revision to the care plan was made on 11/27/18, 3 days after the fall, which stated the resident fell asleep while sitting in wheelchair, fell forward to the floor, sustained bruise to forehead, and it was witnessed by an NAC(nursing assistant). The Goals, revised on 03/28/18, stated the resident will be free of falls. Interventions listed on the care plan were as follows: 1. Call light within reach and encourage her to use it for assistance as needed. 2. Anticipate her needs 3. Encourage her to participate in activities 4. Ensure that she is wearing appropriate footwear when ambulating or mobilizing in wheelchair. 5. Follow facility fall protocol. 6. PT (physical therapy) evaluate and treat as ordered or PRN 7. Offer naps between meals (initiated on 11/27/18, 3 days after fall) and frequent check and observation (Initiated on 01/22/2018) The safety careplan initiated on 01/22/18 included the goal Prevent falls and interventions included: 1. Offer naps between meals (updated on 11/27/18, 3 days after fall) 2. Frequent check and observation. The care plan did not include any other updated interventions to the address the resident's most recent fall. However, an interview with the Resident Care Manager (RCM) mentioned later on in this report, revealed a referral (dated 11/28/18) was made 4 days after the fall, to the Occupational Therapy (OT) department to evaluate the resident's current wheelchair positioning due to her falling forward out of wheelchair. Review of the OT Evaluation and Plan of Treatment showed the resident was evaluated by OT on 12/04/18, 11 days after fall. The evaluation concluded and stated: Patient had recent fall forward out of W/C when she fell asleep in chair. Current w/c noted to meet needs for height and width, but seat is not quite deep enough to fully support her. Also recommended that patient return to bed when fatigued; staff should make every effort to not allow her to sleep in w/c. If patient attempts to sleep in w/c, she would need to be refitted with a drop seat chair. In an observation on 12/04/18 at 1:22 PM, the resident was seen wandering in hallway unsupervised around the 1st floor dining room. Resident seemed confused and was asking, Where am I supposed to be? Other observations made between 12/4/18 -12/06/18 were as follows: 6 episodes at various times of the day, the resident was observed sleeping with head slumped forward in her wheelchair unsupervised or no staff present; and 7 episodes of the resident either wandering in her wheelchair or up alone in dining room. An observation made on 12/06/18 at 10:36 AM, from the hallway looking into the resident's bathroom, the resident was seen sitting on toilet commode. The resident stood up leaning face forward to wipe herself, pulled up her pants without holding on to anything, she then pushed the wheelchair that was positioned at the door out into the room, struggled to reposition the chair to push it to her bed. Parked the chair by her bed and started rearranging the pillows standing up. No staff was present to assist the resident during the observation. In an interview on 12/04/18 at 10:18 AM, the resident stated she recently fell out of her wheelchair face forward, hit her face on the ground. She stated she felt dizzy, light headed immediately after the fall. Observation of the resident's face showed she was bruised from her forehead all the down to her cheeks bilaterally. In an interview on 12/06/18 at 11:11 AM, Staff EE, Nursing Assistant (NA) stated the resident frequently used the bathroom by herself although she was a one person assist. Staff EE stated she tried to watch the resident as much as possible whenever she could but it was not always possible. She stated when the resident fell and hit her head on the ground, it was a very loud thud and stated she feared the worst for the resident. She stated she actually saw the resident slump forward, but by the time she got to the resident it was too late. In an interview on 12/06/18 at 12:24 PM, Staff FF, Resident Care Manager (RCM) stated the resident was confused and has always been confused. She stated the resident fell asleep in her chair at the time of the fall which happened frequently. When asked what was different with this fall she stated, I'm not sure. She stated interventions in place was a referral to OT for a wheelchair assessment to see if a chair that leaned back would be more appropriate for the resident. She stated the assessment was still in progress, otherwise they were offering naps and checking on the resident. She stated the resident spent a lot of time in the dining room where staff could keep watch. She also stated there were no other interventions. She stated the staff were not documenting the visual checks. She stated the resident went to bathroom on her own, but when asked if the resident was supposed to Staff FF said, No. She also stated she would have to consult the Interdisciplinary team (IDT) to determine if the resident was safe from the same thing happening again. Staff FF stated the care plan interventions were adequate to keep the resident safe. In an interview on 12/06/18 at 02:25 PM, Staff II, Therapy Director, was asked to state how she conducted a wheelchair assessment. She stated she first checked the nurse's notes to find out why it was needed. She then would check the resident in the chair to see how the resident fit as well as functions in the chair. She stated the assessment took a couple days or weeks if she had to order the chair. She stated when the assessment was completed, she stated she did an OT plan of care that was given to the nurses. In the resident's case, she stated she ordered a chair for the resident and was waiting for the chair to fit the resident in. Staff gave the surveyor a copy of the referral. Staff II stated results of the wheelchair assessment showed the resident's current wheelchair was not deep enough and if she fell asleep in it she could potentially fall again. She stated she had ordered a Bentley (wheel)chair which had a drop seat that would help keep the resident's knees higher than her torso and prevent falls if she fell asleep in it. In an interview on 12/06/18 at 03:27 PM, a surveyor passed by the resident's room to find the resident sitting in her wheelchair sleeping with her head slumped over. There was no staff available and surveyor waved to the administrator to come and see the resident's position. The administrator and Staff FF RCM came to find the resident sleeping in her wheelchair apparently the same way she was when she had initially fallen. Surveyor brought up the concerns regarding the resident's safety to the RCM and administrator who stated they were aware and agreed the resident was in a position where she could fall out of her wheelchair. The Administrator stated What would you suggest we do? Surveyor stated that the facility would need to decide how they were going to keep the resident safe if she fell asleep while waiting for the wheelchair. On 12/06/18 at 03:55 PM IJ concerns were communicated to the administrator and DNS related to F-689 risk for accidents for falls. She stated the new chair was just implemented before they were notified of the IJ. It was communicated a verbal removal was needed with a written to be provided the next day. Administrator stated a verbal removal was to have the resident in the new chair and update the care plan. It was decided and communicated by administrator to the surveyor that 30 minute checks of the resident would be done and documented for a week until the wheelchair assessment, done by OT, was completed to determine if the new chair was effective for the resident. In an observation on 12/07/18 at 08:51 AM, the resident was observed sitting in her new wheelchair, which looked upon observation was slightly scratched on the back wheelchair handle and looked as if it was used. In a follow up interview at 9:48 AM, the surveyor requested a receipt or invoice for the new chair. Staff II stated there was no invoice or receipt for the chair, since it was already part of their in house stock. When she was asked why there was a delay in the resident getting the wheelchair sooner, she stated I am the PT/OT director and sometimes the only OT person and the referral was not a priority and I just didn't get to it. Staff II stated the administrator had said that from now on, all fall referrals should be made a priority. In an interview on 12/13/18 at 10:14 AM, the surveyor spoke to the DNS who stated she needed clarification on the events around the IJ. The IJ protocol was explained to the DNS and based on the interviews from the Staff II, she stated she understood the reasoning behind the IJ concern. She stated she also understood where, what or when the immediacy was for the resident's safety and preventing a fall with serious outcomes given the facts presented by the survey team. Summary Given the nature of the Resident 97's fall and injury, the facility failed to immediately identify any changes with the resident's condition or physical state to prevent future falls of this nature. The facility investigation did not include a summary or conclusion to what may have contributed to the resident's fall or immediate interventions to prevent another fall occurance. It was documented and stated by staff members the resident fell out of her wheelchair face forward in the dining room after she had fallen asleep in the wheelchair during a meal service. There were staff members present in the dining room when the fall occurred, however staff could not get to her in time. A referral was made to OT for a wheelchair assessment, submitted 4 days after the fall; OT identified the resident as needing a special wheelchair, and had made the recommendation for nursing staff not to allow the resident to fall asleep in her wheelchair. Staff II had stated in an interveiw the resident was at risk for a fall without the special wheelchair. According to the Therapy Director, the wheelchair assessment should have only taken 2 days, but was not made a priority and therefore ended up taking 2 weeks after the fall to be completed. The facility failed to provide effective monitoring and supervision, and failed to implement adequate fall interventions to prevent Resident 97 from future falls, after the resident fell face forward after falling asleep in her wheelchair and sustained a head injury. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to comprehensively assess and ensure 5 of 6 residents (146, 21, 86, 48 and 3) received appropriate care and services necessary to maintain, improve and/or avoid loss of bowel and bladder functions. These failures caused harm to Resident 146, 21, 48, 86 and 3 who suffered harm in the form of anger, self-humiliation and had contributed to the development of skin breakdowns, bladder infections and pain. The facility's failure to have a written policy and procedures related to bowel and bladder assessments and lack of written directive to staff placed all 150 residents of the facility at risk for harm and diminished quality of life. Findings included: RESIDENT 146 Resident 146 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition and needed 1 person assistance with activities of daily living including toileting needs. The resident was identified to be continent of bowel. The MDS showed the resident was incontinent of bladder and was not on a scheduled toileting program/no trial of a toileting program had been attempted since admission or since urinary incontinence was noted in the facility. Review of the resident's re-admission assessment dated [DATE], showed the resident was continent of bowel and bladder. Review of the resident's bladder pattern from 11/16/18 to 12/03/18, showed the resident was occasionally incontinent of bladder. The resident had continent episodes on 11/16/18, 11/17/18, and from 11/22/18 to 12/02/18. Review of the resident's bowel care plan created and initiated on 08/22/18 and recently revised on 11/15/18, showed the resident had bowel incontinence. The resident had no plan of care specific to address the resident's bladder incontinence. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) In an interview on 12/04/18 at 10:09 AM, the resident stated, I can still feel the urge to urinate and have a bowel movement. They just need to get to me on time. According to the resident, she had a few Urinary Tract Infections (UTI's) in the past. The resident stated, she had one before coming to the facility and had another one that she developed here in the facility because she had to sit in urine and bowel movement for a long time. The resident further stated, and the hygiene too. No showers for 3 weeks, can you imagine? (Refer to F561 - Self Determination for more information.) During an interview and record review on 12/06/18 at 10:15 AM with Staff O, Registered Nurse/Admissions Nurse, (RN/Admissions), stated, the resident was readmitted to the facility as continent of bowel and bladder. Staff O stated, the resident was not on a specific toileting program/not on a restorative program currently, and had no trial/attempt was made since admission to either regain and/or maintain the resident's bowel and bladder functions. Staff O further stated, the resident's clinical records, showed no evidence of any comprehensive assessment/plan of care that identify the resident's type of incontinence or the possible root cause/origin of the resident's incontinence. During a joint interview on 12/06/18 at 11:01 AM with the resident and Staff O, RN/Admissions, the resident stated, she had to wait a long time to get help when she needed to go to the bathroom and would have accidents in bed and have to sit on her own urine. The resident stated, No staff member had offered to toilet her and she was not on a specific program to address her toileting needs. According to the resident, she felt It's like being a child. It is embarrassing and humiliating. The resident further stated, she had UTI's in the past and it may have been related to her incontinence. During a joint record review and interview on 12/06/18 at 11:09 AM with Staff O, RN/Admissions, stated, the resident was hosptalized on [DATE] and re-admitted to the facility on [DATE]. Review of the hospital record dated 11/15/18, showed the resident's discharge [DIAGNOSES REDACTED]. Review of the hospital's Discharge summary report documented, the resident was admitted with complicated UTI and was treated with antibiotics. Recurrent bacteruria (presence of bacteria in urine)/[DIAGNOSES REDACTED] Variicola (a type of bacteria) UTI . concerning for [MEDICAL CONDITION], due to persistent repeated UTI's . Urine culture 10/30 [DIAGNOSES REDACTED] Variicola grew again (third time this month) though now a FQ (Fluoroquinolone - a type of antibiotic) resistant bug . Review of the resident's clinical records, showed no specific care plan for UTI/history and increase risk of acquiring UTI's and/or specific bowel and bladder and toileting needs. In an interview on 12/06/18 at 11:13 AM with Staff R, Nursing Assistant, (NA), and Staff MM, NA, each staff member stated, the resident was not on a specific toileting program/not on a restorative program to either regain and/or maintain the resident's bowel and bladder functions. In a follow-up interview on 12/06/18 at 11:35 AM, the resident stated, she felt really bad about having to go in her brief. The resident further stated, she wasn't safe to go alone in the bathroom but she had no choice because she would either had an accident in bed or go to the toilet and risk having a fall. RESIDENT 21 Resident 21 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident had intact cognition and needed one person assistance with bed mobility, transfers and toilet use. The MDS showed the resident was incontinent of bowel and bladder and was not on a scheduled toileting program/no trial of a toileting program had been attempted since admission or since urinary incontinence was noted in the facility. Review of the Nursing Admission assessment dated [DATE], showed the resident showed the resident was continent of bowel and bladder. Review of the resident's bladder pattern from 11/04/18 to 12/03/18, showed the resident was occasionally incontinent of bladder. The resident had incontinent episodes on 11/05/18, 11/06/18, 11/08/18, 11/17/18, 11/21/18, 11/24/18, 11/26/18 and 11/27/18. Review of the resident's bowel pattern from 11/04/18 to 12/03/18, showed the resident was occasionally incontinent of bowel. The resident had incontinent episodes on 11/05/18 and 11/24/18. Review of the resident's bowel and bladder care plan created and initiated on 08/31/18 (11 days after admission) and revised on 09/19/18, showed the resident was occasionally incontinent of bladder r/t (related to) impaired mobility. The resident had no plan of care specific to address the resident's bowel incontinence. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) In an interview on 12/03/18 at 3:06 PM, the resident stated I am continent. The resident also stated, she was able to feel the urge on when to urinate and when to go to the bathroom. However, according to the resident, but since they cannot get to you on time, I guess I become incontinent. The resident added, This happened mostly at night because there's nobody to come and help you. The resident further stated, It was embarrassing. They just need to help me timely. I felt really bad. During an interview and observation on 12/05/18 at 10:13 AM, the resident stated, she had to change her brief. The resident had incontinent of urine present. During an interview and record review on 12/05/18 at approximately 10:15 AM with Staff O, RN/Admissions, stated, the resident had no recent comprehensive bowel and bladder assessment and plan of care completed in the clinical record. Staff O stated, the only bowel and bladder assessment in the clinical record was the one she completed on admission. According to Staff O, there should be another nursing assessment, bowel and bladder assessment this quarter. Staff O further stated, the resident specific toileting needs was not specified on the plan of care and the resident was not on a scheduled toileting plan or schedule. During an interview and record review on 12/05/18 at 3:28 PM with Staff P, Resident Care Manager/Registered Nurse, (RCM/RN), stated, the resident was on a scheduled toileting program. Staff P added, the resident's care plan showed she's incontinent of bowel and bladder. Staff P further stated, there was no specific assessment for bowel and bladder on the clinical record and not comprehensive, just NAC's (nursing assistant certified) charting every shift. In an interview on 12/06/18 at 8:46 AM with Staff Q, NA, stated the resident was not on a scheduled toileting program. She is mostly continent. She is continent during my shift. Staff Q also stated, She would ask for brief at times to change but she's usually doing it herself. I don't help her to the toilet. In an interview on 12/06/18 at 8:51 AM with Staff R, NA/shower aide, stated, the resident was not on a scheduled toileting program. Staff R further stated, the resident was usually continent and was able to toilet self independently. During an interview and record review on 12/06/18 at 8:55 AM with Staff S, NA, stated, the resident was not on a scheduled toileting program. She is usually able to do it herself. During an interview and record review on 12/06/18 at 9:02 AM with Staff P, RCM/RN, stated, I don't think we have specific assessments for bowel and bladder. Staff P added, the bowel and bladder assessments could have been incorporated in other assessments like Braden. Staff P added, staff should have followed up on and reviewed the resident incontinent episodes to identify what the cause of the problem. Staff P further stated, she understood the problem of not having an up to date assessment, no follow-up on regarding the resident's incontinent episodes and for not having a specific person centered care plan to meet the resident needs. According to Staff P, she would feel embarrassed if she was in the resident's situation of having incontinent episodes and the resident would have felt the same. In an interview on 12/06/18 at 9:58 AM, the resident stated, as humiliating as it is sitting on your own waste as an adult is never acceptable and I'd never imagine I would experience such bad care like this in my life. The resident was tearful during the interview and added, It was hard to be with people knowing you don't smell good or smell of urine. In a follow-up interview on the same day at 10:17 AM, the resident stated, the staff do not offer to toilet her and would simply asked her if she had a bowel movement or if she was incontinent of bowel or urine, so I would just answer them no to not embarrass herself. The resident further stated, Staff would ask this question in the dining room for example so what should I say? I told them no. RESIDENT 86 Resident 86 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident had impaired cognition and needed 2 person assistance with bed mobility and transfers. The MDS showed the resident was incontinent of bowel and bladder and was not on a scheduled toileting program/no trial of a toileting program had been attempted since admission or since urinary incontinence was noted in the facility. Review of the nursing admission assessment dated [DATE], showed the resident was incontinent of bowel and bladder. Review of the bowel and bladder care plan initiated on 07/16/18 and revised on 07/27/18, showed the resident has Bowel and Bladder Incontinence. The care plan was due for a review and was missing specific information on what type of incontinence the resident has. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the resident's skin care plan initiated on 07/16/18 and revised on 10/25/18, showed the resident developed an open area on left buttocks on 08/30/18. The care plan stated, the resident was at high risk for skin breakdown related to stroke and immobility and due to incontinence of bowel and bladder. (Refer to F686 Treatment/Services to Prevent/Heal Pressure Ulcers for more information.) During an interview and observation on 12/03/18 at 9:39 AM with Staff D, RN, the resident stated she had been sitting on her own waste (bowel and urine) since about 8:00 AM and the staff just keep telling her they're coming. According to the resident, this happened every day and she feels like a baby, helpless and waiting for somebody to care for her. The resident was visibly upset (cursing and speaking loudly) but later apologized to the surveyor and explained that her anger is out of frustration. The resident further stated, the longest time she had to wait was for few hours, 2-3 hours to get help and since she had a bowel movement, she can't wait any longer. In an interview on 12/03/18 at 2:12 PM, the resident stated, her bottom hurts big time . I sit in urine and bowel movement for a long time. The resident added, I don't like lying on my own piss. It happened all the time. The resident further stated, I still feel the urge when to piss but they took a long time to get to you. According to the resident, I'm [AGE] year old, it made me really feel bad. I'm not a baby. The resident stated, If I have a choice, I can use the bed pan or the toilet. The staff just keeps telling you to go on your brief. Not good. The resident also stated, I don't take no bull . to anybody. I called them out on it. But even with that, they still don't come on time. Makes me feel angry and like a baby. During an interview and observation on 12/04/18 at 9:36 AM, the resident was heard screaming and calling out pain. The resident was cursing and stated, the staff had not changed her for about an hour now. According to the resident, she was changed early in the morning when the new shift came early morning around 6ish but she had a bowel movement around 7:00 AM and since then, she had been calling for staff to change her but they are busy and need to deliver the meals first. The resident stated, That's bull . That's why I'm upset and mad. That's why I cursed. They know I don't take bull The resident further stated, she was angry about the staff and her situation and she don't like the feeling of a baby[***]ing and sitting on her own waste for a long time. A bowel movement odor was present during the interview. During an interview and observation on 12/11/18 at 9:48 AM, the resident stated she needed to be changed and was sitting on her own[***]again. According to the resident, the staff cannot toilet her because she needed 2 people most of the time. The resident said, there was only one staff here so they had to wait for another person to come and help her. By the time they get to you, it's already too late. The resident further stated, I can sense it. I just need them to get here on time. In an interview on 12/11/18 at 2:22 PM with Staff OO, RN, stated, the resident was incontinent of bowel and bladder and not on a scheduled toileting program. Not sure about the specific toileting needs but staff would change her in bed. In an interview on 12/11/18 at 2:31 PM with Staff PP, NA, stated, the resident was incontinent of bowel and bladder and not on a scheduled toileting program. Staff PP stated, they do not offer bed pan or any toileting equipment we change her in bed. During an interview and record review on 12/10/18 at 10:24 AM with Staff E, RCM/RN, stated, the resident was not on a scheduled toileting program and no trial of a toileting program was initiated or attempted since admission to the facility to either regain or maintain/improve the resident's incontinence. Staff E added, the resident's clinical record showed no recent bowel and bladder assessment. Staff E also stated, the resident's care plan was due for a review, not person centered and does not specify the resident's type of incontinence and specific toileting needs. Review of the resident's clinical records, showed no evidence of a comprehensive bowel and bladder assessment completed since admission to the facility on [DATE]. The only bowel and bladder assessment in the clinical record was from admission and it was missing specific information regarding the type of incontinence the resident had and failed to identify if the resident's incontinence was reversible or irreversible. RESIDENT 48 Resident 48 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had mild cognitive impairment and needed 1 person assistance with transfers, toilet use, personal hygiene and 2 person assistance with bed mobility and bathing. Review of the resident's most recent bowel and bladder assessment (periodic care review) dated 09/08/17, showed the resident was frequently incontinent of bowel and bladder and the resident was able to express her toileting needs when she is awake. The clinical records showed no other comprehensive assessment specific for the resident's bowel and bladder/current toileting needs. Review of the bowel and bladder care plan initiated on 05/23/13 and revised on 07/02/13, showed the resident had Deficit in toileting related to impaired mobility, pain, side effects of pain medication secondary to late effect of [MEDICAL CONDITION]. The care plan was due for a review and was missing specific information on what type of incontinence the resident has and showed conflicting information on how much assistance the resident needed to complete the task. The most recent interventions for the care plan were reviewed and revised on 09/14/17. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the resident's bowel and bladder pattern from 11/05/18 to 12/03/18, showed the resident was occasionally incontinent of bowel and bladder. During an interview and observation on 12/04/18 at 1:42 PM, the resident stated, the staff would tell her to just go to her brief. According to the resident, she would have accidents because she cannot get the help she needed to go to the bathroom. The resident further stated, staff do not offer to toilet her and only change her instead. It's embarrassing. I have hemorrhoids and it is very painful. Everything hurts, my back and my legs. The resident was crying and tearful/screaming of pain. The resident had incontinent of bowel and urine odor present during the interview. (Refer to F697 - Pain Management for more information.) In an interview on 12/06/18 at 3:33 PM with Staff A, NA, stated the resident was sometimes continent of bowel and bladder and not on a toileting program. Staff A further stated, the resident would call for staff sometimes but she's already wet. She uses brief. In an interview on 12/10/18 at 2:53 PM with Staff B, NA, stated the resident was sometimes continent of bowel and bladder and not on a toileting program. In an interview on 12/10/18 at 2:56 PM with Staff C, NA, stated the resident usually cries and scream of pain related to her hemorrhoids. Staff C added, since she knew the resident, she would be crying and from time to time scream related to pain. When I provide care to her, she would hold my hand and tell me, please stay and don't leave me. During a joint skin inspection on 12/11/18 at 1:58 PM with Staff D, RN, stated, the resident was incontinent of bowel and bladder and currently not on a toileting program. The resident was observed with severe hemorrhoid, measured at approximately 4 centimeter (cm) in length and 4cm wide by Staff D, covering the anus. The resident was also observed with dark black, ashen gray colored [MEDICAL CONDITION] to the groin area extending to the pubis and to the labia. The resident was grimacing and complained of severe pain and sore on the above areas throughout the inspection process. (Refer to F684 - Quality of Care for more information.) During an interview and record review on 12/12/18 at 1:38 PM with Staff E, Resident Care Manager, (RCM/RN), stated the resident had no recent bowel and bladder assessment in the clinical record. Staff E stated the resident was occasionally incontinent of bowel and bladder and currently not on a toileting program. Staff E further stated, the resident's care plan did not have the specific information of what type of incontinence the resident has and the most recent quarterly review only included a statement that documented, the resident had B/B (bowel and bladder) incontinent. During a joint interview and observation on 12/13/18 at 8:09 AM with Staff G, LPN and Staff H, NA, the resident was observed during perineal care. Staff H stated, She cried all the time in pain and will call staff and God for help. Staff H added, the resident would say, help me God. During the observation, the resident reported severe pain related to the [MEDICAL CONDITION]/rash and hemorrhoid, and stated, She needed help and kept calling God for help to ease her pain. The resident had incontinence of urine and bowel during the observation. Further review of the resident's clinical records showed that on 03/30/18, the resident had a change in condition related to Urinary Tract Infection. Review of the Urine Culture and Sensitivity result dated 04/02/18, showed the bacteria present in the urine was positive for Escherichia Coli (E.coli), a bacteria commonly seen/present in the large intestine and the rectum. Review of the Medication Administration Record, [REDACTED]. (Refer to F684 - Quality of Care for more information.) RESIDENT 3 Resident 3 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the annual MDS assessment dated [DATE], showed the resident had impaired cognition and needed one person assistance with transfers and toilet use. Review of the resident's most recent bowel and bladder assessment (periodic care review) dated 08/22/17, showed the resident was incontinent of bowel and bladder. The clinical records showed no other comprehensive assessment specific for the resident's bowel and bladder/current toileting needs. Review of the bowel and bladder care plan initiated on 04/22/14 and revised on 10/02/15, showed the resident had Self-Care Deficit in toileting and risk for UTI related to impaired mobility, history of UTI, cognitive deficits and activity intolerance. The care plan was due for a review and was missing specific information on what type of incontinence the resident has. The most recent interventions for the care plan was reviewed and revised on 09/13/17. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the resident's bowel and bladder pattern from 11/05/18 to 12/03/18, showed the resident was incontinent of bowel and bladder. In an interview on 12/04/18 at 8:37 AM, the resident stated, staff would tell him to just go in my pants. The resident stated It's embarrassing. You know, when you're like a baby. That what I feel. According to the resident, he was getting used to it now. The resident further stated, It's not good but I have no choice. I guess they want me to use the toilet but they can't make it on time. During an observation and interview on 12/06/18 at 2:58 PM, the resident reiterated and stated, staff were telling him to go to his brief like a baby. According to the resident, it happened a lot of times and it doesn't make him feel good. The resident further stated, he had fallen in the past for attempting to go to the bathroom alone because they don't come when you call them . they only listen to what they want to here. The resident had incontinent of urine odor present during the interview. During a record review and interview on 12/06/18 at 3:14 PM with Staff E, RCM/RN, stated, the resident was incontinent of bowel and bladder and not on a toileting program. According to Staff E, the resident had no recent bowel and bladder assessment in the clinical record and the staff just document and chart daily on bowel and bladder task. No assessment. Staff E further stated, We cannot say if the resident's bowel and bladder had changed and/or improved or declined because there was no assessment. In an interview on 12/06/18 at 3:25 PM with Staff G, LPN, stated, the resident was incontinent of bowel and bladder and not on a toileting program. In an interview on 12/06/18 at 3:29 PM with Staff T, LPN, stated, the resident was incontinent of bowel and bladder and not on a toileting program. In an interview on 12/06/18 at 3:33 PM with Staff A, NA, stated, the resident was incontinent of bowel and bladder and not on a toileting program. According to Staff A, the resident needed help with toileting and if needed to be changed. Staff A further stated, the resident has redness on his buttocks. I put cream myself. I don't know if evening shift or other staff put the cream (on). In a follow-up interview on 12/06/18 at 3:43 PM, the resident stated, the problem he had with toileting pretty much happened all the time . Especially at night. According to the resident, the staff would just told him to go in bed. I don't know why they do that. I mean, they treat you like a baby and preferred to clean the mess in bed. The resident further stated, I told them, this could be messy, but they said, its ok. We are busy . Makes you feel helpless. During a joint skin inspection and interview on 12/06/18 at 3:51 PM with Staff A, NA, and Staff E, RCM/RN, the resident's buttocks and Peri-area skin was intact with minimal redness observed. Staff A stated, this redness was better and now closed before the skin was open. Staff E directed a question to Staff A if she had reported the skin breakdown to the nurse on duty. Staff A stated, Yes, the nurses area aware and she was not sure why they did not follow-up. Review of the skin observation documentation sheet from 11/07/18 to 12/05/18, showed the NAC's had documented red area on 11/18/18, 11/25/18 and 12/03/18. The clinical records showed no documented description of the red area, no evidence that a licensed nurse had followed up on and assessed the resident's skin and no documentation that the resident's physician was notified of the skin breakdown. (Refer to F684- Quality of Care for more information.) During a meeting on 12/14/18 at 2:03 PM with the Administrator, the Director of Nursing (DNS) and another surveyor, the DNS stated, bowel and bladder assessment should have been initiated and completed upon admission, on a quarterly basis and with a change in condition. According to the DNS, the nurses usually just document the resident's bowel and bladder condition in a progress note but the facility have a comprehensive assessment tool in Point Click Care, (PCC/electronic medical record), and the nurses failed to complete one for the residents. The DNS further stated, the NA's should document their bowel and bladder observations and the expectation was for the Licensed Nurses to initiate the assessment process but the nurses are not doing bowel and bladder assessment in PCC and they should. In summary, there was no documentation the facility had identified, comprehensively and accurately assessed, and/or treated/addressed Resident 146, 21, 86, 48 and 3's bladder and bowel incontinence. There was no documentation in the medical record for Resident 86 that the facility had completed a trial for bowel and bladder retraining to further improve or restore continence. Resident 146, 21, 86, 48 and 3's bowel and bladder incontinence issues were not accurately care planned, not person centered to identify the resident's strengths, goals and were missing interventions to address the root cause of the incontinent problem. There was no documentation in Resident 146, 21, 86, 48 and 3 medical record from admissions to 12/10/18 that a facility physician, or a specialist had identified, assessed, or provided any treatment or services to either achieve or maintain as much normal bowel and bladder function as possible for Resident 146, 21, 86, 48 and 3. These failures caused physical and psychosocial harm to Resident 146, 21, 86, 48 and 3. A reasonable person would experience anxiety, low self-esteem, and would feel humiliated/embarrassed related to bowel and bladder incontinence/accidents. The facility's failure to have a written policy and procedures related to bowel and bladder assessments and lack of written directive to staff placed all 150 residents of the facility at risk for harm and diminished quality of life. Reference (WAC) 388-97-1060 (3)(c)

Based on observations, interviews, and record reviews, the facility failed to provide necessary care and services to ensure a pattern of neglect and inactions did not occur. The facility failed to recognize ongoing staffing issues, which lead to delayed call light issues, failed to identify accident prevention risks which resulted in an Immediate Jeopardy, failed to have acting functional QA program to identify and correct past and ongoing issues, failed to provide ongoing identification and accurate thorough nursing assessments, failed to assess or monitor bowel or bladder conditions, failed to recognize lack of restorative functional nursing assessments, failed to adhere to professional standards of practice, and failed to have clinical systems in place to identify contributing risk factors of skin or bowel and bladder issues, which affected 36 of 49 residents (3, 6, 10, 11, 16, 23, 21, 27, 29, 30, 35, 37, 45, 47, 48, 57, 58, 59, 62, 63, 71, 73, 84, 86, 89, 90, 97, 103, 107, 112, 121, 131, 140, 146, 447 and 450) reviewed for abuse, prevention of pressure ulcers, accidents/hazards, bowel and bladder care, nutritional care, pain management, dementia care, restorative services and sufficient staffing. These failures resulted in the skin deterioration which led to infections, the development of avoidable pressure ulcers with pain, and complications resulting in hospitalization s. Residents feeling humiliated due to soiled briefs and frustration because the administration did not address their concerns. Findings include: Per the Revised Code of Washington (RCW) Neglect means (a) a pattern of conduct or inaction by a person or entity with a duty of care that fails to provide the goods and services that maintain physical or mental health of a vulnerable adult, or that fails to avoid or prevent physical or mental harm or pain to a vulnerable adult; or (b) an act or omission by a person or entity with a duty of care that demonstrates a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the vulnerable adult's health, welfare, or safety, including but not limited to conduct prohibited under RCW 9A.42.100. Facility Policy for Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition, revision date of (MONTH) (YEAR) Policy: Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Each resident also has the right to be free from mistreatment, neglect, and misappropriation of property. Foss implements policies and procedures so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents. The facility definition of Neglect: Failure of Foss, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility policy definition of neglect differs from the RCW. Refer to the below for additional inactions of the facility to provide necessary services. Refer to F 565 CRF 483.10(f)(5) Resident Council The facility failed to take action or respond to the resident council members concerns. During a meeting on 12/4/18 at 10:15 AM, 11 resident council members voiced concerns and agreed there was not enough staff to answer call lights timely, especially on the weekends and nights. They also stated there is not enough help in the dining rooms during meal times. In addition, the residents complained of not getting showers or restorative services because the shower aids and restorative aids were pulled from providing Restorative services, to work on the floor. These concerns affected 11 residents and had the potential to impact every resident in the facility (Residents 10, 11, 16, 23, 27, 57, 63, 71, 73, 84 and 121) Refer to F 684, CFR 483.25, Quality of Care; The facility failed to provide care that would prevent, monitor and treat skin breakdown which resulted in harm to 4 residents (6, 21, 48 & 107) Refer to F 686, CFR 483.25 (b)(1), Treatment/Services to Prevent/heal Pressure Ulcers; The facility failed to have a clinical system in place that followed standards of practice to identify risk factors and prevent pressure ulcers. This resulted in harm to 5 residents (6, 30, 107, 86, 45) and impacted 3 others, (62, 103 & 140) Refer to F 688 restorative; 483.25(C)(3) The facility failed to ensure there was a structured nursing restorative program that had consistent oversight of a licensed nurse to thoroughly assess the functional ability of residents and monitor the program. This caused harm to 1 resident (58) who had a decline and affected 4 other residents with the potential to affect all 48 resident who were identified to be on restorative programs. (Residents 45, 58, 89, 90) Refer to F 689 CFR 483.25 (d)(2), Accidents/Supervision; The facility failed to have enough staff to keep all residents safe and free from accidents. This caused an immediate jeopardy for Resident 97 and had the potential to affect all residents. Resident 97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Minimum (MDS) data set [DATE] the resident scored a 6 on the Brief Interview for Mental Status (BIMS), which indicated cognitive impairments. A facility fall risk assessment reviewed dated 10/25/18 identified the resident as a high risk for falls. Record review showed that staff was aware that Resident 97, was confused and would fall asleep in her wheel chair and self-transfer self to toilet. After the fall the facility's inaction to prevent another fall. Including not assessing the wheel chair, not providing increased supervision, or documenting increased supervision, resulted in an immediate jeopardy. During a review of the incident log showed that in: August (YEAR), there were: 28 falls, 1 elopement, 9 residents with bruising, 4 self-inflicted injuries, 2 skin tears September (YEAR), there were: 23 falls and 4 self-inflicted injuries October (YEAR), there were: 19 falls, 8 with injuries and 1 allegation of abuse November (YEAR), there were 29 falls, 8 with injuries, 5 reports of bruising, 1 resident-to-resident altercation Refer to F 690, CFR 483.25 (e)(2) Bowel Bladder / Incontinence; The facility failed to comprehensively assess and ensure residents received appropriate care and services necessary to maintain, improve and/or avoid loss of bowel and bladder functions. This resulted in harm for 5 residents (Residents 3, 21, 48, 86 & 146) Refer to F 692, CFR 483.25 Nutrition/hydration status maintenance; The facility failed to comprehensively assess and initiate interventions as needed to prevent significant weight loss. These failures caused harm to 6 residents who had unplanned weight loss (Residents 48, 107, 45, 6, 90 & 112) Refer to F 697, CFR 483.25(k) Pain management; The facility failed to ensure a pain management regime was provided and consistent with professional standards of practice. This caused harm to 3 residents. (Residents 6, 48 & 107) Refer to F 745, CRF 483.35, Sufficient Nursing Staff; The facility failed to provide adequate staff to meet and provide the basic needs of the residents or ensure services were provided to keep all residents at their highest practicable, physical, mental and psychosocial well-being. All below interviews were conducted on 12/3/18 and 12/4/2018 unless otherwise stated. Resident 58 The resident stated he uses the call button, but it is too late. The staff cannot get to you on time when you need help. If you need to go to the bathroom, they cannot get to you until 30-60 minutes. By the time they get to you, you have already wet yourself. Resident 89 The resident stated that she is unable to transfer or turn and is frustrated with the mattress. She stated that she had a fall out of bed and fractured her shoulder, can no longer walk because nobody has helped her get up. Resident 450 The resident stated that she had to ask her roommate to call for help, because there was no usable call light and the resident had two incontinent episodes on 12/3/18. Resident 37 An observation of the resident showed that the call light was not in reach, but lying on the floor. Resident 86 The resident stated that staff don't answer call lights, they are slow to get to you. It is not ok, to sit in your own, feces or urine for a long time. Resident 146 The resident stated they don't get to me on time, or honor you with respect or dignity, I have to wait for a long time. It's 40 minutes to go to the bathroom. The resident also stated, due to the long waits, the resident would have accidents in bed and have to sit on her own urine. The resident also reported she felt, It's like being a child. It is embarrassing and humiliating. Resident 48 The resident was observed and heard crying out, Please help me, Please God help me, I am hurting everywhere. It hurts. During an interview, she stated staff tell her to go to the bathroom in her brief. I don't get showered regularly, I itch and feel dirty. I have rash and yeast all over me I hate it. The resident also felt the facility does not have enough staff. Resident 21 The resident stated, one time she wanted to use the call button, but it was on the floor and I waited hours for someone to come, I have not had a shower 3 weeks. I need help with discharge (from the facility) and the Social Worker told her to do it herself. When she requests assistance, staff tell her they are too busy. Staff tell her they are short all the time. Especially at night Resident 3 The resident stated the facility does not have enough staff and I am not getting my bath regularly, I cannot get the help I need to go to the bathroom. Resident 59 The resident stated she felt I am not getting showers consistently. Resident 131 The resident stated that he gets his showers late, shower aides are pulled to floor. It comes out in the resident council meeting, but we do not get a resolution. It affects my way I socialize, no one wants to sit next to someone that smells. He went on to say that I was in the bathroom, got locked in, rang the call bell and had to wait 45 minutes. Resident 47 The resident stated that she went a long time without a shower. I have to wait a long time; it depends on who the aide is. I put my call light on this morning and because the state was in the building, 5 people came to my door to see what I needed and that never happens. The staffing is always short here. Resident 30 I tried to use my call light, but no one came so I try to either go by myself or have accident in my bed. They don't have enough staff here. They are overwhelmed on all shifts but nights are 20 to 30 minutes longer wait times. Resident 103 The resident stated he is not getting showered or shaved, and he would prefer to not have facial hair. Resident 447 The resident stated there are long waits for assistance, one night I could not find the call light and had to yell out for help. Resident 6 The resident stated that there is not enough staff and night shift is the worst. I have had to wait a long time, I go in my pants and they have to clean me up because I have to wait. Resident 35 The resident stated that he has been told I am not the only person here and I wait sometimes 30-40 minutes. They tell me they are busy. Reference: WAC 388-97-0640(1)(3)(c)

Based on observation, interview and record review, the facility failed to prevent, comprehensively assess, monitor and treat skin breakdown for 3 of 5 residents (6, 107 and 21) reviewed for skin and non-pressure related conditions. These failures caused harm to Resident 6, 107 and 21 who developed a severe Moisture Associated Skin Damage (MASD), rash, pain, and placed Resident 140 at significant risk for harm and related complications. Additionally, the facility failed to accurately assess, monitor and treat skin conditions for Resident 48. These failures caused harm to Resident 48 who experienced severe pain and diminished quality of life. Findings Included: Moisture Associate Skin Damage or MASD is defined as an inflammation and erosion of skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate (discharge), mucus or saliva. RESIDENT 6 Resident 6 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had impaired cognition and needed 2 person assist with bed mobility, transfers and toilet use. During a joint skin inspection and interview on 12/12/18 at approximately 2:29 PM with Staff E, Resident Care Manager/Registered Nurse, (RCM/RN), and Staff Z, NA, the resident was observed with severe excoriation and redness to the groin area, extending to the inner hip, buttocks and the resident's back. The resident was observed with 3 open areas with partial thickness skin loss. The resident stated he had the redness and sore area for a while now. Staff Z also stated the resident's redness on his groin area has been there for almost a week now and the redness and skin breakdown on the resident's back and buttock area had been there for almost 2 weeks. Staff Z further stated the resident would scream of pain every time he changed and cared for him. The resident was screaming and had verbalized pain throughout the observation. During a joint interview and record review on 12/12/18 at 3:31 PM with Staff M, Licensed Practical Nurse, (LPN), stated, the resident had no record of current skin breakdown as observed and no current skin treatment in place on the resident's clinical record. Staff M added, the resident had no specific pain medication regimen for the skin breakdown and no recent comprehensive pain assessment completed. (Refer to F697 - Pain Management for more information.) In an interview on 12/12/18 at 2:37 PM with Staff AA, (Advanced Registered Nurse Practitioner, (ARNP), stated she was just notified by the facility of the resident's skin breakdown today and was not aware of the resident's pain. During a joint skin inspection and interview on 12/12/18 at 3:39 PM with Staff AA, ARNP, Staff E, RCM, and another surveyor, the resident was observed with multiple skin breakdown. Two open areas were observed on the right and left sacral area measured each at approximately 1.5 centimeters (cm) in length and 1.5cm wide. The third open area was observed on the left buttocks but was not able to measured due to the resident complaining of severe pain. The resident reported 10 out of 10 pain to the ARNP and the surveyors. (Refer to F686 - Treatment/Services to Prevent/Heal Pressure Ulcer for more information.) Review of the nursing progress notes dated 12/13/18 showed the resident had a change of condition and showing signs and symptoms of shock (low blood pressure, elevated heart rate and fever). The resident was transported to the hospital at 3:45 AM via EMS (emergency medical services). Review of the hospital's Emergency Department (ED) report dated 12/13/18 showed the resident was admitted to the hospital with [REDACTED]. The ED report documented, SKIN: Pressure ulcer, Ecchymosis (discoloration of the skin from bleeding underneath), Lesion, Redness, Rash, Signs of Infection to buttocks, lower back, sacrum, Pressure ulcer present on the sacrum, drainage noted which is clear, depth is stage II, wound is bilateral ulcers on sacrum, redness across all of buttocks, sacrum, lower back extending up back, normal, hot, most. (Refer to F600 - Free from Abuse and Neglect for more information.) RESIDENT 107 Resident 107 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's admission MDS assessment dated [DATE], showed the resident had impaired cognition and needed two person assist with bed mobility, transfers and toilet use. Review of the admission skin assessment dated [DATE], showed the resident admitted to the facility with intact skin. During a joint observation and interview on 12/11/18 at approximately 11:27 AM, Staff E, RCM with Staff K, NA, Staff L, NA, and Staff M, LPN, the resident received perineal care and was observed with severe skin breakdown, open skin and redness to the groin and buttocks area. Each staff member stated, the resident's skin breakdown on his groin and buttocks area were not new and Staff K, stated she had putting the house cream to the resident's skin breakdown. The resident was screaming in pain throughout the observation, Aww, Aww, No, No, Oh, God. The resident stated his legs hurt a lot. Staff E stated, the resident was not on an air mattress before the resident's pressure ulcer had developed. Staff E further stated, the facility had just put in the air mattress after the pressure ulcer were identified, and No, the care plan wasn't updated. (Refer to F686 - Treatment/Services to Prevent/Heal Pressure Ulcers and F697 - Pain Management for more information.) Review of the NA's skin observation sheet from 11/11/18 to 12/09/18, showed the NA's had documented red area on 11/13/18 and 11/15/18. Staff E stated she was not sure what were the red areas observed by the NA's, and the NA's should have notified the nurses about the observation. During a joint interview and record review on 12/11/18 at 11:48 AM with Staff M, LPN, stated, the resident's clinical records showed no evidence that the facility had any record, no specific treatment plan of care and interventions for the resident's skin breakdown/excoriation to the groin and buttocks area. The clinical records showed no evidence that the facility had comprehensively assessed the resident's skin breakdown and evidence that a physician was notified and/or alerted regarding the resident's change in skin condition. During a meeting and joint record review on 12/13/18 at 1:27 PM with Staff O, RN/Admissions nurse and the facility's Medical Director, (MD), MD stated, she was notified or aware of the resident's Red-inflamed skin. The MD stated, she would expect staff to report this kind of change to her. The MD added, what should have happened here was the NA should have reported the skin problem to the nurse and the nurse should have assessed and documented any findings in the body audits and progress notes. Staff O concurred and stated, that was supposed to be the process but it wasn't followed here, on this case. RESIDENT 48 Resident 48 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had mild cognitive impairment and needed 1 person assistance with transfers, toilet use, personal hygiene and 2 person assistance with bed mobility and bathing. In an interview on 12/06/18 at 3:33 PM with Staff A, Nursing Assistant, (NA), stated the resident would scream and moan of pain every morning especially during pericare. Staff A stated, the resident's [MEDICAL CONDITION] was so bad as well as the resident's hemorrhoid. In an interview on 12/10/18 at 2:53 PM with Staff B, NA, stated it is normal for the resident to cry and scream in pain related to the resident's hemorrhoid. She's always been like this. In an interview on 12/10/18 at 2:56 PM with Staff C, NA, stated the resident usually cries and scream in pain related to her hemorrhoids. Staff C added, since she knew the resident, she would be crying and from time to time scream related to pain. When I provide care to her, she would hold my hand and tell me, please stay and don't leave me. (Refer to F697 - Pain Management for more information.) In a follow-up interview with Staff B, NA, on the same day at 2:58 PM, stated the resident would always scream and call out in pain on a daily basis. The resident would complain about her hemorrhoid and groin area. It is very bad. During a joint skin inspection on 12/11/18 at 1:58 PM with Staff D, Registered Nurse, (RN), the resident was observed with a severe hemorrhoid, measured at approximately 4 centimeter (cm) in length and 4cm wide by Staff D, covering the anus. The resident was also observed with dark black, ashen gray colored [MEDICAL CONDITION] to the groin area between the thigh and abdomen, extending to the pubis and to the labia. The resident was grimacing and complained of severe pain and sore on the above areas throughout the inspection process. In a follow-up interview on the same day at 2:10 PM with Staff D, RN, stated since she started working with the resident, the resident has been in pain. Staff D stated, the facility's Advanced Registered Nurse Practitioner (ARNP) just recently ordered for the resident to see the dermatologist and have a surgical consultation. Review of the resident's physician order [REDACTED]. The facility received an order for [REDACTED]. Review of the resident's progress notes from 11/01/18 to 12/10/18, showed that the resident's lesion and hemorrhoid were described as tender to touch ., Right groin dark [MEDICAL CONDITION] and redness, tender to touch during care, right groin has suspected seborrheic [DIAGNOSES REDACTED]. Area painful to touch ., A/C (alert charting) redness swelling on right groin area ., hemorrhoid is about the size of a ping pong ball . The progress notes also documented, the resident was either yelling, screaming, and/or complained of pain. During an interview and record review on 12/12/18 at 1:38 PM with Staff E, RCM, stated the facility do not put rash, [MEDICAL CONDITION] or hemorrhoids in monitoring or body audits per their policy. When asked with clarifying questions on how the facility was monitoring the progression and/or improvement of the resident's current skin condition including how the facility was monitoring the effectiveness of the treatment prescribed to the resident, Staff E stated, the nurses should be monitoring it during treatment. Review of the TAR for (MONTH) (YEAR), showed the resident had an order for [REDACTED]. Review of the resident's clinical records showed no evidence of any comprehensive assessment with accurate description and/or wound measurements to accurately assess and treat the resident's skin condition and hemorrhoids. The records also showed the NA's Skin observation from 11/13/18 to 12/11/18, showed the resident had Red Area documented on 11/14/18 to 11/19/18, 11/22/18 to 11/26/18, 11/29/18 to 12/03/18, 12/06/18, 12/08/18 and 12/10/18. During a follow-up interview and record review on 12/12/18 at 2:11 PM with Staff E, RCM, stated, the last she saw the resident's skin was about 2-3 weeks ago and it was like a black lesion/grayish, but it was not red area. Staff E reiterated, the facility would not document skin conditions to the body audit sheet because it was not pressure. When asked with clarifying questions on how the facility knew the documented Red area was not pressure related injury and how the facility can accurately monitor the resident's skin condition and effectively evaluate the treatment/interventions in place, Staff E responded, she wasn't sure. During a joint interview and observation on 12/13/18 at 8:09 AM with Staff G, LPN and Staff H, NA, the resident was observed during perineal care. Staff H stated, She cried all the time in pain and will call staff and God for help. Staff H added, the resident would say, help me God. During the observation, the resident reported severe pain and stated, She needed help and kept calling God for help to ease her pain. Staff G, stated the resident has always been like this every morning and the facility's nurse practitioner was aware of the resident's condition. Staff G further stated, she believed that the resident's medication was not enough to ease the resident's pain. During a meeting on 12/13/18 at 10:41 AM with Staff U, ARNP, and Staff I, Registered Dietitian, (RD), Staff U stated, she was aware of the resident's hemorrhoids it's pretty big and I'm sure it's painful. Staff U also stated, the resident's lesion or rash was black and not red in color. Staff U further stated, she was very concerned about the resident's current condition so she would immediately check and follow-up with the resident today. RESIDENT 21 Resident 21 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident had intact cognition and needed one person assistance with bed mobility, transfers and toilet use. Review of the resident's clinical records, showed the resident had missed 2 weeks of skin checks for 11/04/18 and 11/18/18. The resident's most recent body audit assessment was dated 09/30/18 and documented, No open areas or wounds on body . Review of the resident's skin care plan initiated/created on 08/20/18 and revised on 09/19/18, showed the resident has potential for impaired skin integrity and had no active/current skin breakdown. The plan of care directed the facility staff to monitor the resident's skin appearance and report changes to the skin. During an interview and observation on 12/03/18 at 3:02 PM, the resident stated she had lots of yeast and rash infection, It's on my skin fold, on my abdomen. According to the resident, the reason why she had rashes and yeast infection(s) was she haven't had a bath or shower for 3 weeks now. The resident also stated, I put my own powder and tried washing myself. I told them the first time I had it, but it was too hard to get any staff member to do it for me so I gave up. The resident pulled a bottle out of her bedside drawer and showed the surveyor an open and used bottle of [MEDICATION NAME] Powder (an anti-fungal cream) that she stated she was using to treat her yeast and rash infection. The resident showed the surveyor her abdominal area. The resident's left abdominal area was noted with severe rash and redness, had open skin, moist and the resident reported burn like pain to the area. According to the resident, she had been applying the cream herself and that sometimes her roommate would help her. The resident further stated, The staff don't check or offer to check my skin so they wouldn't know what I had. I haven't had shower for 2-3 weeks now. That's what's causing it. The dirt and the moisture. (Refer to F561 - Self Determination for more information.) During a record review and interview on 12/05/18 at 3:28 PM with Staff P, RN/RCM, stated the resident only had 2 skin checks on (MONTH) of (YEAR). Staff P also stated, the resident had no documented skin breakdowns and/or any active treatment for [REDACTED]. The record also showed no self-medication assessment and/or plan of care for the resident to safely administer any type of medication unsupervised. During a record review and interview on 12/05/18 at 3:40 PM with Staff XX, RN/Treatment Nurse, stated I don't physically check her skin, because she preferred female. According to Staff XX, this preference was not documented on the resident's clinical records and/or care plan. Staff XX further stated, the resident had no current skin breakdown and no current treatment for [REDACTED]. During a joint skin inspection and interview on 12/05/18 at 4:10 PM with Staff YY, RN and another female surveyor, the resident was observed with skin breakdown/Rash on the left outer abdominal area. The resident stated she had been self-treating her skin breakdown and at times, she would ask her roommate to help her apply the medication because she couldn't visualize the area that was sore and irritated. Staff YY stated she was not aware of the resident's skin breakdown and no treatment was in place or being administered currently. In an interview at approximately the same time of the above joint inspection, the resident's roommate confirmed and stated, she had been applying the powder for her roommate. In an interview on 12/06/18 at 8:46 AM with Staff Q, NA, stated, he was not aware of the resident's skin breakdown and I don't check her skin because the resident preferred a female caregiver. In an interview on 12/06/18 at 8:51 AM with Staff R, NA/shower aide, stated, the resident had a shower yesterday, 12/05/18 and she noticed some redness on her abdominal area like rash. In a follow-up record review and interview on 12/06/18 at 9:02 AM with Staff P, RN/RCM, stated, she clearly understood the problem of not having an up to date assessments and the lack of monitoring of the resident's skin. Staff P stated, the resident's clinical records showed no evidence that the facility had comprehensively assess the resident's current skin breakdown, no evidence the physician was notified of any skin problems/breakdown and the resident's plan of care was not up to date and person centered. In an interview on 12/06/18 at 9:58 AM, the resident stated, the rash and yeast infection she had caused her severe discomfort and burning pain especially when the infection was new. Review of the resident's MAR for (MONTH) (YEAR) showed the resident had order for a routine [MEDICATION NAME] 20mg(milligrams) every 6 hours routinely (a narcotic pain medication) and an as needed order for [MEDICATION NAME] 5mg every 4 hours as needed for pain control. During a meeting on 12/14/18 at 2:03 PM with the Administrator, the Director of Nursing (DNS) and another surveyor, the DNS stated, It's never been a protocol here before to check every body's skin. The DNS further added, The NA's do the skin checks for now and the facility had no skin protocol for weekly skin checks and documentations at this time. The DNS further stated, the expectation for the nurses was to document any skin problems, assess the concern skin area, write a progress note and notify the physician of the skin breakdown/concerns to obtain an order, if necessary. Reference: WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown and follow written policy and procedures, failed to develop and implement timely interventions necessary to prevent the development of avoidable pressure ulcers for 8 of 9 residents (6, 30, 107, 86, 45, 62, 140 and 103), reviewed for pressure ulcers. These failures caused harm to Residents 6, 30, 107, 86 and 45 who developed facility acquired pressure ulcers with partial and full thickness skin loss, pain and placed the other residents at risk for serious harm and diminished quality of life. Findings included: The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Review of the facility policy titled, Pressure Ulcer Assessment and Treatment dated (MONTH) (YEAR), stated to ensure that a resident who has a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The policy directed the facility staff to: 2. Assessment is completed by LN (Licensed Nurse) weekly and documented on a body audit form (which notes areas of skin alterations, site, type, measurements,etc) in Point Click Care (PCC - electronic medical record). 9. Wound Care Specialists are consulted for severe wounds, or ulcers that are difficult to heal. The facility policy was missing/did not include information on how staff would identify risk factors, develop and implement measures or interventions for prevention and/or how to minimize the risk of developing avoidable pressure ulcers. RESIDENT 6 Resident 6 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had impaired cognition and needed 2 person assist with bed mobility, transfers and toilet use. The MDS also identified the resident to be at high risk for developing a pressure ulcer. Review of the resident's most recent Braden Scale Assessment (assessment to determine risk for developing skin breakdown) dated 11/14/18, showed the resident was at moderate risk for developing skin breakdown/pressure ulcer. Review of the resident's most recent head to toe skin assessment/body audit dated 05/02/18, showed the resident had no current skin breakdown and/or pressure ulcer. Review of the resident's clinical records showed the resident did not have any other/more recent documented skin checks/assessments and body audits despite being at high risk for developing skin breakdown/pressure ulcers. Review of the resident's skin care plan initiated on 07/28/16 and revised on 07/23/18, showed the resident was at high risk for skin breakdown related to impaired mobility, urinary incontinence, and chronic pain issue. The care plan documented the resident had a history of [REDACTED]. The care plan was due for a review, and the interventions were last reviewed and revised on 01/22/18. During an observation on 12/12/18 at 2:28 PM, the resident was heard screaming and calling out in pain in his room. The door room was closed and the resident could be heard outside saying, Please help me, help. The surveyor knocked on the door and asked permission to come in. The resident stated, Yes, please come and help me. The resident was observed receiving perineal care from Staff Z, Nursing Assistant, (NA), and was complaining of pain throughout the observation. During a joint skin inspection and interview on 12/12/18 at approximately 2:29 PM with Staff E, Resident Care Manager/Registered Nurse, (RCM/RN), and Staff Z, NA, the resident was observed with severe excoriation and redness to the groin area, extending to the inner hip, buttocks and the resident's back. The resident was observed with 3 open areas(2 on the sacral area, 1 on buttock) with partial thickness skin loss. The resident stated he had the redness and sore area for a while now. Staff Z also stated the resident's redness on his groin area has been there for almost a week now and the redness and skin breakdown on the resident's back and buttock area had been there for almost 2 weeks. Staff Z further stated the resident would scream in pain every time he changed and cared for him. The resident was screaming and had verbalized pain throughout the observation. During a joint interview and record review on 12/12/18 at 3:31 PM with Staff M, Licensed Practical Nurse, (LPN), stated, the resident had no record of current skin breakdown as observed and no current skin treatment in place on the resident's clinical record. Staff M added, the resident had no specific pain medication regimen for the skin breakdown and no recent comprehensive pain assessment completed. (Refer to F684 - Quality of Care and F697 - Pain Management for more information.) In an interview on 12/12/18 at 2:37 PM with Staff AA, (Advanced Registered Nurse Practitioner, (ARNP), stated she was just notified by the facility of the resident's skin breakdown today and was not aware of the resident's pain. During a joint skin inspection and interview on 12/12/18 at 3:39 PM with Staff AA, ARNP, Staff E, RCM, and another surveyor, the resident was observed with multiple skin breakdowns. Two open areas were observed on the right and left sacral area measured each at approximately 1.5 centimeters (cm) in length and 1.5cm wide. The third open area was observed on the left buttocks but was not able to measure due to the resident complaining of severe pain. The resident reported 10 out of 10 pain to the ARNP and the surveyors. Review of the nursing progress notes dated 12/13/18 showed the resident had a change of condition and shows signs and symptoms of shock (low blood pressure, elevated heart rate and fever). The resident was transported to the hospital at 3:45 AM via EMS (emergency medical services). Review of the hospital's Emergency Department (ED) report dated 12/13/18 showed the resident was admitted to the hospital with [REDACTED]. The report documented that the resident had pressure ulcers on sacrum. During a meeting and joint record review on 12/13/18 at 1:27 PM with Staff O, RN/admissions nurse and the facility's Medical Director, (MD), the MD stated she was not aware of the resident's skin breakdown and pain problem until she was notified and was consulted by the ARNP on 12/12/18. Review of the resident's clinical records showed no evidence the facility had identified, monitored, treated, and developed and/or implemented any preventative measures to minimize the risk and prevent the development of a preventable facility acquired pressure ulcer. RESIDENT 30 Resident 30 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident had intact cognition and needed 2 person assistance with bed mobility and transfers. The MDS also identified the resident to be at high risk for developing a pressure ulcer. Review of the resident's skin care plan, initiated on 05/27/17 with revision date of 11/06/18, showed the resident had an actual skin impairment related to fragile skin-pressure area. The revised care plan also showed the resident was diagnosed with [REDACTED]. Review of the resident's admission skin assessment dated [DATE] showed the resident was admitted with no pressure ulcers. The resident was identified to be at high risk for developing a pressure ulcer, and had documented history of flap repair (surgical repair of skin) to the coccyx area. No rash or skin breakdown was identified to the resident's buttocks, coccyx/sacrum, and hip/trochanter areas. Review of the subsequent skin assessment/body audit sheets documented the following: 1. Body Audit dated 06/13/17 completed and signed on 07/12/17 at 5:40 PM. A. Coccyx rash measured at 0.8cm in length, 0.5cm wide and 0.1cm in depth. Described with 100% [MEDICATION NAME] tissue. B. Right buttock trauma measured at 1.2cm in length, 1.5cm wide and 0.1cm in depth. No description. 2. Body Audit dated 06/20/17 completed and signed on 07/12/17 at 5:45 PM. A. Coccyx wound resolved this week. B. Right buttock trauma measured at 2.1cm in length, 2.7cm wide and 0.1cm in depth. The wound was described as: 25% slough, 75% eschar with scant serosanguineous drainage (with clear liquid and blood discharge). 3. Body Audit dated 06/27/17 completed and signed on 07/12/17 at 6:00 PM. A. Right buttock pressure stage III measured at 2.0cm in length, 3.2cm wide and 0.0cm in depth. The wound was described as: 25% granulation, 75% slough with scant serosanguineous drainage. 4. Body Audit dated 07/04/17 completed and signed on 07/12/17 at 5:57 PM. A. Right buttock pressure stage III measured at 1.8cm in length, 3.2cm wide and 0.2cm in depth. The wound was described as: 75% granulation, 25% slough with scant serosanguineous drainage. 5. Body Audit dated 07/11/17 completed and signed on 07/12/17 at 6:28 PM. A. Right buttock pressure stage III measured at 2.3cm in length, 3.3cm wide and 0.2cm in depth. No wound description. B. Left buttock pressure unstageable measured at 5.1cm in length, 4.6cm wide and 0.1cm in depth. No wound description. 6. Body Audit dated 07/18/17 completed and signed on 07/20/17 at 1:55 PM. A. Right buttock pressure stage III measured at 1.5cm in length, 3.1cm wide and 0.1cm in depth. No wound description. B. Left buttock pressure unstageable measured at 5.5cm in length, 5.2cm wide and 0.2cm in depth. No wound description. The resident's computerized clinical records showed the skin assessments were dated by initiation dates rather than the actual assessment completion dates. The resident was missing skin assessments/body audits from 07/11/17 to 12/27/17. In an interview on 12/04/18 at 9:16 AM, the resident stated he came in to the facility with no pressure ulcer. The resident stated he was admitted initially on the first floor (rehab unit). The resident added that the staff were not offering to turn him and his pressure ulcers could have been prevented. The resident further stated the staff would use a mechanical lift device (Hoyer Lift) to transfer him, which left him sitting on top of the Hoyer sling and then, The staff would just forcefully pull the sling causing severe friction and shearing. That's what happened. The resident stated the staff did not know anything about his pressure ulcers until it started bleeding, Now I have two stage 4's and a bone infection. I'm on IV (intravenous) antibiotics. The resident added, I'm getting an MRI (magnetic resonance imaging - medical imaging) next week, and the sore had caused pain, especially the left side. The resident further stated, It does affect my quality of life because now I cannot go out every day or be up in my wheelchair. During a joint skin inspection and interview on 12/04/18 at 11:44 AM with Staff C, NA, and Staff D, RN, the resident was observed with a large open wound to his left trochanter (hip) area with exposed muscle and adipose (fat) tissues. The wound was measured at approximately 9 cm in length, 4 cm wide and 1 cm in depth by Staff D. The surrounding skin was red and tender, the wound edge were macerated and had moderate amount of drainage with minimal odor. The resident reported severe pain rated at 7/10 to the area. The resident stated his wound had originated from the Hoyer sling and was a Trauma when he was at the rehab unit of the facility. During a joint interview and record review on 12/05/18 at 2:43 PM with Staff O, RN/Admission nurse, stated the resident was admitted to the facility with no pressure ulcers. Staff O stated the nurses on the floor were supposed to complete weekly skin checks and document any findings or no findings in PCC using the Body Audit assessment. Staff O stated, the resident had no body audit checks in PCC from 07/19/17 to 09/11/17 and from 09/13/17 to 12/26/17. Staff O stated, the resident's most recent body audit in PCC was completed on 03/13/18. In an interview on 12/06/18 at 3:25 PM with Staff G, LPN, who stated the resident came to the second floor with pressure ulcers. Staff G further stated the resident's wound got infected twice and currently the resident was receiving intravenous antibiotics. In an interview on 12/06/18 at 3:29 PM with Staff T, LPN, stated he was not sure about the origin of the resident's wound. Staff T stated the resident was transferred from the first floor with pressure ulcers. Review of the resident's clinical records, showed the resident was hosptalized on [DATE] for possible [DIAGNOSES REDACTED]. Review of the hospital records dated 03/06/18 showed the resident was admitted to the hospital for right femoral head osteo[DIAGNOSES REDACTED]. Other major [DIAGNOSES REDACTED]. During an interview and record review on 12/10/18 at 10:24 AM with Staff E, RN/RCM, who stated the resident admitted to the facility with no pressure ulcers and now has a stage 4 pressure ulcer. Staff E stated the resident was being followed by a wound specialist and being seen weekly. Staff E added, the nurses were not doing a head to toe skin assessment/body audits because the resident was being followed by the wound specialist. Staff E stated the most recent body audit (in PCC) was completed on 03/13/18, and the resident had missed a wound assessment last week because the wound specialist was out sick. According to Staff E, there was no measurement and wound description available for the week of 12/03/18 to 12/07/18 . When asked with clarifying questions on how the facility would know and assess the wound progression and/or if the wound had deteriorated from the prior week, Staff E stated she would simply rely on the nurses who do the treatment. However, Staff E said, The nurses don't measure and write the description of the wounds. Review of the resident's clinical records showed the resident had no specific preventative interventions/measures in place from admission to 06/22/17. All the specific treatment and interventions listed and documented on the resident's plan of care for skin and pressure ulcers were initiated on 06/22/17. Review of the wound consultation report dated 06/06/17, showed the resident's sacral wound is felt to be r/t (related to) shear . and wound consultation report dated 06/13/17, documented, he does have a new wound on his R (right) buttock, which was attributed to shear from a brief. During an interview and record review on 12/11/18 at 11:28 AM with the Director of Nursing, (DNS), and another surveyor, the DNS stated, she was not directly involved with the resident and the facility had no record of any investigation regarding the resident's wound and documented trauma. (Refer to F600 - Free from Abuse and Neglect for more information.) The facility failed to investigate and identify/correct potential cause of the injury to the resident and develop/implement timely and appropriate interventions as needed to minimize the risk of further skin breakdown. In a follow-up interview on 12/11/18 at 2:52 PM, the resident stated, his wounds could have all been prevented if the NA's on the first floor had not forcefully pull the Hoyer sling under him that caused the trauma and shearing to his skin. The resident reiterated, his wound had caused him to just lay in bed and avoided him to do things that are really important to him such as going out using is power chair in the community. Further review of the resident's clinical records, showed the resident developed another wound infection (osteo[DIAGNOSES REDACTED]) on 11/26/18 and was being treated with and intravenous antibiotics. RESIDENT 107 Resident 107 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's admission MDS assessment dated [DATE], showed the resident had impaired cognition and needed two person assist with bed mobility, transfers and toilet use. The MDS also identified the resident to be at high risk for developing a pressure ulcer. Review of the admission skin assessment dated [DATE], showed the resident admitted to the facility with no pressure ulcer. The admission skin documented, Coccyx intact with blanchable redness. Review of the resident's current care plan created and initiated on 10/30/18 with revision date of 11/26/18, showed the resident has potential for impaired skin integrity r/t (related to) impaired mobility. Has unstageable pressure ulcer on coccyx. Care plan interventions included the following: A. Air mattress in bed, monitor for proper inflation and functions every shift. Initiated on 11/26/18. B. Monitor for changes in skin appearance every week and complete body audit under assessments. Initiated on 10/30/18. C. Offload coccyx every 2-3 hours when up in wheelchair. Initiated on 11/26/18. D. Staff also apply house barrier cream to help protect skin and report to licensed nurses changes in skin issue noted during care. Review of the resident's clinical records from admission to 12/10/18, showed the resident had no documented weekly skin assessments/body audits from admission to 11/26/18. Review of the skin assessment/Body audit dated 11/26/18, showed the resident was found with new pressure ulcer to his coccyx described as unstageable measured 2.5cm in length, 2cm wide and 0.0cm depth. Resident was noted with unstageable pressure ulcer area on his coccyx today. Area is covered with 100% eschar, depth undetermined. Peri wound with some redness . Review of the skin assessment/Body audit dated 11/30/18 (completed and locked on 12/10/18), showed the resident was found with new pressure ulcer to his coccyx described as unstageable measured 2.5cm in length, 2cm wide and 0.0cm depth. Wound now has 25% slough and 75% eschar tissue in wound bed. During an interview and observation on 12/10/18 at 10:19 AM, the resident reported severe pain to his legs, buttocks and back area. The resident was observed up on his wheelchair with facial grimacing. During an interview and record review on 12/10/18 at 10:24 AM with Staff E, RCM, stated the resident had developed 2 in-house acquired pressure ulcers. According to Staff E, the resident had an unstageable pressure ulcer on his coccyx which was first identified on 11/26/18 and a suspected deep tissues injury to his left back identified today, 12/10/18. Staff E stated, the resident was being followed by wound specialist and being seen weekly. Staff E added, the nurses were not doing a head to toe skin assessment/body audits because the resident was being followed by the wound specialist. Staff E stated, the most recent body audit was completed on 11/30/18 and the resident had missed a wound assessment last week because the wound specialist was out sick. According to Staff E, there were no measurement and wound description for the week of 12/03/18 to 12/07/18 available. When asked with clarifying questions on how the facility would know and assess the wound progression and/or if the wound had deteriorated from the prior week, Staff E stated, she would simply rely on the nurses who does the treatment. However, Staff E said, The nurses don't measure and write the description of the wounds. Staff E stated, the resident was not on an air mattress before the resident's pressure ulcer had developed. Staff E further stated, the facility had just put in the air mattress after the pressure ulcer were identified, and No, the care plan wasn't updated. Review of the NA's skin observation sheet from 11/11/18 to 12/09/18, showed the NA's had documented red area on 11/13/18 and 11/15/18. Staff E stated she was not sure what were the red areas observed by the NA's, and the NA's should have notified the nurses about the observation. During an interview and observation on 12/11/18 at 09:01 AM, the resident reported severe pain to his legs, buttocks and back area. The resident was observed sitting on his wheelchair with the Hoyer Sling underneath and in between the wheelchair cushion and the resident's clothing. During an interview and observation on the same day at 11:15 AM, the resident was observed in the same position as above. The resident was observed trying to wheel himself out of his room calling for staff. The resident stated, I've been sitting here too long. The resident complained of pain to his tailbone and back area describing the pain as very bad including his legs. During a joint observation and interview on 12/11/18 at 11:25 AM with Staff K, NA, Staff L, NA, and Staff M, LPN, Staff K and Staff L stated, The Hoyer sling shouldn't be left under the resident buttocks because it defeats the purpose of the cushion causing added pressure to the skin. Staff M concurred and stated, Specifically for Resident 107, he has pressure ulcer so he needed the cushion to help ease the pressure. At approximately 11:27 AM, Staff E, RCM entered the resident room. The resident received perineal care and was observed with severe skin breakdown, open skin and redness to the groin and buttocks area. Each staff members stated, the resident's skin breakdown on his groin and buttocks area were not new and Staff K, stated she had putting the house cream to the resident's skin breakdown. The coccyx wound was covered with 100% slough and measured approximately 2-3cm in length, 2-3cm wide with depth unable to determine per Staff E. The back pressure ulcer was observed with intact skin with dark black area, was tender and sore according to the resident upon palpation by Staff E. The pressure ulcer was measured at approximately 3cm in length and 3cm wide by Staff E. The resident was screaming of pain throughout the observation, Aww, Aww, No, No, Oh, God. The resident stated, His legs hurts a lot. (Refer to F684 - Quality of Care and F697 - Pain Management for more information.) Both Staff K, NA and Staff M, LPN, stated, the resident would get up at around 8am for breakfast and will not be back to bed until after lunch at around 1 PM. Staff M further stated, the resident should not be sitting on his wheelchair for a long time since he has a pressure ulcer. The resident stated, he may have gotten his sore because he's been sitting on the wheelchair so much and too much sitting. During a meeting and joint record review on 12/13/18 at 1:27 PM with Staff O, RN/Admissions nurse and the facility's Medical Director, (MD), MD stated, she was notified of the resident's coccyx wound on 11/26/18 and wasn't aware of the back pressure ulcer until 12/11/18. MD stated, the resident had lost a lot of weight and was at very high risk for developing pressure ulcer(s). RESIDENT 86 Resident 86 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident had impaired cognition and needed 2 person assistance with bed mobility and transfers. The MDS also identified the resident to be at high risk for developing a pressure ulcer. Review of the nursing admission assessment dated [DATE], showed the resident admitted with no pressure ulcers. The assessment identified the resident to be at high risk for developing a pressure ulcer. Review of the resident's skin care plan initiated on 07/16/18 and revised on 10/25/18, showed the resident developed an open area on left buttocks on 08/30/18. The care plan stated, the resident was at high risk for skin breakdown related to stroke and immobility and due to incontinence of bowel and bladder. Review of the resident's clinical records, showed there were no findings from their skin assessments from admission till 08/28/18. Review of the skin assessment/body audit dated 08/28/18, showed the resident was noted to have a pressure ulcer (suspected deep tissue injury/SDTI) to the left buttocks measured at 4cm in length, 1.0cm wide and 0.0 cm in depth. Review of the subsequent skin assessment and body audits showed the following: A. 08/30/18 - stage 2 pressure ulcer to left buttocks measured at 3cm in length, 1.7cm wide, and 0.1cm in depth. Wound description: left buttock SDTI now has open area 3.0cmx1.7cmx0.1cm. Length of non-blanchable area 5.5cm . B. 09/07/18 - left buttock pressure ulcer. No stage documented. Wound measured at 5cm in length 2.2cm wide and 0.1cm in depth. Wound description: open area on left buttock was initially noted in TCU (transitional care unit) prior to transfer to LTC (long term care) . Resident is on air mattress. Will request referral to wound specialist . C. 09/10/18 - left buttock pressure ulcer stage 3. D. 09/18/18 - left buttock pressure ulcer stage 3. The resident was missing skin assessments/body audits from 09/19/18 to 10/26/18. The nursing progress notes and body audit sheet/skin assessment dated [DATE], showed different, conflicting information on what type of skin breakdown/pressure ulcer the resident had. In an interview on 12/03/18 at 2:12 PM, the resident stated, My bottom hurts. I don't know if I have a sore. I sit in urine and BM (bowel movement) for a long time. I don't like lying on my own piss. It happened all the time. The resident added, I'm [AGE] year old. It made me really feel bad. I'm not a baby. (Refer to F690 - Bowel and Bladder Incontinence for more information.) During an interview and observation on 12/04/18 at 9:36 AM, the resident was heard screaming and calling out of pain in her room. The resident stated, The staff had not changed her for about an hour now. According to the resident, she was changed early in the morning when the new shift comes around 6ish but she had a bowel movement around 7 in the morning. The resident further stated, she had been calling the staff to change her but they are busy and need the meals first. The resident stated, I had a sore in my bum and I don't want that to open again. During an interview and record review on 12/10/18 at 10:24 AM with Staff E, RCM/RN, stated, the resident was admitted to the facility with no pressure ulcer. Staff E also stated, the resident developed the pressure ulcer in the facility, and there was no preventative measures in place prior to the development of the pressure ulcer. According to Staff E, there was no evidence of any documentation or follow-up related to the redness documented by the NA's on 11/27/18 and she was not sure what the redness was and if it's still there or not. The resident's care plan showed, interventions specific for the prevention and treatment for [REDACTED]. The resident was placed on a pressure relieving mattress/special mattress on 09/07/18. The last documented skin assessment/body audit was dated 10/27/18 and documented, no new skin issues. However, review of the skin observation documentations from (MONTH) (YEAR) to 12/11/18, showed the resident had red areas identified on 11/27/18 and 12/11/18. During a meeting on 12/14/18 at 2:03 PM with the Administrator, the Director of Nursing (DNS) and another surveyor, the DNS stated, It's never been a protocol here before to check every body's skin. The DNS added, the RCM would determine if a resident is at high risk for skin breakdown and would put them on weekly skin check. According to the DNS, at this time, the facility have no protocol in place and there's no documentation that a weekly head to toe skin check was being (TRUNCATED)

Based on observation, interview and record review, the facility failed to comprehensively assess and initiate interventions as needed to prevent significant weight loss for 6 of 8 residents (48, 107, 146, 45, 90, and 112) reviewed for nutritional status and weight loss. These failures caused harm to Resident 48, 107, 146, 45, 90 and 112 who had significant and unplanned weight loss and placed other residents at risk for continued decline in nutritional status and related complications. Additionally, the facility failed to follow written physician orders and provide Resident 146 a nourishing, well balanced diet that meets the resident's daily nutritional and special dietary needs. This failure caused harm to Resident 146 and placed the resident for a decline in nutritional status. Findings included: A review of the facility policy titled, Weight Monitoring dated 09/12/14, showed, the objective of the policy was To provide a systematic approach for obtaining resident's weight in order to identify residents at risk for unintentional weight loss. The policy directed the facility staff to do the following: 8. A significant difference in weight from prior weighing greater than 5 lbs. (pounds) will trigger a reweigh, for accuracy. 9. A Registered Dietitian (RD) reviews weight/diet upon admission, annually and upon a change in goal weight. 10. Clinical Care Managers review weights/vitals reports routinely to identify residents triggering weight loss. 11. Approaches/interventions to address weight loss are provided in an algorithm. 12. Notify the Provider of weight change to obtain orders, if indicated. 13. Add problem related to weight loss/gain to the resident's care plan. Review of the Weight Loss-Unintentional Algorithm documented, if weight loss was a concern/confirmed, the facility should do an assessment including history, physical exam, medication review, pertinent laboratory testing and RD referral. For weight loss with probable or definite cause, treat identified cause. For weight loss with no identified cause or the resident's condition was not treatable, provide nutritional support, eliminate dietary restrictions, provide frequent small meals, allow unlimited intake of favorite foods, and provide nutritional supplements. RESIDENT 48 Resident 48 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had mild cognitive impairment and needed 1 person assistance with transfers, toilet use and eating. Review of the resident's nutrition care plan initiated on 05/23/13 with the most recent revision date of 06/26/17, showed the resident had an Alteration in Nutrition related to Diabetes, history of weight gain, and depression. The care plan was due for a review. The most recent intervention was revised/entered on 03/12/18. The care plan showed the resident weight goal was to at 200 lbs. +/- 5 lbs. (195 lbs. to 205 lbs.) A review of the resident's Weight Summary showed the following weights: 12/10/18 = 191.0 lbs. 12/03/18 = 195.0 lbs. 11/16/18 = 198.0 lbs. 11/09/18 = 201.0 lbs. 10/29/18 = 204.0 lbs. 09/23/18 = 200.0 lbs. 09/03/18 = 203.0 lbs. The resident weight on 11/09/18 was 201.0 lbs. The resident weight on 12/10/18 was 191.0 lbs. A loss of 10.0 lbs. in 1 month, a 4.98% loss of body weight. Review of the resident's food intake from 11/14/18 to 12/12/18, showed the resident was eating an average of 25% to 75%. The resident had documented less than 25% of food intake in 24 hours on 11/18/18, 11/21/18, 11/24/18, 11/28/18 12/03/18, 12/07/18, and 12/08/18. Review of the resident's total fluid intake from 11/14/18 to 12/12/18, showed the resident was drinking less than 1000 mL (milliliters) of fluid per day. The resident had documented fluid intake of less than 500 mL on 11/15/18, 11/18/18, 11/19/18, 11/21/18, 11/24/18, 11/25/18, 11/27/18, 11/28/18, 11/29/18, 12/03/18, 12/07/18, 12/08/18 and 12/11/18. During multiple observations on 12/04/18 at 2:02 PM, 12/06/18 at 9:05 AM, 12/11/18 at 1:54 PM and at 1:58 PM, the resident was observed with dry skin, poor skin turgor, and cracked lips. The resident had no water pitchers of fluids in the room. During a joint skin inspection and interview on 12/13/18 at 8:09 AM with Staff G, Licensed Practical Nurse, (LPN), and Staff H, Nursing Assistant, (NA), the resident was observed with very dry skin. The resident had cracked lips and dry oral mucosa. The resident was screaming and complaining of severe pain related to [MEDICAL CONDITION]/rash and presence of hemorrhoids throughout this observation. (Refer to F684 - Quality of Care and F697 - Pain Management for more information.) During a dining observation on 12/13/18 at 8:48 AM, the resident was observed grimacing and complaining of pain. The resident was staring at her food. At 8:58 AM, the resident started, calling out God help me, God help me. Another resident sitting next to her intervened and stated, Resident 48, you have to eat. You like Cheerios. Come on. There was no staff member around to assist or cue the resident, nor acknowledge the resident pain. (Refer to F725 Sufficient Nursing Staff and F550 - Resident Rights/Exercise of rights for more information.) In an interview with another resident in the dining room at the time of the observation, stated, She is always like this. She don't eat or drink much. Further review of the resident's clinical records, showed the resident had an elevated Blood Urea Nitrogen (BUN) and Creatinine levels, a possible indicator of poor hydration/dehydration. The resident's Basic Metabolic Panel (blood test to check electrolytes and kidney functions) showed the following results; A. 11/13/18 - BUN of 42 (normal range 7-25) and Creatinine of 1.6 (normal range 0.4 to 1.4). B. 07/30/18 - BUN of 48 and Creatinine of 1.9. C. 07/24/18 - BUN of 39 and Creatinine of 1.7. D. 06/30/18 - BUN of 38 and Creatinine of 1.5. During an interview and record review on 12/13/18 at 10:25 AM with Staff I, RD, stated, the last RD visit she had with the resident was on 03/12/18. Staff I stated, the resident's recommended fluid intake was 2000 mL per day and the resident was not drinking enough to meet this needs. According to Staff I, she was not able to determine if the resident was getting extra fluids because the facility does not measure/document other fluids, if any was given to the resident. Staff I further stated, at this time, based on the resident's clinical records and physical symptoms, including poor food and fluid intake and recent weight loss, the resident was not getting adequate nutrition/hydration. Staff I added, the resident should have been seen at least every quarter because she is high risk for nutritional decline. During a joint record review and interview on 12/13/18 at 10:41 AM with Staff I, RD and Staff U, Advanced Registered Nurse Practitioner, (ARNP), stated, she was not aware and was not notified of the resident's poor hydration, poor meal intake, and recent weight loss. During a meeting and joint record review on 12/13/18 at 1:27 PM with Staff O, RN/admissions nurse and the facility's Medical Director, (MD), the MD stated, she was not directly involved with the resident's care but the resident should have been seen and referred to the RD at least twice due to the resident's poor intake. RESIDENT 107 Resident 107 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's admission MDS assessment dated [DATE], showed the resident had impaired cognition and needed one person assistance with eating. Review of the resident's nutrition care plan created and initiated on 11/12/18, (14 days after admissions), showed the resident had an alteration in nutrition r/t (related to), recent ICH ([MEDICAL CONDITION]), recent PNA (pneumonia), small B cell [MEDICAL CONDITION] (cancer), dementia, H/O (history of) colon resection, leaves =/> (equal or greater than) 25% uneaten most meals, weight loss, and Unstageable wound in the coccyx. The care plan documented, the resident's weight goal was between 135 lbs. to 145 lbs. The care plan directed the facility staff to: A. Give resident half a sandwich as evening snack. Initiated on 11/30/18. B. 120 mL of Health Shake Three times a day with meals. Date initiated 11/12/18. A review of the resident's Weight Summary showed the following weights: 12/08/18 = 130.0 lbs. 11/30/18 = 134.0 lbs. 11/14/18 = 135 lbs. 11/08/18 = 140 lbs. 11/02/18 = 144.0 lbs. 10/30/18 = 142.0 lbs. (admission's weight) The resident weight on 10/30/18 was 142.0 lbs. The resident weight on 11/30/18 was 134.0 lbs. A loss of 8.0 lbs. in 30 days, a 5.63 % loss of body weight. The resident continued to lose weight. The resident's weight on 12/08/18 was 130.0 lbs. A total weight loss of 12 lbs. in 39 days, an 8.45 % loss of body weight. Review of the resident's food intake from 11/13/18 to 12/11/18, showed the resident was eating an average of 25% to 75%. The resident had documented less than 25% of food intake in 24 hours on 11/19/18, 11/30/18 and 12/03/18. Review of the resident's total fluid intake from 11/13/18 to 12/11/18, showed the resident was drinking less than 1500 mL (milliliters) of fluid per day. The resident had documented fluid intake of less than 1000 mL on 11/14/18, 11/16/18, 11/17/18, 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/25/18, 11/29/18, 11/30/18, 12/03/18, and 12/08/18. During a joint observation and interview on 12/11/18 at approximately 11:27 PM with Staff K, NA, Staff L, NA, Staff M, LPN and Staff E, RCM, the resident was observed with poor skin turgor and dry skin. The resident had skin breakdown, open skin and redness to the groin and buttocks area. The resident was also observed with a full thickness skin loss wound on the coccyx and a suspected deep tissue injury on the back area. The resident was screaming of pain throughout the observation. (Refer to F684 - Quality of Care, F686 - Treatment/Services to Prevent/Heal Pressure Ulcers, and F697 - Pain Management for more information.) Review of the Medication Administration Record, (MAR), and Treatment Administration Record, (TAR), for (MONTH) (YEAR), showed the resident only received the 120mL of health shake twice per day (with lunch and dinner) from 11/12/13 to 11/30/18, instead of 3 times a day, as directed by the resident's nutrition plan of care. Review of the MAR and TAR for (MONTH) (YEAR), showed the resident had refused his sandwich for 7 out of 10 days from 12/01/18 to 12/10/18. During an interview and record review on 12/13/18 at 10:57 AM with Staff I, RD, stated, the resident's recommended fluid intake per day was 1800mL. No, the resident was not receiving adequate fluids as documented in the record. According to Staff I, she saw the resident on 11/12/18, and recommended snacks and health shakes to help supplement the resident's meals and intake for wound healing. Staff I further stated, she was not notified of the resident's continued weight loss including the resident's poor intake, refusals of snacks and of any new pressure ulcers. Staff I added, the resident had a significant weight loss and should have been looked at and followed-up on. During a meeting and joint record review on 12/13/18 at 1:27 PM with Staff O, RN/admissions nurse and the facility's Medical Director, (MD), the MD stated, she was not aware/was not notified of the resident's refusals of snacks and the staff should have notified me or the RD. RESIDENT 146 Resident 146 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], showed the resident had an intact cognition and needed 1 person assistance with activities of daily living. Review of the resident's nutrition care plan created and initiated on 10/01/18 (40 days after admission), showed the resident had an alteration in nutrition related to Diabetes, [MEDICAL CONDITION] post renal transplant, weight fluctuations related to heart failure, [MEDICAL CONDITION] and diuretic use. The care plan also showed, the resident had depression, reflux disease, and allergy to gluten and whole eggs. The phsyician orders dated 11/15/18, documented the resident had been prescribed a gluten free diet and identified an egg allergy. In an interview on 12/04/18 at 9:57 AM, the resident stated, I have Celiac (an immune reaction to eating gluten). The resident added, her food options become less and less and she had this problem since admission to the facility. According to the resident, the facility did not give her the menu options and food list until yesterday, 12/03/18. I am allergic to eggs, wheat, gluten, etc . so that's the problem. The resident further stated, This is why my blood sugar is always low. I don't get snacks here. The resident stated, for 2 days now, she had episodes of low blood sugar. If only I have snacks in the evening or have a substantial meal, it could have been prevented. According to the resident, we eat dinner here at 5pm and we don't eat again until 7am the next day. Review of the resident's clinical records and nursing progress notes from admission to 12/04/18, showed that on 10/30/18 at 2:08 PM, the resident was found shaking sitting on her wheelchair . her whole body was shaking and twitching on and off. BS (blood sugar) was 64, [MEDICATION NAME] shot given, and it was 54 when rechecked. Glucose oral gel was given. Pt (patient) went to Overlake ER . Progress notes dated 11/29/18, 12/02/18 and 12/03/18, showed the resident had hypoglycemic (low blood sugar in the blood) reactions that needed further interventions from staff. Review of the hospital Discharge summary report dated 11/15/18, showed the resident's [DIAGNOSES REDACTED]. AKI unclear etiology, volume loss and dehydration is leading cause right now. (Refer to F690 - Bowel/Bladder Incontinence, Catheter, UTI for more information.) Review of the resident's physician order sheet showed the resident was on the following medications that could potentially alter/effect the resident blood sugar readings. A. [MEDICATION NAME] (antibiotics) daily. B. [MEDICATION NAME] (steroids) daily. C. Insulin [MEDICATION NAME] (long acting insulin) 13 units every 12 hours. D. [MEDICATION NAME] (antibiotics) 2 times daily. E. Insulin [MEDICATION NAME] (short/rapid acting insulin) 5 units before meals. The physician orders also showed an order for [REDACTED]. During an interview and record review on 12/06/18 at 11:01 AM with the resident and Staff O, RN/Admissions nurse, the resident stated, she just recently received her diet options about 2 days ago and nobody had talked to her about her diet preferences. The resident stated how important it was to get meals and snacks because of her diabetes and she was not getting her snacks because none was available to meet her specific dietary needs. The resident further stated, her low blood sugar episodes could have been prevented, or the risk could have been minimized if she was given the food or snacks she could eat without worrying for side effects like diarrhea. The resident reported several episodes of hypoglycemic episodes recently because she had not eaten enough and there were no snacks or meals after 5-6 pm until the following morning around 7-8am. There's just no food options given and available for me . During a joint interview on 12/06/18 at 11:13 AM with Staff R, NA, and Staff JJ, NA, both staff members stated, the resident had no snacks and they have not personally given snacks to the resident. In an interview on 12/06/18 at 11:15 AM with Staff KK, LPN, stated, the snack for Resident 146 just started this week and there was no order for a snack prior. In an interview on 12/06/18 at 11:16 AM with Staff LL, Dietary Manager, (DM), stated, she was not in-charge of snacks. Not all diabetics get a snack. According to Staff LL, nurses usually give her a copy of the order for her to send a snack. Staff LL stated, for Resident 146, she did not receive any communication that the resident needed a snack. Staff LL also stated, she just given the resident the food options available for her this week based on the resident's diet restrictions. During a joint interview on 12/06/18 at 11:29 AM with the resident and Staff LL, DM, the resident told Staff LL how important it was for her to get the meals and snacks because of her diabetes and she was not getting her snacks because none was available to meet her specific dietary needs. In a follow-up interview with Staff LL, DM, on the same day at 11:32 AM, stated, she had not met with the resident recently about her food preferences and she had not made any gluten free snacks recently. In an interview on 12/13/18 at 11:15 AM with Staff I, RD, stated, Resident 146 was not given the food options and menu for her diet. Staff I also stated, the nursing department did not communicate the resident's order for snacks so it was not delivered until the surveyor had inquired and talked to the Dietary Manager on 12/06/18. Staff I further stated, Yes, it was critical for her because she was diabetic and receiving regular insulin. During a meeting on 12/14/18 at 2:03 PM with the Administrator, the Director of Nursing (DNS) and another surveyor, the DNS stated, the resident weights were monitored by the RCM and the RD. According to the DNS, the RCM would review the weekly weight report and monitor trend and work directly with the RD. The DNS stated, if the resident was not consuming enough fluids per day or not eating enough solid food, the NA's should report poor intake to the nurse and the nurse should have followed-up and report the concerns to the RD and MD. The DNS further stated, resident's that are high risk for nutrition and hydration decline including resident's with weight loss and poor intake should have been seen and evaluated by the RD at least quarterly and until they are stable. RESIDENT 45 Resident 45 was admitted to the facility in (YEAR) with multiple medical [DIAGNOSES REDACTED]. An annual MDS assessment, dated 08/02/18, indicated the resident needed extensive assistance from one staff for eating, and noted the presence of a stage one pressure ulcer. A full assessment was completed on 09/18/18 after a significant change in condition was identified. On 11/04/18 at 9:00 a.m. during the breakfast meal service, Resident 45, was observed sleeping in bed. Staff BB, reported Resident 45's usual routine, included sleeping until about 10:00 a.m., after arising breakfast was provided. On 11/04/18 at 11:15 a.m., Resident 45 was observed seated at the dining room alone. The resident had been served breakfast, which was on a plate at the table with several glasses of fluid with straws. When greeted the resident stated I am a little behind and was observed to eat very slowly. Although the staff was in close proximity to the dining area, Resident 45 did not receive assistance or cueing with the breakfast meal. On 12/11/18 between 12:10 p.m. and 12:40 p.m. Resident 45 was observed with a plate of food and three glasses of fluids with straws at the table setting. The resident was observed sleeping intermittently throughout the meal and consumed less then half of the meal served. An unnamed staff member was seated at the same table assisting another resident but was not observed to cue or assist Resident 45. The resident would intermittently awaken, and take bites of food from the plate or a drink and then doze off to sleep through out the observation period. Review of Resident 45's weight history showed the resident had experienced weight loss. The record identified a significant weight loss of 12.5 lbs (or > 7.5 % ) between 08/21/18 and 10/30/18. The weights were documented as follows: 08/21/18: 162 lbs 09/25/18: 154 lbs 10/30/18: 150 lbs 11/13/18: 149 lbs 11/27/18: 148 lbs 12/04/18: 147 lbs On 12/04/18, the resident weight was 147 lbs, and the weight record identified, each of the weights record as a significant weight loss of 7.5 %. According to the nutrition policy and algorthym to address weight loss should have been assessed for causes and or contributing factors, however the last dietary assessment was dated 10/22/18. A Quarterly Nursing Review, dated 10/01/18, identified the resident had a history of [REDACTED]. Which noted a gradual weight loss of 15 lbs over a six month period. The care plan noted the resident was at risk for alteration in in nutritional status, was provided a regular diet with meat cut up, thin liquids, and identified the resident was provided supplements 4 times a day. The identified goals including stable weight (160 lbs plus of minus 5 lbs) and improved nutritional status as demonstrated by wound healing. A dietary assessment dated [DATE], coincided with the significant change in condition assessment, and had been identified with a stage IV pressure ulcer. The RD noted the resident weight was 157 which was within the goal weight. The recommendations at the time were to continue with the current interventions and offer supplements with medication pass, and health shakes to increase calorie intake. Another dietary assessment, dated 10/22/18, noted a decline in BMI to 18.5, which the clinician noted less then 18.5 was described as Cachexia. (Cachexia is a condition which is characterized as weight loss, wasting of muscle, loss of appetite, and general debility. ) The dietician recommended the addition of a protein supplement two times a day to aid in wound healing. The Medication Administration Record (MAR), for (MONTH) (YEAR) noted the protein supplement was given two times a day as ordered and health shakes were provided two times a day with breakfast and lunch. Although the MDS assessments documented the resident needed extensive physical assistance from staff for eating, the care plan described assistance with meals as setup/cues /supervision with eating. (The care plan was last revised on 09/13/18.) RESIDENT 90 Resident 90 was last re-admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The comprehensive MDS assessment, dated 07/18/18, noted the resident had a significant change in condition, and had declined in the ability to participate in activities of daily living,(i.e. dressing, grooming, hygiene, and eating.) The assessment noted the resident was provided with set up and cueing for meals. The next quarterly MDS dated [DATE], noted a decline in the ability to eat and needed extensive assistance to eat. During observation on 12/04/18, Resident 90 was sleeping at the DR table with a breakfast meal on the table, less then 1/4 of food served had been consumed. On 12/04/18, between 12:10 p.m. and 12:37 p.m., Resident 90, was seated in the dining room for lunch. No staff members were observed to provide verbal or physical assistance. The resident was eating canned pears from a dessert cup, using her fingers to scoop the item from the desert dish. After the resident left the table, 3/4 of food offered remained on the plate. On 12/11/18 during observations of the noon meal, Resident 90 was seated at the dining room table sleeping in a wheelchair . At approximately 12:13 p.m., Staff GG, a Registered Nurse, approached the table and verbally cued Resident 90 that her lunch was ready, and asked if she needed the meat cut. The resident opened her eyes and replied yes; the staff then adjusted the resident's chair to sit closer to the table. The resident then picked up a spoon and placed it into her coffee cup, and took a small sip of the liquid, and then picked up her fork and placed it on her plate, but was not able to get food on to the utensil. The resident then picked up the coffee mug to take a drink, and set it in the center of the plate of food. An unnamed staff, a NA, then approached the table, moved the coffee cup off of the plate surface. The NA speared food with the fork, placed it on the plate, and cued Resident 90 to eat. The resident readily consumed the food from the fork, and the staff then walked away from the table. The resident was then observed using her fingers to eat. At the end of the meal, Resident 90 had consumed less then 50% of foods offered at the meal. The weight history revealed the following: 08/28/19 105 lbs 09/27/18 104 lbs 10/29/18 100 lbs 11/05/18 98 lbs 11/12/18 99 lbs 11/19/18 98 lbs 12/10/18 98 lbs 12/17/18 97 lbs The weight history showed a significant weight loss of 8 lbs weight loss (or 7.5% loss of body weight) when comparing the (MONTH) weight to the December. The electronic weight record identified each weight recorded in the record after 10/29/18, as a significant weight loss. The last review by Staff I, the RD, was dated 10/15/17, which coincided with the last quarterly MDS assessment. The assessment noted the resident's weight was 100 lbs, and below the goal weight of 109 lbs., plus or minus five pounds. The RD noted the BMI was 17.7, which was described as Cachexia. The assessment indicated the resident received med pass 2.0 two times a day (nutritional drink), which was accepted in variable amounts, and noted the resident should be offered a Magic cup nutritional supplement daily with dinner. The assessment adjusted the goal weight to 105 lbs. plus or minus five pounds. Review of care plan interventions indicated Resident 90 was provided 120 cc's of Med Pass 2.0 twice a day for caloric and protein support (initiated 10/15/18), identified the resident liked toasted raisin bread with jelly at breakfast and might request it at other times, received a Magic cup nutritional supplement at dinner, staff provide set up assistance and encouragement in the dining room, and noted the resident kept snacks in the night stand drawer in her room. On 12/13/18 at 1:30 p.m., the Registered Dietitian, Staff I was interviewed. Staff I stated she was not alerted that Resident 90 was losing weight. After reviewing the (MONTH) (YEAR) MAR, Staff I reported the resident was refusing the supplement. Staff I looked back at the monthly MAR's, found Med Pass 2.0 had been in place since (MONTH) of (YEAR). The review of the MAR for (MONTH) (YEAR) showed the resident had accepted Health Shakes (a different supplement) in the past. Resident #112 Resident 112 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. On 12/03/18 between 12:00 p.m. and 12:20 p.m. during observation of the noon meal, Resident 112 was observed wandering in the common area, adjacent to the dining room. When asked if Resident 112, had eaten, Staff WW stated the staff had attempted to get the resident to eat, however the resident was not interested. The resident was frequently observed wandering in the common area and/or dining room during the meal service. Staff I, reported the resident would frequently wander and was difficult to redirect. The weight history revealed the following: 10/31/18 134 lbs 11/05/18 130 lbs 11/26/18 127 lbs 12/04/18 125 lbs 12/10/18 123 lbs The weight history showed, an 11 lbs (or 8.5 % of body weight) weight loss since admission. The electronic record identified the weights recorded on 11/26/18 and 12/10/18 were identified as a significant weight change. Review of the RD assessment dated [DATE], identified the resident was on a regular diet, and needed extensive assistance with meals. The assessment identified Resident 119 with poor hand and mouth coordination, forgets to eat, and noted feeds self with cueing. The care plan goal was to maintain weight 134 plus or minus five (lbs); and directed staff to continue current care plan. The care plan noted the goals described above and identified the following interventions: Fluids encouraged between meals, offer finger foods, snacks, fresh fruits, and vegetables (which were a resident preference), and dines in common area with set up and extensive assist. Although the weight history identified a significant weight loss, the facility had not alerted Staff I, RD, of the weight change. By not ensuring an RD referral was made to reassess Resident 112, after significant weight loss was identified, resulted in additional weight loss. On 12/13/18 at 1:30 p.m., the Registered Dietitian, Staff I was interviewed about the referral process. Staff I reported she had not received a referral to review Resident 45 or 90 for weight loss. On 12/13/18, at 3:00 p.m., the Resident Care Manager (RCM) assigned to the Dementia Special Care Unit (where residents 45, 90 and 112 resided) Staff FF, was interviewed. When asked about how referrals to the Registered Dietitian when significant weight loss is identified. Staff FF, reported the electronic weight history identifies when significant weight loss occurs, open and displayed Resident 45's weight history, which was cued 5 times for significant weight loss since 10/20/18. Staff FF acknowledged, she had not referred the residents to the RD after the significant weight loss occurred. During a meeting on 12/14/18 at 2:03 PM with the Administrator, the Director of Nursing (DNS) and another surveyor, the DNS stated, the resident weights were monitored by the RCM and the RD. According to the DNS, the RCM would review the weekly weight report and monitor trend and work directly with the RD. Reference (WAC) 388-97-1060 (3)(h)(i)

Based on interviews and record review, the facility failed to ensure there was sufficient numbers of nursing staff to provide care and services or provide adequate supervision to prevent accidents. The facility failed to meet the needs or wants of the residents, failed to ensure all residents receive showers, failed to answer call lights were answered timely, and ensure residents were assisted to the bathroom, failed to have enough staff to have consistent clinical systems in place to identify skin issues, bowel and bladder issues, supervision of restorative assessments/programs. These failures caused harm for residents, placed residents at risk for unmet care needs and caused negative outcomes. Finding Included: Facility Assessment The facility assessment (FA) was reviewed on 12/07/18 at 10:31 AM. The FA had a revision date of (MONTH) (YEAR). The FA indicated under Resident Profile the facility was licensed for 211 beds and budgeted to care for 143 residents. The FA also indicated the daily, average census was 152, which was 9 over what the facility determined they were budgeted for. The FA indicated the building had 3 units that housed residents: The Transitional Care Unit (TCU) that could house 35 residents. The Memory Care Unit that could house 22 residents. The 2 Long Term Care units that could house 100 residents. Which totaled 157 residents, and which was 14 over the 143 the facility documented it was budgeted for. The assessment indicated the TCU unit cared for residents with more needs for intravenous (IV) medications, high frequency and extensive therapy services as well as more frequent wound care treatments. The rest of the population in all of the other units had higher needs in activities of daily living (ADLs). The FA indicated the staffing plan was the general pattern, to ensure that you have, sufficient staff to meet the needs of the resident at any given time. The FA indicated the facility needed: 47 to 50 nursing assistants (NACs) per 24 hours 3 bath aides (BA) per 24 hours and 2 restorative aides (RA) per 24 hours. The facility did not document on the FA, of how, when, where, it would increase or decrease staffing to ensure residents received consistent services, or what formula they used to determine these numbers met the needs of the residents. There was no evidence the resident's concerns were taken into consideration and no evidence that facility incidents or past injuries were considered. Staffing Patterns On 12/3/18, the Director of Nursing (DNS) submitted a 15-day, actual staffing pattern dated 11/19/18 to 12/4/18. The staffing coordinator submitted a second document for the same timeframe. The documents showed: On Monday, 11/19/18, the facility had 49 NACs for a census of 153. The staffing coordinator (SC) documented there were 50 NACs Two RAs were pulled to the floor that day On Tuesday, 11/20/18, there were 46 NACs, for a census of 149. The SC documented there were 44 NACs. Two RAs and a Bath Aide were pulled to the floor. On Wednesday, 11/21/18, the facility had 49 NACs for a census of 148 The SC documented there were 49 NACs There were 3 identified incidents that day, 3 falls. 2 logged 1 not logged. On Thursday, 11/22/18, the facility had 50 NACs for a census 148 The SC documented there were 50 NACs On Friday, 11/23/18, the facility had 47 NACs for a census 148 The SC documented there were 46 One RA was pulled to the floor. On Saturday, 11/24/18, there were 44 NACs, for a census of 152 The SC documented there were 45 NACs One RA was pulled to the floor. There were 4 incidents reported that day, 2 falls, and 2 allegations of neglect. The Census was higher at 152 yet there were less NACs on for this day. On Sunday, 11/25/18, there were 40 NACs, for a census of 151 The SC documentation showed there were 39 NACs that day. One RA was pulled to the floor. There were 5 identified incidents that day, 2 falls, 1 skin tear & 2 residents found with a bruise. On Monday, 11/26/18, there were 45 NACs for a census of 153. The SC documented there were 44 NACs. Two RAs and a BA were pulled to the floor. There were 3 reported falls that day. On Wednesday, 11/28/18, there were 45 NACs for a census of 150. The SC documented there were 45 NACs. One RA was pulled to the floor. There was 2 falls reported that day. On Thursday, 11/29/18, there were 47 NACs for a census of 149. The SC documented there were 49 NACs There were 5 falls that day. On Friday, 11/30/18, there were 47 NACs for a census of 148. The SC documented there were 48 NACs. On Saturday, 12/1/18 there were 49 NACs for a census of 147 The SC documented there were 49 NACs. One RA was pulled to the floor. On Sunday, 12/2/18, there were 46 NACs, for a census of 149 The SC documented there were 46 NACs. One RA was pulled to the floor. On Monday, 12/3/18, there were 46 NACs for a census of 147 The SC documented there were 46 NACs. On all days, of the staffing pattern, there were more residents than the 143, the facility indicated they were budgeted for. There was no consistency to the staffing pattern. The pattern showed that on some days the facility had less residents, yet they were staffed with more NACs. On days when there were more residents they staffed with less NACs. There was no evidence of consistent staffing and on the days the Restorative staff were being pulled to the floor, no one covered their work. A review of the SC documentation for Restorative Aides (RA) and Bath Aides (BA) scheduling from 10/1/18 to 10/31/18 showed on: On 14 days in October, the RA staff were pulled to work on the floor On 3 days in October, the BA staff were pulled to work on the floor From 11/1/18 to 11/30/18 On 17 days in November, RA staff were pulled to work on the floor On 4 days in November, BA staff were pulled to work on the floor From 12/1/18 to 12/10/18 For 5 of the 10 days in December, RA staff were pulled to floor For 1 of the 10 days in (MONTH) the BA staff were pulled to floor Review of the Grievance log showed that in October (YEAR) there were 42 grievances submitted November (YEAR) there were 10 grievances submitted During a review of the incident log showed that in: August (YEAR), there were: 28 falls, 1 elopement, 9 residents with bruising, 4 self-inflicted injuries, 2 skin tears September (YEAR), there were: 23 falls and 4 self-inflicted injuries October (YEAR), there were: 19 falls, 8 with injuries and 1 allegation of abuse November (YEAR), there were 29 falls, 8 with injuries, 5 reports of bruising, 1 resident-to-resident altercation There was no evidence to show the facility was staffed sufficiently to prevent all of the above incidents. In an interview on 12/03/18 11:55 AM, Resident 89 stated she can no longer walk because nobody has helped her get up and walk. She stated my legs are just weak and I would love to get up and walk. I am just stuck in bed getting weaker and weaker. In an interview on 12/03/18 at 02:49 PM, Resident 21 stated I fell going to the bathroom. I believe I tripped. I sat down for a long time before somebody got me. I cannot get any help at that time. They close the door. In an interview on 12/04/18 at 10:14 AM, Staff M, LPN was asked how many NACs worked on the memory care unit and she stated 2, asked if she feels there is sufficient NACs for her to be able to get her work done and she stated No, there is never enough staff . During a meeting with 11 resident council members on 12/4/18 at 10:15 AM. The group voiced concerns and agreed there was not enough staff to answer call lights timely, especially during shift change, getting up times and on the weekends (there are no administrative staff available) We deserve the same service every day, it is different on weekends and nights. They also stated there is not enough help in the dining rooms during meal times. In addition, the residents complained of not getting showers or restorative services because the shower aids and restorative aids are pulled to work on the floor. They stated staff turn off the call lights and say I'll be back and never return. These concerns are brought up at Resident Council but not resolved. They do call light audits, but if NAs are turning off the lights and leaving, audits are not going to show this. The Administrator does not resolve the issues. The Resident Council statement through review of the minutes were verified. In an interview on 12/04/18 at 10:12 AM, Resident 146 stated I fell going to the bathroom. I tried to call and use my call light, but no one came for almost 30 minutes so I tried to go by myself. I know I shouldn't but I have no choice. You either risk yourself falling or having accidents in your bed. I decided I could go on by myself but I guess I can't. In an interview on 12/06/18 at 11:11 AM, Staff EE, NAC stated Resident 97 frequently uses the bathroom by herself although she is a one-person assist. Staff EE also stated she tries to watch her as much as possible, whenever she can, but it not always possible. In an interview on 12/07/18 at 2:31 PM, Staff GG stated there were 2 full time Restorative Aides and 1 part time weekend restorative aid. She stated that she was constantly pulled from restorative duties to help with resident care, and therefore residents were not getting the restorative they need. She stated at one point there were 4 full time restorative aides but when the census went down they dropped down to two. She stated the census has since gone up, but they have not seen an increase in restorative staff to meet the resident needs. She stated they have communicated this concern to their supervisor, but have not seen any changes in restorative staffing. She stated sometimes I cannot get to everyone, but I do the best that I can do. In an interview on 12/07/18 at 2:33 PM, Resident 58 and his spouse stated that the biggest concern is the resident does not qualify for skilled rehab, and is paying privately. He is supposed to be receiving restorative rehab by the aides. The spouse and resident both stated this is not happening, due to staffing shortages. They said he is maybe getting 1 to 2 sessions in a week and that is not nearly enough. The spouse stated that his muscles are atrophying due to this and he is less strong than before. He is weight bearing and should be doing restorative rehab. In an interview on 12/12/18 at 1:36 PM, Resident 58's physician with Kaiser Permanente, stated, I am writing another order for a restorative program. I spoke with the resident and his spouse, they stated he is not receiving restorative rehabilitation from the facility. When patients are located in the TCU there are no restorative aides assigned over there. In an interview on 12/12/18 at 1:43 PM, Staff NN, the minimum data nurse (MDS) stated we do not have a set restorative nurse over the program. I am not over the restorative program. The process, for a long time, was the Staff Development Coordinator (SDC) was over the program, but then we lost her. I input on the care plan the number of days the resident is to receive restorative but I do not put the day of the week because the RA's often are called off restorative and need to work the floor. 12/13/18 09:05 AM - Interview and record review with Staff BBB, Dining room server, there are 8 more residents that weren't serve breakfast. Per Staff BBB, this situation happened 2-3 times a week. The staff are so busy and sometimes, no staff or short. In an interview on 12/17/18 at 3:09 PM with the Administrator and the Director of Nursing (DNS), the Administrator stated, as for staffing, they will look at the staffing numbers to determine need for staff. The DNS stated the NAC/resident ratio is low. During an interview on 12/17/18 at 03:55 PM, the Administrator and Staffing Coordinator stated staffing needs are based on resident needs. The SC stated on the TCU staffing is census based and is constant everywhere else. He stated there has been a lot of pulling of care staff especially RA's to perform regular NAC duties due to related to turnovers, call in's and loss of on call staff. For further information in regards to low staffing Refer to F 684, CFR 483.25, Quality of Care; The facility failed to provide care that would prevent, monitor and treat skin breakdown which resulted in harm to 4 residents (6, 21, 48 & 107) Refer to F 686, CFR 483.25 (b)(1), Treatment/Services to Prevent/heal Pressure Ulcers; The facility failed to have a clinical system in place that followed standards of practice to identify risk factors and prevent pressure ulcers. This resulted in harm to 5 residents (6, 30, 107, 86, 45) and impacted 3 others, (62, 103 & 140) Refer to F 688 restorative; 483.25(C)(3) The facility failed to ensure there was a structured nursing restorative program that had consistent oversight of a licensed nurse to thoroughly assess the functional ability of residents and monitor the program. This caused negative outcome to 1 resident (58) who had a decline and affected 4 other residents with the potential to affect all 48 resident who were identified to be on restorative programs. (Residents 45, 58, 89, 90) Refer to F 689 CFR 483.25 (d)(2), Accidents/Supervision; The facility failed to have enough staff to keep all residents safe and free from accidents. Resident 97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Minimum (MDS) data set [DATE] the resident scored a 6 on the Brief Interview for Mental Status (BIMS), which indicated cognitive impairments. A facility fall risk assessment reviewed dated 10/25/18 identified the resident as a high risk for falls. Record review showed that staff was aware that Resident 97, was confused and would fall asleep in her wheel chair and self-transfer self to toilet. After the fall the facility's inaction to prevent another fall. Including not assessing the wheel chair, not providing increased supervision or documenting increased supervision, resulted in an immediate jeopardy. During a review of the incident log showed that in: August (YEAR), there were: 28 falls, 1 elopement, 9 residents with bruising, 4 self-inflicted injuries, 2 skin tears September (YEAR), there were: 23 falls and 4 self-inflicted injuries October (YEAR), there were: 19 falls, 8 with injuries and 1 allegation of abuse November (YEAR), there were 29 falls, 8 with injuries, 5 reports of bruising, 1 resident-to-resident altercation Refer to F 690, CFR 483.25 (e)(2) Bowel Bladder / Incontinence; The facility failed to comprehensively assess and ensure residents received appropriate care and services necessary to maintain, improve and/or avoid loss of bowel and bladder functions. This resulted in harm for 5 residents (Residents 3, 21, 48, 86 & 146) Refer to F 692, CFR 483.25 Nutrition/hydration status maintenance; The facility failed to comprehensively assess and initiate interventions as needed to prevent significant weight loss. These failures caused harm to 6 residents who had unplanned weight loss (Residents 48, 107, 45, 6, 90 & 112) Refer to F 697, CFR 483.25(k) Pain management; The facility failed to ensure a pain management regime was provided and consistent with professional standards of practice. This caused harm to 3 residents. (Residents 6, 48 & 107) WAC 388-97-1080 (1), 1090 (1)

Based on observation, interview and record review, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements related to sufficient staffing resulting in neglect, lack of supervision resulting in accidents, not responding to resident group/grievances, lack of oversight related to quality of care including skin assessments, restorative programs, bowel and bladder assessments, failed to ensure previous citations were not repeated. Failure to provide oversight resulted in an Immediate Jeopardy (IJ) on 12/06/18 for Accidents Hazards/Supervision/devices, which had the potential to endanger the residents' safety and quality of life and had the potential to affect all residents. A written plan to remove the IJ was accepted on 12/07/18. The administration failed to ensure the facility was in compliance with regulatory requirements (see below). This failure represented a pattern and/or widespread deficiency, in the following requirements. This is a repeat citation from 9/26/18. Findings included: Refer to F 565 CRF 483.10(f)(5) Resident Council The facility failed to take action or respond to the resident council members concerns. During a meeting on 12/4/18 at 10:15 AM, 11 resident council members voiced concerns and agreed there was not enough staff to answer call lights timely, especially on the weekends and nights. They also stated there is not enough help in the dining rooms during meal times. In addition, the residents complained of not getting showers or restorative services because the shower aids and restorative aids were pulled from providing Restorative services, to work on the floor. These concerns affected 11 residents and had the potential to impact every resident in the facility (Residents 10, 11, 16, 23, 27, 57, 63, 71, 73, 84 and 121) Refer to F 684, CFR 483.25, Quality of Care; The facility failed to provide care that would prevent, monitor and treat skin breakdown which resulted in harm to 4 residents (6, 21, 48 & 107) Refer to F 686, CFR 483.25 (b)(1), Treatment/Services to Prevent/heal Pressure Ulcers; The facility failed to have a clinical system in place that followed standards of practice to identify risk factors and prevent pressure ulcers. This resulted in harm to 5 residents (6, 30, 107, 86, 45) and impacted 3 others, (62, 103 & 140) Refer to F 688 restorative; 483.25(C)(3) The facility failed to ensure there was a structured nursing restorative program that had consistent oversight of a licensed nurse to thoroughly assess the functional ability of residents and monitor the program. This caused harm to 1 resident (58) who had a decline and affected 4 other residents with the potential to affect all 48 resident who were identified to be on restorative programs. (Residents 45, 58, 89, 90) Refer to F 689 CFR 483.25 (d)(2), Accidents/Supervision; The facility failed to have enough staff to keep all residents safe and free from accidents. This caused an immediate jeopardy for Resident 97 and had the potential to affect all residents. Resident 97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Minimum (MDS) data set [DATE] the resident scored a 6 on the Brief Interview for Mental Status (BIMS), which indicated cognitive impairments. A facility fall risk assessment reviewed dated 10/25/18 identified the resident as a high risk for falls. Record review showed that staff was aware that Resident 97, was confused and would fall asleep in her wheel chair and self-transfer self to toilet. After the fall the facility's inaction to prevent another fall. Including not assessing the wheel chair, not providing increased supervision, or documenting increased supervision, resulted in an immediate jeopardy. During a review of the incident log showed that in: August (YEAR), there were: 28 falls, 1 elopement, 9 residents with bruising, 4 self-inflicted injuries, 2 skin tears September (YEAR), there were: 23 falls and 4 self-inflicted injuries October (YEAR), there were: 19 falls, 8 with injuries and 1 allegation of abuse November (YEAR), there were 29 falls, 8 with injuries, 5 reports of bruising, 1 resident-to-resident altercation Refer to F 690, CFR 483.25 (e)(2) Bowel Bladder / Incontinence; The facility failed to comprehensively assess and ensure residents received appropriate care and services necessary to maintain, improve and/or avoid loss of bowel and bladder functions. This resulted in harm for 5 residents (Residents 3, 21, 48, 86 & 146) Refer to F 692, CFR 483.25 Nutrition/hydration status maintenance; The facility failed to comprehensively assess and initiate interventions as needed to prevent significant weight loss. These failures caused harm to 6 residents who had unplanned weight loss (Residents 48, 107, 45, 6, 90 & 112) Refer to F 697, CFR 483.25(k) Pain management; The facility failed to ensure a pain management regime was provided and consistent with professional standards of practice. This caused harm to 3 residents. (Residents 6, 48 & 107) Refer to F 745, CRF 483.35, Sufficient Nursing Staff; The facility failed to provide adequate staff to meet and provide the basic needs of the residents or ensure services were provided to keep all residents at their highest practicable, physical, mental and psychosocial well-being. Review of the (MONTH) (YEAR) Resident Council minutes showed that the Grievance officer for the building was the Administrator for resolution of concerns. The residents complained that call lights were not being answered timely and residents did not feel there was enough staff to meet their needs, by being taken back to rooms timely, showers, call lights. The Administrator signed off on the minutes monthly, but the same issues were brought up again consistently for the next month. Administration did not follow through to correct the problem. The same concerns were voiced every month from (MONTH) to (MONTH) and were not resolved. During the Resident council meeting on 12/11/18, the residents stated they did not feel the facility was following up on their concerns. Review of the (MONTH) (YEAR) Grievance log showed a resident complained of long wait for call lights. The same grievance was submitted for every month there after until (MONTH) of (YEAR). The Administration did not follow up or resolve grievances, even though they were related to staffing and documented the concern was resolved. The Administration has not consistently been overseeing nursing staff to ensure there is enough staff to answer call lights and provide needed every day care. The lack of administrative oversight has led to short staffing which has led to residents not getting showers, receiving restorative, lack of pain management, and lack of or ineffective policies for skin. During a Quality Assurance interview on 12/17/18 03:49 PM the Administrator was asked about how the facility staff had been trained in regards to the new regulations . The Administrator stated leading age had supplied the Resident Care Managers, Social Service Director, Staff developer education materials and other key individuals. She stated there was no sign in sheet and did not have a copy of the materials that were given. WAC: 388-97-1620(1)

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance Program (QAA) that identified deficiencies, and implemented appropriate preventative or corrective actions. The facility's QAA program failed to timely recognize already compromised care and services that resulted in the severity of harm, immediate Jeopardy (IJ), as well as a potential for a pattern of resident harm. Findings included: Free from Abuse and Neglect (Please refer to F600) The facility failed to recognize and/or address ongoing staffing issues, did not have clinical systems in place to identify or manage risk factors of conditions, implement proactive measures to avoid complications of infections, which demonstrated a pattern of allowing neglect and the inaction and serious disregard for consequences reviewed for abuse, prevention of pressure ulcers, accidents/hazards, bowel and bladder care, nutritional care, pain management, dementia care, restorative services and sufficient staffing. Quality of Care (Please refer to F684) The facility failed to prevent, comprehensively assess, monitor and treat non pressure related skin breakdown. As well as failed to ensure timely update & review for certification for comprehensive set of services identified and coordinated by an interdisciplinary group to provide for needs of a resident on hospice, as delineated in a specific patient plan of care. Treatment/Services to Prevent/Heal Pressure Ulcers (Please refer to F686) The facility failed to comprehensively assess the increased risk for skin breakdown and follow written policy and procedures, failed to develop and implement timely interventions necessary to prevent the development of avoidable pressure ulcers In an interview on 12/17/18 at 3:28 PM, the DNS stated the nurses would do a head to toe skin assessment weekly as they were not documented by LN's that were previously being done by the nursing assistant. She stated this plan was going to be presented to the QAA that a Licensed Nurse's would be overseeing skin issues. She stated more oversight will be placed over the nurse, skin checks and assessments would start immediately and ongoing. Free Of Accident Hazards/Supervision/Devices (Please refer to F689) The facility failed to provide effective monitoring, supervision and implement adequate fall interventions to prevent resident (97) from future falls, after a resident fell face forward after falling asleep in her wheelchair and sustained a head injury. This failure placed the resident at risk for falls with serious injuries or death thus resulting in an immediate jeopardy (IJ) that was called on 12/06/18. Bowel and Bladder Incontinence (Please Refer to F690) The facility failed to comprehensively assess and ensure 5 of 6 residents (146, 21, 86, 48 and 3) received appropriate care and services necessary to maintain, improve and/or avoid loss of bowel and bladder functions. These failures caused harm to Resident 146, 21, 48, 86 and 3 who suffered harm in the form of anger, self-humiliation and had contributed to the development of skin breakdowns, bladder infections and pain. The facility's failure to have a written policy and procedures related to bowel and bladder assessments and lack of written directive to staff placed all 150 residents of the facility at risk for harm and diminished quality of life. Nutrition/Hydration Status Maintenance (Please Refer to F692) The facility failed to comprehensively assess and initiate interventions as needed to prevent significant weight loss. Sufficient Staffing (Please refer to F725) The facility failed to ensure the facility had a sufficient number of nursing staff to provide care and services to provided adequate supervision to prevent accidents, to meet the needs or wants of the residents, failed to ensure all residents receive showers, that call lights were answered timely, and ensure residents were assisted to the bathroom, failed to have enough staff to have consistent clinical systems in place to identify skin issues, bowel and bladder issues, supervision of restorative assessments/programs. In an interview on 12/17/18 at 3:09 PM, the DNS stated the QAA met monthly, or sometimes daily and stated they reported on skin issues, urinary tract infections [MEDICAL CONDITION], other infections and quality measures. She stated they were working on the Restorative program, documentation and skin. She stated they will be looking into getting more information to mitigate the concerns brought forward and as for staffing, they would be looking at the staffing numbers to determine the need for staff and implementing evening programs. She also stated education will be implemented for nursing not to change staffing numbers such as pulling Restorative Aides away to do care. Summary The current facility QAA/QAPI process failed to identify critical areas of care that were ultimately elevated to the level of harm and immediate Jeopardy (IJ). The DNS and the Administrator stated what they were going to do moving forward to address the concerns. The DNS also stated she would be looking into getting more information to mitigate the concerns brought forward, however this showed the facility QAA/QAPI process evidently failed to provide early detection of these concerns. Reference (WAC) 388-97-1760 (1)(2)

Based on interview and record review, the governing body acted with disregard to the well-being of the residents of the facility, by not providing adequate oversight and monitoring of the appointed Corporate Officers/Administrator or the Director of Nursing. The governing body failed to recognize a pattern of widespread neglect by staff which resulted in harm to residents. The governing body failed to ensure clinical systems were in place and followed to prevent and monitor pressure ulcers, bowel and bladder programs, prevent weight loss. The governing body failed to ensure the Administrator staffed the building to meet the needs of the residents, so the residents received showers, restorative programs, call lights were answered timely, and residents were toileted timely. The governing body failed to ensure the administrator responded to resident council issues and or grievances. In addition, the governing body failed to ensure there was increased supervision to prevent accidents related to a fall, which led to substantial injury, with no preventative measures put in place, and created an immediate jeopardy situation for resident (97). These failures also resulted in harm to residents and had the potential to place residents at risk of negative outcomes. Findings Include: The undated Governance Policy indicated the facility was governed by it's Board of Directors which delegates responsibility for management of day-to day operations to the Corporate Officers who are appointed by the board. The Corporate officers include: 1. President and Chief Executive Officer 2. Vice President of Health Services and Nursing Home Administrator 3. Vice President and Chief Financial Officer 4. Vice President of Human Resources and Support Services. A Primary function of the Board is to provide strategic organizational direction and oversight of the President and Chief Executive Officer (CEO) to which it delegates administration and management of daily operations for the facility. The policy went on to say . With oversight from the CEO, the Vice President of Health Services/Nursing Home Administrator (NHA) assumes full legal authority and responsibility for the operation of the Skilled Facility. The NHA is responsible for assuring that all aspects of our Quality Assurance and Performance (QAPI) program are developed, implemented, and maintained. The governing body failed in its duties to recognize patterns of potential abuse and neglect by staff members as documented and reported in the resident council group meetings, which resulted in harm to residents in the form of fear, feeling of abandonment and neglected. Refer to F 565 CRF 483.10(f)(5) Resident Council The governing body failed to ensure action or a response was given to the resident council members concerns. During a meeting on 12/4/18 at 10:15 AM, 11 resident council members voiced concerns and agreed there was not enough staff to answer call lights timely, especially on the weekends and nights. They also stated there is not enough help in the dining rooms during meal times. In addition, the residents complained of not getting showers or restorative services because the shower aids and restorative aids were pulled from providing Restorative services, to work on the floor. These concerns affected 11 residents and had the potential to impact every resident in the facility (Residents 10, 11, 16, 23, 27, 57, 63, 71, 73, 84 and 121) Refer to F 610, CFR, 483.12, Investigate/Prevent/Correct Alleged Violation. The governing body failed to ensure investigation were thorough and accurate for 1 of 3 investigations reviewed for abuse and/or neglect (58). This is a repeat citation from 12/20/17, 03/14/18 and 09/26/18. Refer to F 684, CFR 483.25, Quality of Care; The governing body failed to ensure care was provided that would prevent, monitor and treat skin breakdown which resulted in harm to 4 residents (6, 21, 48 & 107) Refer to F 686, CFR 483.25 (b)(1), Treatment/Services to Prevent/heal Pressure Ulcers; The governing body failed to ensure the facility had clinical systems in place that followed standards of practice to identify risk factors and prevent pressure ulcers. This resulted in harm to 5 residents (6, 30, 107, 86, 45) and impacted 3 others, (62, 103 & 140) Refer to F 688 restorative; 483.25(C)(3) The governing body failed to ensure there was a structured nursing restorative program that had consistent oversight of a licensed nurse to thoroughly assess the functional ability of residents and monitor the program. This caused harm to 1 resident (58) who had a decline and affected 4 other residents with the potential to affect all 48 resident who were identified to be on restorative programs. (Residents 45, 58, 89, 90) Refer to F 689 CFR 483.25 (d)(2), Accidents/Supervision; The governing body failed to ensure the facility had enough staff to keep all residents safe and free from accidents. This caused an immediate jeopardy for Resident 97 and had the potential to affect all residents. Refer to F 690, CFR 483.25 (e)(2) Bowel Bladder / Incontinence; The governing body failed to ensure clinical systems were in place to comprehensively assess and ensure residents received appropriate care and services necessary to maintain, improve and/or avoid loss of bowel and bladder functions. This resulted in harm for 5 residents (Residents 3, 21, 48, 86 & 146) Refer to F 692, CFR 483.25 Nutrition/hydration status maintenance; The governing body failed to ensure nutritional support was in place to comprehensively assess and initiate interventions as needed to prevent significant weight loss. These failures caused harm to 6 residents who had unplanned weight loss (Residents 48, 107, 45, 6, 90 & 112) Refer to F 697, CFR 483.25(k) Pain management; The governing body failed to ensure there was a pain management regime that provided and was consistent with professional standards of practice. This caused harm to 3 residents. (Residents 6, 48 & 107) Refer to F 745, CRF 483.35, Sufficient Nursing Staff; The governing body failed to ensure there was adequate staff to meet and provide the basic needs of the residents or ensure services were provided to keep all residents at their highest practicable, physical, mental and psychosocial well-being. In Addition, the governing body failed to ensure the Facility Assessment addressed staffing needs of the facility. This had the potential to affect all of the residents in the facility. Refer to F 835, CFR 483.70, Administration The governing body failed to ensure the administrator effectively and efficiently managed facility compliance with federal regulatory requirements related to sufficient staffing resulting in neglect in restorative programs, bathing and the answering of call lights, lack of supervision resulting in accidents, not responding to resident group/grievances, lack of oversight related to quality of care including skin assessments, bowel and bladder assessments. In addition, the Administrator failed to ensure previous citations were not repeated. The governing body failed to ensure the facility had or maintained a Quality Assessment and Assurance Program (QAA) that identified deficiencies, and implemented appropriate preventative or corrective actions. The facility's QAA program failed to timely recognize already compromised care and services that resulted in the severity of harm, immediate Jeopardy (IJ), as well as a potential for widespread scope of resident harm. The Governing body failed to ensure repeat citations were corrected. Repeat Citations: Refer to F 610, CFR 483.12, Investigate/Prevent/Correct Alleged Violation, this is a repeat citation from 9/26/18. Refer to F 684, CFR 483.25, Quality of Care, this is a repeat citation from 9/26/18. Refer to F 689 Free of Accident Hazards / supervision/devices, this is a repeat citation from 8/20/18 Refer to F 697, CFR 483.25, Pain Management, this is a repeat citation from 3/14/18 Refer to F 835, CFR 483.70, Administration, this is a repeat citation from 9/26/18 Reference: WAC 388-97-1620 (2)(c)

Based on observation, interview and record review, the facility failed to comprehensively assess, failed to ensure pain management was provided consistent to professional standards of practice, facility policy and resident directed plan of care, and failed to develop effective pain management regime for 3 of 5 residents (48, 107, 6) reviewed for pain. These failures caused harm to Resident's 48, 107 and 6 who experienced uncontrolled pain and diminished quality of life. This is a repeat citation from 03/14/18. Findings included: According to the United States Library of Medicine National Institute of Health and National Center for Biotechnology Information (NCBI), Chronic geriatric pain may be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, for persons who are either aged (65 to [AGE] years old) or very aged (80 and over) and who have had pain for greater than 3 months. The consequences of this pain include impaired activities of daily living (ADLs) ambulation, and depression. Pain may also be related to complications associated with deconditioning, gait abnormalities, accidents, polypharmacy, and cognitive decline. The treatment of [REDACTED]. Without a thorough assessment, pain that is causing severe impairment may not be revealed for an array of personal, cultural, or psychological reasons. Evaluation of the patient's level of function is important as it affects the degree of independence, level of need for caregivers, as well as overall quality of life. Review of the facility's Pain Management policy dated (MONTH) 2014, stated, All residents will be assessed for pain, provided treatment for [REDACTED]. The policy directed facility staff to: 1. All residents will be assessed for pain or potential for pain on admission, in collaboration with all required MDS assessments, and when any new pain is reported by resident or observed by staff. 2. Any indication that the resident is experiencing pain will be followed by a comprehensive assessment by the LN and documented on the Comprehensive Pain Assessment form. 3. In addition, medication nurses assess residents each shift for indicators of pain using the 0-10 pain scale or Discomfort Indicator scale and document assessment and treatment effectiveness on the pain protocol sheet in the MAR. 4. MD/provider will be notified of any new onset of pain, or on-going unresolved pain. 5. Care plans will address individualized approaches/interventions to reduce pain. RESIDENT 48 Resident 48 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had mild cognitive impairment and needed 1 person assistance with transfers, toilet use, personal hygiene and 2 person assistance with bed mobility and bathing. Review of the resident's pain care plan created and initiated on 07/02/13 with the most recent revision on 09/14/17, stated, the resident had chronic pain related to [DIAGNOSES REDACTED]. The resident care plan was due for a review. The resident's pain interventions were last revised on 09/14/17. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) The resident's care plan directed the facility staff to: A. Provide small pillow to support right shoulder when the resident is in bed. B. Staff to report behaviors such as: increase anxiety, [MEDICAL CONDITION] and hypersensitivity to touch as this may indicate that the resident is in pain. During an observation and interview on 12/03/18 at 8:52 AM, the resident was observed to be tearful and screaming of pain. The resident stated, Please help me. Please God help me. Everything hurts. On the same day at 9:25 AM, the resident continued to scream and verbalized pain. The resident reported generalized pain and stated, Oh no, my leg, it hurts. The resident was tearful and was observed crying in bed. The resident was positioned flat in bed without any supporting pillow or small pillow to the right shoulder as directed by the resident's plan of care. During an observation and interview on 12/04/18 at 10:12 AM, the resident was observed in bed crying and tearful. The resident reported generalized pain and specific pain to both her shoulders, groin and buttocks area. The resident was positioned flat in bed without any supporting pillow or small pillow to the right shoulder as directed by the resident's plan of care. During a follow-up interview on the same day at 3:18 PM, the resident stated, her hemorrhoid really hurts. I am not able to sleep good at night and it wakes me up. The resident was grimacing and tearful during the interview. I am not enjoying my day at all. The resident added, If she had a bowel movement, her pain level is 10 (Pain scale of 0 for no pain and 10 for severe pain). During an observation and interview on 12/06/18 at 9:05 AM, the resident was observed crying and screaming of pain in her room. The resident reported severe pain to her buttocks area. The resident was positioned flat in bed without any supporting pillow or small pillow to the right shoulder as directed by the resident's plan of care. In an interview on 12/06/18 at 3:33 PM with Staff A, Nursing Assistant, (NA), stated the resident would scream and moan of pain every morning especially during pericare. Staff A stated, the resident's [MEDICAL CONDITION] was so bad as well as the resident's hemorrhoid. In an interview on 12/10/18 at 2:53 PM with Staff B, NA, stated it is normal for the resident to cry and scream of pain related to the resident's hemorrhoid. She's always been like this. In an interview on 12/10/18 at 2:56 PM with Staff C, NA, stated the resident usually cries and scream of pain related to her hemorrhoids. Staff C added, since she knew the resident, she would be crying and from time to time scream related to pain. When I provide care to her, she would hold my hand and tell me, please stay and don't leave me. In a follow up interview with Staff B, NA, on the same day at 2:58 PM, stated the resident would always scream and call out of pain on a daily basis. The resident would complain about her hemorrhoid and groin area. It is very bad. During a joint skin inspection on 12/11/18 at 1:58 PM with Staff D, Registered Nurse, (RN), the resident was observed with severe hemorrhoid, measured at approximately 4 centimeter (cm) in length and 4cm wide by Staff D, covering the anus. The resident was also observed with dark black, ashen gray colored [MEDICAL CONDITION] to the groin area extending to the pubis and to the labia. The resident was grimacing and complained of severe pain and sore on the above areas throughout the inspection process. In a follow-up interview on the same day at 2:10 PM with Staff D, stated, since she started working with the resident, the resident has been in pain. Staff D stated, the facility's Advanced Registered Nurse Practitioner (ARNP) just recently ordered for the resident to see the dermatologist and have a surgical consultation. Review of the resident's physician order [REDACTED]. The order was written on 12/04/18. However, the resident did not see any specialist until 12/14/18 (10 days after). Review of the resident's progress notes from 11/01/18 to 12/10/18, showed that the resident's lesion and hemorrhoid were described as tender to touch ., Right groin dark [MEDICAL CONDITION] and redness, tender to touch during care, right groin has suspected seborrheic [DIAGNOSES REDACTED]. Area painful to touch ., A/C (alert charting) redness swelling on right groin area ., hemorrhoid is about the size of a ping pong ball . The progress notes also documented, the resident was either yelling, screaming, and/or complained of pain. (Refer to F684 - Quality of Care for more information.) The progress notes dated 12/10/18 at 11:05 PM, documented, neighboring resident c/o (complaint of) resident calling out/moaning loudly during the day and night. Interviews on 12/12/18 at 1:06 PM, 1:12 PM, and 1:14 PM with other residents living in the same unit confirmed and validated the documented concerns for Resident 48's calling out/moaning loudly during the day and night. One resident stated, Resident 48 would scream and moan and would call for help, help me, help me, oh God, and she sounds to be in severe pain the way she called for help. It happened every night. Another resident stated, Resident 48 would call for help and scream all the time. She sounds to be in distress for sure. Another resident described the concerns as, Resident 48, screams and calls out for help almost every day and night. Resident 48 would say, oh God, oh God help me, or help me, help, I need help. The resident stated, It would last for a long time and she sounds in severe distress and pain. Review of the Physician order [REDACTED]. A. Pain Protocol every shift. Document every shift non-pharmacological interventions used during shift. Order initiated on 09/14/18. B. [MEDICATION NAME] 500 milligram (mg) tablet - give 2 tablet 2 times a day for pain/temp. Order initiated on 09/21/16 and revised on 12/04/18. C. [MEDICATION NAME] (Tylenol) 650mg three times a day and every 4 hours as needed. Order initiated on 12/04/18. D. [MEDICATION NAME] Cream 1% to anal area every 12 hours as needed for hemorrhoid pain. Notify provider if used more than 7 consecutive days. Order initiated on 08/27/18. E. [MEDICATION NAME] Patch 5% to right shoulder every evening. Order initiated on 09/21/16. F. [MEDICATION NAME] 10mg (a narcotic pain medication) daily. Monitor for any sign of pain. Order initiated on 08/04/17. Review of the Medication Administrator Record (MAR) and Treatment Administration Record (TAR) for (MONTH) (YEAR) showed the resident reported at least 21 days of pain from 11/01/18 to 11/30/18. The MAR showed no evidence that the facility had initiated/followed non-drug interventions specific and as directed by the physician's orders [REDACTED]. The TAR for (MONTH) (YEAR) documented the resident was only sleeping for an average of 5-6 hours per day. Review of the MAR and TAR for (MONTH) (YEAR) (12/01/18 to 12/12/18), showed the resident reported pain for at least 10 days. The MAR showed no evidence that the facility had initiated/followed non-drug interventions as directed as directed by the physician's orders [REDACTED]. The TAR for (MONTH) (YEAR) documented the resident was only sleeping for an average of 5-7 hours per day. The resident was receiving the scheduled pain medications as ordered. However, the record did not reflect/showed no evidence of documentations that the facility had consistently evaluated the effectiveness of the regularly scheduled pain medication on a routine basis. The pain medication orders were not clear and specific on when the staff should be giving the as needed [MEDICATION NAME] tablets instead of the narcotic pain medication ([MEDICATION NAME]). During an interview and record review on 12/12/18 at 1:38 PM with Staff E, Resident Care Manager, (RCM/RN), stated, the resident had no recent comprehensive pain assessment completed in the clinical record. Staff E stated, the most recent comprehensive pain assessment for Resident 48 was completed on 06/21/17. During an interview and record review on 12/12/18 at 2:03 PM with Staff F, Social Services, stated it would be hard to determine if the resident was experiencing behavior versus pain because there was no recent pain assessment in the clinical record. Staff F stated, there was no evidence in the resident's clinical record that the facility had ruled out pain and/or if the resident was just simply experiencing a behavior. During an interview and record review on 12/12/18 at 2:11 PM with Staff E, RCM, stated the resident had no recent comprehensive pain assessment in the clinical record and the resident was only sleeping 4-7 hours per day (2-4 hours at night). Staff E stated she was not able to determine if the resident was experiencing pain or if it was a behavior, because the resident pain has not been ruled out and the resident has reasons to be in pain. Staff E also stated, the resident was receiving the routine pain medication as ordered, but the facility had no way of evaluating the resident's routine medication if it was effective or not because the nurses do not have that option in PCC (Point Click Care). Staff E further stated, the resident's routine [MEDICATION NAME] and Tylenol should have a follow-up assessment to evaluate if it was effective or not. During an interview and record review on 12/13/18 at 8:06 AM with Staff G, Licensed Practical Nurse, (LPN), stated Resident 48 always screams in pain, I float here, but worked maybe 2-3 times per week but every time I worked with her, she screams of pain to her hemorrhoid and groin area. Staff G added, She does have behaviors of calling out, but you can see if she's in pain like today, she reported 10/10 pain. In an interview on 12/13/18 at 8:07 AM with a neighboring resident of Resident 48, stated, Resident 48 was her friend. She calls for help and scream of pain every night and every day. She would say, God, oh God, please help me, please help me. The neighboring resident further stated, she knew what's bothering her friend because staff had told her, Resident 48 had bad hemorrhoids . I know how bad it is. During a joint interview and observation on 12/13/18 at 8:09 AM with Staff G, LPN and Staff H, NA, the resident was observed during perineal care. Staff H stated, She cried all the time in pain and will call staff and God for help. Staff H added, the resident would say, help me God. During the observation, the resident reported severe pain and stated, She needed help and kept calling God for help to ease her pain. Staff G, stated the resident has always been like this every morning and the facility's nurse practitioner was aware of the resident's condition. Staff G further stated, she believed that the resident's medication was not enough to ease the resident's pain. During a meeting on 12/13/18 at 10:41 AM with Staff U, ARNP, and Staff I, Registered Dietitian, (RD), Staff U stated, she was not notified of the resident's uncontrolled pain and the resident's less hours of sleep. Staff U added, she was aware of the resident's hemorrhoids it's pretty big and I'm sure it's painful. Staff U further stated, she was not sure why the staff are not monitoring and evaluating the resident's routine pain medication for effectiveness. Staff U further stated, she was very concern about the resident's current condition so she would immediately check and follow-up with the resident today. Review of the ARNP visit note dated 12/13/18 at 1:51 PM, documented, Nurse Reports pt (patient) is c/o (complaining of) 10/10 rectal pain r/t (related to) her [MEDICAL CONDITION] hemorrhoids. Pain has been increasing over the last several days. Assessment and plan, documented, the resident's rectal pain has been escalating the last few days and today it was 10/10. Medication adjustments included changing the resident's routine [MEDICATION NAME] from 10mg every morning to 5mg three times a day given with additional [MEDICATION NAME] 650mg three times a day. ARNP documented, asked nurses to chart effectiveness of pain medications after administration. RESIDENT 107 Resident 107 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's admission MDS assessment dated [DATE], showed the resident had impaired cognition and needed two person assist with bed mobility, transfers and toilet use. Review of the resident's current care plan created and initiated on 10/30/18, showed the resident has no specific plan of care for pain that includes the resident's potential risk factors and /or current pain problems. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the resident's clinical records showed the resident's most recent comprehensive pain assessment was completed on 10/29/18. The pain assessment documented, no pain. Review of the Physician order [REDACTED]. A. Pain Protocol every shift. Document every shift non-pharmacological interventions used during shift. Order initiated on 10/29/18. B. Monitor pain every shift. C. [MEDICATION NAME] 650mg every 4 hours as needed for pain. Review of the resident's MAR and TAR for (MONTH) (YEAR), showed the resident reported and/or had documented new onset of pain beginning 11/16/18. The resident reported pain on a daily basis. Review of the Pain Protocol documentation for (MONTH) (YEAR), showed the resident received the following non-pharmacological interventions for: (code 1 = reposition, code 5 = rest) daily from 11/16/18 to 11/30/18. Review of the nursing progress notes from admission to 12/10/18, showed the resident had a change of condition and developed pneumonia (lung infection) on 11/12/18. The progress notes dated 11/26/18, showed the resident developed an in-house acquired pressure ulcer with full thickness skin loss and a Deep Tissue injury on 12/10/18. (Refer to F684 - Quality of Care and F686 - Treatment/services to prevent/heal Pressure Ulcers for more information.) The resident had a new onset of pain beginning 11/16/18. The resident had a change in condition and developed Pneumonia and pressure ulcers but the facility failed to comprehensively assess the resident's pain, failed to identify the root cause, failed to develop a person centered and individualized plan of care as directed by the facility policy. During an interview and observation on 12/10/18 at 10:19 AM, the resident reported severe pain to his legs, buttocks and back area. The resident was observed up on his wheelchair with facial grimacing. During an interview and record review on 12/10/18 at 10:24 AM with Staff E, RCM, stated the resident had no recent comprehensive pain assessment completed or documented in the clinical record. The resident's most recent comprehensive pain assessment was dated 10/29/18. During an interview and observation on 12/11/18 at 09:01 AM, the resident reported severe pain to his legs, buttocks and back area. The resident was observed sitting on his wheelchair. During an interview and observation on the same day at 11:15 AM, the resident was observed on the same position as above. The resident was observed trying to wheel himself out of his room calling for staff. The resident stated, I've been sitting here too long. The resident complained of pain to his tailbone and back area describing the pain as very bad including his legs. During a joint observation and interview on 12/11/18 at 11:25 AM with Staff K, NA, Staff L, NA, and Staff M, LPN, the resident was observed being transferred using a mechanical lift (Hoyer lift) device. The resident was screaming out in pain throughout the transfer process. The resident reported pain on his back and both legs. The resident stated, what makes the pain worse was positioning and moving his legs. The resident further stated, it hurts the most when staff open his legs to clean him, during positioning, and when staff turn him. Staff K, NA, stated, the resident has been like this complaining of pain every time she cared for him and since he knew the resident. According to Staff K, the nurses were aware of the pain problem for the resident and that he scream of pain every time we turn him or clean him. Staff M, LPN, stated she was aware of the resident's pain but there was no specific medication or treatment order for the resident's pain except the as needed Tylenol which was only given to the resident once for the month of (MONTH) (YEAR). The resident received perineal care and was observed with severe skin breakdown, open skin and redness to the groin and buttocks area. Each staff members stated, the resident's skin breakdown on his groin and buttocks area were not new and Staff K, stated she had putting the house cream to the resident's skin breakdown. The resident was screaming of pain throughout the observation, Aww, Aww, No, No, Oh, God. The resident stated, His legs hurts a lot. During a record review and interview on 12/11/18 at 11:48 AM with Staff M, LPN, stated, the resident's clinical record showed no evidence of any recent comprehensive pain assessment and/or person centered care plan specific for the resident's pain. Staff M stated, both (MONTH) and (MONTH) (YEAR) MAR and TAR, showed the resident complained of pain on a daily basis from 11/16/18 to 12/10/18 but there was no evidence that the resident's pain was followed-up on and that the resident's physician was notified of the resident's pain. In an interview on 12/11/18 at 1:27 PM, the resident's roommate stated, My roommate, Resident 107, he would scream out in pain every time they touch him. Oh yah, every day, all the time. In an interview on 12/12/18 at 1:56 PM with Staff N, NA, stated, he was very familiar with Resident 107 and he screams out in pain every time you move him. Staff N further stated, the resident would specifically complain of pain when you clean him and the pain was all over his legs. Review of the MAR and TAR for (MONTH) (YEAR), showed the resident continued to receive the following non-pharmacological interventions for: (code 1 = reposition, code 5 = rest) daily from 12/01/18 to 12/10/18 despite of the resident's complaint of pain when turning and repositioning. The resident had documented pain every day from 12/01/18 to 12/10/18. Review of the resident's clinical records from 12/01/18 to 12/10/18, showed no evidence that the facility had followed-up on the resident's complaint of pain, no evidence that a comprehensive pain assessment was completed and the doctor was notified, and no person centered and individualized plan of care was developed related to pain as directed by the facility policy. During a meeting and joint record review on 12/13/18 at 1:27 PM with Staff O, RN/admissions nurse and the facility's Medical Director, (MD), MD stated, the resident had pain every time you move him. He will always complain of pain. The MD stated, the facility's current non-pharmacological intervention (repositioning) was not appropriate because it could cause the resident to experience more pain, and she had recently prescribed a narcotic pain medication to effectively manage the resident's pain. Review of the resident's Physician order [REDACTED]. RESIDENT 6 Resident 6 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident had impaired cognition and needed 2 person assist with bed mobility, transfers and toilet use. Review of the resident's pain care plan initiated on 04/21/16 and revised on 05/22/17, showed the resident had pain related to arthritis, [MEDICAL CONDITION] joint disease of both knee and shoulder, and decrease ability to perceive pain due to [MEDICAL CONDITION]. The resident care plan was due for a review. The resident's pain interventions were last revised on 06/28/17. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) The resident's care plan directed the facility staff to: A. Assess pain medication effectiveness and report to MD (Medical Doctor). B. Monitor and report non-verbal signs and symptoms of pain, complaint of pain, changes in behavior (aggressive behavior, yelling, combative with care, irritability and unable to focus to task.) Review of the resident's most recent comprehensive pain assessment dated [DATE], showed the resident had chronic pain related to arthritis. Review of the Physician order [REDACTED]. A. Pain Protocol every shift. Document every shift non-pharmacological interventions used during shift. Order initiated on 01/28/18. B. [MEDICATION NAME] 1000mg three times a day for pain. C. [MEDICATION NAME] 650mg every 6 hours as needed for pain or fever. Review of the resident's MAR and TAR for (MONTH) and (MONTH) (YEAR), showed the resident reported pain on a daily basis. However, there was no evidence that the facility had followed up on and comprehensively assess the resident's pain. The resident was receiving the scheduled pain medications as ordered. However, the record did not reflect/no evidence of documentations that the facility had consistently evaluated the effectiveness of the regularly scheduled pain medication on a routine basis. During an observation on 12/12/18 at 2:28 PM, the resident was heard screaming and calling out in pain in his room. The door room was closed and the resident could be heard outside saying, Please help me, help. The surveyor knocked on the door and asked permission to come in. The resident stated, Yes, please come and help me. The resident was observed receiving perineal care from Staff Z, NA and was complaining of pain throughout the observation. During a join skin inspection and interview on 12/12/18 at approximately 2:29 PM with Staff E, RCM and Staff Z, NA, the resident was observed with severe excoriation and redness to the groin area, extending to the inner hip, buttocks and the resident's back. The resident was observed with 3 open areas with partial thickness skin loss. The resident stated, he had the redness and sore area for a while now. Staff Z also stated, the resident's redness on his groin area has been there for almost a week now and the redness and skin breakdown on the resident's back and buttock area had been there for almost 2 weeks. Staff Z further stated, the resident would scream of pain every time he change and care for him. The resident was screaming and had verbalized pain throughout the observation. During a joint interview and record review on 12/12/18 at 3:31 PM with Staff M, LPN, stated, the resident had no record of current skin breakdown as observed and no current treatment in place on the resident's clinical record. Staff M added, the resident had no specific pain medication regimen for the skin breakdown and no recent comprehensive pain assessment completed. Staff M further stated, the most recent pain assessment was completed 03/08/18, and the resident should have one completed at least every 3 months. (Refer to F684- Quality of Care and F686 - Treatment and Services to Prevent/Heal Pressure Ulcers for more information.) In an interview on 12/12/18 at 2:37 PM with Staff AA, ARNP, stated, she was just notified by the facility of the resident's skin breakdown today and was not aware of the resident's pain. During a joint skin inspection and interview on 12/12/18 at 3:39 PM with Staff AA, ARNP, Staff E, RCM, and another surveyor, the resident was observed with multiple skin breakdowns. The resident reported 10 out of 10 pain to the ARNP and the surveyors. In an interview on 12/12/18 at 4:01 PM with Staff V, LPN, stated, the resident was only on routine Tylenol but it was for Arthritis. Staff V further stated, Yes, he complain of pain a lot. Review of the nursing progress notes from 12/12/18 at 5:21 PM, documented, She (ARNP) was not able to measure the left buttock wound at this time since resident was yelling and complaining of generalized pain. Review of the subsequent progress notes for 12/13/18, showed the resident had a change of condition and shows signs and symptoms of shock (low blood pressure, elevated heart rate and fever). The resident was transported to the hospital at 3:45 AM via EMS (emergency medical services). Review of the Hospital's Emergency Department report dated 12/13/18, showed the resident was admitted to the hospital with [REDACTED]. During a meeting and joint record review on 12/13/18 at 1:27 PM with Staff O, RN/admissions nurse and the facility's Medical Director, (MD), MD stated, she was not aware of the resident's skin breakdown and pain problem until she was notified and was consulted by the ARNP on 12/12/18. During a meeting on 12/14/18 at 2:03 PM with the Administrator, the Director of Nursing (DNS) and another surveyor, the DNS stated, a comprehensive pain assessment should have been initiated upon admission, during change of conditions and the nurses should monitor the effectiveness of the pain medication given with every dose whether PRN (as needed) or routine. The DNS added, the facility had a specific pain assessment tool in PCC that the nurses should be utilizing for pain and not just in progress notes. The DNS further stated, she would expect a completed pain assessment for conditions such as hemorrhoids, [MEDICAL CONDITION], Moisture Associated Skin Damage and if the resident had a new onset of pain/reports of constant pain. The DNS stated, she would expect staff to notify the doctor for any new onset of pain and if the resident reports of constant pain. Reference WAC: 388-97-1060 (1)

Based on interview and record review the facility failed to follow Physician orders [REDACTED]. Additionally the facility failed to follow Basic Life support (BLS) standards of practice issued by the American heart Association to provide these interventions timely. These failures prevented Resident 1 from receiving lifesaving or death reversing interventions and resulted in an immediate jeopardy related to these events (Please refer to F684 for more information.) The failure to ensure employee performance evaluations and skills checklists were complete or up to date prevented care staff from providing optimal resident care, not only to sustain life but also to provide resident quality of care. (Please refer to F 726 for more information.) In addition, the facility failed to maintain up-to-date written policies on CPR, ensure staff maintained Basic Life Support (BLS) certification and provide ongoing education on BLS. Additionally the facility failed ensure staff had adequate knowledge of how to immediately obtain code status so emergency CPR could be started. These failures affected 46 full code residents and prevented Resident 1 from receiving CPR and possibly reversing death on [DATE]. The facility's failure to provide basic life support including CPR to a resident who required resuscitative care, lack of policy to direct staff to provide basic life support including CPR as indicated and failure to ensure staff had knowledge, skills and receive current training in CPR constituted an Immediate Jeopardy (IJ) situation on [DATE]. Findings Included: In (YEAR), the American Heart Association issued CPR guidelines for healthcare workers certified BLS in the event of a patient or individual found unresponsive. The guideline listed the following: 1. If the victim is unresponsive, shout for help or activate the Emergency Response System (EMS). 2. Assess for breathing and pulse, if not breathing or has no pulse, start CPR immediately and continue CPR until EMS personnel arrives. Code Status referred to the level of medical interventions a person wished to have started if their heart or breathing stopped. Code status included but was not limited to Full code (implement lifesaving interventions such as CPR) or Do not Resuscitate (DNR). The facility policy and procedure titled, CPR code status dated ,[DATE], documented, to determine and document the resident/surrogate decision regarding life-sustaining treatment including CPR, using the POLST form. The policy was missing the provision of basic life support and CPR, including the following instructions on: A. Directing staff to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death. B. Directing staff to initiate CPR for residents who have requested CPR in their advance directives, and/or have not formulated an advance directive. C. Directing staff to initiate CPR for residents who do not have a valid DNR order. Additionally, the policy was missing directions for staff to initiate and provide basic life support, including initiation of CPR, to a resident who experiences cardiac or respiratory arrest in accordance with that resident ' s advance directives or in the absence of advance directives or a DNR order. Resident 1 Resident 1 re-admitted to the facility on [DATE]. A review of the resident's Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition and required 2 person assist with bed mobility and transfers. The MDS also showed that the resident had no condition or chronic disease that may result in a life expectancy of less than 6 months, and showed he scored a 15 on the Brief Interview of Mental Status (BIMS) and was able to make his needs and preferences known. Review of the resident's signed Physician order [REDACTED]. Review of the facility progress notes dated [DATE] documented by Staff A, Registered Nurse (RN), stated, Resident was found by CNA (certified nursing assistant) at 1100 not breathing, color pale/white. I was notified by CNA at 1100. When I went to check resident was in his bed with the HOB (head of bed) elevated and O2 (oxygen) was on via NC (nasal cannula) at 4 L (4 liters). I observed resident to be pale, pupils fixed and dilated, skin cool to touch. No heartbeat or respiration noted. No pulse. Called 911 they arrived and CPR not started d/t (due to) futility of the situation. Review of the Seattle Fire Department Patient Care Record showed EMS personnel (That included Paramedics and Emergency Medical Technicians, EMTs) responded to a 911 call to the facility that was received by EMS at 11:16 AM on [DATE]. The report showed the paramedics and EMT's arrived at the resident's bedside at 11:23 AM and stated 73 yo (year old) male lying in bed in SNF. Found by staff to be pulseless, not breathing with no CPR started. The report further stated Pt warm to touch, in asystole (no heartbeat), no lividity (black and blue discoloration of the body). Review of the CNA Kardex (Care plan), CNA daily assignment sheet, and licensed nursing staff assignment showed resident Code status information was not readily available. Observation of resident name bands also did not show any evidence of code status readily available. In an interview on [DATE] at 3:15PM, the resident's son stated his dad had just died earlier that day and was not showing any signs of distress prior. He stated the family had discussions on his code status but he stated his dad insisted on remaining a full code and knew what he wanted. In an interview on [DATE] at 3:25 PM, Staff A, Registered Nurse (RN) stated the resident had requested his pain medication, which she gave at 9:45 AM, and she went back in at 10:00 AM and he appeared fine. She stated Staff B, CNA, called Staff A to the resident's room at around 11:00 AM. She stated the resident was already cold and he had already died . She stated the resident was a full code; however, no CPR was initiated to attempt to reverse the death. In a later interview, Staff A stated she then alerted Staff FF (RN) who then alerted Staff DD (RN) on another facility unit to assist. In an interview on [DATE] at 5:23 PM, the Administrator stated the facility did not have a CPR policy that instructed staff on what to do in a code situation but stated staff knew to follow current standards of practice for CPR. In a later interview, the DNS also confirmed this. Interviews on [DATE] and [DATE] with Staff GG, II, JJ, KK, OO, PP, SS, TT, and (CNA's) stated they would call the nurse and wait for instructions if they found a resident, unresponsive, with no pulse and was not breathing. Staff KK, LL, MM, PP, QQ, SS, TT, UU (All CNA's) stated they did not know what a full code was. All CNA's stated they were CPR Certified. At the time these interviews were conducted, Staff JJ, OO, PP, and UU had expired CPR certifications. (Refer to F726 for more information) In an interview on [DATE] at 12:51 PM, the Administrator She stated she did not have enough information to speak regarding the events around the resident's death. However stated the system in place was for the CNAs to call for help. She stated and agreed that more education was needed to educate the CNAs on where to immediately find the code status of the resident to help prevent a delay in life saving interventions such a CPR. She stated the verbal removal plan was to conduct immediate in-services for the CNAs on how to find code status and when initiate CPR. She stated she would install a code blue system to better alert staff of a code situation. She stated A better system needs to be in place for better code alert and response. In a joint interview on [DATE] at 10:18 AM, Staff B, II, and JJ (CNAs) stated they knew what a full code was, however they stated they did not know where to find code status. Staff B stated if she found a resident unresponsive with no pulse and not breathing, she would start CPR. She further stated We don't always know who is a full code or not. The code status is not in the Kardex or the daily assignment sheets, so there is really no way for us to know. In a later interview, Staff VV (CNA) had the same concern. Staff B also stated she was the CNA that found the resident unresponsive at 11 AM and had been in the resident's room [ROOM NUMBER] minutes earlier at 10:30 AM and stated the resident was complaining of pain, but did not show any other signs of distress. She stated she did not know why she did not initiate CPR and all she knew to do was to get the nurse. Interviews conducted with licensed nursing, Staff AA (RN), Staff CC (RN) and Staff FF (RN) all stated the expectation was to initiate CPR if a resident was found unresponsive, with no pulse, not breathing with a full code status. Staff CC RN, Staff BB, Licensed Practical Nurse (LPN) stated having CNA's know the code status would prevent a delay in CPR initiation when needed. In an interview on [DATE] at 11:33 AM, Staff DD (RN) recalled the events surrounding the resident's code situation. She stated when Staff A (RN) learned of the resident not breathing or with no pulse, she went to the Resident Care Manager, Staff FF (RN), who then went to the Transitional Care Unit (TCU) and alerted her about the resident. Staff FF approached her, took her to a small admissions office at the TCU nurses station, and then proceeded to tell her the resident was dead and a full code. She stated she immediately went to the resident's bedside. When she arrived at the scene, she stated all the nurses alerted were standing around the resident and she asked them why they were not doing CPR. She stated she assessed the resident who was not mottled, was still warm, and then instructed the staff to call 911. She stated she was disturbed at the fact that no one had initiated CPR and when she brought this up to the administrator, she was told to by the administrator Oh well, his health wasn't that good anyway and felt there was little concern to the problem of no one initiating CPR. In an interview on [DATE] at 12:16 PM, Staff FF RN and Resident Care Manager stated she was notified about the resident's situation by Staff A. Staff FF stated she then went to another unit to alert Staff DD who immediately went to residents bedside. She stated she eventually went to the resident's room ,[DATE] minutes later after he was found. She did not know why CPR was not initiated when the resident was initially found unresponsive, no pulse, no breathing and was a full code. At 12:44 PM, the DNS was asked if there was a Code blue or when to initiate CPR policy and she stated the facility did not have one but stated they used standard nursing practice. She stated that as of now there was no facility policy to direct licensed staff or CNA's on what to do if there was a potential or actual code blue situation. In an interview on [DATE] at 1:35 PM, the DNS she stated, moving forward she would implement a policy that stated all personnel that were CPR certified would start CPR if they were a full code until paramedics or EMT's arrived. She stated she had been out of the facility for a month, did not know the details of the events would start a formal investigation. CPR TRAINING AND CERTIFICATION A sample of employee records were reviewed for current CPR certification. Four of seven Licensed Nurses (A, BB, EE, and FF) employees did not have current CPR certification. Five of 12 CNA's (HH, JJ, KK, OO, and PP) employees did not have current CPR certification. In a joint interview on [DATE] at 2:23 PM with Staff C, Vice President Human Resources, and Staff D, Cardio-Pulmonary Resuscitation Instructor. They concurred some staff had expired CPR certifications. They said the Staff Development Coordinator (SDC) is supposed to keep track of trainings. The facility has been without an SDC since [DATE]. There is no way at this time, to track all the training and competencies. Reference (WAC) [DATE](1)

Based on observation, interview and record review, the facility failed to protect and to ensure staff followed facility policy for not receiving cash or gifts from residents for his/her personal gain for 1 of 2 residents (2) reviewed. This failure caused harm to Resident 2 in the form of anger, anxiety, and lack of sleep and placed other residents at risk for financial misappropriation. Findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition dated (MONTH) (YEAR), defined exploitation as: taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Resident 2 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the resident's Annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had intact cognition and needed one-person staff assistance with activities of daily living. A review of the document provided to the department on 09/11/18, showed the resident was involved in an incident involving a possible misappropriation/financial exploitation in the facility. In an interview on 09/26/18 at 9:45 AM, the resident stated, she and her husband had given Staff E, Nursing Assistant Certified, (NAC), cash money, close to at least three thousand one hundred dollars ($3,100.00). According to the resident, the money was given to Staff E, to support a charity and an orphanage, which Staff E told them he was supporting in Africa. The resident also stated, they also purchased a guitar initially for Staff E to use. However, the guitar was eventually donated to the facility. The resident stated she and her husband gave Staff E some cash prior to purchase another guitar because she felt bad that Staff E could not take the guitar home. The resident stated everything started when she asked Staff E about his place of origin and personal life. According to the resident, Staff E willingly shared his personal life story. This was how she found out Staff E, was allegedly supporting a church and orphanage in Kenya. The resident stated, they came up with the $3100.00 amount because Staff E told them he needed that amount for the orphanage to secure rent and location for the children in need. The resident added, that this situation made her feel obligated to support and reward Staff E as he was a very hard working caregiver. This whole situation had caused me to lose sleep at night and caused physical symptoms, nerve problems because I am so stressed and worried about his family and those kids he was supporting. In a follow-up interview at 12:21 PM, the resident and her husband stated and confirmed the cash amount given to Staff E. Both the resident and her husband added, there were at least 1 or 2 more occasions in the past, where they had given Staff E few hundred dollars cash as a gift donation. They both further stated, the transactions happened outside of the facility and Staff E would initiate the call and set up a meeting. The resident and her husband both stated, they voluntarily gave Staff E the money as a gift and donation because they knew that Staff E's family needed some money as well as the church and the orphanage he allegedly supported in Africa. The resident added, Staff E had a wife and kids back in Kenya and felt that they needed help based on what Staff E had told them. The resident's husband added, Staff E had not refused or said no to them when offered cash gifts. Both the resident and her husband stated they did their own research about Staff E's church and orphanage online and were able to verify existence of the organization. However, they weren't sure how the money was sent and if and who received their cash donations. According to the resident's husband, there was no receipt or tax form issued for the cash gift. The resident also stated, she and her husband had offered gifts and rewards to other staff in the past but they all refused except Staff E. During the interview, the resident was tearful. The resident stated she was angry and worried at the same time. The resident further stated that she was not able to sleep at night for almost a week because she was thinking of Staff E, his family and the kids in the orphanage and church that Staff E was supporting. The resident's husband also stated, they both had been stressed and worried about the situation to a point that they both could not sleep at night and enjoy their day-to-day activities. We felt bad about him. We think he lost his job. The resident also added, the whole situation caused her more than emotional stress and now she was experiencing some physical symptoms and nerve problems. During several interviews on 09/26/18 at 10:14 AM, each staff member, Staff F, Registered Nurse, at 11:00 AM, Staff G, Resident Care Manager, at 11:08 AM, and Staff H, NAC, each stated, the resident was neither on alert charting nor being monitored for signs and symptoms of psychological harm related to the incident. Each staff member stated, the resident would ask and inquire about Staff E from time to time. They stated the resident expressed she was worried if Staff E had left the facility or was terminated and expressed concerns with Staff E's life situation/condition. Each of the staff members stated, the conversation between the resident and Staff E should have not happened, and they all reiterated that staff should not take any gifts from the residents, especially if it was for personal gain. Review of the resident's clinical records showed no evidence of follow-up or monitoring including any mental health support for the resident related to the incident. There was no evidence of alert monitoring/clinical progress notes or visits related to the resident's mood or how the resident was adjusting to the situation. In a phone interview on 09/26/18 at 12:52 PM, Staff E, stated he received the cash gift from Resident 2 and her husband and he knew what he was doing was wrong. Staff E further stated, he knew what financial exploitation was and he felt like he took advantage of the resident and the situation for his personal gain and should have not accepted the cash gifts and donation. Staff E added, this whole situation started when the resident asked about his personal life. I knew I should have not told her my story. I knew I should have not told her about my church, the orphanage, and the money itself. Staff E stated the money was gone and had already been sent to Africa. During an interview and record review on 09/26/18 at 1:46 PM, the Administrator stated, the facility had substantiated that a guitar had been purchased and that there was money received by Staff E as a gift from Resident 2 and her husband. The Administrator stated, she was not able to substantiate the intent of Staff E and she was not aware that there were other transactions between Staff E, the resident, and the resident's husband. The Administrator also stated the resident was not put on alert charting or monitoring to monitor the resident's mood or response to the situation. (Refer to F610 - Investigate/Prevent/Correct Alleged Violation for more information.) A review of an electronic mail (email) sent by Staff E on 09/27/18 at 11:35 PM, Staff E documented he sent a copy of the transaction to whom he sent the money. The transactions showed three recipients of the money for a total amount of $2,394.00. In a follow-up phone interview on 09/28/18 at 8:25 AM, Staff E stated, the $3,000.00 he received from the resident and her husband was used to pay his personal loans from 2 different bank accounts. Staff E stated that out of the $3,000.00 he received from the resident, he sent at least $700.00 to his wife and he used $300.00 for his own personal needs. Staff E further stated, he was willing to return the money back if needed. During a phone interview on 10/01/18 at 11:35 AM, a family member stated, she was very concerned about the resident and Staff E's unusual close relationship. The family member stated, when she found out that the resident and the resident's husband bought a guitar for Staff E, noticed multiple phone calls from/to Staff E, and recently giving cash assistance/gifts. This was when she realized she had to report her concerns to the facility. The family member stated she was able to verify with the resident's husband the recent cash transactions of at least $3,100.00 cash given to Staff E and another amount of cash for $400.00 in the past to purchase a guitar. The family member added, she had verified a few other cash transactions that occurred in the past with Staff E and was worried about how the gifting got out of hand. The family member stated she was concerned because the resident and the resident's husband have memory problems and The resident's mood and depression had gotten worse because of this incident. Resident 2 sent multiple emails and communications to me in the past week alone regarding Staff E and why her husband wouldn't call to check on Staff E. Resident 2 was very concerned about Staff E and she was upset and mad about the whole situation. Reference: (WAC) 388-97-0640 (3)(c)(d)

Based on interview and record review the facility's administration failed to effectively use its resources to maintain facility compliance with federal regulatory requirements to ensure: 1. There was written policies and procedures to direct staff of what to do in the event a resident was found unresponsive, pulseless and not breathing; 2. Direct care staff were knowledgeable to Basic Life Support (BLS) standards of practice; 3. Direct care staff had current CPR (Cardiopulmonary Resuscitation) certifications; 4. Direct care staff had up to date competencies and skills; 5. Protect a resident from financial exploitation and psychological harm; 6. Report and complete thorough facility investigations timely and accurately. These failures delayed/prevented Resident 1 from receiving life sustaining or death reversing interventions, such as CPR per the resident's written and physician ordered request, which resulted in an immediate Jeopardy (IJ) on [DATE] and placed 45 other residents in the facility at risk of not having their requests acknowledged and carried out which could lead to death. Resident 2 experienced financial exploitation that resulted in psychosocial harm and the loss of thousands of dollars. Findings included: POLICIES AND PR[NAME]EDURES The facility Administrator failed to develop policies that followed the current regulations at F684 for Cardiopulmonary Resuscitation (CPR), failed to report to the state agency an unexpected death, and failed to do a thorough investigation to rule out abuse and or neglect after a Licensed Nurse and the emergency medical response team expressed serious concerns to facility staff about not starting CPR. In an interview on [DATE] at 5:23 PM, the Administrator stated the facility did not have a CPR policy that instructed staff on what to do in a code situation but stated staff knew to follow current standards of practice for CPR. In an interview on [DATE] at 11:33 AM, Staff DD (RN) stated, she was disturbed at the fact that no one had initiated CPR and when she brought this concern to the facility administrator, the administrator told her, Oh well, his health wasn't that good anyway and felt there was little concern to the problem of no one initiating CPR. In an interview on [DATE] at 1:35 PM, the Director of Nursing (DNS) stated, moving forward she would implement a policy that stated all personnel that were CPR certified would start CPR if they were a full code until paramedics or EMT's arrived. The DNS further stated, she had been out of the facility for a month, did not know the details of the events would start a formal investigation. (REFER TO F678 - Cardio-Pulmonary Resuscitation and F684 - Quality of Care for more information.) STAFF TRAINING, COMPETENCIES, SKILLS AND CPR CERTIFICATION The facility Administrator and Director of Nursing Services failed to ensure nursing staff had the appropriate competencies/skill sets and CPR certifications to provide nursing and related services to ensure resident safety to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by the facility's assessment and individualized resident's plan of care. During a joint interview of the facility assessment on [DATE] at 3:44 PM, the Administrator and the Director of Nursing stated, they did not have a specific training provided to staff and no competency/skills demonstration completed based on the facility and resident population needs assessment. Review of 3 of 7 Licensed Nurses (BB, EE and FF) and 4 of 12 CNA's (JJ, OO, KK and UU) employees did not have current CPR certification as required. During a meeting on [DATE] at 2:23 PM with Staff C, Vice President of Human Resources and Staff D, CPR Instructor and Staff Development Assistant, confirmed the expired CPR cards for the listed employees. (REFER TO F726 - Competent Nursing Staff and F730- Nurse Aide Performance Review for more information.) ABUSE AND NEGLECT The facility administration failed to ensure staff followed and implemented abuse and neglect policies and procedures for reporting, investigation and protection of residents in the facility. RESIDENT 1 The Administrator and Director of Nursing Services failed to implement facilities written abuse and neglect procedures related to an unexpected death of Resident 1. During a meeting on [DATE] at 2:31 PM, with the Administrator, Chief Executive Officer, (CEO), and Vice President of Human Resources, (VP of HR) the Administrator stated, the unexpected death of Resident 1 on [DATE], was not reported to the State agency, as required, and the facility had not completed the investigation. When asked why the incident wasn't reported to the State agency and why the facility did not have a completed and thorough investigation related to the unexpected death. The Administrator stated, she would have to check the Purple Book regarding the reporting guidelines before she could answer the surveyor's question. RESIDENT 2 The Administrator and Director of Nursing Services failed to ensure a thorough and accurate investigation was completed for an allegation of financial exploitation. During an interview and record review on [DATE] at 1:46 PM, the administrator stated, she was not able to substantiate the intent of Staff E and she was not aware that there were other transactions between Staff E, the resident, and the resident's husband. The Administrator also stated the resident was not put on alert charting or monitoring to monitor the resident's mood or response to the situation or allegation. Review of a facility incident report dated [DATE], showed the facility Social Worker reported on [DATE] to the local law enforcement or the Department when they became aware of an allegation of financial exploitation. (REFER TO F602 - Free From Misappropriation/Exploitation, F607 - Development and Implementation of Abuse and Neglect Policies, F609 - Reporting of Alleged Violation and F610 - Investigate/Prevent/Correct Alleged Violation for more information.) Reference (WAC) [DATE] (1)

Based on observation, interviews and record review Staff B (NAC) failed to perform cardio-pulmonary resuscitation (CPR) in a timely manner to 1 of 1 resident (1), and left the scene, to call for Staff A (Registered Nurse), Staff A's decision, that too much time had elapsed to warrant basic life support measures, prevented Resident 1 from receiving CPR even though it was his desire to be a full code. This failure caused a delay and prevented Resident 1 from receiving possible reversal of death. Findings Included: In (YEAR), the American Heart Association issued BLS guidelines for healthcare workers certified BLS in the event of a patient or individual found unresponsive. The guideline was listed as follows: 1. If the victim is unresponsive, shout for help or activate the Emergency Response System (EMS). 2. Assess for breathing and pulse, if not breathing or has no pulse, start CPR immediately and continue CPR until EMS personnel arrives. 3. Ethical implications to consider where death is irreversible were listed as follows: Few criteria can accurately predict the futility of continued resuscitation. In light of this uncertainty, all pediatric and adult patients who suffer [MEDICAL CONDITION] in the hospital setting should have resuscitative attempts initiated unless the patient has a valid DNR order or has objective signs of irreversible death (e.g., dependent lividity). The American Red Cross is an organization that certified healthcare workers in BLS and listed BLS guidelines based on the American Heart Association guidelines that listed as follows: 1. If the patient is unresponsive, shout for help and activate EMS. 2. Check the airway by placing the patient in a supine position (laying on back face up, Perform Head-tilt/chin lift technique.) 3. Check for breathing, look to see if the patient's chest rises and falls, listen for escaping air and feel for it against the side of your cheek while checking for pulse by palpating the carotid artery by sliding two fingers into the groove of the patient's neck, being careful not to reach across the neck and obstruct the airway. 4. If there is no breathing or pulse begin cardiopulmonary resuscitation (CPR) that starts with the immediate delivery of chest compressions followed by ventilations. Patient needs to be situated supine on a hard surface such as the ground or CPR board. Resident 1 Resident 1 re-admitted to the facility on [DATE]. The resident's most recent Minimum Data Set (MDS) showed he scored a 15 on the Brief Interview of Mental Status (BIMS) and was able to make his needs and preferences known. Review of the resident's Physician order [REDACTED]. This form was signed by a Physician and was considered an active Physicians order. Review of the facility progress notes dated [DATE] documented by Staff A, Registered Nurse (RN), stated, Resident was found by NAC (certified nursing assistant) at 1100 not breathing, color pale/white. I was notified by NAC at 1100. When I went to check resident was in his bed with the HOB (head of bed) elevated and O2 (oxygen) was on via NC (nasal cannula) at 4 L (4 liters). I observed resident to be pale, pupils fixed and dilated, skin cool to touch. No heartbeat or respiration noted. No pulse. Called 911 they arrived and CPR not started d/t (due to) futility of the situation. Components of this progress note showed the following: 1. The progress did not state whether the code status was reviewed and if it was determined, the resident was a full code or Do not Resuscitate (DNR) by the NAC or the nurse who initially found the resident. 2. According to the fire department records obtained, the paramedics received the 911 call at 11:16 on [DATE], which was a 16-minute delay in activating EMS after the resident was found not breathing with no pulse. 3. The nurse stated in the progress note she found the resident's head of bed (HOB) elevated however did not assume the resident to the correct position to assess for breathing and a pulse according to the standards of practice mentioned above. The note also failed to indicate the nurse assessed the resident for irreversible signs of death such as dependent lividity. 4. The progress note showed life-sustaining interventions such as CPR were not initiated as ordered in the POLST and the resident wishes to implement life sustaining interventions were not honored. In an interview on [DATE] at 3:15 PM, the resident's son stated, his dad had just died earlier that day and was not showing any signs of distress prior. He stated the family had discussions about the Resident's code status, but he stated his dad insisted on remaining a full code, and knew what he wanted. In an interview on [DATE] at 5:23 PM, the Administrator stated they did not have a CPR policy that instructed staff on what to do in a code situation but stated staff knew to use the standard of practice for CPR. In an interview on [DATE] at 11:33 AM, Staff DD (RN) recalled the events surrounding the resident's code situation. She stated when Staff A (RN) learned of the resident not breathing or with no pulse, she went to the Resident Care Manager, Staff FF (RN), who then went to the Transitional Care Unit (TCU) and alerted her about the resident. Staff FF approached her, took her to a small admissions office at the TCU nurses station, and then proceeded to tell her the resident was dead and a full code. She stated she immediately went to the resident's bedside. When she arrived at the scene, she stated all the nurses alerted were standing around the resident and she asked them why they were not doing CPR. She stated she assessed the resident who was not mottled, was still warm, and then instructed the staff to call 911. She stated she was disturbed at the fact that no one had initiated CPR and when she brought this up to the administrator, she was told to by the administrator Oh well, his health wasn't that good anyway and felt there was little concern to the problem of no one initiating CPR. In an interview on [DATE] at 12:44 PM, Staff FF, Registered Nurse (RN) who was the also one of the nurse managers stated she understood the POLST form was a signed order and the expectation for the licensed staff was to follow the order to initiate CPR if the resident was a full code. In an interview on [DATE] at 12:44 PM, the DNS stated the POLST is a direct order to initiate life-sustaining interventions such as CPR. Multiple staff interviews conducted showed NACs were not able to state the standard practice for BLS, with some staff members not knowing what a full code on the POLST was or how to obtain it, including the NAC that initially found the resident. Please see F678 for more information on the interviews conducted. Reference: WAC [DATE](1)

Based on interview and record review, the facility failed to provide adequate pain treatment and management for 1 of 2 residents sampled for substantial injuries (Resident #1). This failure led to harm to resident while experiencing uncontrolled pain with movement after a fall with a [MEDICAL CONDITION]. Findings include: --also see F580; F610-- Review of facility medical records revealed, Resident #1 resided at the facility for long term care and had severe dementia. According to the facility Minimum Data Set assessment ((MDS) dated [DATE], Resident #1 had severe cognitive impairment and needed extensive assistance from facility staff for all activities of daily living. Review of the facility incident report and investigation dated 01/05/18, revealed Resident #1 had an unwitnessed fall in her room and was found on the floor, by the bathroom, with a bleeding skin tear on her left elbow that required first aide. The resident yelled help me. The facility report noted Resident #1 had vocal complaints of pain, facial expressions and protective body postures as well as non-verbal pain sounds such as crying, moaning with a pain level of 4/10 after the fall. The report noted Resident #1 was alert and confused. The facility investigation also noted Resident #1 had pain on movement, as documented in the incident report, by Staff A, a Licensed Nurse (LN), and guarding of the left hip with yelling when the leg was raised. Further review, of the facility fall investigation, also revealed, Staff B, the caregiver on duty, documented on a witness statement that Resident #1 was in pain after the fall. Staff C, a caregiver, also documented on a written witness statement that Resident #1 was in pain after the fall. In addition, Staff D, the caregiver who found Resident #1 on the floor, documented on a witness statement that Resident #1 was on the floor yelling for help and was in pain. Record review revealed, Staff E, a Nurse Practitioner on duty at the time of the fall, documented her assessment of Resident #1 after the fall dated 01/05/18, and noted left hip was tender with touch, Staff E ordered an x-ray, and wrote a plan to give Tylenol 500 mg, one to two tablets every 4 to 6 hours for pain, and the facility staff were to report the x-ray result to the evening, on call, Practitioner. This routine Tylenol order for pain was not noted by the facility in the medical record. Review of the x-ray report dated 01/05/18 revealed, Resident #1 had a [MEDICAL CONDITION] hip from the fall. In an interview on 02/07/18 at 12:35 p.m., Staff E, a practitioner for Resident #1 as above, confirmed Resident #1 had pain in her hip when it was touched after the fall, and Staff E acknowledged she wrote the above Tylenol order after the fall. Staff E stated if the x-ray showed a fracture she would have ordered narcotics for pain, as she noted in her anticipatory care plan notes, however, another on call Practitioner, that evening received the [MEDICAL CONDITION] x-ray results. In an interview on 02/16/18 at 11:30 a.m., Staff M, a LN, on duty at the time of the fall, stated after the fall (between 2:20 p.m. and 3:00 p.m.), Resident #1 was in the wheelchair where they could watch her and she was screaming in pain ouch that hurts when the NAC tried to move the footrests, on the wheelchair. Staff M stated she did not give pain medication to Resident #1 at that time. Review of the facility Medication Administration Record [REDACTED]. In an interview on 02/07/18 at 2:00 p.m., Staff A, a LN, stated Resident #1 yelled in pain when they picked her up from the floor and placed her in the wheelchair. According to the Medication Administration Record, [REDACTED]. In an interview on 03/05/18 at 3:10 p.m., Staff H, the Practitioner, on call, Friday the evening of 01/05/18, confirmed Resident #1 had pain with movement, and stated the facility did not ask for a narcotic pain medication order after the [MEDICAL CONDITION] for Resident #1. In an interview on 02/15/18 at 2:20 p.m., Staff L, a caregiver who cared for Resident #1, on the evening shift of the fall, 01/05/18, stated she found Resident #1 on the floor after the fall and she was yelling which was not usual behavior for her. Staff L stated Resident #1 was in a lot of pain and was screaming it hurts, ouch and yelling. Staff L also stated Resident #1 was uncomfortable in the wheelchair and Staff L checked on her every 2 hours, and stayed with her a lot, she was wincing and shifting in the wheelchair and she said she was uncomfortable. Staff L stated the Tylenol did not help, she was still uncomfortable, then she fell asleep in bed, (Resident #1) screamed when we put her in bed, she howled with any movement including when the x-ray person came. Resident #1 howled loudly every time she was moved, she was quiet if not moved, but howled with any movement on Friday evening. In an interview on 02/25/18 at 10:40 p.m., Staff K, a caregiver, stated when she arrived at work on Friday, the night of the fall, 01/05/18. She was told Resident #1 fell , and she could tell she was in pain when she checked her every two hours, as she usually talked at night when she cared for her, but that night she did not talk. Staff K stated she did not turn her all the way, because she was told it was very painful for her. Staff K stated Resident #1 grimaced when Staff K cared for her Friday night. In an interview on 02/25/18 at 11:05 p.m., Staff I, a direct caregiver for Resident #1 stated, when she arrived to work for the night shift, after the fall on 01/05/18. Resident #1 was pale, and the doctor ordered a chest x-ray. Staff I stated the chest x-ray was done and she saw Resident #1, while they were trying to sit her up, for the chest x-ray. Staff I stated Resident #1 said no it hurt her hip, to sit up, so they did the x-ray with her lying down in the bed. Staff I stated the nurse on duty, Staff A, told her at that time not to sit Resident #1 up because it causes too much pain. Staff I also stated they did not turn Resident #1 as much during the night, after the fall, because of the pain, from the fracture. Review of the x-ray report revealed, the chest x-ray above dated 01/06/18, was done at 3:00 a.m., Saturday morning, after the fall. In an interview on 02/23/18 at 12:45 p.m., Staff J, a caregiver, stated Resident #1 was in very bad pain with turning during care on Saturday, 01/06/18, the day after the fall. In an interview on 02/23/18 at 2:00 p.m., Staff G, a LN stated, on Saturday, the day after the fall, Staff G worked day shift and evening shift, and stated we did not want to move her much because she had pain with movement, I thought she was on routine Tylenol. In a subsequent interview on 02/25/28 at 6:40 p.m., Staff G stated Resident #1 was in pain, the day after the fall, every time they moved her for care she would grimace and say ouch but she was not screaming. Staff G stated she did not talk to the DPOA for Resident #1 about pain when she visited on Saturday 01/06/18. In an interview on 02/25/18 at 10:15 p.m., Staff F, a LN, at night shift, on the weekends, stated he didn't really see her Friday night, Saturday night, or Sunday night, as he covered three halls on the night shift and was not on the unit much where Resident #1 resided throughout the shift that weekend. In an interview on 02/23/18 at 12:20 p.m., Staff B, a caregiver, stated Resident #1 was in pain and said ouch when she went to change her on Sunday morning, then the daughter came to visit and got upset that Resident #1 was in such extreme pain. In an interview on 02/16/18 at 11:30 a.m., Staff M, the LN on duty, Sunday morning, stated Resident #1 had pain when the facility staff touched her, such as when the staff tried to collect a urine sample after a high white blood cell count was reported to the practitioner on Sunday, Resident #1 was screaming ouch. Staff M stated she gave Resident #1 Tylenol but she was still in pain with turning, and the DPOA was upset and wanted something stronger for the pain for Resident #1. Although Staff A, F, G, licensed nurses, charted no pain was observed on the facility Medication Administration Record [REDACTED]. There was no pain medication administered to Resident #1 after the [MEDICAL CONDITION], after one 500 mg tablet of Tylenol was given Friday at 4:21 p.m. on 01/05/18, until Sunday morning 01/07/18 when Tylenol was given again. Reference (WAC) 388-97-1060(1)

Based on interview and record review, the facility failed to immediately notify the physician/practitioner and the legal representative for 1 of 3 residents (#1) sampled for substantial injuries, abnormal blood tests, and when the resident had uncontrolled pain from a substantial injury ([MEDICAL CONDITION]). This failure led to harm in the form of uncontrolled pain, a delay in treatment for [REDACTED]. Findings include: --see also F610; F697; F770-- UNCONTROLLED PAIN --Please see data in F697 regarding uncontrolled pain-- In an interview on 02/05/18 at 3:20 p.m., the DPOA stated she was told by staff, after Resident #1 had a fall, that she was resting comfortably. The DPOA stated she was not notified that Resident #1 was in pain or having discomfort when staff would move her on Friday, 01/05/18 or Saturday, 01/06/18, while providing care. On Sunday the DPOA heard Resident #1 scream when staff barely touched her. She stated she had never heard Resident #1 yell out in pain like that, which was very upsetting. The DPOA stated she demanded pain medication and agreed for Resident #1 to be sent to the hospital after seeing her in so much pain. In an interview on 03/07/18 at 2:20 p.m., the DPOA for Resident #1 stated, if the facility staff would have notified and informed her that Resident #1 was in pain with any care, turning, touching or movement. She would have sent Resident #1 to the hospital much sooner, rather than waiting until 3 days later, because she thought Resident #1 was resting comfortably, while she decided what to do. The facility's failure to notify the Practitioner/MD about the pain with movement for Resident #1 on 01/05/18 and 01/06/18, prevented Resident #1 from receiving care and services to treat the pain, and prevented the MD/practitioner and the DPOA from making informed decisions about an earlier hospitalization and treatments. STAT (to be done immediately) LAB (laboratory) / CRITICAL LAB GLUCOSE (sugar)/HIGH WHITE COUNT (WBC) -No NOTIFICATIONS TO MD or FAMILY Review of the facility lab blood draw log revealed, the lab drew the STAT blood tests at 11:50 a.m. on 01/06/18, almost twelve hours after they were ordered STAT. Review of the facility Progress Notes dated Friday, 01/05/18, after a fall, revealed Resident #1 had a respiratory change of condition after midnight, and the practitioner ordered a STAT chest x-ray and blood tests. Review of the practitioner notes dated 01/05/18 and 01/06/18 revealed, the STAT labs were ordered during a phone call with Staff A, right after midnight, the night of the fall on 01/05/18 by Staff H, the practitioner who was on call. This abnormal white blood cell count or a critical high blood sugar of 402 was not reported to the physician until 01/07/18 (as per a date stamp on the lab result paperwork by Staff M, a licensed nurse), more than 24 hours after it was ordered STAT. The printed lab result for the critical glucose was dated 01/06/18 at 9:07 p.m. In an interview on 02/05/18 at 3:20 p.m., the DPOA stated she was not notified of the critical high blood sugar on Saturday 01/06/18 or the high white blood cell count. In an interview on 02/23/18 at 2:00 p.m., Staff G, a Licensed Nurse (LN) on duty Saturday during the day and evening shift on 01/06/18, stated the lab was phoned to her, notifying her of a critical high blood sugar, and other lab results on Saturday evening. She left a voicemail for the practitioner, but received no return call. Staff G stated she did not attempt to phone the Physician or Medical Director about the abnormal blood test results. Even though, the day shift, on call, practitioner told her, to be sure the evening shift practitioner, got the STAT blood test results. Staff G stated she also did not notify the DPOA about any abnormal blood test results. Staff G stated I guess I should have called the doctor about the abnormal lab results. In an interview on 02/23/18 at 2:30 p.m., Staff M, a LN stated she received the STAT lab results on Sunday, 01/07/18 and notified the Physician. I found them on the fax machine in the facility Sunday morning. In an interview on 03/12/18 at 11:00 a.m., the Physician for Resident #1, and the Medical Director for the facility, stated she did not receive a call regarding the abnormal blood test results, including the high blood sugar, until Saturday, 01/06/18 and was not notified of Resident #1's pain until Sunday, 01/07/18. The Physician/Medical Director (MD) also stated she would have liked to have had that information immediately, as it arrived at the facility. The facility should have notified a Practitioner or Physician about the pain, after the fall and fracture, as you cannot have a fracture without pain. In addition, the MD also stated pain with movement is not pain management or comfort care for the resident. The facility's failure to notify the MD/practitioner, and the DPOA for Resident #1 of abnormal blood test results (high blood sugar and high white blood cell count) after a change in condition, prevented the MD/practitioner from making timely treatment decisions, and prevented the DPOA for Resident #1 from making informed decisions about the care and treatment for [REDACTED]. Reference (WAC) 388-97-0320(1)(a-d)(2)(a)

Based on interview and record review, the facility failed to prevent an accident for 1 of 4 residents reviewed, (Resident #1) when Resident #1 fell and sustained a fractured hip. This failure led to Resident #1's experience of pain, and a transfer to acute care for surgery after the fall. Findings include: Record review of facility medical records revealed, Resident #1 was admitted to the facility in 2015 for long term care with Alzheimer's dementia, and had a history of [REDACTED]. According to the facility Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a BIMS score of 07/17, and needed extensive staff assistance for transfers and ambulation, as well as other activities of daily living. Review of the facility Care Plan for Resident #1 dated 02/24/16 revealed, Resident #1 was at high risk for falls and needed supervision and assistance for all decision making. In addition, Resident #1 needed safety cueing with the walker, as well as supervision for safety, forgets to use the walker and needs reminder for safety. Additional care plan interventions included, do not leave unattended on the toilet. In an interview on 04/21/16 at 12:00 p.m., Staff B, a nurse, stated the staff have to keep an eye on her, she gets up by herself and then forgets to use her walker and we catch her because she will lose her balance. In an interview on 04/21/16 at 2:15 p.m., Staff C, a caregiver who worked with Resident #1 stated, the staff watch her 24/7 and have to remind her to use her walker to ambulate safely, usually the nurse watches Resident #1 in the common area. Review of the facility Progress Notes dated 03/26/16 revealed, Resident #1 lost her balance in the common area and fell , she was found on her right side on the floor. Review of the facility incident report dated 03/26/16 revealed, Resident #1 had a fall that resulted in a fractured hip on 03/26/16 in the hall/common area of the facility. Resident #1 was found on the floor in pain and transported to the hospital for a fractured hip. In an interview on 04/21/16 at 12:00 p.m., Staff B, a nurse, stated she stepped away from the common area where Resident #1 was sitting so she could give a medication to another resident, and the caregiver assigned to Resident #1 was in another room, so there were no staff watching resident #1 when she got up from the loveseat and fell . Staff B stated Resident #1 gets very confused about the walker so they normally are always there with her. Failure of the facility to provide supervision for safety as care planned for Resident #1 led to an unwitnessed fall with substantial injury and pain, as well as hospitalization for a fractured hip.

Based on interview and record review, the facility failed to support a resident's right to be informed of their total health status and medical condition for 1 of 4 residents sampled (Resident #1) when the facility failed to inform the resident's legal power of attorney of the health status change for Resident #1 during a documented period of health decline, over an 8 month period (August 2013-May 2014). --Also see F250 - Findings include: According to record review of the facility medical record for Resident #1 on 05/22/2014, Resident #1 had resided in the facility since February 2012, and had a [DIAGNOSES REDACTED].#1 had a height of 72 inches and a weight of 134 pounds, needed extensive assistance with eating, and was totally dependent on staff for locomotion and transfers. Review of the subsequent MDS about 90 days later dated 04/30/14 revealed, Resident #1 weighed 116 pounds. Further review of the record for Resident #1 revealed, a Physician order [REDACTED]." and "Long-term artificial nutrition by tube" , and "discussed with patient and DPOA" . Record review on 05/22/2014 of the facility weight record for Resident #1 revealed resident #1 weighed 144 pounds in September 2013 and 116 pounds in May 2014. Review of the facility Registered Dietician (RD) assessment dated [DATE] revealed, Resident #1 lost 12.5 percent of weight in the last 12 months (first year resided at the facility). Additional review of the RD assessment revealed, Resident #1 spits out food, had aspiration risk and had weight loss risk. AUGUST 2013 Review of facility Laboratory Report for Resident #1 dated 08/01/2013 revealed, Resident #1 had a low protein level in the blood of 5.5 (normal 6.1 to 7.8). There was no documentation of any notification or information given to Resident #1 ' s legal decision makers about the medical decline: weight goal change to 140 pounds for the residen's weight, nor any notification regarding the decrease in BMI and the low protein blood level. OCTOBER/NOVEMER 2013 Review of the facility Interdisciplinary Progress Notes on 05/22/2014 revealed, a note dated 10/13/2013 by a facility licensed nurse that noted, Resident #1 continued to eat less than 25 percent of meals and weight continued to drop, he pulls food out of mouth. There was no documentation of any notification or information about the continued medical decline/weight loss being discussed with the legal decision makers for Resident #1. Record review of the facility Long Term Care Facility Rounding Report signed by a medical practitioner and dated 11/20/2013 noted, Resident #1 had "protein calorie malnutrition" , and was further losing weight with a weight of 132 pounds. There was no documentation of any notification or information about the decline/continued weight loss and protein malnutrition discussed with the legal decision makers for Resident #1. DECEMBER 2013 Further record review of the RD assessment dated [DATE] revealed, Resident #1 had a weight of 132 pounds, below weight goal, had a body mass index of 19.6 (normal 24-29), ate less than 25 percent of meals, removed food from mouth, and a plan to "encourage intake". Record review revealed no notification or information given to the resident legal decision makers regarding this additional decline in Resident #1's weight and nutritional status. JANUARY/FEBRUARY 2014 Review of the facility Interdisciplinary Notes dated 02/15/2014 revealed a note by a facility licensed nurse: (Resident #1) lost 5 pounds in the last week, eating one third. Review of a subsequent note by the same nurse dated 02/19/2014 revealed: lost another pound in 4 days. Record review revealed no notification or information given to the resident's legal representatives of the continued decline in weight and nutritional status for Resident #1. MARCH/APRIL 2014 Review of facility MD notes dated 03/24/2014 by a medical practitioner revealed, a [DIAGNOSES REDACTED]. form on record. Record review revealed no notification to the resident's legal representatives of the continued decline in weight, malnutritional status, and/or discussion of possible additional treatment choices for Resident #1. Additional record review of the RD assessment dated [DATE] revealed, Resident #1 had a weight of 124, a low protein level in the blood, and Long Term Care Medically Assisted Nutrition via tube chosen on record. There was no documentation of any notification to the resident's decision makers about the decline in weight and health status. Although the RD noted a feeding tube was chosen by the resident's decision maker on the resident's POLST form on file in the facility, there was no facility discussion of additional treatment options/choices for the declined nutritional status for Resident #1. Review of the RD assessment dated [DATE] revealed, Resident #1 had a weight of 118 pounds and had "Cachexia" with a body mass index of 17.53 (normal 24-29) and "Anorexia". There was no notification of the resident's legal decision makers about this declined medical/nutritional status, or "Cachexia", or a discussion of treatment plan options/choices for weight loss and malnutrition beyond some suggested medication changes. In an interview on 05/19/2014 at 10:45 a.m., and again on 05/29/2014 at 12:45 p.m., the primary legal decision maker for Resident #1 stated the last weight known to her for Resident #1 was around 160 pounds. Additionally during these interviews, the decision maker for Resident #1 stated she had no knowledge and no notification from any facility staff that Resident #1 had lost a significant amount of weight during the past 8 month period, or had malnutrition and low protein diagnoses. During further interview, the legal decision maker for Resident #1 also stated the form they signed on admission to the facility represented the resident's decision maker's choice that all interventions possible for Resident #1 for nutrition if needed, however, no one at the facility discussed these options with them during the resident's stay at the facility after admission, nor during the past 8 month period of significant weight loss and nutritional status decline. In an interview on 05/28/2014, Staff A, a licensed nurse, stated she spoke with Resident #1's decision maker on 05/06/2014 when the resident became ill, and the decision maker was "very unhappy about the weight loss and not knowing about it, seemed to be out of the loop about the weight loss". In an interview on 05/28/2014 at 12:10 p.m., Staff D, a licensed nurse who completed the MDS assessments for Resident #1 in 2014, stated she did not notify Resident #1's decision makers about the significant weight loss, malnutrition or discuss the resident's treatment option choices with them or the care team. In an interview on 05/28/2014 at 2:30 p.m., Staff F, a licensed nurse, stated Resident #1 was no longer interested in eating and would let the food drool out. Staff F was not aware of the significant weight loss and she never talked to the decision makers for Resident #1 about weight loss or discussed other possible treatment options/choices. Failure of the facility to fully inform Resident #1's legal decision makers about his significant weight loss and malnutrition, denied the right and denied the opportunity for the decision makers to address the significant change in condition and discuss treatment plan options. This failure led to harm in Resident #1's inability to exercise the right to full information about health status and possible additional treatment options. Resident #1 was unable to remain in the facility, and experienced an acute care transfer during a subsequent illness on 05/07/2014.

Based on interview and record review, the facility failed to provide medically-related social services to 1 of 4 residents sampled (Resident #1) when the facility Social Services failed to advocate for the resident with the resident ' s surrogate decision maker when the resident's medical well-being was declining. Failure to afford the opportunity for the decision maker to be fully informed of the residents declining condition prevented the decision maker from participating in care decisions effecting the physical health of the resident. --Also see F 154- Findings include: Record review on [DATE] of the facility procedure for CPR Code Status dated ,[DATE] revealed, the facility had an objective to "determine and document the resident/surrogate decision regarding life-sustaining treatment including CPR, using the POLST form". Additional review of the facility procedure for POLST revealed, the facility reviews the POLST annually and with change of condition. In an interview on [DATE] at 11:20 a.m., Staff B, a licensed nurse who worked with Resident #1, stated she did not have any conversations with Resident #1's decision makers about weight loss this year (2014) or any review of treatment choices on the record for Resident #1. Staff B further stated social services would be the facility staff who would discuss weight loss and review treatment choices on the POLST with a resident's family at a care conference. In an interview on [DATE] at 11:55 a.m., Staff C, a social service staff member, stated the facility had not had a policy for care conferences beyond admission. Staff C stated she scheduled a conference only if a family member requested it. Staff C also stated any treatment choices with change of condition, such as those noted on the POLST form, should be discussed and reviewed by nursing in the facility, not social services. Staff C stated she never reviewed treatment choices/POLST forms with Resident #1's decision makers in regards to weight loss, or malnutrition. Staff C also stated she called Resident #1's decision makers only to review the discharge plan during each facility quarterly care plan review. In an interview on [DATE] at 10:00 a.m., Staff G, an administrative employee, stated she expected the licensed nurses to assess the weight loss, discuss with the facility care team including social services, review resident choices with assistance of social services, and document this process in the chart. Staff G confirmed this process did not occur for Resident #1 and his decision makers for the significant weight loss and malnutrition that was documented in the record for the past 8 months. In an interview on [DATE] at 11:10 a.m., Staff H, a registered dietician for the facility, stated she did not recall having any conversation with nursing or social services or the resident's decision makers, regarding the weight loss, malnutrition or review of resident treatment choices for Resident #1. The facility failure to provide social services support and coordination of care plan review with Resident #1's legal decision makers, led to the resident's decision makers' lack of knowledge and denied their ability to make treatment plan choices for Resident #1's lack of nutritional well-being. This failure led to Resident #1 not having information about prognosis and additional treatment options to address the significant change in condition and discuss all possible treatment options with the facility, before Resident #1 further declined in condition and was transferred to an acute care facility on [DATE].