Every finding on record at Washington Care Center

Based on interview and record review, the facility failed to complete the appropriate transfer notifications for 7 of 7 residents (Residents 1, 5, 11, 8, 23, 4, & 105) reviewed for hospitalization. The failure to offer bed holds (Residents 1, 5, 11, 8, 23, & 4), provide a written transfer notice (Residents 1, 5, 11, 8, 23, 4, & 105), and notify the State Long Term Care Ombudsman (LTCO) timely of resident discharges (Residents 1, 8 & 23) placed residents at risk for a disruption in their continuity of care, an undesired room change upon readmission, and not having the opportunity to make informed decisions about their transfer/discharge rights, and inappropriate transfers.Findings included .<Policy>According to a facility policy titled Bed Hold, dated 05/2025, the facility would inform the resident or the resident's representative of a bed hold within 24 hours of being transferred.According to a facility policy titled Transfer and Discharge, dated 05/2025, the facility would provide the resident or resident representative with the name, address, and telephone number of the state health department agency designated to handle appeals of transfers and discharges. The policy states the facility would send a copy of the notice to the LTCO, document the transfer in the resident's medical record and communicate appropriate information to the receiving care institution.<Resident 1> According to the 11/12/2025 Discharge Return Anticipated Minimum Data Set (MDS- an assessment tool), Resident 1 discharged to the hospital on [DATE] related to a change in the resident's condition. The MDS showed Resident 1 had medical conditions including bladder infection and lower back pain. Record reviews showed no documentation facility staff offered bed hold to the resident and provided Resident 1 or their representative with a written notification of the reason for transfer to the hospital as required. In an interview on 12/12/2025 at 12:02 PM, Staff F (Resident Care Manager/RCM) stated they notify the resident's family about transferring residents to the hospital and send the hospital transfer form (e-INTERACT) to the hospital with residents. Staff F stated nursing staff were responsible to offer bed hold to residents/representatives during transfers/hospitalizations, nursing staff were responsible to provide written discharge notice to residents and/ or their representatives and social services were responsible to notify the LTCO during residents' hospitalizations. In an interview on 12/15/2025 at 12:47 PM, Staff B (Director of Nursing/DON) stated nursing staff were responsible to offer bed hold and to provide written discharge notice to residents/their representative during hospitalizations. Staff B reviewed Resident 1's record and stated they did not offer bed hold to the resident and did not provide discharge notice to the resident during hospitalizations. Staff B stated the facility should have offered bed hold and provided the written discharge notice to Resident 1, but they did not. <Resident 5> According to the 10/01/2025 Discharge Return Anticipated MDS, Resident 5 was discharged to the hospital on [DATE] related to deficiency of red blood cells and change in mental status. Record reviews showed no documentation facility sent e-INTERACT to the hospital with Resident 5, no documentation showed staff offered bed hold to the resident and provided Resident 5 or their representative a written notification of the reason for transfer to the hospital as required. In an interview on 12/15/2025 at 10:12 AM, Staff E (RCM) stated their expectations from staff were to prepare all the paperwork to send with residents during transfers to the hospital including face sheet, physician orders, complete e-INTERACT. Staff E reviewed Resident 5's record and stated nursing staff should send complete e-INTERACT, offer bed hold to Resident 5/their representative, and provide written discharge notice to Resident 5/their representative, but they did not. <Resident 11> According to the 07/21/2025 Discharge Return Anticipated MDS, Resident 11 was discharged to the hospital on [DATE] related to multiple medical conditions including dialysis and leg fracture. Review of Resident 11's record showed no documentation facility sent the e-INTERACT with Resident 11 to give report to the hospital, no documentation showed staff offered bed hold to the resident and did not provide Resident 11 or their representative with written notification of the reason for transfer to the hospital as required. In an interview on 12/15/2025 at 10:12 AM, Staff E reviewed Resident 11's record and stated nursing staff should send the completed e-INTERACT, offer bed hold to Resident 11/their representative, and provide written discharge notice to Resident 11/their representative, but they did not. In an interview on 12/15/2025 at 12:53 PM, Staff B stated nursing staff were responsible to offer bed hold and to provide written discharge notice to residents/their representative during hospitalizations. Staff B stated the facility should send a completed e-INTERACT with Resident 11 to the hospital, offer bed hold and provide the written discharge notice to Resident 11, but they did not. <Resident 8> According to the 11/10/2025 Quarterly MDS, Resident 8 had no memory impairment. The MDS showed Resident 8 had urinary obstructions with bilateral nephrostomy tubes (tubes inserted into both kidneys) and a urinary catheter (tube inserted into the bladder). Review of Resident 8's health records showed transfers to an acute care hospital on [DATE] with a return to the facility on [DATE], 05/23/2025 with a return to the facility on [DATE], 06/13/2025 with a return to the facility on [DATE], 07/13/2025 with a return to the facility on [DATE], 08/14/2025 with a return to the facility on [DATE], 08/15/2025 with a return to the facility on [DATE], 09/09/2025 with a return to the facility on [DATE], and 10/08/2025 with a return to the facility on [DATE]. Review of the 01/16/2025, 05/23/2025, 06/13/2025, 07/13/2025, 08/14/2025, 08/15/2025, 09/09/2025, and 10/08/2025 hospital transfers showed no report to receiving facilities, and no written transfer notifications being provided to Resident 8. Review of the 05/23/2025, 07/13/2025, 08/14/2025, 08/15/2025, and 10/08/2025 hospital transfers showed no bed holds offered to Resident 8. The facility was unable to provide documentation of Resident 8's records being provided to the receiving hospital for the 01/16/2025, 05/23/2025, 06/13/2025, 07/13/2025, 08/14/2025, 08/15/2025, 09/09/2025, and 10/08/2025 hospital transfers. In an interview and record review on 12/15/2025 at 9:46 AM Staff D (Director of Social Services) reviewed LTCO hospital transfer notifications and stated the LTCO notifications were not being done until November 2025. Staff D stated LTCO should be notified monthly but was not for Resident 8's 01/16/2025, 05/23/2025, 06/13/2025, 07/13/2025, 08/14/2025, 08/15/202, and 09/09/2025 hospital transfers until November of 2025. <Resident 23> According to 06/05/2025 Discharge Return Anticipated MDS, Resident 23 was transferred to an acute care hospital. The MDS showed Resident 23 had severe memory impairment and a diagnosis of chronic respiratory disease. According to a 03/15/2019 Advanced Directive (AD- a document showing a person's wishes regarding medical treatment) Resident 23 had a Designated Power of Attorney (DPOA). According to Resident 23's health records, they transferred to an acute care hospital on [DATE] for respiratory failure and fever. Resident 23's records showed no report was provided to the receiving hospital, no bed hold was offered or written transfer notification provided to Resident 23's DPOA, and the LTCO was not notified of Resident 23's transfer until November 2025, five months later. In an interview and record review on 12/15/2025 at 9:46 AM Staff D stated the LTCO was not notified of Resident 23's transfer to the hospital until five months after the transfer in November of 2025. Staff D stated they should have notified the LTCO within a month of transfer but did not. <Resident 4> According to 11/12/2025 Annual MDS, Resident 4 had diagnoses of anxiety and depression with no memory impairment. According to a 08/26/2022 AD Resident 4 had a DPOA in place. According to a 12/03/2025 nursing progress note, Resident 4 was unresponsive with low blood oxygen levels and transferred to an acute care hospital on [DATE]. Resident 4's records showed no written transfer notification provided to Resident 4's DPOA, no bed hold was offered, and no report provided to the receiving hospital. In an interview on 12/16/2025 at 12:38 PM Staff E stated Resident 8 was not provided with a written transfer notification and staff did not provide a report to the receiving facilities but should have. Staff E stated Resident 8 was not offered a bed hold for the 05/23/2025, 07/13/2025, 08/14/2025, 08/15/2025, and 10/08/2025 transfers. Staff E stated Resident 8's record showed no indication of Resident 8's pertinent health records being provided to the receiving hospitals for the 01/16/2025, 05/23/2025, 06/13/2025, 07/13/2025, 08/14/2025, 08/15/2025, 09/09/2025, and 10/08/2025 hospital transfers. Staff E stated Resident 23's records did not show the facility provided the receiving hospital a report, a bed hold was offered, or that a written transfer notification was provided to Resident 23's DPOA for the 06/05/2025 transfer but should. Staff E stated Resident 4's health record did not show a written transfer notification was provided to Resident 4's DPOA, a bed hold was offered, or staff provided a report to the receiving hospital but should. Staff E stated it was important to provide a written transfer notification to residents or their representatives at the time of transfer to ensure they were aware of their right to appeal and had written instructions explaining how to do that. Staff E stated it was important to offer a bed hold to residents transferring to the hospital to give them the opportunity to return to the same bed if they wished. Staff E stated it was important to provide copies of pertinent health documents to the receiving facilities and provide reports on the residents' condition for continuity of care. <Resident 105> According to a 11/24/2025 e-INTERACT, Resident 105 was transferred to the hospital. In an interview on 12/12/2025 at 9:52 AM, Resident 105 stated they had been recently hospitalized and did not receive a written transfer notice or information to establish a DPOA. In an interview and record review on 12/16/2025 at 12:15 PM, Staff B (DON) stated there was no documentation of the required written transfer notification being provided to Resident 105. Staff B stated they expected staff to provide the document to the resident and document in a resident's medical record. Refer to F578 Advance Directives. Reference: WAC 388-97-0120(1)(2)(a-d)(3)(a)(4)(b)(5), 0080, -0140(1)(a-c)(i-iii).

Based on interview and record review, the facility failed to ensure residents and/or their representatives were informed of the nature and implications of entering into a binding Arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) Agreement (AA) for 3 of 3 residents (Residents 1, 33, & 101) reviewed for arbitration. The facility failed to ensure the arbitration agreement was signed and accepted by the residents and/or their Durable Power of Attorney (DPOA) for financial affairs as required. These failures placed residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of their right to a jury or court trial, and a diminished quality of life. Findings included . <Resident 1>According to the 11/23/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 had intact memory, and was able to make decisions.Review of Resident 1's AA showed the contract was signed by the resident on 05/22/2025 but Resident 1 did not check the column indicating if they accepted or declined the AA contract.In an interview on 12/12/2025 at 10:54 AM, Resident 1 did not remember signing the AA contract and stated they did not know what the AA contract was for.<Resident 33>According to the 11/06/2025 Quarterly MDS Resident 33 had no memory impairment and was able to make their own decisions.Review of Resident 33's AA showed the contract was signed by the resident on 05/20/2025 and Resident 33 did not check the column indicating if they accepted or declined the AA contract.In an interview on 12/12/2025 at 11:02 AM, Resident 33 stated they did not know what the AA contract was for. Resident 33 stated they did not remember signing the AA contract. Resident 33 stated now they knew what the AA contract was for, they would not sign the AA contract.<Resident 101>According to the 10/27/2025 Quarterly MDS Resident 101 had severe memory impairment and was not capable of decision making.Review of Resident 101's AA showed the contract was not signed by the resident and/or their representative. Resident 101's AA contract was prepared on 05/06/2025 and indicated Resident 101 was unable to sign the agreement and did not check the column to show the resident and/or their representative accepted or declined the AA contract.In an interview on 12/12/2025 at 11:43 AM, Staff A (Administrator) stated they were responsible for the AA contract process. Staff A reviewed Resident 1, 33, and 101's AA contracts and confirmed the AA contracts were not complete. Staff A stated it was important to educate residents and/or their representatives of the AA process to ensure they understood what they were entering into. Staff A stated it was their responsibility to ensure residents and/or their representatives understood all the legalities incorporated into the binding AA contract before letting them sign. REFERENCE: WAC 388-97-1620(2)(a)(b)(i), -0180(1-4).

Based on observations, interviews and record reviews, the facility failed to provide care and services in a manner that maintained residents rights for 2 of 5 sampled residents (Resident 23 and 25) and 1 supplementary resident (Resident 7) reviewed for consents and unnecessary medications. This failure placed residents at risk of diminished self-worth and overall well-being.Findings included.<Policy>According to the September 2017 Residents Rights policy, residents are informed about their federal and state rights upon admission and annually during their stay, including the resident's right to refuse any particular service so long as such refusal is documented in the resident's medical record.<Resident 23> According to 10/03/2025 Quarterly Minimum Data Set (MDS -an assessment tool) Resident 23 had severe memory impairment. The MDS showed Resident 23 had a diagnosis of dementia. Review of Resident 23's health records showed a 03/15/2019 advance directive with a healthcare Power of Attorney (POA) appointed by Resident 23. Resident 23's health records showed a 04/25/2025 vaccine consent form with Resident 23's signature declining the Influenza and Covid 19 vaccinations. Resident 23's Immunization report showed the facility administered the Influenza vaccine on 10/09/2025 and 10/10/2025, and the Covid 19 vaccine on 10/21/2025. Resident 23's records showed a 10/16/2025 psychoactive drug consent form with verbal authorization to administer an Antipsychotic medication to Resident 23 by a person that was not Resident 23's POA. In an interview on 12/16/2025 at 9:21 AM Staff B (Director of Nursing) stated they expected staff to follow the residents wishes of declining the immunizations. Staff B stated staff should have addressed consents with Resident 23's POA due to Resident 23 having severe cognitive impairment. Staff B stated it was important to have residents' POA consent prior to administration to ensure staff were implementing the residents' wishes. <Resident 25> According to the 10/23/2025 admission MDS, Resident 25 was admitted to the facility on [DATE] with diagnoses that included dementia, mood disturbance and anxiety. The MDS showed Resident 25 could be understood and was able to understand others. Review of the revised 10/27/2025 Elopement Risk Care Plan (CP) showed Resident 25 wandered and had a history of attempts to leave the facility. Interventions on the CP showed staff would attempt diversional interventions and provide frequent safety checks. The CP showed Resident 25 refused to wear a wander monitoring device. Review of the 10/24/2025 device and enabler evaluation and consent form showed Resident 25 had a wander monitoring device. The form showed Resident 25 gave verbal consent on 10/24/2025 and one staff member signature was handwritten on the form. There was no other witness signature on the form that showed Resident 25 agreed to use of the wander device. Interview and observations on 12/12/2025 at 8:21 AM and 12/15/2025 at 9:14 AM, Resident 25 stated staff would not let them leave the facility and they felt trapped. Resident 25 stated they would not wear the wander device. In an interview on 12/16/2025 at 12:02 PM, Staff R (LPN) stated Resident 25 often removed the wander device, because of this Staff R put the wander device in Resident 25's bag they carried when they walked around. In an interview on 12/16/2025 at 12:09 PM Staff G (LPN Care Coordinator) Staff G stated they determined Resident 25 needed a wander device and put the device on them because they frequently attempted to leave. Staff G stated Resident 25 often refused to wear their wandering device and would cut the device off. In an interview on 12/16/2025 at 1:19 PM, Staff B stated if a wander monitoring device was placed on a resident, staff should evaluate the need for the wander device and obtain correct consent to make sure the resident was fully aware of the consent for safety. <Resident 7> According to the 11/25/2025 admission MDS, Resident 7 admitted to the facility on [DATE] with diagnoses of gout (episode of swelling causing severe joint pain) and no cognitive impairment. Review of a Progress Note on 11/16/2025 showed Resident 7 arranged transportation to leave the facility and appeared confused. Staff notified Resident 7's brother, listed as the resident's emergency contact. Review of the 11/18/2025 Elopement Risk Evaluation showed Resident 7 had attempted to leave the facility without telling staff and continued to express a desire to leave the facility. Review of November 2025 MAR showed a 11/18/2025 physician order for the placement and monitoring of an elopement device (an electronic bracelet worn by residents at risk for leaving the facility without telling staff). Review of a Progress Note on 11/18/2025 at 17:00 showed staff placed the device on Resident 7. Review of the 11/18/2025 Device Consent showed the device would be implemented to alert staff if Resident 7 attempted to leave the facility. Section H showed staff indicated Resident 7 had verbally consented on 11/19/2025 for the use of the device, the day after the device was placed and no staff signatures were present. Review of the 11/19/2025 CP showed Resident 7 used the device for safety and staff were to notify the nurse if the device was missing. Observations on 12/10/2025 at 12:12 PM, 12/11/2025 at 1:46 PM, and 12/12/2025 at 10:23 AM showed the device was attached to the left handle of Resident 7's wheelchair. In an interview on 12/10/2025 at 12:12 PM, Resident 7 stated staff placed the device on their wrist without asking for their permission. Resident 7 pointed to the device hanging from their wheelchair handle and stated that staff placed it there because they refused to wear it. Resident 7 stated they told staff they did not want it on their wheelchair either. Resident 7 stated they told staff they wanted to return home and believed they were being kept at the facility against their will. In a telephone interview on 12/11/2025 at 10:35 AM, Resident 7's representative denied knowledge of the placement of the device and stated they believed Resident 7 was able to sign their own consents. In an interview and record review on 12/16/2025 at 9:32 AM, Staff F (Resident Care Manager) stated they created the verbal consent for Resident 7's device and had not obtained two staff signatures. Staff F stated they should have obtained the staff signatures and followed up by completing a written informed consent to be signed by Resident 7. In an interview on 12/16/2025 at 10:55 AM, Staff B stated they expected staff to obtain written consent from residents prior to implementing interventions and follow the resident's wishes of refusing care. Staff B stated they expected verbal consents to be signed by two staff members, only when written signatures were not possible. Staff B stated they expected all refusals and consents to be documented in the residents' medical record. Refer to F578 Advance Directives. Refer to F658 Services Provided Meet Professional Standards Reference WAC 388-97-0300 (3)(b).

Based on interview and record review, the facility failed to ensure residents and/or their representatives received written information of their right to accept or refuse treatment by formulating an Advance Directive (AD) for 2 (Resident 23 and 105) of 6 sampled residents. This failure placed residents at risk of being denied their right to make health care decisions and preventing them from exercising their right to refuse care.Findings included.<Policy>According to the August 2010 AD policy, residents would be informed of their right to make healthcare decisions including the right to refuse treatments and to prepare an AD. Staff were to obtain written acknowledgements of the receipt of such information in residents' medical record.<Resident 23> According to the 05/01/2025 admission Minimum Data Set (MDS – an assessment tool) Resident 23 had severe memory impairment. The MDS showed Resident 23 admitted to the facility on [DATE]. Record review showed 03/15/2019 AD paperwork with a designated Power of Attorney (POA) by Resident 23. Review of Resident 23's health records showed no contact information for Resident 23's POA. Resident 23's records showed the facility had not utilized their POA and showed the facility was communicating Residents care and treatment with a family member not appointed POA by Resident 23. In an interview on 12/16/2025 at 9:19 AM Staff B (Director of Nursing) stated they expected staff to communicate cares with the residents appointed POA, but they did not for Resident 23. Staff B stated it was important to follow AD to ensure the facility was implementing care and treatment according to the residents' wishes. <Resident 105> According to the 11/26/2025 admission MDS, Resident 105 was admitted to the facility on [DATE] with a brain infection, weakness, and no memory impairment. In an interview on 12/12/2025 at 9:51 AM, Resident 105 stated they did not recall being offered information to review or establish an AD. Resident 105 stated they would have assigned their brother as POA, in the event they were unable to communicate their health care preferences. Review of Resident 105's health records showed contact information for their brother as the primary emergency contact and no documentation the facility aided Resident 105 to understand and implement an AD. In an interview on 12/12/2025 at 9:55 AM, Resident 105's brother stated they had not been informed of the resident's admission by the facility but rather by another family member and when they spoke to Resident 105 via telephone, they were concerned at the significant loss of Resident 105's ability to speak and be understood verbally. Resident 105's brother stated they lived in another state but travelled to the facility to better understand Resident 105's condition. Since arrival, Resident 105's brother had not been approached by the facility regarding ADs. In an interview and record review on 12/15/2025 11:40 AM, Staff D (Social Services Director) stated they were unable to document Resident 105's receipt of information related to AD because Resident 105 was unable to produce speech or sign the form. Staff D stated they should have verbally consented Resident 105 with the AD information and followed up with written consent when the resident was able. Staff D states they had not contacted Resident 105's brother to offer the same information. In an interview on 12/16/2025 at 10:55 AM Staff A (Administrator) stated they expected staff to obtain and document verbal and/or written consents for ADs in the resident's medical record. Refer to F550 Resident Rights. Refer to F628 Hospitalizations. Reference WAC 388-97-0260.

Based on observation, interview and record review, the facility failed to ensure walls, heaters and baseboard in resident rooms were maintained in a safe, clean and homelike condition for 6 of 13 residents (Resident 113, 99, 25, 9, 61 & 23) , failed to ensure privacy curtains were maintained in a clean sanitary condition (Residents 113 & 9) and failed to ensure resident rooms were personalized (Resident 23). These failures left residents at risk for a less than homelike environment and a diminished quality of life. Findings included . <Facility Policy>According to the facility's July 2015 Homelike Environment policy, resident rooms would be personalized and organized in a manner that promotes independence through a homelike environment.<Resident 113> Observations on 12/12/2025 at 12:44 PM, 12/15/2025 at 9:46 AM and on 12/16/2025 at 12:09 PM, a privacy curtain in Resident 113's room, separating their room door and bed, was soiled with several small and large sized spots and splashes that were brown and red in color. <Resident 99> Observations on 12/12/2025 at 12:44 PM, 12/15/2025 at 9:46 AM and on 12/16/2025 at 12:09 PM, a privacy curtain in Resident 99's room was soiled with several small and large sized spots and splashes that were brown and red in color. <Resident 25> Observations on 12/11/2025 at 9:28 AM and on 12/15/2025 at 9:14 AM showed a large gouge and hole in the wall behind Resident 25's bed. Interview on 12/16/2025 at 12:20 PM, Staff C (Maintenance Director) stated they conducted monthly room by room assessments and documented needs in a maintenance log notebook for future repairs. Staff C stated they expected staff to document daily repair needs in the maintenance log binder located at the nursing station in each unit. Staff C stated they toured the facility daily and addressed repair needs listed in each unit binder. After touring the facility, Staff C stated the hole in the wall in Resident 25's room and the privacy curtains in Resident 113 and Resident 99's rooms were not identified in the maintenance log sheets. Interview on 12/16/2025 at 1:39 PM Staff B (Director of Nursing) stated staff should report environmental and homelike setting concerns when they find them. <Resident 9> Observation on 12/11/2025 at 9:02 AM showed a baseboard heater underneath the window in Resident 9's room had a metal end-bracket that was not attached at the bottom edge. The metal bracket was bent and protruded out from the heater into the room. In an interview on 12/11/2025 at 9:02 AM, Resident 9 stated they often accidentally ran into the metal bracket with their wheelchair and got stuck on it. Resident 9 stated they no longer stored their walker in the corner next to the heater because they were afraid they would bump their leg on the metal bracket. Resident 9 stated they mentioned it to the nurse over a month ago, and the nurse said they would call maintenance to fix it. Review of the unit's Maintenance Request Log on 12/11/2025 showed no entry regarding Resident 9's heater. In an observation and interview on 12/16/2025 at 11:45 AM, Staff C, stated Resident 9's heater needed to be fixed to ensure safety. <Resident 61> Observations on 12/10/2025 at 9:20 AM, 12/15/2025 at 9:19 AM, and 12/16/2025 at 12:47 PM showed a baseboard heater underneath the window in Resident 61's room was covered in dark brown spots, splashes, and debris. In an interview on 12/10/2025 at 9:20 AM, Resident 61 stated their heater was dirty. Resident 61 stated the heater should look better and tried covering the heater up. In an interview on 12/16/2025 at 12:53 PM, Staff C stated the maintenance department was responsible for cleaning the heaters, and Resident 61's heater needed to be cleaned. <Resident 23> Observation on 12/10/2026 at 9:49 AM and 12:01 PM, 12/11/2025 at 10:05 AM, 12/12/2025 at 8:38 AM and 1:12 PM, 12/15/2025 at 12:27 PM and 12/16/2025 at 11:47 AM, showed Resident 23 did not have any personal belongings in their room. Resident 23's room did not have any pictures or room decorations. In an interview on 12/16/2025 at 9:23 AM Staff B stated Resident 23 should have room decorations and personal items for a homelike environment. Staff B stated it was important to offer and provide personal items and decorate the residents room to create a homelike environment for the residents. Reference: WAC 388-97-0880.

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the mental health conditions for 4 of 5 residents (Resident 5, 6, 11, & 23) reviewed for PASRR/Unnecessary Medications. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.Findings included.<Policy>According to the facility's revised 01/01/2025 PASARR Process Policy and Procedure policy, facility would ensure all residents had a PASRR screening prior to admission and would keep a copy in the resident's record. The policy showed the facility's Social Services staff were responsible for ongoing maintenance of accurate PASRR screenings, and PASRR screening would be updated as needed to reflect changes both positive and negative to a resident's mental health status. The policy showed the facility would follow up as needed per Federal PASRR rules. <Resident 5> According to the 10/14/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 had moderately impaired cognition (impaired memory and problem solving) and had diagnoses of schizophrenia (mental disorder-characterized by hallucinations, delusions and disorganized thinking or behavior), depression, and anxiety. The MDS showed Resident 5 received antipsychotic and antidepressant medications during the assessment period. Review of 10/28/2025 and 11/25/2025 provider's progress notes showed Resident 5 had diagnosis of schizophrenia, anxiety, and depression disorder. The provider recommended staff continue administering antipsychotic and antidepressant medications as ordered and continue monitoring behaviors. Review of the December 2025 Medication Administration Record (MAR) showed Resident 5 received routine antipsychotic and antidepressant medications every day as ordered related to their diagnosis. Review of the 08/20/2024 Level 1 PASRR completed in the facility showed Resident 5 was identified with Serious Mental Illness (SMI) indicator for Schizophrenia, depression, and anxiety disorder diagnosis, and Level 2 PASRR evaluation was not required. In an interview on 12/15/2025 at 10:56 AM, Staff D (Social Services Director) stated Resident 5's Level 1 PASRR was updated on 08/20/2024 and Level 2 PASRR was not indicated. Staff D reviewed Resident 5's Level 1 PASRR and stated the form was inaccurate and should refer to Level 2 evaluation, but they did not. <Resident 6> According to the 10/17/2025 Quarterly MDS, Resident 6 had diagnoses of schizophrenia, depression, and anxiety. The MDS showed Resident 6 received antipsychotic and antidepressant medications during the assessment period. Review of the Resident 6's December 2025 MAR showed Resident 6 received routine antipsychotic and antidepressant medications every day as ordered related to their diagnosis. Review of the 06/14/2023 Level 1 PASRR showed Resident 6 was identified with SMI indicator for depression, and anxiety disorder diagnosis, and Level 2 PASRR evaluation was not indicated. In an interview on 12/15/2025 at 10:59 AM, Staff D reviewed Resident 6's Level 1 PASRR and stated Resident 6's Level 1 PASRR was not accurate. Staff D stated they should have updated Resident 6's Level 1 PASRR according to Resident 6's current mental condition and referred to Level 2 evaluation, but they did not. <Resident 11> According to the 10/21/2025 Quarterly MDS, Resident 11 had diagnoses of schizophrenia, depression, and anxiety. The MDS showed Resident 11 received antipsychotic and antidepressant medications during the assessment period. Review of the 02/27/2024 Level 1 PASRR showed Resident 11 was identified with SMI indicator for Schizophrenia, depression, and anxiety disorder diagnosis, and Level 2 PASRR evaluation was not indicated. Review of Resident 11's December 2025 MAR showed Resident 11 received antipsychotic and antidepressant medications every day as ordered related to their diagnosis. In an interview on 12/15/2025 at 11:09 AM, Staff D reviewed Resident 11's MAR and Level 1 PASRR and stated Resident 11's Level 1 PASRR was not accurate. Staff D stated they should have updated Resident 11's Level 1 PASRR according to Resident 11's current mental condition and referred to Level 2 evaluation, but they did not. <Resident 23> According to the 05/01/2025 admission MDS, Resident 23 admitted to the facility on [DATE]. The MDS showed Resident 23 was taking antipsychotic and antidepressant medications and had a diagnosis of Dementia (decline in mental ability) and a sleep disorder characterized by difficulty falling or staying asleep. Review of Resident 23's records showed a 04/25/2025 diagnosis of dementia with psychotic disturbances. Resident 23's records showed a PASRR Level 1 with no serious mental illness and no Level 2 PASRR evaluation indicated. Resident 23's PASRR Level 1 file scanned to their records also included hospital notes from 04/24/2025 which indicated Resident 23 was agitated with behaviors, refusing care, and was receiving antipsychotic and antidepressant medications at the hospital. In an interview on 12/15/2025 at 11:09 AM, Staff D reviewed Resident 23's MAR and Level 1 PASRR and stated Resident 23's Level 1 PASRR was not accurate. Staff D stated they should have updated Resident 23's Level 1 PASRR according to the Resident's current mental condition and referred for Level 2 evaluation, but they did not. REFERENCE: WAC 388-97-1915 (1). .

Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed for 4 (Residents 10, 79, 23, & 5) of 25 sample residents reviewed. Failure to ensure CPs were updated to reflect current care needs left residents at risk for unmet care needs, delay in treatments, and a diminished quality of life. Findings included . <Facility Policy>On 12/16/2025, the facility administrator did not provide Care Planning policy and stated it was Standard of Practice. <Resident 10> According to the 11/23/2025 change of condition Minimum Data Set (MDS - an assessment tool), Resident 10 was on end-of-life care services. The MDS showed Resident 10 had pressure areas on their heel and back areas. Review of the revised 11/24/2025 impairment to skin integrity CP showed interventions included hospice services for end-of-life care. The CP did not include staff interventions to address refusals of wound care treatments. Review of Resident 10's progress notes showed Resident 10 refused wound care treatments and/or wound skin assessments on 12/16/2025, 12/12/2025, 12/11/2025, 12/10/2025, 12/9/2025 and 12/8/2025. In an interview on 12/11/2025 at 10:15 AM, Resident 10 stated they had skin problems and had pain during wound care. In an interview on 12/12/2025 at 1:30 PM, Staff T (Licensed Practical Nurse - LPN, wound care nurse) stated Resident 10 often refused wound care and skin assessments. Staff T stated they would monitor Resident's 10's wound more if Resident 10 let them. Staff T stated they needed to check with Hospice services to determine if wound care treatments and measurements should continue because of Resident 10's frequent refusals. In an interview on 12/15/2025 at 1:14 PM, Staff G (LPN Care Coordinator) stated Resident 10 often refused care services and stated Hospice services were aware of refusals. Staff G stated hospice coordination and services should be incorporated into Resident 10's CP, especially for refusals. In an interview on 12/16/2025 at 1:27 PM, Staff B (Director of Nursing) stated the facility nurses should notify the provider or care providers of the refusals and obtain further directions on care needs and update the CP with staff interventions. <Resident 79> According to a 08/27/2025 admission MDS, Resident 79 was dependent on staff for turning side to side in bed. Review of a 08/28/205 impaired skin integrity CP showed staff would assist Resident 79 with frequent repositioning in bed. The 08/28/2025 ADL (Activities of Daily Living) CP showed Resident 79 was dependent on two staff to turn and reposition in bed. Observation and interview on 12/11/2025 at 10:41 AM until 1:21 PM showed Resident 79 lying in bed on their back. Resident 79 stated they needed staff to turn them on their sides because they were unable to do it on their own. Resident 79 stated they were concerned because staff do not offer help with repositioning in bed and they had a history of pressure sores to their buttocks off and on over the years. <Resident 23> According to a 10/03/2025 Quarterly MDS, Resident 23 required substantial/maximal assistance from staff for turning side to side in bed. The MDS showed Resident 23 was at risk for falls. Review of a 05/06/2025 at risk for pressure ulcer development CP showed staff would assist Resident 23 with frequent repositioning. The 04/29/2025 ADL CP showed Resident 23 was dependent on two staff to turn and reposition in bed. The 05/06/2025 communication problem related to impaired ability to make self-understood and understand others CP showed staff would ensure Resident 23's bed would remain in lowest position and avoid isolation. Observation on 12/10/2026 at 9:49 AM and 12:01 PM, 12/11/2025 at 10:05 AM, 12/12/2025 at 8:38 AM until 10:56 AM and 1:12 PM, 12/15/2025 at 12:27 PM, 12/16/2025 at 11:47 AM showed Resident 23 lying on back with their bed raised 36 inches, isolated with their door closed. In an interview on 12/16/2025 at 1:05 PM, Staff S (Registered Nurse) stated staff should reposition Resident 23 in bed every two hours and was unsure why they hadn't been repositioned. Staff S stated if Resident 23 refused repositioning the aides would inform them, the assigned nurse, and document the refusal but they were not informed of Resident 23 refusing repositioning. In an interview on 12/16/2025 at 9:26 AM, Staff B stated Resident 79 and 23 should be repositioned by staff every two hours per CP. Staff B stated they expected staff to reposition all dependent residents every two hours during their rounds and if the resident refused, staff should inform the assigned nurse and document the refusal. Staff S stated staff should keep Resident 23's bed in the lowest position and leave the door open. Staff S stated it was important to keep Resident 23's bed low because the resident is a fall risk and to leave their door open to not isolate them. Staff S stated staff should follow the CP, but they did not. <Resident 5> According to the 10/14/2025 Quarterly MDS, Resident 5 was assessed with moderate cognitive impairment, able to understand and be understood in conversation. The assessment showed Resident 5 was dependent on staff for all activities of daily living including bathing, toileting, and repositioning in bed. Review of Resident 5's Fall CP showed Resident 5 was at risk for fall or injury due to impaired balance, psychotropic medication use, and weakness. The interventions included directions for staff to keep Resident 5's bed in low position and encourage Resident 5 to call staff for assistance. Observations on 10/12/2025 at 10:07 AM, 10/13/2025 at 1:00 PM, and on 10/15/2025 at 8:33 AM showed Resident 5 was lying in their bed and had a concave mattress in bed. These observations showed Resident 5's bed was in the high position. Review of Resident 5's 10/20/2025 nursing progress notes showed Resident 5 had a fall on 10/20/2025 from their bed with an injury on their forehead. Resident 5 was sent to the hospital for further evaluation and treatment. Review of Resident 5's record showed no physician order and no CP for concave mattress in their bed. In an interview on 12/15/2025 at 9:53 AM, Staff E (Resident Care Manager) stated updating the CPs and to follow the CP was very important to provide safe and appropriate care to all residents related to their current medical status. Staff E reviewed Resident 5's CP and stated they did not update the CPs after Resident 5's fall. Staff E stated they should update the CP to prevent further risk for injury related to fall, but they did not. In an interview on 12/15/2025 at 12:23 PM, Staff B stated their expectations from staff were to update the CP timely according to resident's current medical and mental status to provide safe care. REFERENCE: WAC 388-97-1020(2)(c)(d).

Based on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were clarified and followed for 4 (Residents 11, 25, 120, & 23) of 25 sample residents; nurses did not document nonpharmacological interventions for pain medications for 1 (Resident 23); staff did not follow the oxygen orders, the facility Bowel Movement (BM) protocol and pain medication parameters as ordered for 1 (Resident 11); and devices in place without physician order for 1 (Resident 120) of 25 sample residents. These failures placed residents at risk for medication errors, delayed treatment, Resident Rights, adverse outcomes and diminished quality of life. Findings included .<Facility Policy> According to the facility's updated February 2025 Elopement/Wandering policy, if the facility used a monitoring system the facility would obtain a physician's order for use of the device prior to application and after consent was received.According to the facility's updated May 2025 Bowel Protocol, if a resident does not have a bowel movement for three days, the nurse administers the physician ordered bowel program. <Following Physician Orders> <Resident 11> According to the 10/21/2025 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 11 had multiple medically complex diagnoses including kidney failure, chronic pain, and impaired mobility. Record review showed a 10/10/2025 physician order directing staff to provide Resident 11 oxygen at two liters per minute via nasal canula (tubing delivering oxygen directly into the resident's nostrils) continuously and to keep the resident's oxygen level above 94%. Observations on 12/11/2025 at 11:02 AM, 12/12/2025 at 1:21 PM, and 12/15/2025 at 9:00 AM showed Resident 11 received oxygen at three liters per minute via nasal canula. In an interview on 12/15/2025 at 9:08 AM, Staff P (Registered Nurse) reviewed Resident 11's physician orders and confirmed in Resident 11's room oxygen was running at three liters per minute. Staff P stated they should follow the physician orders, but they did not. Record review showed a 07/24/2025 physician order directing staff to provide Resident 11 a non-narcotic pain medication as needed for a pain level of 1-3 on a scale of 0-10, and a 10/07/2025 physician order directing staff to provide Resident 11 a narcotic pain medication as needed for a pain level of 4-10 on a scale of 0-10. Review of Resident 11's December 2025 Medication Administration Record (MAR) showed Resident 11 received their non-narcotic pain medication for a pain of 5 out of 10 on 12/01/2025, for a pain of 8 of 10 on 12/04/2025, and 7 of 10 on 12/13/2025. The December 2025 MAR showed Resident 11 received their narcotic pain medication for a pain of 0 of 10 on 12/06/2025. According to a 07/24/2025 physician order, staff should follow the ordered BM program when Resident 11 did not have a BM for 3 days. Review of Resident 11's record showed Resident 11 did not have a BM on 11/20/2025, 11/21/2025, 11/22/2025, 11/23/2025, and 11/24/2025 for a total of 5 days. Record review showed Resident 11 did not have a BM on 11/28/2025, 11/29/2025, 11/30/2025, 12/01/2025 for a total of 4 days. Review of Resident 11's December MAR showed staff did not follow the physician orders to administer medications as ordered when Resident 11 did not have BM for more than 3 days. In an interview on 12/16/2025 at 9:47 AM, Staff E (Resident Care Manager) reviewed Resident 11's record and stated staff should follow the physician orders for oxygen administration, pain medication parameters, and BM management program, but they did not. <Medication Administration> <Resident 25> According to the 10/23/2025 admission MDS, Resident 25 admitted to the facility on [DATE] with diagnoses that included high blood pressure, anxiety and a wound on their foot. Review of the 10/28/2025 Baseline Care Plan (CP) showed Resident 25 had decreased mobility. The CP included interventions for staff to report any verbal or physical signs of pain and if the pain location was the right foot or left toe. Record review showed a 10/17/2025 Physician order showed a pain medication 325 milligrams (MG) give three tablets every eight hours as needed for pain or fever. The order did not specify the parameter for staff to know how many tablets should administer for pain and how many tablets for fever. Review of December 2025 MAR showed staff administered the pain medication on 12/2/2025, 12/4/2025 and 12/11/2025. The MAR did not have documentation to show the pain medication was used for pain or fever. In an interview on 12/16/2025 at 1:42 PM Staff B (Director of Nursing) stated the order should have an indication for what type of pain the pain medication would be used for and should include a pain range to determine how many tablets were to be used for pain or fever. Staff B stated staff should have documented the reason why the pain medication was used to better track the resident's pain or fever. <Wander Guard> <Resident 25> According to the 10/23/2025 admission MDS, Resident 25 was admitted to the facility on [DATE] with diagnoses that included dementia, mood disturbance and anxiety. The MDS showed Resident 25 could be understood and able to understand others. Review of the revised 10/27/2025 Elopement Risk CP showed Resident 25 wandered and had a history of attempts to leave the facility. Interventions on the CP showed staff should attempt diversional interventions and provide frequent safety checks. The CP showed Resident 25 refused to wear a wander guard. Review of a 10/24/2025 nursing progress note showed staff provided Resident 25 with a wander guard to alert staff if Resident 25 attempted to leave the facility. The nursing progress note did not show Resident 25's provider was notified of the use of the wander guard and did not show a physician order was obtained prior to using on the wander guard for Resident 25. Review of Resident 25's physician orders did not show an order for a wander guard. In an interview on 12/12/2025 at 8:21 AM and 12/15/2025 at 9:14 AM, Resident 25 stated the facility staff would not let them leave the facility and they felt trapped. Resident 25 stated they did not wear a wander guard. In an interview on 12/16/2025 at 12:09 PM Staff G (Licensed Practical Nurse Care Coordinator) stated they determined Resident 25 needed a wander guard and placed the device on them because they frequently attempted to leave the facility. Staff G stated they could not find in Resident 25's medical record that a physician's order was obtained prior to use of a wander guard on the resident. Staff G stated they should follow the facility policy, but they did not. <Resident 23> According to the 10/03/2025 Quarterly MDS, Resident 23 received scheduled pain medications. The MDS showed Resident 23 was at risk for pressure ulcers and falls. Review of Resident 23's record showed Resident 23 received routine pain medications for pain management. Resident 23's records showed no nonpharmacological pain interventions implemented. In an interview on 12/16/2025 at 9:47 AM Staff B reviewed Resident 23's records and was unable to provide documentation of nonpharmacological pain interventions. Staff B stated they expected staff to obtain a physician order for the nonpharmacological pain interventions, but they did not. Refer to F550 Resident Rights REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). .

Based on observation, interview, and record review, the facility failed to offer and provide assistance with Activities of Daily Living (ADL) for 2 of 7 residents (Residents 23 & 79) reviewed who were dependent on staff for daily cares/ADLs. The failure to provide assistance with ADLs placed residents at risk for poor hygiene, diminished feeling of self-worth, and a decreased quality of life.Findings included .<Policy>Facility did not provide ADL policy.<Resident 23> According to the 10/03/2025 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 23 required staff assistance with ADLs. The MDS showed Resident 23 was frequently incontinent of urine and always incontinent of bowels. Review of Resident 23's 05/06/2025 ADL Care Plan (CP) showed they were dependent on staff for bathing, dressing, oral hygiene, and required a mechanical lift with two staff to transfer them out of bed. Review of Resident 23's health records showed an assigned bathing schedule for every Monday and Friday. September 2025 Point of Care (POC- nurse aide documentation) documentation showed Resident 23 refused bathing on 09/17/2025 and 09/20/2025. October 2025 POC documentation showed Resident 23 refused bathing on 10/01/2025, 10/17/2025, 10/24/2025, 10/27/2025, and was not offered bathing on 10/10/2025 per schedule. November 2025 POC documentation showed Resident 23 refused bathing on 11/10/2025, 11/14/2025, 11/17/2025, and 11/21/2025, 21 days without bathing. December 2025 POC documentation showed Resident 23 refused bathing on 12/05/2025. POC documentation for Resident 23 showed no bathing reoffered after documented refusals. Observation on 12/10/2026 at 9:49 AM and 12:01 PM, 12/11/2025 at 10:05 AM, 12/12/2025 at 8:38 AM until 10:56 AM and 1:12 PM, 12/15/2025 at 12:27 PM, 12/16/2025 at 11:47 AM showed Resident 23 lying in bed on their back, their hair not brushed, a sheet pulled up to their waist, and wearing no clothing. In an interview on 12/16/2025 at 1:05 PM Staff S (Registered Nurse) stated staff should offer Resident 23 assistance with morning care to include brushing hair, dressing, and getting out of bed. Staff S stated if Resident 23 refused cares they expected staff to reapproach and document continued refusals. <Resident 79> According to the 11/12/2025 Quarterly MDS Resident 79 required staff assistance with ADLs. The MDS showed Resident 79 was always incontinent of urine and bowels. Review of Resident 79's 08/28/2025 ADL CP showed they were dependent on staff for bathing, dressing, and oral hygiene. The 08/21/2025 baseline plan of care CP showed Resident 79 required a mechanical lift and two staff to transfer them out of bed. Observation and interview on 12/11/2025 at 10:41 AM, 12/15/2025 12:50 PM, and 12/16/2025 from 1:00 PM until 1:21 PM showed Resident 79 lying in bed wearing a gown with messy hair. Resident 79 stated staff did not offer to assist them with hygiene, dressing, or getting out of bed. In an interview on 12/16/2025 at 9:13 AM Staff B (Director of Nursing) stated they expected staff to offer and provide morning care which included face washing, brushing hair and teeth, getting the resident dressed, brief changes if needed, providing assistance in getting the resident up and out of bed, staff introducing themself to the resident and staff to ask the resident if they need anything else. Staff B stated if a resident refused, they expected staff to reapproach the resident and if the resident continued to refuse care, staff were expected to notify the assigned nurse and document the refusal. Staff B reviewed Resident 23 and 79's bathing documentation and stated they expected staff to reapproach daily until they accepted but staff did not. Staff B stated they expected staff to obtain residents' bathing preferences and provide assistance when a resident requested a shower if it was safe for the residents to have a shower. Reference: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards by implementing their system for screening and storing hazardous toxic chemicals in 1 of 4 soiled utility rooms (2 [NAME] Soiled Utility Room) and 1 of 4 clean utility rooms (2 East Clean Utility Room), and 1 of 4 linen rooms (2 [NAME] Clean Linen Room) reviewed. This failure placed residents at risk of injury.Findings included.<Policy>According to the facility policy titled, Storage Areas, Environmental Services, revised February 2021, the facility would ensure housekeeping storage would be maintained in a safe manner.According to a facility policy titled, Medication Storage, dated 01/2023, medications would only be accessible to authorized staff.<2 [NAME] Soiled Utility Room>Observation, record review, and interview on 12/10/2026 at 9:03 AM showed 2 [NAME] Soiled Utility Room door not closed/locked. The soiled utility room had a bottle of shower cleaning chemical, one can of stainless-steel cleaner, and one container for Sani wipes filled with a blue liquid chemical cleaner. Staff K (Certified Nursing Assistant) stated the soiled utility room door should be pulled closed and locked so residents do not have access since there were chemicals stored in there. Staff K stated the shower cleaning chemical, stainless-steel cleaner, and Sani wipes container filled with the blue liquid chemical cleaner should be stored behind locked door for resident safety but was not.In an interview on 12/10/2026 at 9:08 AM Staff L (Infection Preventionist) stated the soiled utility room door should be pulled closed and locked for resident safety because of the chemicals stored in the soiled utility room.<2 [NAME] Clean Linen Room>Observation, interview, and record review on 12/10/2026 at 9:10 AM showed the 2 [NAME] clean linen room behind the nurse's station with no lock on the door. The clean linen room had two bottles of drug disposal chemical digestion gel and medications in them. Staff L stated the drug disposal bottles should be stored behind a locked door in the medication room for residents' safety.<2 East Clean Utility Room>Observation and interview on 12/10/2025 at 9:32 AM showed the 2 East Clean Utility Room door with a keypad lock however the door was not locking when closed. The clean utility room had 50 razors, 10 fingernail clippers, and 5 toenail clippers in it. Staff M (Registered Nurse) stated the clean utility room had sharps stored in there so the door should be locked for resident safety, but the keypad was not working so the door was not locked after it was closed.In an interview on 12/16/2025 at 9:13 AM Staff B (Director of Nursing) stated they expected all chemicals and sharps to be stored behind locked doors for resident safety.Reference: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review the facility failed to appropriately use Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measures used to reduce the spread of multidrug-resistant organisms) for 2 supplemental residents (Residents 28 & 10) who required EBP reviewed for infection control. These failures placed residents at risk for the development and transmission of communicable diseases and an unclean environment.Findings included . <Facility Policy>According to the facility's March 2025 Transmission-Based Precautions policy, EBP required the use of gowns and gloves by care providers during high-contact resident care activities. <Resident 28> Observation on 12/12/2025 at 10:47 AM showed Resident 28's room had an EBP sign posted outside their door. The signage showed staff must clean their hands before entering the room, and wear gloves and gowns for high-contact resident care activities including dressing and transferring residents, providing hygiene and care of a urinary catheter (tubing to assist with urinary drainage). Staff I, (Certified Nursing Assistant - CNA) entered Resident 28's room and did not perform hand hygiene. Staff I and Staff J (CNA) transferred Resident 28 from their bed to a wheelchair, moved a urinary catheter bag to the wheelchair, and assisted Resident 28 with dressing and hygiene. Staff I and Staff J did not wear gowns. In an interview on 12/12/2025 at 11:00 AM, Staff J said the EBP sign showed what PPE they should wear if the resident had a disease, but Resident 28 was not sick so they did not need to wear gowns at that time. Staff J said that they were busy in another room when Resident 28 called to get up from bed, so Staff J had to rush to help and did not have time to put on a gown. <Resident 10> Observation on 12/12/2025 at 9:33 AM, Resident 10's room had an EBP sign posted outside their door. The signage showed staff must wear gloves and gowns for high contact resident care activities. Staff H (Registered Nurse - Medication Nurse) applied a medicated skin cream to Resident 10's left lower leg. Staff H did not wear a gown while applying the cream to Resident 10's leg. In an interview on 12/12/2025 at 9:36 AM Staff H stated they should wear a gown for infection control reasons when they applied the cream on Resident 10's leg but did not. In an interview on 12/12/2025 at 10:49 AM Staff L (Infection Preventionist) stated staff should follow the EBP directions on the sign and wear gloves and a gown when administering skin treatments. REFERENCE: WAC 388-97-1320 (1)(a)(c), (2)(a)(b).

Based on interview and record review the facility failed to implement an Antibiotic (ABO) Stewardship program to promote appropriate use of ABO and reduce the risk of unnecessary ABO use for 2 of 3 residents (Resident 8 & 4) reviewed for unnecessary antibiotics. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of ABOs and placed residents at a greater risk of developing ABO resistance.Findings included.<Policy>According to the facility policy titled, ABO Stewardship Program, dated March 2018, the facility would ensure residents met the McGeers criteria (a tool used for infection surveillance activities and management of ABO usage) for ABO usage. The policy showed the facility would use standard evaluations and communication tools for residents with suspected infections, utilize Antibiogram reports, and implement ABO time outs. <Resident 8>Review of Resident 8's health records showed they received an ABO from 01/23/2025 until 02/02/2025 for a urinary tract infection. Resident 8's records also showed they received an ABO from 04/01/2025 until 04/04/2025 for an upper respiratory infection.<Resident 4>Review of Resident 4's health records showed they received an ABO from 07/01/2025 until 07/02/2025 for a fever only.In an interview and record review on 12/12/2025 at 10:49 AM Staff L (Infection Preventionist) stated they expected staff to track all residents with prescribed ABOs on the facility ABO Stewardship line listing. Staff L stated the facility used the McGeers criteria to assess all prescribed ABOS and would implement an ABO timeout for each prescribed ABO. Staff L stated Resident 8 and 4's ABOs were not on the ABO Stewardship line listing and did not have an ABO timeout or McGeers assessment completed for the 01/2025, 04/2025, and 07/2025 ABOs but staff should have. Staff L stated it was important to assess, monitor, and manage all prescribed ABOs to ensure no inappropriate/unnecessary ABOs were prescribed to prevent residents developing an ABO resistance.Reference: WAC 388-97-1060(3)(k)(i).

Based on observations, interviews, and record review, the facility failed to ensure each resident received assessed level of supervision and assistance to prevent accidents for 1 of 4 sampled residents (Resident 1) reviewed. Resident 1 experienced harm when they fell out of a mechanical lift without the assessed two caregiver assistance, landed on the floor, and sustained a traumatic brain injury (TBI), with multiple areas of bleeding in the brain, upper neck fracture and facial fractures. This failure placed other resident at risk that required assistance of two care givers and a mechanical lift for their Activities of Daily Living (ADLs). The admission Minimum Data Set (MDS-an assessment tool) dated 02/06/2025, Resident 1 required total assistance from staff with all ADLs including Hoyer (mechanical lift) transfers.The Quarterly MDS, dated [DATE], showed Resident 1 was able to make their needs known, could communicate with staff, and had significant cognitive impairment.The Kardex Policy, dated 12/2003, Certified Nursing Assistants (CNA) review the Kardex at the beginning of each shift to understand the current status of each resident, guiding CNAs in their daily routine, precautions for assistance needed to provide safe and appropriate care, and utilizing the Kardex can ensure that staff are giving appropriate care. Staff are to follow all care needs to reduce risky incidents like falls and skin injuries.Review of Resident 1's Kardex with admission date of 12/18/2019, showed Resident 1 was dependent on two staff, total assistance, with transfers.The Kardex, dated 07/17/2025, showed Resident 1 was at risk for falls, required mechanical lift with 2 persons assist for all transfers.According to the Nursing Progress Note, dated 09/03/2025 at 19:17 PM, Resident 1 was alert, responsive, and able to communicate their needs to staff.The Behavioral Health Team progress note dated 9/10/2025 at 08:15 AM showed Patient 1 was verbal and could communicate with staff effectively Review of a Nursing Progress Note dated 9/17/2025 at 11:35 PM showed Resident 1 fell from the mechanical lift, was on the floor unresponsive, had a bleeding wound on their forehead, 911 was called and Resident 1 was sent to the hospital.Review of the hospital Admit Progress notes, dated 09/17/2025 at 08:15 PM, showed Resident 1 was unconscious and unresponsive when admitted to the Emergency Room. A Computed Tomography scan (CT, a computerized, detailed, x-ray) scan of the spine showed a fracture of a vertebrae in the upper neck. CT of the head showed multiple areas of bleeding in the brain, between the brain and skull, and facial fractures.Review of the facility's initial investigation dated 09/17/2025 showed the assigned Certified Nursing Assistant (CNA), Staff C, provided care without a second staff member in attendance. The investigation showed the fall could have been prevented if the plan of care was followed. The failure to follow the plan of care resulted in harm to the resident and put all residents, that require 2-person assistance, at risk.In an interview on 09/18/2025 at 2:07 PM, Staff B, Director of Nursing, stated they would expect the CNA to review the Kardex prior to giving care to the residents to prevent injuries, that all aides were recently re-educated, that two caregivers were required to operate the mechanical lift, and could prevent the fall that resulted in significant injuries.In an interview on 09/18/2025 at 2:30 PM, Staff A, Administrator, stated this incident happened because staff did not follow the Kardex, that two care givers could have prevented the fall and injuriesIn an interview on 09/18/2025 at 3:07 PM, Staff D, Regional Director of Clinical Operations (RDCO), stated Staff C, Certified Nursing Assistant (CNA), was not following the Kardex and this incident could have been prevented. The intervention of 2 people is for resident safety, to help prevent injuries, and is our best practice.In an interview on 09/18/2025 at 3:10 PM, Staff E, Assistant Director of Nursing (ADON) stated by not following the Kardex Resident 1 fell. The intervention of 2 people was for residents and staff safety, to help prevent injuries and harm.Staff C unavailable for comment. REFERENCE: WAC: 388-97-1060 (3)(g)

Based on observations, interviews, and record review, the facility failed to ensure each resident received assessed level of supervision and assistance to prevent accidents for 1 of 5 sampled residents (Resident 1) reviewed. Resident 1 experienced harm when they rolled off the bed when they were repositioned without the assessed two caregiver assistance, landed on the floor, and sustained three fractures to their hip, knee, and back, and required an increase in pain medications. This failure placed other resident at risk that required assistance with Activities of Daily Living (ADLs). The facility's Abuse Prohibition and Prevention policy updated November 2016, showed the facility complied with Federal and State Requirements by training, protecting, and preventing abuse and neglect.According to the admission Minimum Data Set (MDS-an assessment tool) dated 05/09/2025, the assessment showed Resident 1 required substantial/maximal assistance with bathing and bed mobility. Diagnosis included Paraplegia (paralysis of the lower half of the body), seizure disorder, respiratory failure, and multiple other comorbidities. The Care Plan, dated 5/03/2025, showed, Resident 1 was dependent on two staff members for repositioning and turning in bed.Review of Resident 1's Kardex with admission date of 5/23/2025, showed Resident 1 was dependent on two staff for repositioning and turning in bed.Review of the hospital Discharge summary, dated [DATE], showed Resident 1 sustained a fracture of their hip, right kneecap, and a fracture of the spinal column in the mid-back.Review of the facility's investigation dated 07/25/2025, showed the assigned CNA, Staff C, provided care without a second staff member in attendance. The investigation showed the fall could have been prevented if the plan of care was followed and the failure to follow the plan of care resulted in harm to the resident and put all residents at risk.Review of the facility's investigation dated 07/25/2025 showed Staff C, CNA, stated they initiated care independently, without a second staff member, that resulted in Resident 1's fall off the bed and subsequent fractures.Review of July's 2025 Medication Administration Record (MAR) showed Resident 1's pain level increased after the fall that required an increase in pain medications and pain management, that included narcotic pain medications.In an interview on 08/01/2025 at 2:07 PM, Staff A, Director of Nursing, stated they would expect the CNA to review the Kardex prior to giving care to the resident to prevent injuries. Staff A stated the Kardex is always available for the CNAs to read, that two caregivers could have prevented the fall and subsequent injuries, and that education was inadequate.In an interview on 08/01/2025 at 2:14 PM, Staff B, Administrator, stated this incident happened because staff did not follow the plan of care and that two care givers could have prevented the fall.During an interview and observation on 08/01/2025 at 1:22 PM, Staff D, (CNA), stated they had received a reminder to do their training prior to their return to work, that they had worked the day before, and started at 06:00 AM on 08/01/2024 but were just starting the training. During an interview and observation on 08/01/2025 at 1:40 PM, Staff E stated they had received almost daily reminders to complete their training but their log in did not work and had not completed the training. Observation of text reminders observed on Staff E's phone.During an interview and observation on 08/01/2025 at 1:45 PM, Staff F stated, they did not recall having received education, that they had a text reminder that the specified training was due on July 30th, and they had not completed it.Review of the facility provided Kardex Protocol training, dated 08/01/2025, showed Staff D, Staff E, and Staff F had not initiated or completed their training prior to their return to work. Same report showed only 75% of the CNA staff had completed the training. REFERENCE: WAC: 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to establish and maintain infection control practices necessary to provide a safe and sanitary environment and prevent transmission of communicable diseases by having Personal Protective Equipment (PPE) available to staff for 12 of 19 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, &12) observed requiring Enhanced Barrier Precautions (EBP) with specific diagnoses including wounds and indwelling medical devices. The facility failed to ensure alcohol-based hand sanitizer dispensers were properly functioning for 25 of 46 rooms (Rooms 202, 203, 204, 209,211, 208, 215, 216, & 218; and outside rooms 219, 250, 251, 252, 255, 256, 257, 263, 264, 265, 266, 267, 268,270, 273, & 274) observed inside and along the hallway outside occupied resident rooms. These failures placed residents at risk for acquiring and developing communicable diseases, medical complications from infection, and a decreased quality of life. Findings included . <Facility Policy> According to the Enhanced Barrier Precautions-F880, facility policy, revised March 2024, EBP was used as an infection prevention and control intervention to reduce the transmission of Multi-Drug-Resistant Organisms (MDROs) to residents. The EBPs were indicated for residents infected or colonized with a Centers for Disease Control and Prevention (CDC) targeted diagnoses, wounds and/or indwelling catheters. The policy showed PPEs would be available outside of the resident rooms. <Unit 2 East And 2 West> During multiple observations of units 2 East and 2 [NAME] on 11/08/2024 from 10:35 AM to 3:00 PM, 25 hand sanitizer dispensers were observed faulty and unable to dispense hand sanitizer when tested . Observations on 11/08/2024 from 10:35 AM to 3:00 PM of multiple isolation carts posted outside resident rooms designated as EBP showed they were not stocked with proper PPE for staff to provide safe care to residents. During an interview on 1/08/2024 at 11:04 AM, Staff C (Certified Nursing Assistant - CNA) stated the aids should have access to PPE but the supply was not always consistent, .sometimes we [staff] do, sometimes not .have to go look for them. In an interview on 11/08/2024 at 11:08 AM, Staff D (CNA) stated they disregard the isolation sign when providing resident care such as brief changes or linen changes, they did not have an Infection Preventionist (IP) Nurse to ask, and they did not know where to get the PPE supplies from. In an interview on 11/08/2024 at 11:15 AM, Staff E (CNA) stated there was not a lot the staff could do about PPE supply and accessibility, and they were not sure the isolation sign should be posted on the door. In an interview on 11/08/2024 at 11:20 AM, Staff F (CNA) stated they work three days a week on the 2nd floor, and it had been a while since the isolation carts were stocked with PPE. Staff F stated they had not been stocked since the Infection Preventionist Nurse (IP) nurse left. In an interview on 11/08/2024 at 12:05 PM, Staff B (Director of Nursing) stated they would expect the isolation signs to be accurate and that staff would follow the directions provided on the signs and restock PPE as needed. Staff B stated the signs were there to protect staff and other residents, and to reduce the transmission of infections to high-risk individuals. Staff B stated the IP nurse left on 10/28/2024 and the position had not been filled. On 11/08/2024 at 12:10 PM, Staff A (Regional Administrator) stated all staff should know where supplies were kept, should be able to re-stock isolation carts and rooms, and that all hand sanitizer dispensers should function properly to prevent the spread of infection. In an interview on 11/08/2024 at 3:07 PM, Resident 1 stated the staff did not wear a gown and gloves at times when they changed their wound dressing or provided care for their urinary catheter. In an interview on 11/08/2024 at 3:10 PM, Resident 2 stated staff did not wear a gown to change their bed linens, and it was not unusual for the hand sanitizer dispenser to malfunction. Resident 2 stated they brought up the malfunctioning dispenser to the staff's attention, but it did not get fixed or filled. REFERENCE: WAC 388-97-1320 (1)(a), -1320 (2)(b), -1320 (1)(c).

Based on interview and record review, the facility failed to ensure residents were provided informed consent for treatments (ensuring an explanation of the risks and benefits was provided) for 3 of 5 (Residents 113, 21, & 17) residents whose medication regimen was reviewed. The failure to provide informed consent placed residents at risk for unwanted adverse side effects, unwanted treatment, and loss of autonomy. Findings included . <Resident 113> According to the 07/18/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 113 had diagnoses including depression and anxiety. The MDS showed Resident 113 received antidepressant and antianxiety medications. Review of the physician's orders showed a 04/26/2024 order for an antidepressant to be administered to Resident 113 at bedtime for insomnia. Record review showed no evidence the risks and benefits of the antidepressant medication were explained to Resident 113. There was no evidence Resident 113 consented to the medication prior to treatment. In an interview on 08/20/2024 at 4:50 PM Staff C (Regional Director of Clinical Operations) stated they did not see an informed consent was provided to Resident 113 prior to treatment. Staff C stated they would expect a consent for a psychotropic medication. 45941 <Resident 17> According to the 06/13/2024 Significant Change MDS, Resident 17 had a diagnosis of depression with suicidal ideation. The MDS showed Resident 17 received antidepressant and antipsychotic medications during the assessment period. Review of Resident 17's record showed no consent was obtained for the antidepressant medication prior to implementing the medications. In an interview on 08/20/2024 at 3:35 PM, Staff C stated they did not see an informed consent was provided to Resident 17 prior to treatment. Staff C stated there should be a consent signed prior to starting an antidepressant medication. <Resident 21> According to the 05/14/2024 Quarterly MDS, Resident 21 had diagnoses including depression, anxiety, and a psychotic disorder. The MDS showed Resident 21 received antipsychotic and antidepressant medications during the assessment period. Review of Resident 21's record showed the consent form for the antipsychotic medications was signed in 2016 and no diagnosis was checked for Resident 21 to know why they were receiving the medication. Another consent form for the antidepressant medication was signed on 02/08/2022 but no diagnosis was checked. In an interview on 08/20/2024 at 3:35 PM, Staff C stated staff should have explained the reason and diagnosis to the resident or their representative prior to starting any psychotropic medications. REFERENCE: WAC 388-97-0260(1)(a)(b)(i)(ii)(iii).

Based on observation and interview, the facility failed to ensure the facility maintained a homelike environment for 2 of 4 units, and 1 of 1 entry way. The failure to ensure resident rooms were free of wall scrapes, stained doors and walls, damaged flooring, damaged closet doors, missing/damaged ceiling tiles, and dirty privacy curtains, and the failure to ensure the entry way was in good condition, placed residents at risk for a less than homelike environment, frustration, and a diminished sense of self-worth. Findings included . <100 Unit > Observations of the first-floor shower room door on 08/14/2024 at 1:27 PM showed multiple tan colored smears and marks on the outside visible from the hallway. In an interview on 08/21/2024 at 11:27 AM, Staff X (Maintenance Director) looked at the shower room door, stated it looked dirty and should be cleaned up and painted. Observations of the shared bathroom in room [ROOM NUMBER] on 08/15/2024 at 8:52 AM showed dried brown raised debris areas on the wall to the right of the toilet, the wall across from the toilet, and on the floor next to the toilet. The same brown debris areas were still observed four days later, on 08/19/2024 at 7:34 AM. In an interview and observation on 08/21/2024 at 11:27 AM, Staff X confirmed the debris areas were still present, six days after the original observation was made, and stated the areas should have, but were not cleaned by housekeeping staff. Observations on 08/19/2024 at 6:26 AM showed the supply closet doors across from room [ROOM NUMBER] were misaligned and unable to be closed. The doors remained partly open and were visible in the hallway. In an interview and observation on 08/21/2024 at 11:27 AM, Staff X checked the supply room doors and confirmed they were not functioning correctly. Staff X stated their expectation was for staff to report issues found so they can be fixed promptly. Observations on 08/14/2024 at 9:17 AM and on 08/19/2024 at 6:30 AM, five days later, showed the ceiling tiles inside room [ROOM NUMBER] were hanging vertically down, and only being held by the corners of the tile against the frame. In an interview on 08/21/2024 at 11:27 AM, Staff X stated they had just fixed the ceiling tiles and expected any concerns to be fixed promptly for safety and to provide a homelike environment for residents. Observations on 08/19/2024 at 7:34 AM showed a box fan sitting on the floor of room [ROOM NUMBER] that was full of dust debris on the entire front grill. The debris was blowing and moving with the flow of air in the room during observations. In an interview and observation on 08/21/2024 at 11:27 AM, Staff X confirmed the fan in room [ROOM NUMBER] was full of dust debris and stated the fans should be cleaned regularly by the housekeeping staff to prevent build up. Staff X stated it was important and was their expectation that staff provide residents a clean and homelike environment to promote their quality of life. <200 East Unit> Observation on 08/14/2024 at 9:02 AM showed room [ROOM NUMBER] had a wheelchair parked in the bathroom and dirty bedside commode bucket in the wheelchair. Behind the resident's bed in room [ROOM NUMBER], big deep scratches were observed on the wall. The closet in room [ROOM NUMBER] had multiple wood chunks missing and metal hardware was exposed. Observations on 08/14/2024 at 10:11 AM and on 08/19/2024 at 11:00 AM showed room [ROOM NUMBER] had a broken floor tile next to the resident's bed. Observations on 08/14/2024 at 12:26 PM and on 08/19/2024 at 9:22 AM showed the closets in room [ROOM NUMBER] and room [ROOM NUMBER] were very worn with large chunks of wood was missing. The closet in room [ROOM NUMBER]'s was supported with adhesive tape. Observations on 08/15/2024 at 8:45 AM and on 08/19/2024 at 10:21 AM in room [ROOM NUMBER] showed the wall behind the resident's bed had multiple big deep scratches and the baseboard was broken. Observation on 08/19/2024 at 8:22 AM in room [ROOM NUMBER] showed the privacy curtain was dirty with brown stains on it. In an interview on 08/21/2024 at 11:00 AM, Staff X observed the rooms were not clean, gauges in walls, and broken closets and stated the rooms were not homelike. Staff X stated the facility was waiting for an order to be approved for the backing behind the beds. <Facility Entrance> Observations on 08/16/2024 at 2:07 PM showed broken and missing cement tiles at the entrance to the facility on the pathway staff, residents, and visitors walked on to enter the facility. In an interview and observation on 08/21/2024 at 11:27 AM, Staff X confirmed the cement tiles at the facility entrance were broken and stated they needed to be replaced to decrease the risk of injury. REFERENCE: WAC 388-97-0880(1)(2). 45941

Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 5 (Residents 127, 34, 113, 55, & 96) of 7 residents reviewed for hospitalization s. Failure to provide written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Resident 127> Review of Resident 127's 06/18/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on 06/18/2024, with their return anticipated. Record review showed no documentation staff provided written notification to Resident 127 and/or the resident's representative regarding their discharge as required. <Resident 34> Review of Resident 34's 08/14/2024 MDS showed the resident was transferred to an acute care hospital on 08/14/2024, with their return anticipated. Record review showed no documentation staff provided written notification to Resident 34 and/or the resident's representative regarding their discharge as required. <Resident 113> According to the 07/18/24 Quarterly MDS Resident 113 readmitted to the facility from the hospital on 04/26/2024. The MDS showed Resident 113 had medically complex conditions including an infection with a Multi Drug Resistant Organism (MDRO - a germ not effectively treated by many common antibiotics) and muscle weakness. According to a 04/19/2024 progress note Resident 113 was sent to the hospital for further evaluation after a follow up appointment. Record review showed no documentation staff provided written notification to Resident 113 regarding their discharge as required. In an interview on 08/20/2024 at 12:09 PM, Staff E (Social Services Director) stated they did not complete a written notice of transfer when a resident is transferred to the hospital. When asked if there was any documentation the residents and/or representatives were notified of the transfers to the hospital in writing, Staff E stated they were not aware of any documentation. Staff E stated they only complete the notice of transfer when a resident was being discharged from the facility, not transferred to the hospital as required. Staff E confirmed they did not have a written notice of transfer for Resident 127, Resident 34, or Resident 113. 42203 <Resident 55> Review of the 03/05/2024 Discharge Return Anticipated MDS showed Resident 55 discharged to an acute care hospital on 03/05/2024. Review of Resident 55's record on 08/19/2024 showed no documentation staff provided the required written notification to Resident 55 and/or their representative regarding their discharge on 03/05/2024. <Resident 96> Review of the 12/11/2023 Discharge Return Anticipated MDS showed Resident 96 discharged to an acute care hospital on 12/11/2023. Review of Resident 96's record on 08/19/2024 showed no documentation staff provided the required written notification to Resident 96 and/or their representative regarding their discharge on 12/11/2023. In an interview on 08/20/2024 at 12:09 PM, Staff E stated they were not aware of the requirement for written notification to residents/their representatives regarding discharges and they did not provide any written notification to residents/their representatives upon discharges. REFERENCE: WAC 388-97-0120 (2)(a-d). 45941

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained for 3 (Residents 134, 85, & 113) of 7 sampled residents reviewed for PASRR evaluations. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Facility Policy> Review of the undated PASRR Completion facility policy showed the designated staff would make sure the PASRR was completed on all potential residents. This policy showed if the referral indicated the resident had a serious mental illness or intellectual disability, the PASRR would be completed prior to admission. <Resident 134> According to the 07/07/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 134 had no cognitive impairment and had diagnoses of anxiety disorder and a chronic mental illness that caused extreme mood swings. This MDS showed Resident 134 was not considered by the state level II PASRR process to have a Serious Mental Illness (SMI). Review of Resident 134's 07/16/2024 Level I PASRR showed the resident had diagnoses of a mood disorder and anxiety. This PASRR showed staff indicated a referral for a Level II PASRR was needed due to the resident showing indicators of a SMI. Review of Resident 134's record showed no documentation a referral for a Level II PASRR was sent. In an interview on 08/20/2024 at 12:09 PM, Staff E (Social Services Director) reviewed Resident 134's record and confirmed the resident should be referred for a Level II evaluation but was not. Staff E confirmed staff should have followed up on the referral for the Level II but staff did not. 50511 <Resident 85> According to the 07/04/2024 Quarterly MDS, Resident 85 admitted to the facility on [DATE]. The MDS showed Resident 85 had diagnoses of anxiety, depression, psychoactive substance abuse, and bipolar disorder. Review of the 03/07/2023 Level I PASRR showed Resident 85 had serious mental illness (SMI) indicators for mood and anxiety disorders. A level two evaluation referral was indicated on the PASSR form due to SMI. Review of Resident 85's medical records did not show a Level II PASRR with recommendations for the resident's behaviors was completed. In an interview on 08/15/2024 at 1:26 PM, Staff E stated the Level II PASRR follow-up should have been completed but was not able to find a PASSR II evaluation for Resident 85. Staff E stated that a PASSR II was important to determine the level of care needed for the resident and would help with interventions to help care for the resident. 42203 <Resident 113> According to the 07/18/2024 Quarterly MDS, Resident 113 had medically complex conditions including anxiety, depression, and opioid dependence. The MDS showed Resident 113 took antipsychotic and antidepressant medications. Review of the 03/13/2024 Level I PASRR showed Resident 113 exhibited serious functional limitations in the past six months prior to completion of the form related to a serious mental illness. The form showed Resident 113 required a Level II PASRR evaluation for SMI. Record review showed no Level II PASRR evaluation in place for Resident 113. In an interview on 08/20/2024 at 3:51 PM Staff E stated Level II services were not in place for Resident 113 but their expectation was Level II services should have been followed up on to reflect the Level I PASRR but weren't. REFERENCE: WAC 388-97-1915(2)(4).

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment accurately reflected residents' mental health conditions for 3 of 5 (Resident 34, 113, & 17) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Facility Policy> According to the facility's undated PASRR policy, all residents would have a Level I PASRR screening completed prior to admission. <Resident 34> According to a 07/30/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 34 had multiple medically complex diagnoses including depression and Post Traumatic Stress Disorder (PTSD - a mental health condition caused by an extremely stressful or terrifying event) and required the use of antidepressant and antianxiety medications during the assessment period. Review of a 07/23/2024 Level 1 PASRR showed Resident 34 had no Serious Mental Illness (SMI) indicators. Staff did not identify Resident 34 had depression or PTSD, and required the use of medications. In an interview on 08/20/2024 at 12:09 PM, Staff E (Social Services Director) stated they check a resident's records upon admission to the facility to assure the PASRR Level 1 was accurate from the hospital. Staff E stated it was important for a PASRR Level 1 to be accurate in order to determine the level of care a resident required. Staff E reviewed Resident 34's PASRR Level 1 and stated it was inaccurate and needed to be updated. 42203 <Resident 113> According to the 07/18/2024 Quarterly MDS, Resident 113 had medically complex conditions including anxiety, depression, and opioid dependence. The MDS showed Resident 113 took antipsychotic, and antidepressant medications. Review of the physician's orders showed Resident 113 currently took two antidepressant medications and an antipsychotic medication from 03/28/2024 until discontinued on 07/25/2024. The indication for the antipsychotic medication was for auditory hallucinations. Review of the comprehensive Care Plan (CP) showed Resident 113 had a Target Behavior due to Psychosis CP. This CP included a goal for staff to assist Resident 113 with daily episodes of psychosis. Review of the 03/13/2024 Level I PASRR indicated Resident 113 had a mood disorder and an anxiety disorder. This Level I PASRR did not show Resident 113 had a psychosis diagnosis, or otherwise address Resident 113's auditory hallucinations. The form showed Resident 113 exhibited serious functional limitations in the past six months prior to completion of the form related to a serious mental illness. In an interview on 08/21/2024 at 11:11 AM Staff E stated the Level I PASRR did not but should reflect Resident 113's psychosis diagnosis and treatment. 45941 <Resident 17> According to the 06/13/2024 Significant Change MDS, Resident 17 had moderately impaired cognition (impaired memory and problem solving) and diagnoses of schizophrenia (a disorder affecting a person's ability to think and behave clearly) and depression. The MDS showed Resident 17 regularly used antipsychotic, and antidepressant medications during the assessment period. The MDS showed Resident 17 had Level II PASRR services related to a Severe Mental Illness (SMI). Review of the 07/11/2024 psychiatric progress notes showed Resident 17 had diagnoses of schizophrenia and depression and received antipsychotic and antidepressant medications. The psychiatrist recommended staff continue administering antipsychotic and antidepressant medications as ordered and continue monitoring behaviors. Review of the 09/08/2023 Level 1 PASRR showed Resident 17 was identified with SMI indicators for schizophrenia and depression, and a Level II PASRR evaluation was not required. This PASRR showed Resident 17's primary language was English. Staff documented on Resident 17's PASRR Level I, a request for invalidation (denial of Level II services) on 09/08/2023. Record review showed no documentation the facility obtained Resident 17's invalidation report. In an interview on 08/20/2024 at 12:09 PM, Staff E stated Resident 17's Level I PASRR was updated on 09/08/2023 and a Level II PASRR was not indicated. Staff E reviewed Resident 17's Level I PASRR and stated the form was inaccurate for language and should be referred for a Level II evaluation. REFERENCE: WAC 388-97-1915 (1). 51149

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse for 1 of 3 residents (Resident 1) reviewed for sexual assault. This failed practice resulted in psychological harm, applying the reasonable person approach, for Resident 1 who experienced an attempted sexual act by another resident (Resident 2) and resulted in Resident 1 being transferred to a hospital emergency room (ER) for evaluation. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life. Findings included . Review of the facility policy titled, Abuse and Neglect- Clinical Protocol, revised 03/2018, showed sexual abuse was defined as a nonconsensual sexual contact of any type with a resident. The policy showed the nurse would assess the resident and document related findings, such as; injury and pain assessment, and report findings to the physician. The physician would evaluate or refer the resident for evaluation to rule out sexual assault. The physician's input would be included to investigate alleged abuse or neglect and the physician would order measures required to address the consequences of the abuse situation, such as a psychological evaluation. <Resident 1> Review of a Quarterly Minimum Data Set (MDS), an assessment tool), dated 02/27/2024, showed Resident 1 had severe impairments to their decision-making ability, had no behaviors, could usually understand and be understood by others . The MDS showed Resident 1 had medically complex conditions including heart disease, dementia, and disorientation. The MDS showed Resident 1 used a walker to ambulate, was independent with bed mobility, and required supervision for transfers. Review of an At risk for decline in mood state Care Plan (CP), revised 05/29/2024, showed Resident 1 was at at risk for decline in mood due to feeling down, having a diagnosis of dementia, and a history of emotional disturbances. The CP directed staff to provide assistance with situations that caused distress, anger, and anxiety. Review of a trauma CP, dated 07/28/2022, showed Resident 1 had a history of trauma due to a difficult childhood and serious undiagnosed mental issues. The CP directed staff to inform social services if Resident 1 displayed any new behaviors and monitor for signs and symptoms of residual trauma. Review of a Nursing Progress Note (NPN), dated 05/22/2024, showed Staff C (Assistant Director of Nursing, Licensed Practical Nurse, LPN) documented at 6:30 PM a staff member walked passed Resident 1's room and saw Resident 2 with their pants down and on top of Resident 1 who was exposed from the waist down. The staff member intervened, removed Resident 2 who was placed with a one-on-one caregiver and called the physician who gave orders for Resident 1 to be evaluated at the hospital. Staff C documented police officers arrived at the facility and interviewed Resident 1 who stated they had a visitor in their room, initially said they were playing, and stated yes, they had intercourse. Staff C documented that Resident 1 stated they allowed the intercourse to occur. The NPN showed Staff C documented police officers interviewed Resident 2 who stated yes they were in another resident's room, denied having intercourse with Resident 1 and stated they were just talking. Review of a NPN, dated 05/23/2024, showed the hospital social worker called the facility to inquire if Resident 1 and Resident 2 were boyfriend and girlfriend because Resident 1 told hospital staff that Resident 2 was their boyfriend, they didn't do anything that Resident 1 didn't want them to do. An additional NPN, dated 05/23/2024 showed Resident 1 returned back to the facility and had sexually transmitted infection tests done at the hospital with results still pending. Review of hospital documents, dated 05/22/2024, showed hospital staff documented that Resident 1 reiterated that they engaged in consensual sexual activity of kissing and intercourse with their boyfriend (Resident 2). The hospital documents showed Resident 1 did not want to be seen for sexual assault and Resident 1's Collateral Contact (CC) agreed to not have a Sexual Assault Nurse Examiner (SANE) complete an exam. The hospital documents showed Resident 1 had their urine tested , had a Urinary Tract Infection (UTI) and was given medication to treat the infection. In an interview on 05/24/2024 at 11:50 AM Staff C stated that Resident 1 was diagnosed with a UTI and told hospital staff that Resident 2 was their boyfriend. Staff C stated staff had never observed them together or attempting to follow each other. Staff C stated Resident 1 had no history of sexual behaviors, hospital staff assessed Resident 1 with no physical signs of sexual intercourse, so a rape kit (a kit to collect evidence of a sexual assault) was not done. In an interview on 05/24/2024 at 12:20 PM Staff F (LPN) stated they were not present for the incident between Resident 1 and Resident 2. Staff D stated Resident 1 was confused, would say things that did not make sense and did not have any sexually inappropriate behaviors. In an interview and observation on 05/24/2024 at 12:22 PM, Resident 1 was observed sitting on the edge of the bed eating lunch. When asked about the sexual incident Resident 1 stated no, nothing happened and they had not been touched inappropriately but worried about the older man. Resident 1 stated, I was okay that day and after being at the hospital was worried about the old man and their safety. Resident 1 stated they (the old man) was their friend and I was too close to him, he was suffering. <Resident 2> Review of a Annual MDS, dated [DATE], Showed Resident 2 had some impairments to their decision making, had no behaviors, sometimes was able to understand others, and usually could make themselves understood. The MDS showed Resident 2 had diagnoses including non-traumatic brain dysfunction, dementia, depression, and a psychotic disorder (a mental disorder characterized by disconnection from reality). The MDS showed Resident 2 had no impairments to their upper or lower body, used a walker and a wheelchair to ambulate, and was independent with toileting, personal hygiene, bed mobility and transfers. Review of a Decline in mood state CP, revised 02/01/2023, showed Resident 2 had a decline in mood due to dementia with behavioral disturbances, psychosis and fluctuating levels of confusion. The CP directed staff to provide assistance with situations that caused distress, anger or anxiety. A behavior CP, initiated 07/31/2019 and revised on 05/23/2024, showed Resident 2 had behaviors of sexual encounters with other residents. The CP directed staff to re-direct Resident 2 away from female residents and a one-on-one caregiver to re-direct the resident. Review of a NPN, dated 05/22/2024, showed Staff D Licensed Practical Nurse (LPN) documented Resident 2 was forgetful and oriented to self and was last seen watching television in the day room at 5:40 PM. Staff D documented at 6:40 PM they were notified that Resident 2 was found with their pants and underwear pulled down on top of Resident 1 who was lying on their back with their groin area exposed trying to perform sexual act. Staff D documented they did not observe any skin to skin contact or penile erection. Staff D documented both residents were separated, Resident 1 was assessed for injury to their groin area and no injuries or skin issues were noted. Resident 1 told Staff D that Resident 2 was their friend, this was not their (Resident 2) fault, did not hurt them, and please don't tell anyone. Staff D documented that Resident 2 stated to them that Resident 1 let them touch them, they didn't force anything, did nothing wrong, just touched them. Staff D placed Resident 2 on a one on one caregiver and moved Resident 2's room to a different floor of the facility. Review of a NPN, dated 05/28/2024, showed Resident 2 remained with a one on one caregiver and made multiple attempts to enter another resident's room but was redirected by staff. In an interview on 05/24/2024 at 11:50 AM Staff A (Administrator) stated that staff were not aware of Resident 2's sexual inappropriateness but when reviewing Resident 2's record found in February 2020 Resident 2 was found lying in bed with a female resident, was put on a one-on-one caregiver at that time for 10 days. Staff A stated the one on one caregiver was discontinued and they couldn't determine why the one on one caregiver was discontinued. Staff A stated they were surprised by the incident but staff were not monitoring Resident 2 any sexually inappropriate behaviors. Review of Resident 2's NPN's dated 07/19/2019, showed no documentation on why staff initiated a behavior CP for sexual encounters. Review of NPN, dated 02/2020, showed no documentation of Resident 2's incident of being found lying in another female resident's bed. In an interview and observation on 05/24/2024 at 12:10 PM, Resident 2 was observed sitting in their wheelchair and a one-on-one caregiver was present in the room. Resident 2 stated they did not know anyone at the facility, didn't have a girlfriend at the facility, and didn't remember what happened the other day. Resident 2 stated it was a misunderstanding, they don't want to be the bad guy and was innocent. Resident 2 stated they were getting a lot of attention lately which concerned them, it was freaking them out and they didn't understand what was going on. In an interview on 05/24/2024 at 12:39 PM, Staff D LPN stated they were not present for the incident between Resident 1 and 2 but they were familiar with Resident 2. Staff D stated they used to work with Resident 2 in the past and had not observed any sexually inappropriate behaviors prior to the incident. REFERENCE: WAC 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to provide supervision for 1 (Resident 1) of 3 sample residents at risk for elopements who eloped from the facility and was missing for at least eight hours unbeknownst to staff. Resident 1 experienced harm when they left the building unsupervised, for several hours, and sustained a fall with multiple injuries that required further evaluation at the hospital. Findings included . According to the 04/13/2023 Admission Minimum Data Set (MDS-an assessment tool) Resident 1 admitted to the facility with diagnoses of non-traumatic brain dysfunction, traumatic brain injury (TBI), disorientation, history of falling, and muscle weakness. Resident 1 had severe cognitive and daily decision-making impairments, needed supervision on and off the unit, was not steady when walking, and had a history of falls and wandering. The 04/14/2023 Wandering Risk Assessment showed Resident 1 needed assistance with mobility and had a history of wandering. The 04/14/2023 At Risk for Elopement Care Plan (CP) showed Resident 1 was at risk for elopement and documented a goal for the resident not to wander out of the facility. The CP showed interventions to have a WanderGuard bracelet (a device used to alert staff to a resident leaving the facility or unit) in place. Review of a late entry nursing note dated 04/15/2023 at 2:14 PM showed Resident 1 eloped from the building around 6:30 AM, was found in the facility parking lot, and brought back into the building. The CP had been updated for Resident 1 to wear a WanderGuard to prevent Resident 1 from wandering out of the facility. The 04/27/2023 Facility Incident Report Investigation showed Resident 1 left the facility at 09:01 AM and was not identified as missing from the building until 5:00 PM. During an interview and observation on 05/03/2023 at 11:30 AM, Resident 1 was found wandering the halls on the third floor, alone. Resident 1 was observed with bruising around both eyes, had abrasions to their right forehead and nose, and complained about pain in their knees. When asked if they had a fall, Resident 1 stated, Yes, I hit my head. During an interview on 05/03/2023 at 1:00 PM, Staff B, Director of Nursing, stated Resident 1 had a TBI and was wearing a WanderGuard bracelet because Resident 1 was at risk for elopement. Staff B stated the facility administrative staff reviewed the video that showed Resident 1 walked out the front door, the alarm went off and a nurse came out and reset the alarm without going outside to see if a resident had left the facility. During an interview on 05/03/2023 at 1:10 PM Staff C, Central Supply Director, stated the video footage showed someone, a nurse or an aide, went out the front door and Resident 1 followed the staff member out the door. The alarm went off and Staff D, Licensed Practical Nurse, came out of Unit 1, turned off the alarm, looked around the inside of the lobby, did not go outside to look for a resident. Staff C stated the receptionist was not at the desk. During an interview on 05/03/2023 at 1:30 PM, Staff D stated they were unaware anyone had gone out the front door, did not know what the alarm was sounding for, and turned off the alarm. Staff D stated they assumed another resident in the lobby had tugged on the door. When asked what time the alarm sounded and what time Staff D turned off the alarm, Staff D stated they could not recall what time it was, but thought it was in the morning. During an interview on 05/03/2023 at 1:55 PM Staff A, Administrator, stated they could not recall or provide any information or documentation when the facility staff realized Resident 1 eloped from the facility. Staff A stated according to the video Resident 1 eloped from the facility at 9:01 AM. When asked what time the staff were aware that Resident 1 was missing, Staff A stated around 5:00 PM. When asked what time Resident 1 was found by the police, Staff A stated it was about 6:30 PM, but then Resident 1 was transported to the hospital for evaluation. During a phone interview on 05/03/2023 at 2:58 PM Staff E, Licensed Practical Nurse, stated they started their shift at 2:00 PM on 04/27/2023, did not see Resident 1 throughout their shift. About dinner time they were notified by the Staff J, (Resident Care Manager), that Resident 1 was missing from the facility. Review of the 04/27/2023 at 8:35 PM Nurse Progress Note showed Resident 1 was not in their room around 5:00 PM, staff looked in every room but were unable to find Resident 1 and activated a code yellow (missing person) drill. Review of the 04/27/2023 at 7:28 PM emergency room Provider notes showed Resident 1 was seen for a fall with a head injury, altered mental status, pain in both thighs and knees, and had been missing from the facility since the morning of 04/27/2023. Injuries noted were a moderate sized right frontal (forehead) scalp hematoma (a solid swelling of clotted blood under the skin surface) and swelling of both knees. REFERENCE: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure 2 (Resident 1 & 2) of 3 residents reviewed for pressure ulcers (PUs) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to complete weekly skin assessment as ordered, document wound progress and update the Care Plans (CP) placed residents at risk for deterioration in skin condition, and diminished quality of life. Failure of the facility to assess skin integrity to identify PUs timely, and implement interventions to include updating the CP, caused harm to Resident 1 who developed a facility acquired right heel PU, which deteriorated and resulted in hospitalization where identification of multiple untreated, facility acquired PUs on left side of the resident's body were discovered. Failure of the facility to identify PUs timely, and implement a preventative measure timely caused the harm to Resident 2 who experienced worsening of a sacral (lower back bone area) PU from intact skin to open wound and developed two facility acquired bilateral heel PUs. Findings included . According to the National Pressure Injury Advisory Panel (NPIAP) PU/PI staging definitions include: a Stage 4 PU is a wound with full thickness skin and tissue loss with exposed fascia (connective tissue), muscle, tendon, ligaments, cartilage, or bone; a Stage 3 PU with full thickness loss of skin, in which fat is visible on the ulcer and rolled wound edges is present; an Unstageable PU is defined as a full thickness skin and tissue loss where the base of the wound is obscured by slough (dead skin cells) and/or eschar (dead tissue) where until sufficient slough and/or eschar can be removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; Deep Tissue injury (DTI) is intact or non-intact skin with localized area of persistent non blanchable deep red, maroon or purple discoloration. Pain and temperature change often precede skin color changes. Resident 1 According to the 09/24/2022 Admission/5 day MDS, Resident 1 admitted to the facility on [DATE], cognitively intact and had diagnoses including Asthma, Malnutrition, and immune thrombocytopenic purpura (bleeding disorder when blood does not clot properly). According to this assessment, Resident 1 was at risk for developing pressure ulcers and had no unhealed PU, Resident 1 required two-person extensive assistance for bed mobility and toileting. According to the 09/20/2022 nursing admission skin assessment, Resident 1 admitted with no PUs. A review of Resident 1's December 2022 assessments showed facility failed to complete the weekly skin assessments on 12/13/2022 and 12/20/2022. A review of Resident 1's 12/21/2022 nursing progress note showed the resident had open area on left hip and DTI PU on right heel. This note showed Resident 1 preferred to lay in bed on their left side due to often pain in their right lower body. A 12/27/2022 physician note showed Resident 1 had a stage two PU on left hip and the resident complained of pain nine out of 10 on pain scale and went down to seven out of 10 after pain medication provided. Physician note showed no documentation about Resident 1's right heel PU. Review of a 01/03/2023 wound care provider's progress note showed Resident 1's PU deteriorated to a stage three PU on left hip which measured 1centimeter (cm) X 2 cm X 0 cm with moderate drainage and Unstageable PU on right heel which measured 6 cm X 6 cm X 0 cm with moderate drainage. Wound care provider documentation showed Resident 1's both lower extremities were warm and well perfused (sufficient blood flow to the extremities). A review of Resident 1's record showed the facility was aware Resident 1 was at risk for developing PUs but failed to evaluate the need for and implement additional pressure relief such as an air mattress until 01/05/2023 to prevent PUs. The 01/06/2023 revised skin CP showed Resident 1 was at risk for skin issues related to decreased mobility, incontinent of bowel and bladder, use of anticoagulant medications and refusal of repositioning. Nursing interventions included instructions to staff to provide diet as ordered, incontinence care, to use pressure reducing devises and for nurses to do weekly skin assessment, document, and report to the provider any changes. Review of a 01/10/2023 wound care provider's progress note showed the left hip wound was resolved and the right heel wound was surgically debrided and continued to assess the wound on weekly wound round. The 02/27/2023 revised skin CP showed Resident 1 had a right heel wound. Nursing interventions included instructions for staff to avoid pressure, perform treatment as ordered, provide positioning devices as pillows or wedges and conduct weekly skin assessments The weekly skin assessments dated 02/28/2023, 03/07/2023, and 03/15/2023 addressed the right heel PU. There were no weekly skin assessments completed on 03/22/2023 and 03/29/2023 as the physician ordered. Review of a 03/28/2023 wound care provider's progress note showed Resident 1's stage four PU on right heel had deteriorated with increased necrotic tissues and heavy bloody drainage with strong odor, and measured 6 cm X 5 cm X 1.5 cm with undermining (when wound edges separated from the surrounding healthy tissue under the wound) 2cm from 12 to 1 o' clock. A 03/28/2023 Nursing progress note showed Resident 1 was scheduled to go for CT scan for right heel on 03/27/2023 and the resident refused to go in the wheelchair related to pain in their back. Resident 1 was sent to the hospital for right heel CT scan on 03/29/2023 around 4:30 PM in a stretcher. According to hospital record, on 03/29/2023 at 5:31 PM Resident 1 was admitted in the emergency department for right heel wound evaluation. The hospital record showed Resident 1 admitted with six PUs not previously identified by the facility. According to the hospital records, Resident 1 had multiple wounds on their left side of the body including left sacrum with DTI PU which measured 4 cm X 7.5 cm, left lower back with DTI PU which measured 2 cm X 1 cm, Stage three PU on Left buttock which measured 4.5 cm X 6cm, DTI PU on left trochanter which measured 0.5 cm X 2cm, Stage two PU on left upper spine which measured 5 cm X 2cm, DTI PU on left lower/lateral spine which measured 0.5 cm X 1.5cm. Observation and interview on 03/31/2023 at 3:07 PM, while Resident 1 was at the hospital, showed Resident 1 was lying in bed, alert and able to make their needs known. Resident 1's right heel was wrapped with dressing, left buttock with purple color DTI, left sacrum with dark purple color DTI, left upper and lower spine wounds were covered with dressing. When the resident was asked about their wounds, Resident 1 stated they had two wounds that they knew of: One on their right heel and one on left hip. Resident 1 stated they had those two wounds for a while, unable to remember exact date. Resident 1 stated they needed help to turn on their side in bed, but they liked to stay on their left side due to pain on their right side of the body. Resident stated they had chronic pain which was managed with pain medications. In an interview on 03/31/2023 at 10:54 AM, staff I (Licensed Practical Nurse- LPN) stated Resident 1 had an open wound on right heel, which was not improving and the wound doctor sent the resident out to the hospital for evaluation. When staff I was asked about the facility process for sending any resident out to the hospital, Staff I stated the nursing staff completed the resident's head to toe skin assessment, pain assessment and copy of physician orders and sent with the resident to the hospital. When staff I was asked for Resident 1's skin assessment or pain assessment documentation, Staff I was unable to locate the documentation and said that they did not check the resident's skin. Staff I said that they should have completed the skin check before Resident 1 left the facility. In an interview on 03/31/2023 at 11:08 AM, Staff C (Resident Care Manager- RCM) stated Resident 1 admitted to the facility in September 2022 with no PU. The resident had COVID 19 (a contagious disease caused by a virus, the severe acute respiratory syndrome) in December 2022 and they developed PU on their right heel. Staff C stated Resident 1 did not show severe symptoms but was moved to COVID unit. Resident 1 preferred to stay on their left side in bed, and was at high risk for developing PU. The facility provided an air mattress in their bed to relieve pressure after they developed the PU on their heel. Staff C stated nursing staff was doing weekly skin assessment and documented in the resident's record. A wound team with a wound care provider had been doing weekly wound assessment. When staff C was asked about the difference between the weekly skin assessment and wound assessment, staff C stated weekly skin assessment was completed by nursing staff and documented in the resident's record, and weekly wound assessment was completed by wound care provider with wound team only for the residents with open wounds. Staff C stated Resident 1 had only one PU on their right heel. Staff C was unable to locate the skin assessment or pain assessment for Resident 1 completed on 03/29/2023 in their record. In an interview on 04/04/2023 at 1:45 PM, Staff K (Wound Care provider) stated Resident 1 was assessed by wound team on 03/28/2023 for a right heel wound. Staff K stated the right heel wound was the only wound on their list to assess, the facility staff did not notify them of any other wound for Resident 1 that needed to be assessed. In an interview on 04/04/2023 at 4:04 PM, Staff J (Certified Nursing Assistant- CNA) stated they took care of Resident 1 on 03/28/2023 and the resident stayed in bed all shift on their left side. Staff J stated they emptied the resident's urinal once and they did not have to provide incontinence care because the resident did not have bowel movement on that day. Staff J stated they did not look at their skin. In an interview on 04/04/2023 at 2:34 PM, Staff C stated Resident 1 was at risk for developing PUs. Staff C stated Resident 1 had behavior of refusing care, repositioning, and staying on their left side in bed. Staff C confirmed they did not update the CP about the resident preference to be on their left side to instruct the staff to offer other options and implement other devices or interventions. Staff C stated they should have placed the interventions like air mattress or heel floaters in bed earlier to prevent the PUs but they did not. In an interview on 04/04/2022 at 4:30 PM, Staff B (Director of Nursing) stated they were aware of Resident 1's wound history and stated that staff missed weekly skin assessments and head to toe skin check prior to sending the resident out to the hospital and staff should have done. Staff B stated weekly skin assessment, early identification of skin impairments and implementing PU prevention timely were important to maintain skin integrity and to prevent new PU from developing. Resident 2 According to the 12/06/2022 Admission/5 day Minimum Data Set (MDS- an assessment tool), Resident 2 admitted to the facility on [DATE] with complex medical diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on its own), Asthma (a condition in which airways get swollen and makes hard to breathe), and Cognitive communication deficit (difficulty with thinking and how someone uses language). The skin assessment showed Resident 2 had two stage one PUs (non-blanchable redness) (skin color stays red when pressed with fingertip and when pressure removed) on buttocks (lower back area) and was at risk for developing pressure ulcers. This assessment showed Resident 2 required two-person extensive assistance with bed mobility and toileting. According to the 11/29/2022 nursing admission note, Resident 2 admitted with blanchable redness (skin turns white when pressed with fingertip and then turns red when pressure removed) to sacrum that measured 9.5 cm X 11.5 cm, and blanchable redness to right upper buttock that measured 4.0 cm X 4.0 cm and no open wound. The 11/29/2022 Skin CP showed Resident 2 had alteration in skin integrity. On 02/13/2023 the CP was revised to include moist associated skin damage (MASD) open area to the scrotum. On 02/21/2023 the CP was updated to reflect the stage one sacral PU had deteriorated to a stage three PU. Nursing interventions included instructions to staff to do treatment as ordered, notify physician and family for any skin change, and for nurses to do weekly skin assessments. Review of a 03/07/2023 wound provider notes showed Resident 2 was assessed with a stage three sacral wound that measured 0.5 cm X0.5 cm X 0.1cm with minimal drainage. A review of Resident 2's medical record showed a 03/09/2023 nursing progress note documentation for suspected deep tissue injury (DTI) versus open area to coccyx/left buttock area and redness to midback area. A 03/11/2023 progress note showed Resident 2 was sent to hospital for evaluation related to respiratory issues. According to the 03/11/2023 Discharge return anticipated MDS, Resident 2 had one stage three PU, and two unstageable/DTIs PUs, none of which were present at admission. A review of the 03/24/2023 readmission assessment showed Resident 2 readmitted with three PUs; two stage three PUs on right buttock which measured 4 cm X 4 cm and 5 cm X 5 cm, and a stage one PU on middle spine which measured 6 cm X 3 cm X 0 cm. The assessment failed to identify the depth of the wounds on right buttock. A review of Resident 2's CP showed CPs were not updated or revised upon readmission on 03/24/2023. Further review of the resident record showed no weekly assessments for the other two PUs documented on readmission assessments on 03/24/2023. Review of a 03/28/2023 wound care provider's progress note showed Resident 2 had one unstageable PU on sacrum which measured 3.5 cm X 7 cm X 0.3 cm with moderate drainage. Observation on 03/31/2023 at 1:23 PM showed Resident 2 was sleeping on their right side on a regular mattress in their bed A 04/02/2023 nursing progress note showed Resident 2's guardian came to visit the resident and noticed Resident 2 complained of pain in their feet. The guardian informed staff about the concern. At that time, staff looked at Resident 2's feet and noted new PU on their right heel. Further review of Resident 2's record showed no pain assessment was completed after staff was notified regarding the resident's complained of pain. A review of Resident 2's pain assessment record showed last pain assessment was completed on 03/24/2023 on readmission. Review of Resident 2's March 2023 and April 2023 MARs showed nursing staff failed to complete the weekly skin assessments as ordered by the physician on 03/27/2023 and 04/03/2023. On 04/04/2023 at 12:42 PM, Resident 2 was observed lying in bed with their both heels resting on the mattress and at 1:45 PM, Resident 2 was sleeping on their back in bed with pillows under their right side and heels. The wound team with the wound care provider assessed the resident's wounds and provided the treatment in their room. In an interview on 04/05/2023 at 12:45 PM, Resident 2's representative (RR) stated they visited the resident on 04/02/2023, Resident 2 was lying in bed and complained of severe pain in their feet. RR stated they notified the nursing staff that Resident 2 was in pain. RR stated the nursing staff looked at the resident's feet and noted the PU which caused the pain. RR stated they had to ask the staff multiple times to place air mattress in Resident 2's bed to relieve the pressure. In an interview on 04/04/2023 at 1:50 PM, Staff G (Licensed Practical Nurse) stated they were Resident 2's regular nurse and worked there since November 2022. Staff G stated Resident 2 liked to stay in bed and needed extensive assistance with feeding and bed mobility. Staff G stated Resident 2 had sacral open wound and two days ago, another new wound developed on their right heel. Staff G stated nurses provided weekly skin assessment and documented in the resident's records as ordered. When Staff G was asked about Resident 2's last skin assessment record, Staff G could not find weekly skin assessment since readmission 03/24/2023 in the record. Staff G stated they missed Resident 2's weekly skin assessment. In an interview on 04/04/2023 at 2:00 PM, Staff K stated Resident 2 was seen for sacral wound for few weeks and today Resident 2 's two new PUs; a stage 3 on the right heel and a DTI on the left heel, were assessed. In an interview on 04/04/2023 at 2:16 PM, Staff D (Resident Care Manager) stated Resident 2 was admitted to the facility in November 2022 with no open wounds. Resident 2 developed sacral open wound in the facility in December 2022 and this week they developed two new PUs on their heels. Staff D stated the wound care provider assessed the wounds every week and recommended the treatments. Floor nurses provided weekly skin assessment and documented in the resident's records. Staff D was unable to locate any weekly skin assessment for Resident 2 in their record after 03/24/2023. Staff D stated they missed the weekly skin assessments as ordered by the physician for Resident 2. In an interview on 04/04/2023 at 3:52 PM, Staff B stated weekly skin assessment, monitoring, early identification of skin impairments and implementing PU prevention timely were important to maintain skin integrity and to prevent new PU from developing. Staff B stated they were aware of Resident 2's wound history and confirmed staff missed weekly skin assessments as ordered. Staff B stated staff should have done weekly skin assessment as ordered. REFERENCE: WAC 388-97-1060(3)(b)

Based on observation, interview and record review the Administration failed to utilize resources to operate the facility with functional essential equipment and infrastructure, and for fire watch (a tour of the entire facility to ensure there is no fire or smoke in the facility) conducted every 15 minutes throughout the nursing facility, which encompasses three floors, five units, and 139 current residents, while the automatic and manual fire alarm system was not functional, as directed by the State Fire Marshal. The failure to perform fire watch, in the absence of a functioning automatic and manual fire alarm system, in the event of an actual fire would likely cause a delayed response, which placed all residents at risk for smoke inhalation, [CONDITION(S)], displacement from their homes, and death, and constituted an immediate jeopardy (IJ) to resident health and safety. Findings included . On 07/13/2022 at 11:00 AM, during and unannounced Complaint Investigation, the facility failed to maintain their automatic and manual fire alarm system which would not properly operate in the event of a fire, which would endanger the residents, staff and visitors within the facility. The fire alarm panel was reading trouble status. The Deputy State Fire Marshal (DSFM) directed the facility to perform 15-minute checks until the system was repaired. This was discussed with the facility Maintenance Director who stated they were aware of the trouble status. On 07/13/2022: The facility was cited at the F (widespread) Scope and Severety level in K-345 Fire Alarm Sysytem - Testing and maintenance. The facility was going to conduct fire watching until having a functioning fire alarm system. Meanwhile, the facility tried to apply for a waiver to use unauthorized parts to repair the fire alarm system panel, which was denied by the State Fire Marshal's Office. The above was discussed and acknowledged by the Facility Maintenance Director interviewed on 08/02/2022 at 9:40 AM who stated he was aware of the trouble status and that a repair vendor was schedule for 07/14/2022 to locate and replace the defective duct detector. Review of the Facility Policy titled Emergency Response, Emergency Procedure-Fire Watch, revised October 2012, stated Fire Watch tours occur at one-half hour intervals, 24 hours a day. The policy described the fire watch tour as a periodic walking tour of the entire facility by one or more assigned and trained staff. The tour monitors the facility through direct observation of all rooms, including resident rooms, mechanical and electrical rooms, kitchen, laundry, etc. for possible signs of fire. Fire watch tours were documented with findings noting date, time, and staff initials. Fire watch tours were to be performed by personnel solely dedicated to the fire watch with no other facility-related activities or events. The policy also states that the Fire Watch is not terminated until all fire protection equipment has been restored to normal operating condition and upon the authority of the Administrator/Incident Commander or designee. Observation on 08/02/2022 at 9:28 AM, during an unannounced Complaint Investigation the fire watch was not done appropriately. In an interivew on 08/02/2022 at Staff D Assistant Director of Nursing stated that maintenance was inchange of fire watch and yes the facility was still on fire watch. Review of the Life Safety Code statement of deficiencies dated July 13, 2022, based upon observation and staff interviews on 07/13/2022 during the physical tour of the facility between approximately 1100 and 1130 hours the facility failed to maintain their automatic and manual fire alarm system in accordance with NFPA 72. This could result in a failure of the fire alarm system to properly operate in the event of a fire, which would endanger the residents, staff and/or visitors within the facility. According to the SDFM, Staff W on 08/02/2022 at 11:30 AM the fire alarm panel was entering trouble status intermittently due to a defective duct detector. The facility was unable to determine which detector was malfunctioning. During observations and interview on 08/02/2022 at 9:28AM Staff D, Assistant Director of Nursing (ADON), was observed not performing fire watch duties. While being observed, Staff D stated the facility was still on fire watch, and the facility Maintenance was in charge of fire watch, and the fire watch logs were at the nurse's station. When asked if they could locate the fire watch logs they stated no they could not, they did not have them, and they did not know where they were at, and they had not completed any in quite awhile. During observations on 08/02/2022 at 10:00AM Fire watch logs could not be located on the 1st floor nurse's station, 2nd floor nurse's stations, and 3rd floor nurse's station. In an interview on 08/02/2022 at 9:30AM Staff O, Restorative Assistant, stated they did not see or hear anything that would indicate they were on fire watch. Maybe they fixed it [The fire alarm sysytem]? In an interview on 08/02/2022 at 9:32AM Staff E, Registered Nurse (RN), stated they knew nothing about fire watch but could find out. When asked if they performed any fire watch duties they stated No I have not. When asked where the fire watch forms were located, they stated they did not know. In an interview on 08/02/2022 at 9:37AM Staff P, Lab employee, stated they were not aware of or were notified of the facility was doing fire watch. In an interview on 08/02/2022 at 9:40AM Staff Q, Minimum Data Set (MDS) Nurse stated they participated in the morning meetings (a daily meeting held with all managers and administration), but denied knowledge of fire watch being completed in the facility. In an interview on 08/02/2022 at 9:45AM Staff C, Maintenance Director, stated maintenance was doing fire watch checks facility wide and the nurses were doing fire watch on their units as a double check in case one person missed an area. When asked if maintenance or the nurses had other duties assigned to them they stated yes, their regular job. Staff C stated that the Administrator gave each unit the forms to complete. When asked to show the location of the fire watch binders they were not able to be located. On 08/02/2022 between 9:20AM to11:55AM the surveyor walked throughout the facility, including all three floors, five nursing units, individual resident rooms, offices, and other areas in an attempt to observe staff conducting fire watch. No staff were observed walking around with a fire watch log. In an interview on 08/02/2022 at 9:50AM Staff F, Licensed Practical Nurse (LPN), stated they worked full time and were not aware of the fire watch status. I think two weeks ago we were but not now I don't think. This staff denied receiving notification of fire watch or duties related to fire watch. Observation of Units 2 East and West nurse's station showed a fire watch binder could not be located by the staff. In an interview on 08/02/2022 at 9:55AM Staff G, LPN, stated they were not made aware of fire watch or duties related to fire watch. In an interview on 08/02/2022 at 10:00AM Staff H, RN, stated the facility was on fire watch about three weeks ago, they did it for about a week, but not anymore. This staff denied knowledge of fire watch sheets at the nurse's station. Observation of the 3rd floor Nurses station showed a fire watch binder could not be located by the staff. In an interview on 08/02/2022 at 10:05AM Staff I, RN, stated we check our rooms every 15-30 minutes. We used to do it on paper but not anymore. When asked if they had knowledge if the system was functional they stated that would be a question for maintenance. Staff I was unable to locate a fire watch binder at the nurse's station. In an interview on 08/02/2022 at 10:45AM Staff A, Administrator, stated the facility was still on fire watch. This staff stated the nurses performed fire watch on the nursing units and maintenance and the managers performed fire watch also. Fire watch was being performed in every single room, every 15 minutes. The fire watch binder had been delivered to the nurse's stations but must have been misplaced. When asked if the nurses were aware of the binders or fire watch duties Staff A did not comment. In an interview on 08/02/2022 at 10:55AM Staff S, Dietary Manager, stated maintenance usually does fire watch. Staff S stated they were unaware the facility was currently on fire watch, and denied completing any fire watch duties. On 08/02/2022, IJ in K-345 Fire Alarm System -Testing And Maintenance was called by the State Fire Marshal due to the facility failure to have maintained the fire alarm system in function and failure to conduct fire watch per state issued guidance and policy. Multiple unsuccessful attempts by the DSFM were made to activate the automatic and manual fire system. 08/04/2022: IJ K-345 was removed after an onsite validation by the State Fire Marshall. The new conditions for 24/7 continuous fire watching remaining in effect, as well as the requirement of repairing the Fire Alarm System. During observations on 08/09/2022 at 10:20AM Staff J, Fire Watcher, was observed doing fire watch on 1st floor. Observation of Staff J performing a fire watch rotation showed multiple rooms, offices, and other locations not observed in the 15 minute observation. Those rooms missed included all resident rooms and bathrooms, administrative offices, dining room and soiled linen room. When asked who is responsible for the resident rooms Staff J stated Not sure, I think someone else. When the question was asked Do you know who is responsible for the resident rooms and the rest of the 1st floor, they stated Not exactly. When asked who educated them on fire watch duties, Staff J was unable to identify a staff member that had educated them, but the directions for doing a fire watch were in the Fire Watch binder. In an interview and observation on 08/09/2022 at 10:43AM Staff I, RN, stated they were doing 15-minute checks of their assigned unit. During observation Staff I missed a resident room and bathroom. During observations on 08/09/2022 at 10:50AM, Staff T, RN, missed multiple resident rooms, on their assigned unit, during their fire watch rounds. In an interview and observation on 08/09/2022 at10:53AM, Staff K, Admissions Assistant, and Staff N, Nurse's Assistant, showed both staff members completed their fire watch duties. Twenty three minutes later the staff members stated they had finished their fire watch round. The entire East side of the facility was missed during their rounds. Fire watch logs showed staff signed a complete fire watch round was completed. In an interview and observation on 08/09/2022 at 11:54AM Staff L was observed completing their fire watch rounds. Multiple rooms were missed including resident rooms and bathrooms. During interview with Staff L they were asked How do you check rooms that are closed with a sign on the door, or rooms that have the middle curtain closed, they were unable to give response as they were told by Staff V, Regional Chief Nursing Officer (RCNO) to not stop their rounds because they were being timed. During an interviews on 08/09/2022 at 11:09AM Staff F, LPN, stated they were doing fire watch on their assigned unit but were unable to complete it at times due to their other duties of taking care of the residents. Observation of fire watch logs provided by Staff F showed missing data entries. During observations on 08/09/2022 at 11:09AM Staff F, LPN, was observed during fire watch. Multiple resident rooms were missed during fire watch rounds. During an interviews on 08/09/2022 at 11:15AM Staff M, Licensed Practical Nurse (LPN), stated they were assinged fire watch duties for their unit but were unable to complete them during busy times, such as medication pass times. During an interview and observations on 08/09/2022 at 11:21, Staff U, LPN, stated this was their first day working at the facility. Staff U was observed documenting fire watch logs on the wrong log. Staff U stated they put the information on the wrong log but were unable to do a complete fire watch due to other duties. Observation on 08/09/2022 at 11:58AM showed Staff C re-training Staff J on fire watch. During observation Staff C and Staff J missed a staff bathroom near the nurse's station. 08/09/2022: Another IJ in K-346 - Fire Alarm System - Out Of Service was called by State Fire Marshal due to the facility failing to conduct fire watches as required by the conditions. The IJ in K-346 was unremoved when the Fire Marshal exited the facility on 08/10/2022. The Fire Watch logs provided on 08/02/2022 showed that one fire watch round of the building was taking 2-3 hours per floor to finish. The faclility policy indicated the entire facility would be checked for fires every 15 minutes. On 08/02/2022 at 9:40AM Staff C stated the fire watch was completed by staff who had other duties assigned to them. Staff C stated the nurses had their nursing duties to perform and Maintenance had to complete their duties in addition to fire watch rounds. Record review of the Fire Watch Log Sheets dated 07/23-08/02/2022 showed that it required six hours for the entire building to be checked by Staff C. Fire watch logs provided by the facility showed staff checked the facility four times in the 24-hour period, not every 15 minutes. Review of Fire Watch logs provided 08/09/2022 at 10:30AM showed on 08/05/2022 multiple times where fire watch had not occured as directed. Multiple time slots showed lack of documentation and only certain areas of the floor were watched, not the entire floor. The Maintenance Department, on 08/02/2022, was the designated person completing the required fire watch. When asked the Maintenance Director stated he was conducting his regular duties while he was making his fire watch rounds. Through interview and Department investigations it was observed that the Fire Watch documentation form was being pre-filled out prior to watches being conducted. The above was discussed and acknowledged by the facility staff. IJ in K346 and F835 both were not removed prior to exit. F921-Safe/functional/sanitary/comfortable Enviroment was cited at scope and severity level F, due to the facility unable to ensure a safe enviroment for the residents. Reference F921 for further details.

Based on interview and record review, the facility failed to implement their abuse and neglect policies. Facility failure to identify, investigate, suspend suspected staff, rule out allegations of abuse, and effectively train staff on abuse prevention left all residents at risk for abuse, and psychosocial harm. An Immediate Jeopardy (IJ) was called on 03/04/2022 at 10:00 AM related to CFR 483.12 F-607, Develop/Implement Abuse/Neglect Policies. The IJ was removed on 03/08/2022 with a validation date of 03/08/2022 at 12:23 PM when an on-site inspection confirmed the facility implemented their removal plan by providing training to staff, interviewing all residents and suspending staff of concern. Refer to: F-600 Findings included . The Code of Federal Regulation (CFR) defines abuse as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Facility Policy The facility's 4/14/2020 Abuse and Neglect Policy's defined abuse to include intimidation or punishment with resulting physical, emotional or psychological harm, pain or mental anguish. The policy defined any act that makes a resident fearful, [or] feel belittled as mental abuse. The policy showed any accused staff members will be immediately removed from the resident suspected of being abused and the resident's safety will be protected and that the Administrator and the DNS [Director of Nursing Services] will investigate and report all allegations of abuse to the State Agency. The policy stated all employees must attend abuse prevention training on hire and annually, and that the training must include definitions of abuse and neglect. The 4/14/2020 policy included a Prevention section. This section showed all reports whether from family, residents or staff will be reported immediately to the DNS, after which, an incident report is completed. The policy's Investigation section showed all accused staff must be removed from contact with the resident suspected of being abused to protect the resident's safety. The Investigation section showed: The Administrator and DNS should separately interview all concerned parties; the investigation should conclude with fact-finding, root-cause analysis and comparison of information; the results of the investigation should be provided to the proper authorities and alleged violations and substantiated incidents to the appropriate state agency. The policy's Mandated Reporting of Incidents section showed any employee who observed an incident or was informed by a resident, Resident Representative (RR), volunteer or visitor of potential abuse must report what they saw or heard. Failure To Identify/Log/Investigate According to the 08/25/2021 Admissions MDS (Minimum Data Set - an assessment tool) Resident 176 admitted to the facility on [DATE] and was cognitively intact. The MDS showed Resident 176 had moderate hearing impairment and adequate vision, and had no behaviors. The MDS showed Resident 176 required extensive assistance for most care needs. Review of the facility's September 2021 Grievance Log (a document maintained by nursing homes were all grievances from residents and/or their representatives are logged, processed, and tracked) revealed a 09/08/2021 showing A nurse covered a resident's mouth. The log had a Resolution Description column that showed resident's story inconsistent. Care plan updated to cares and [sic] pairs. The associated 09/08/2021 Grievance Form was completed by Staff B (Director of Nursing - DNS) who signed the form on 09/09/2021. The form showed Resident 176's RR called on 09/08/2021 to express that Staff ZZ (Licensed Practical Nurse - LPN) was rude to the resident and Staff ZZ put their hand up to their resident's face similar to a 'stop' hand sign. The Grievance Officer Review section of the Grievance Form was signed by Staff B on 09/10/2021, indicating completion of the process. The form's Investigation and follow up action section instructed staff to include all relevant documentation and gave staff in-services as an example of relevant information. This section was completed by Staff B, dated 09/10/2021, and stated that Staff ZZ denied the allegation. Staff B wrote that when the facility interviewed Resident 176, they clarified that Staff ZZ shook their finger at Resident 176. Review of the facility's September 2021 Incident Log revealed no entry for the potentially abusive incident. In an interview on 03/03/2022 at 03:25 PM, Staff B stated that both placing a hand up to a resident's face and shaking a finger at a resident were potentially abusive and should be investigated. Staff B stated when a resident or their representative made an allegation of abuse, the facility suspended the identified staff member until abuse was ruled out by investigation, and the incident of potential abuse must be reported to the department. Staff B reviewed the Incident Log and stated the allegation was not logged and not reported to the state. Staff B stated Staff ZZ was not suspended until abuse was ruled out and continued to work without interruption. Staff B stated they did not know if the allegation was investigated and would provide a copy of the facility's investigation, if completed. No incident investigation was later provided. Training Provision and Effectiveness During an interview on 03/04/2022 at 8:45 AM Staff GGG (certified Nursing Assistant - CNA) stated that if they witnessed abuse they would Report to my nurse. When asked further, and provided cues, Staff GGG did not include any measures to protect the resident, nor indicate a need to report to the abuse hotline as a mandated reporter. During an interview on 03/04/2022 at 9:00 AM Staff HHH (Housekeeper) stated that abuse was fighting, hitting, and that's all I know. Staff HHH stated that if they witnessed abuse, they would tell them to stop and go report to the nurse immediately. Staff HHH did not know they were to report to the abuse hotline as a mandated reporter and when asked if they had received abuse training, Staff HHH, stated, No, not that I know. During an interview on 03/04/2022 at 9:15 AM Staff III (CNA) stated that forcing a resident to do something they did not want, or taking advantage of a resident was abuse. If they witnessed abuse, Staff III stated they would talk to the person (abuser), tell them not to do that and report to the nurse in charge at the time. Staff III stated they had not had abuse training at the facility as they were new and had only been in the facility two days. During an interview on 03/04/2022 at 9:16 AM, when asked to list the types of abuse, Staff JJJ (LPN) stated neglect, verbal, and physical. When asked for others, Staff JJJ stated, I can't think of those. During an interview on 03/04/2022 at 8:46 AM Staff GG stated that there was physical and mental abuse and requested to go to their office to obtain a paper on Abuse and Neglect. Reading from the paper Staff GG stated that other types of abuse included lack of care, psychosocial, assault, battery, mental, and physical. During an interview on 03/04/2022 at 8:54 AM when the surveyor attempted to conduct an abuse interview, Staff LLL, Housekeeper, stated, I don't understand English. The surveyor attempted verbal and visual cues and Staff LLL just smiled and stated, Sorry. Review of Abuse and Neglect Training documents showed Staff AAA received training on 10/11/2021 and 10/14/2021, Staff HHH received training on 10/14/2021, Staff DDD received training on 10/12/2021. There was no documented training for Staff III or Staff LLL. Staff ZZ was not listed as in attendance at the 10/11/2021 Abuse in-service, and was noted to be on vacation on the 10/14/2021 in-service attendance records. During an interview on 03/04/2022 at 9:35 AM Staff EE (Staffing Coordinator) stated that it was Staff CCC's first day at the facility as agency and they did not receive facility abuse training prior to being placed on the floor. During an interview on 03/04/2022 at 9:30 AM staff II (Staff Development) stated that the facility had the capability of virtual/computer training and they planned to sign staff up for abuse and neglect training the following week. In an interview on 03/04/2022 at 12:19 PM, Staff II stated the facility did not, but should, have a system to ensure that staff who are not available at the time receive required in-service training. Reference: WAC 388-97-0640(2)(a)(b)

Based on interview and record review, the facility failed to ensure one supplemental resident (Resident 176) reviewed for abuse was free from abuse related to the facility's failure to susupend staff when Resident 176 accused staff of abuse. This failure increased the likelihood of ongoing abuse and psychosocial harm. An Immediate Jeopardy (IJ) was called on 03/03/2022 at 6:30 PM related to CFR 483.12 F-600, Freedom from Abuse, Neglect and Exploitation. The IJ was removed on 03/08/2022 with a validation date of 03/08/2022 at 12:23 PM when an on-site inspection confirmed the facility implemented their removal plan by providing training to staff, interviewing all residents and suspending staff of concern. Refer to: F607, Develop and Implement Abuse and Neglect Policies. Findings included . The facility's 4/14/2020 Abuse and Neglect Policy defined intimidation or punishment with resulting [ .] psychological harm, pain or mental anguish. The policy showed: any accused staff members will be immediately removed from the resident suspected of being abused and the resident's safety will be protected; the Administrator and the DNS [Director of Nursing Services] will investigate; the Administrator or DNS will report all allegations of abuse [ .] to the State Agency. The policy defined any act that makes a resident fearful, [or] feel belittled as mental abuse. Resident 176 According to the 08/25/2021 Admissions MDS (Minimum Data Set - an assessment tool) Resident 176 admitted to the facility on [DATE] and was cognitively intact. The MDS showed Resident 176 had moderate hearing impairment and adequate vision, and had no behaviors. The MDS showed Resident 176 required extensive assistance for most care needs. Review of the facility's September 2021 Grievance Log (a document maintained by nursing homes were all grievances from residents and/or their representatives are logged, processed and tracked) revealed an entry logged on 09/08/2021 that stated A nurse covered a resident's mouth. The log had a Resolution Description column. The entry under this column for the 09/08/2021 stated resident's story inconsistent. Care plan updated to cares and [sic] pairs. Review of the facility's September 2021 Incident Log (a document maintained by nursing homes were all incidents, accidents, and abuse allegations from residents, their representatives or staff are logged, invstigated and tracked) revealed no entry logged for the potentially abusive incident involving Resident 176. The 09/08/2021 Grievance Form associated with this grievance was completed by Staff B (Director of Nursing - DNS) who signed the form on 09/09/2021. The form showed Resident 176's Resident Representative (RR) called Staff B on 09/08/2021 to complain that Staff ZZ (Licensed Practical Nurse - LPN) was rude to the resident and Staff ZZ put their hand up to the resident's face similar to a 'stop' hand sign. The form also included a section called Grievance Officer Review that was signed by Staff B on 09/10/2021, indicating completion. The form included an Investigation and follow up action section that instructed staff to include all relevant documentation (i.e. staff inservice [sic]). This section was completed by Staff B, dated 09/10/2021 and showed that Staff ZZ denied the allegation made by Resident 176's RR. Staff B further wrote that when the facility interviewed Resident 176, the resident clarified that Staff ZZ shook their finger at Resident 176. In an interview on 03/03/2022 at 05:01 PM, Resident 176's RR stated they recalled discussing the potential abuse with Staff B and stated they received no follow up from Staff B after the initial discussion. The RR stated the incident with Staff ZZ traumatized Resident 176, and added it affected [Resident 176] and we all were traumatized. The RR stated they told the head nurse if it happened again, they would call the police and expressed concern for the facility's nonverbal residents. In an interview on 03/15/2022 at 10:37 AM, the RR stated the first time they visited Resident 176 after 09/08/2021, Resident 176 talked at length about Staff ZZ's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The RR stated Resident 176 was angry and upset that a male staff member treated them the way they did. The RR expressed frustration that the facility never followed up with the RR after the initial phone call. In an interview on 03/03/2022 at 03:25 PM, Staff B stated that staff putting an open hand up to a resident's face was potential abuse and should be investigated to rule out abuse. Staff B stated that staff wagging their finger (in a scolding gesture) was also potentially abuse and should be investigated. Staff B stated when a resident or their representative made an allegation of abuse, the facility suspended the member until abuse is ruled out by investigation, and the incident of potential abuse is reported to the department. Staff B reviewed the Incident Log and verified that the allegation was not logged and not reported to the state, as required. Staff B stated that Staff ZZ was not suspended until abuse was ruled out and continued to work without interruption. Staff B stated they did not know if the allegation was investigated and would provide a copy of the facility's investigation if completed. No incident investigation was provided, indicating the facility did not follow their policy's direction to identify, report, and investigate all allegations of abuse and that the facility did not protect the resident from the alleged staff. Reference: WAC 388-97-0640 (1)

Based on interview and record review, the facility failed to ensure four (Resident 1, 2, 3, & 4) of 4 residents reviewed for abuse, were free from physical abuse when an unsupervised resident wandered into other residents' rooms. The facility's failure to supervise Resident 1 and implement adequate measures to protect Resident 2, 3, and 4 from abuse, resulted in emotional and physical harm to Resident 1, and posed potential risk of psychological harm to Resident 2, 3, and 4 and had the potential to affect other residents. Findings included . The facility's April 14, 2020 policy and procedure for abuse and neglect prevention included .Every resident has the right to be free from abuse in all forms. Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents . Resident 1 Resident 1 admitted to the facility on [DATE] according to the 5/23/ Minimum Data Set (MDS, an assessment tool). Staff assessed Resident 1 with long and short-term memory problems, severely impaired ability to make decisions, disorganized thinking and difficulty focusing. According to the 01/02/2021 annual MDS, the resident had disabling conditions including, Alzheimer's Dementia and wandering behavior. According to this MDS, Staff assessed the resident to be dependent on one person for supervision with Activities of Daily Living (ADLs) including redirecting and cueing when Resident 1 wandered into other residents' rooms. The MDS documented Resident 1 had severely impaired cognition. As a result of this assessment the facility developed 01/21/2021 Care Area Assessments (CAA) that included staff's recognition of Resident 1's continued wandering behavior into residents' rooms. Staff determined they would redirect the resident and cue the resident to stay away from and out of residents' rooms. The 09/07/2021 quarterly MDS described Resident 1 as displaying a severely impaired ability to make decisions, was continuously inattentive, and exhibited disorganized thinking. According to the 03/18/2020 abuse prevention Care Plan (CP), Resident 1 was, At risk for injury to themselves or others due to the resident's wandering behavior into residents' rooms and bathrooms, contributing to male residents increased behaviors to act out. Staff were instructed to implement interventions that included but were not limited to; set the resident up in a rocking recliner to watch television, provide the resident with a stuffed animal, supervise to prevent resident to resident altercations, walk three time a shift with supervision, provide snacks and allow (resident) to relax in rocking chair or bed, remove resident from area of other residents and closely observe, and redirect if found in another resident's room. Resident 4 According to the 08/23//2021 quarterly MDS Resident 4, male resident, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 According to the 08/23/2021 quarterly MDS, Resident 3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 The 06/21/2021 MDS indicated Resident 2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . First Incident Review of the 08/08/2021 Incident Investigation Report (IIR) showed that, at 10:40 AM on 08/08/2021, Staff E, RN, heard Resident 1 from Resident 2's room, speaking with a loud voice and instructing Resident 2 to sit down. When Staff E entered Resident 2's room, Staff E found Resident 1 sitting in Resident 2's wheelchair. According to the 08/08/2021 IIR Resident 2 was not happy when Resident 1 wandered into their room. Resident 2 got upset and got up from lying down and asked Resident 1 to leave the room. As Resident 1 was being assisted to leave the room by Staff E, Resident 2 followed Resident 1 and hit Resident 1 with a slipper to the right side of the face. Review of the investigation report conclusion dated 08/08/2021, showed no documentation to support the facility revised Resident 1's CP or implemented new interventions to prevent further resident to resident altercations. The impermissible action that caused Resident 2 to become upset and react to Resident 1 with physical abuse and at the same time suffer emotional distress was the fact Resident 1 entered Resident 2's room without permission. Resident 2 did not want Resident 1 in their room. Second Incident Review of the IIR dated 08/20/2021 showed on 08/20/21 at 8:35 AM (11 days after the first incident) another resident to resident altercation occurred. Staff F (CNA), observed Resident 3 hitting Resident 1 on the right arm with a walking cane, when Resident 1 wandered into Resident 3's room. According to the IIR, Resident 1 was noted to touch their right arm and grimace in pain. Staff I, RN, assessed Resident 1 with redness to the resident's right arm. According to the 08/20/2021 investigation report summary, Resident 1 was re-assessed to be confused, wandering and inappropriate with unwanted sexual behavior towards male residents, this indicated an increased risk for Resident 1 to experience altercations with other residents. A reasonable person would be upset if an intruder entered their home. Resident 3's room was his home and Resident 1 was the intruder. Although Resident 1 was struck and injured physically and emotionally by two residents, review of Resident 1's CP showed no indication that the facility developed or revised Resident 1's CP or implemented interventions to prevent further resident to resident altercations. Review of Resident 1's progress notes from January 2021 to August 2021, showed Resident 1 exhibited increased wandering behaviors on a daily basis during the day and evening shifts. Third Incident Observation on 09/13/2021 at 3:00 PM, showed Resident 1 wandering in the hallway without supervision. Observation at 3:20 PM, showed Resident 1 entering Resident 4's room uninvited, without knocking. After entering the room, Resident 1 sat on the chair adjacent to Resident 4's head of the bed. Further observation showed, no staff redirected Resident 1 from wandering into Resident 4's room. This was inconsistent with Resident 1's 03/18/2021 CP, which instructed staff, to redirect or cue the resident when the resident wandered into other resident's rooms. There was also no observation of a rocking recliner chair or a stuffed animal in the resident's room to be used as diversion for wandering. On 09/13/2021 at 3:45 PM, Resident 4 was asked, by Staff C, a Registered Nurse (RN), how he felt when Resident 1 wandered into Resident 4's room. Resident 4 mumbled angrily and stated, (using hands, and facial gestures due to anger and difficulty speaking) Resident 1 always wanders into (my) room uninvited. The fact Resident 4 became upset after Resident 1 repeatedly entered Resident 4's room against Resident 4's will demonstrated the facility ignored physical and emotional abuse of all four residents involved in the most recent incidents as described above. Staff Interviews In an interview on 09/13/2021 at 3:50 PM, Staff G (CNA) the CNA regularly assigned to care for Resident 1, acknowledged Resident 1 entered other residents' rooms uninvited. Staff G stated that, Resident 1 especially wandered into male residents' rooms. Staff G stated that it was difficult to monitor Resident 1 all the time as Staff G had other residents that required care. On 09/27/2021 at 2:45 PM, in an interview, Staff C, Resident Care Manager (RCM), stated they were not sure what interventions to initiate, as Staff C was new on the job and was in training at the time of incident the first two incidents. Staff C further stated they never witnessed any resident to resident altercation. In an interview on 09/27/2021 at 3:30 PM, Staff B, Director of Nursing Services (DNS) was asked how the facility ensured Residents were protected from abuse. Data was requested but none provided. Staff B stated that, the facility was experiencing a staffing shortage and was doing its best. In an interview on 09/26/2021 at 9:00 AM, Staff A (Administrator) acknowledged staff did not put in place adequate measures to protect Residents 1, 2, 3, and 4 from physical or emotional abuse. Reference WAC 388-76-0640(1)

Based on interview and record review, the facility failed to ensure an environment that was free from accidents for one (Resident 1) of eight sampled residents reviewed for accidents. The facility failed to implement preventative interventions based on the resident's assessed care needs to prevent further falls. This failure resulted in harm when Resident 1 fell backwards and sustained a laceration to the back of the head, resulting in hospitalization for a [MEDICAL CONDITION]. Findings included . An undated facility policy titled, Accidents/Incidents and Supervision, showed, that the facility will provide the residents an environment free of accident hazards. This policy also showed the facility will identify, evaluate and analyze potential hazards and risks, and monitor and modify the effectiveness of interventions. An 11/26/2020 Admission Minimum Data Set (MDS - an assessment tool) showed, Resident 1 was admitted to the facility on [DATE] with medically disabling conditions, and had a history of [REDACTED]. Review of 12/03/2020 Care Area Assessments (CAA - a care summary) showed Resident 1 was incontinent of urine. This CAA showed staff were to provide assistance with each episode of incontinence, and offer the resident to use the bathroom before meals, after meals, at bed time, and when awake. This CAA also indicated the resident required non skid socks when in bed. An 11/20/2020 comprehensive Care Plan (CP) showed, Resident 1 required stand by assistance of staff for toileting and staff were to ensure the resident had appropriate footwear at all times (non skid socks). Further review of the CP did not show specific interventions to instruct staff how often and when staff were to toilet Resident 1 and ensure toileting needs were met, as indicated in the 12/03/2020 CAA. In an interview on 03/20/21 at 8:50 PM, when Staff E, a Registered Nurse (RN) who completed Resident 1's CAA for toileting dated 12/03/2020, was asked how Resident 1's toileting needs were implemented, Staff E stated, I did not include care instructions in the care plan. When asked if she communicated the identified toileting needs and interventions upon completion of the toileting assessment to other staff members who provided care for the resident, Staff E stated, No, I forgot. Review of progress notes dated 01/05/2021 showed, Resident 1 had an unwitnessed fall in the bathroom at 11:15 PM. The resident was found by Staff K, Licensed Practical Nurse (LPN), sitting on the bathroom floor with the incontinence brief pulled half way down, was bare foot, and not wearing nonskid socks as indicated in the care plan. Review of a 01/05/2021 Incident Investigation Report (IIR) showed that the resident told staff that when they attempted to ambulate to the sink to wash their hands after using the toilet, they felt dizzy, lost their balance and fell backwards. This IIR showed, it was completed by Staff B, Director of Nursing Servises (DNS), and concluded Resident 1's cause of the fall was due to Resident 1's poor judgement, failure to call for assistance and wanting to be independent. Review of therapy notes, dated 01/07/2021 and written by Staff G, Physical Therapist, showed Resident 1 had a decline in cognition, did not always use the call light for assistance, and required a higher level of supervision due to increased risk of falling. In an interview on 03/16/2021 at 3:00 PM, Staff G said she notified Staff C, Resident Care Manager (RCM), when she assessed Resident 1 had a decline in cognition. Staff G stated she also recommended a revision to the Resident 1's CP plan, to include close supervision of the resident due to the poor safety judgement and forgetfulness. Review of Resident 1's Care Plan (CP) dated 11/20/2020, showed no documentation staff revised the CP to reflect the level of care and higher level of supervision Resident 1 required as recommended by Staff G. In addition, there were no documented measures to compensate for the resident's poor safety judgement, failure to call for assistance, and perception of independence. In addition, the CP did not include specific interventions to instruct staff how often and when staff were to toilet the resident, and ensure toileting needs were met. In an interview on 03/16/2021 at 3:30 PM, Staff H, Certified Nurse's Aide (CNA) who regularly provided care for Resident 1, stated that she toileted Resident 1 when the resident requested to be toileted. Staff H also said, the resident sometimes did not call for assistance and toileted herself, inconsistent with the resident's identified toilet care needs which required staff to toilet the resident on awakening, before and after meals, and at bed time. Review of progress notes dated 01/12/2021 showed that at 11:40 PM, Staff D, LPN, observed Resident 1 sliding out of bed while attempting to get out of bed without assistance, and did not use the call light. Staff D assisted the resident to sit at the edge of the bed to prevent the resident from falling. Resident 1 stated, I want to go to the bathroom. Review of progress notes dated 01/14/2021 showed, during night shift, Staff D noted Resident 1 standing in the bathroom washing her hands. The resident did not turn on the call light to ask for assistance to ambulate to the bathroom and use the toilet. Review of progress notes dated 01/16/2021, showed, the resident was forgetful at times. Review of progress notes dated 01/18/2021 showed Resident 1 was forgetful, and showed Staff D observed Resident 1 walking to the bathroom unassisted and using a front wheeled walker. Resident 1 told Staff D, I'm too old and forget a lot. Review of an IIR dated 01/26/2021 at 1:00 PM (after lunch meal) showed, Resident 1 was found sitting on the floor in her room. Staff K, LPN, assessed the resident and noted an injury to the back of the head, hematoma (collection of blood outside the blood vessel) measuring 2.5 CM (centimeters) x 3 CM and a laceration measuring 0.5 CM. According to the IIR, Resident 1 stated that she was going to the toilet, and showed that the resident was walking alone and did not have non-skid socks on. This IIR showed Staff B, Director of Nursing, concluded that Resident 1's fall was due to the resident wanting to be independent and discharge home, and not to another facility and, the facility's Resident Care Manager had talked to the resident several times about using the call light for help with ambulation, but the resident was not compliant. Despite the resident's assessed care concerns, per nurses and physical therapy notes, which included the resident's poor safety awareness, forgetfulness and inability to use the call light for assistance, there was no documentation to show the facility addressed the resident's care needs to prevent her from falling. After the resident fell on [DATE], Staff I, notified the resident's representative and the resident's doctor about the incident. The doctor assessed the resident and issued new orders to provide first aide including pain medications and continue close monitoring of the resident for any change in condition. Review of progress notes dated 01/28/2021 showed, Resident 1 had a change in condition of nausea and headache, while at an orthopedic follow-up appointment. The orthopedic doctor issued an order to transfer Resident 1 to the hospital for further evaluation. Resident 1 was diagnosed with [REDACTED]. The above findings were shared with Staff A, Administrator, and Staff B on 03/19/2021 at 2:45 PM. Staff B acknowledged Resident 1's CP did not show the resident's toileting care needs. Staff A stated the facility was working on improving interdisciplinary collaboration of resident care. Despite facility staff awareness of Resident 1's decline in cognition, continued inability to call for assistance due to forgetfulness, and a required higher level of supervision, the facility failed to put in place measures to prevent falls and associated substantial injury for Resident 1. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to ensure 17 of 18 staff members (Staff C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, and S) consistently implemented the facility's written infection control policies and procedures and follow standards of practice related to proper use of required 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. Additionally, the facility failed to ensure [MEDICATION NAME] visitors were notified and educated of infection control practices /expectations while visiting in the facility with COVID-19 outbreak. These failures constituted a situation of an Immediate Jeopardy (IJ). On 01/06/2021, the facility was notified of an IJ related to CFR 483.80 F880, Infection Prevention and Control. On 01/22/2021, the validation of the IJ removal occurred through observations and review of records, including staff education, audits, staff schedules, employee screening logs, policies and procedures, and medical records. Findings include . CENTERS FOR DISEASE CONTROL (CDC GUIDELINES) According to the 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 face mask 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. FACILITY POLICY A review of facility policy titled, Special Droplet/Contact Precautions, dated 10/07/2020, showed that all facility staff, including doctors, essential support staff and [MEDICATION NAME] visitors, were to clean the hands, wear a surgical mask and face shield and be screened when entering the facility's main entrance to prevent the spread of respiratory viruses, including COVID-19. BREACH IN PPE USAGE and HAND HYGIENE Observations on first floor Unit, 2 EAST Unit, 2 WEST Unit and the third floor Unit on 01/05/2021 between 12:00 PM and 2:00 PM, and on 01/06/2021 between 5:00 AM and 8:00 AM, showed numerous staff with double masks in various configurations: an N95 mask over an N95 mask, a surgical mask over an N95 mask, a surgical mask over a surgical mask, cloth mask over a surgical mask. On 01/06/2021, observations throughout the facility, showed multiple staff on all facility units wearing improperly fitting N95 respirator masks, loose and without a seal, inconsistent with CDC guidelines which requires proper positioning of N-95 masks, the top strap to be positioned at the crown of the head, and the second strap positioned at the base of the neck and under the hair in order to fit and seal properly. In an interview on 01/06/2021 at 12:00 PM, Staff A, Administrator, stated that staff were double masking as a way of protecting the N95 mask to allow for prolonged use, as the facility did not have a sufficient supplies of the N95. 1st FLOOR Observation on 01/05/2021 at 12:35 PM, showed, Staff M, a Certified Nurse's Aide (CNA) provided care to COVID-19 positive residents. Staff M was observed wearing a N95 mask over another N95 mask, Staff M was observed with a top strap from one N95 mask strapped to the back of the neck , and the bottom strap from the second N95 mask, strapped to the back of his head. Staff M did not wear a face shield while serving lunch to COVID-19 positive residents. On 01/05/2021 at 12:40 PM, when asked what PPE he was taught to wear when providing care for COVID-19 positive resident, Staff M did not answer. Observation on 01/06/2021 at 5:10 AM, showed Staff C, a night shift Charge Nurse and Licensed Practical Nurse (LPN), provided care for COVID-19 positive residents and COVID-19 negative residents. A further observation showed Staff C wore double surgical masks (a surgical mask over a surgical mask). When asked, Staff C stated that he wore the double surgical masks, because the N95 mask was too tight and uncomfortable. When asked if he had been fit tested for the N95 mask. Staff C said, No. Similar observations were noted for Staff D, a night shift Nurse's Aide, who was working under the supervision of Staff C. Staff D was also assigned to COVID-19 positive residents and COVID-19 negative residents. Staff D was observed wearing a surgical mask and no face shield while providing care in the COVID-19 positive unit. On 01/06/2021 at 5:18 AM, Staff D stated that was the only mask she had and she did not know what a N95 mask was. Observation on 01/06/21 at 6:40 AM, showed, Staff J, a Nurse's Aide, coming out of the elevator with two other staff members. Staff J was not wearing a mask or a face shield. Staff J did not implement social distancing and stood in close proximity (about two feet apart) while talking with other staff members. When asked, Staff J stated that the front desk receptionist was responsible for giving her the mask and shield, but the receptionist had not yet reported for work. Observation of the front desk on 01/06/2021 at 5:15 AM and 6:53 AM, showed, the receptionist sitting at the front desk with a couple boxes of N95 masks and surgical masks. DISINFECTION OF SHARED EQUIPMENT/ HAND HYGIENE Review of the facility's policy for infection control dated 10/07/2020, showed the facility used an approved disinfectant for cleaning of shared resident equipment. This policy showed staff were to wipe down shared equipment between each resident use to prevent spread of viruses that cause infections including COVID-19. Observation on 01/06/2021 at 6:30 AM, showed Staff M, a Nurse's Aide, was assigned to provide general resident care including taking vital signs of residents on a COVID-19 Positive unit. On 01/06/2021 at 6:40 AM, Staff M entered Room # 117 (a shared room) and took vital signs for Resident #3 and Resident #4. Staff M did not sanitize the vital signs machine between resident use. Staff M, then came out of the room, took off the gloves and, without washing his hands and disinfecting the vital sign machine, donned on a pair of clean gloves and proceeded to room [ROOM NUMBER] where he took vital signs for resident #8. On 01/06/2021 at 6:50 am, when asked Staff M stated, I know I'm supposed to wipe the vital signs machine with a disinfectant between residents, but I forgot UNIT 2 EAST (Designated COVID-19 POSITIVE UNIT) An observation on 01/06/2021 at 5:20 AM showed Staff E, a Nurse's Aide entered room [ROOM NUMBER] and provided resident care. Staff E wore a loosely fitting N95 without a seal around the rim of the mask, and was not wearing a face shield. After providing resident care, Staff E exited room [ROOM NUMBER] without removing the gloves. Staff E removed the gloves outside of the resident's room, inconsistent with the facility's policy and procedure for infection control dated July 2019 which instructed staff to remove and dispose all contaminated gloves in the resident's room before exiting. Staff E then proceeded, without performing any form of hand hygiene, donning on a clean pair of gloves, entered Room # 213, and provided care without wearing a face shield. On 01/06/2020 at 5:20 AM, when asked, what training he received related to COVID-19 infection, Staff E stated that he was an agency nurse's aide, and it was his first day to work in the nursing home. Staff E stated that he had not received any education before beginning of the shift. When staff E was asked why he was not wearing a face shield, he stated, I did not know I was supposed to wear one. On 01/06/2021 at 5:30 AM, Staff F, a Registered Nurse (RN), acknowledged he did not provide any education to Staff E prior to beginning of the shift. Staff F stated that he thought Staff E had already been educated. On 01/06/2021 at 12:00 PM, Staff A, the Administrator, confirmed Staff E had not received education related to COVID-19 infection, or any orientation prior to providing resident care on the COVID-19 positive unit. Staff A stated that the facility did not have a system in place to provide orientation to agency staff, and that the facility was working on implementing a system to educate and orient agency staff prior to assigning residents to them. Observation on 01/05/2021 at 12:30 PM, showed Staff N, Occupational Therapist (OT) walking in the facility hallway toward the main entrance, wearing a surgical mask, and no face shield. When asked, Staff N stated, I just came from my lunch break, I'm supposed to have the face shield on, but I forgot. Observation on 01/05/2021 at 12:38 PM, showed staff O, Central Supplies staff, delivered resident care supplies while wearing a surgical mask, and no face shield. When asked, he said he forgot. Observation on 12/05/2021 at 1:00 PM, showed Staff P, CNA, entered room [ROOM NUMBER] and delivered a lunch tray for the resident. Staff P wore a surgical mask, but was not wearing a face shield before entering the resident's room. When asked, he stated that he left the face shield at the nurse's station. Observation on 01/05/2021 at 1:10 PM, showed Staff Q, Restorative Aide, entering the facility main entrance after accompanying Resident #5 to a doctor's appointment outside the facility. Staff Q was wearing a cloth mask over a surgical mask, but did not have a face shield on. Observation on 01/06/2021 at 6:35 AM, showed Staff L, CNA, exiting the COVID- 19 positive unit (2 East Unit), a designated COVID-19 positive Unit. Staff L took off the gloves and isolation suit at the designated area. With the contaminated face shied and face mask still on, Staff L proceeded to the clock out area while interacting with oncoming staff. Staff L proceeded to the 1st floor, took off the face shied and threw it in a nearby garbage can. With a contaminated mask on, she exited the facility. Staff L's actions were inconsistent with the facility's policy for infection control and CDC guidelines which instruct staff to dispose of contaminated PPE on exit from COVID-19 positive unit, to prevent the spread of [MEDICAL CONDITION]. 2 WEST Observation on 01/06/21 at 6:15 AM, showed Staff K , a Nurse's Aide, wore double masks (surgical mask over N95 mask). When asked, Staff K stated that she wore two masks for more protection in case the resident was coughing while providing care, or another staff member was coughing nearby. 3rd FLOOR Observation on 01/05/2021 at 12:45 PM, showed room [ROOM NUMBER] with two residents (#2 and #7) positive for COVID-19. There was an isolation cart outside the residents' room including signage instructing staff to wear full PPE (N95 mask, isolation gown, face shield and gloves)before entering the room to provide resident care. Staff G was assigned to provide care for COVID-19 positive residents in Room # 320 and other residents who did not have COVID-19 infection on the same unit. Observation on 01/06/2021 at 5: 28 AM, Staff G, a Nurse's Aide, entered a COVID-19 positive room (#320) to provide care. Staff G wore a surgical mask and with no face shield. On 01/06/2021 at 6:35, in an interview, Staff G stated that she always used a surgical mask and no face shield when providing care for COVID-19 positive residents or COVID-19 negative residents. Observation on 01/05/2021 at 12:45 PM, showed Staff S, Dietary Aide, delivered snacks for the residents on the unit with COVID-19 outbreak. Staff S wore a cloth mask and did not have a face shield. When asked, Staff S stated that he was aware of the N95 mask and face shield requirement, and that he could not wear them because they were uncomfortable. Observation on 01/06/2021, at 5: 55 AM, showed Staff I, a Nurse's Aide, wore a surgical mask over a N95 mask. When asked, Staff I stated that she covered the N95 mask with a surgical mask to protect and extend the use of the N95 mask. Observation on 01/06/2021 at 5: 48 AM, showed Staff H, LPN, was assigned to provide care for COVID-19 positive residents in room [ROOM NUMBER] as well as the rest of the residents on the unit who were COVID-19 negative. Staff H wore a surgical mask over a N95. On 01/06/21 at 6.05 AM, Staff H stated that she wore the surgical mask over the N95 mask for more protection and prolonged use of the N95 mask. FAILURE TO EDUCATE VISITORS Observation on 01/05/2020 at 12:47 PM, showed Resident #6 (a hospice resident) sitting close to a family member ([MEDICATION NAME] visitor) less than 6 feet apart having a meal together. Further observation showed, approximately 15 minutes later, Resident #6's family member was observed wearing a cloth mask without a face shield, assisting Resident#6 to ambulate to the weight room across from Resident #6's room. The resident was not wearing a face mask, a face shield or gloves. The resident's family member was observed holding the resident's hand while assisting the resident to ambulate to the weight room. On 01/05/2021 at 1:00 PM, when the resident's family member was asked if the facility educated her about required PPE usage while she visited the resident, she said No. On 01/05/2021 at 1:30 PM, when Staff R, Social Worker (SW), was asked, Staff R was unable to provide documentation to show the facility educated the family member about the required PPE usage during visits. On 01/05/2021 at 1;45 PM, In an interview, Staff T, LPN, was asked how he ensured Resident #6's family member followed infection control practices related to COVID-19, while visiting Resident #6. Staff T stated that he was not aware Resident #6 was scheduled for a visit. On 01/06/2021 at 12:00 PM, Staff A stated that the facility was working on developing a system to educate visitors about infection control practices during in-room visits. Review of the facility's infection control line listing, showed, that the COVID-19 outbreak started on 12/04/2020 with a single active case. As of 01/06/2020, a total of 54 residents and 21 staff had since tested positive for COVID-19, and eight residents infected with COVID-19 passed away. in an interview on 01/06/2021 at 1:00 PM, when asked about the root cause of the spread of COVID-19 infection, Staff A stated that the facility had not completed a root cause analysis of the spread the infection of COVID-19 yet, one month since the COVID-19 outbreak. The failure to identify the root cause of the spread of the COVID-19 infection and implement interventions based on identified root cause to prevent further spread of infection, placed all residents and staff at risk for contracting the dangerous [MEDICAL CONDITION] resulting in serious health complications and or death. REFERENCE: WAC 388-07-1320(1)(a)(c).

Based on interview and record review, the governing body did not recognize and acted with disregard to the well-being of the residents of the facility, by not being reponsible, effective, taking adequate active and engaged action when the facility became aware of financial crisis. This impacted all 130 residents in the facility. The Treasurer who was the only representative from the governing body made threatening statements of letting staff go, which created an immediate jeopardy of not having staff to care for residents and the potential of psychological harm for residents of becoming homless or having no choices of where they would go. Findings Included . A review of an undated copy of Draft 4.0 Amended and restated by laws of Washington Care Services. Article 1 Name/Purpose and Geographical Focus. 1.1 Name: The name of this nonprofit Corporation shall be Washington Care Services (WCS or the Corporation) Article III Board of Directors 3.1.c Authorize signing of contracts and payment of bills. Article IV Officers 4.5 Treasurer: The Treasurer shall: a) Participate in the preparation of the annual budget, financial reports and financial consulting as requested by the President of the Board of Directors; d) Supervise all funds of the organization, whether said funds are handled by a bookkeeper, accountant, or other employee of the Corporation; In a morning meeting on 5/24/19, which included, the Facility Attorney, the Administrator and the department. The facility stated the facility was in a financial crisis and there was no reason to think it will be any different on 06/07/19 when it remains a risk of the company not making payroll. The facility board has determined they need to close the facility. The facility has issued 60 days notices to residents, staff and the government regulators. The facility closure would take effect on 07/23/19. The facility indicated they were good up to 06/23/19 for payroll per revised projections from the outside accountant. The facility was collecting around million dollars this month. The facility also had a couple of Medicaid conversations and the board stated the facility could not meet the mission of providing care due to the decrease in revenue. The board got a report from the outside accountant on 05/07/19 and the panic button was hit indicating that they can't meet payroll. In addition, the mortgage on the building has been missed for (MONTH) and (MONTH) of the current year. On 05/28/18 at 12:05 pm during a telephone interview, the board of director's treasurer stated the financial situation has been a multi-year issue going back as far as (YEAR). He stated that he had been in contact with the Department of Social and Health Services since (YEAR) about Medicaid rates. He also stated the rates for Medicaid needed to be increased and the stair step drops were what was hurting their building, that has a large amount of Medicaid residents. Even the smallest of cuts creates a large impact on the facility. The treasurer went on to say the cost for a Medicaid client is $290.00 per day and the state was only paying the facility $250.00 per day. If their facility census was at 145 they would be breaking even, but there was no profit margin. So when the census falls below the 145 they are burning cash. The state, (Home and Community Services office) does not help; they will not move Medicaid residents to reduce the amount of Medicaid residents that are in the facility. He also stated the facility did not have additional support services, like an A/L or other charitable funds that they could draw from. The facility hired an outside Accounting firm in (YEAR), to help the facility with their financial situation. According to the treasurer, the facility had tried every trick in the book to survive. Cutting costs is what has let us survive. The Accounting firm notified them on (MONTH) 7th that they would be out of money by mid-June. Their last payroll would be 6/23/19, then they will be out of money. All of the bills are current, but again, in (MONTH) they will not be. As of (MONTH) 7, residents will be in trouble, because they cannot keep staff with no money to pay them. The treasurer stated there is a law, if you knowingly allow people to work, you become personally liable. I will be personally responsible for their pay. Pay roll is $250,000.00 per month and I cannot afford that. The treasurer stated he felt the state caused and owned this problem by cutting Medicaid rates, so they need to fix it. In a conference call on 05/29/19 at 3:00 pm, Home and Community Services (HCS), Residential Care Services (RCS), the facility lawyer, the Administrator, and the treasurer were all present. The remainder of the board (President, Vice President, Secretary etc. were not present on the call) The treasurer re-stated that there is a law that prevents a facility from retaining staff if there are no funds to pay them. If the facility keeps staff on and there are no funds, the board would be held responsible. So when it comes to a vote the treasurer stated that he would vote to let staff go so there would be no staff to care for the residents. It was also discussed that there were several offers for a management team to come in and take over the building until new owners could be found. The one offer though did not meet the terms of what the board was wanting to see. The facility was going to contact them again and discuss further options then the board would have to take a vote. In a phone interview on 5/30/19 with the Administrator to review paperwork. He stated the board did not vote for a Change of Ownership due to some verbiage that was purposed by the perspected change. The Administrator indicated that he did not feel the Treasurer was acurate with his take on the finances. During a review of the paperwork submitted by the facility, showed the facility was operating under a different name then their licence had. The Administrator stated the facility changed it's name several years ago and he was under the impression that the paperwork was submitted to the department. In addition, the billing showed that there 8 vendors, in which were 91 plus day past due for a total of $1,175,074.99, 4 vendors that were 61 - 90 days past due for a total of $331,416.60. The Administrator indicated that payment arrangements had been made with all of the past due vendors. The total amount owing was $2,003,160.80. None of these amounts included payroll or food. The facility Census at the time of the interview was 130 residents with 91 of those residents being Medicaid. The Administrator stated that since they were closing, they had put themselves in stop placement. In an interview on 06/3/19 at approximately 8:30 am, the Administrator stated that he did not feel the board was functional at that time. He felt the financial situation was not as bad as the Treasurer stated. During all of the meetings, both in person and on the phone the only board member present was the treasurer, the remainder of the board did not participate in conversations in regards to the outcome of the facility. Reference: WAC 388-97-1620(1)(2)(i)(c)

Based on observation, interview, and record review, the facility failed to ensure two (#s 18 & 86) of three residents reviewed for Range of Motion (ROM) and two supplemental residents (#s 71 & 90) identified by staff with decreased ROM, received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This failure resulted in harm to Resident #71 who developed contractures to the right and left elbows and left wrist, and placed other residents at risk for further decline in ROM. Findings include: Refer to: CFR 483.25(e)(1), F-317, No Reduction in ROM CFR 483.30(a), F-353, Sufficient Staff RESIDENT #71 According to the 10/11/16 Quarterly Minimum Data Set (MDS - an assessment tool), Resident #71 had ROM impairment of both Upper Extremities (UE) and on one Lower Extremity (LE). According to the MDS, the resident received Occupational Therapy (OT) until 08/19/16 and Physical Therapy (PT) until 09/15/16. The resident received Restorative Nursing Assistance (RA) for Passive Range of Motion (PROM) on seven days of the observation, no Active Range of Motion (AROM), and no splint or brace assistance. Review of a Therapy RA Referral Form dated 09/08/16, listed the approach of BUE/BLE (Bilateral) A/AROM (Active Assistive) or PROM all planes, x 10 (reps), for 15 minutes, six times a week, with the goal To maintain ROM and strength. Review of the 04/08/17 Limited mobility Care Plan (CP) listed the approach of BUE/BLE A/AROM all planes x 10 = 15 min 6x week, assigned to the RA, with the goal to maintain ROM and strength. The CP did not include the provision of PROM as directed in the RA referral. In an interview on 09/12/17 at 10:44 a.m., when asked if Resident #71 could perform Active ROM, Staff P (Restorative Consultant) replied Some days she can. Staff P added, It's mostly AAROM or they are doing Passive (ROM) and it's not recorded as such. Staff P updated the care plan and P(NAME) (Point of Care-computer documentation for restorative programs) documentation to reflect the addition of PROM. According to the 04/11/17 Annual MDS, the resident received RA services less than the six days a week as ordered; AROM was provided four of seven days. Similar findings were noted on the 07/11/17 Quarterly MDS, where the resident received AROM five of seven days. In an interview on 09/12/17 at 12:10 p.m., Staff Q (Rehab Director) said, After we create a restorative program, we let the care manager know, give them a copy of the handwritten referral, provide training if needed, and from that point we assume (the resident is) being seen six times a week for 15 minutes. Review of the P(NAME) records revealed, staff documented performance of AROM: in May 2017 on 16 of 31 days, June 2017 for 13 of 30 days, July 2017 nine of 31 days, August 2017 on seven of 31 days, and in September 2017 on three (09/3/17, 09/04/17, 09/06/17) of eleven days. Review of a Therapy RA Referral Form dated 05/12/16 listed an approach of, Apply palm protectors to B hands for 6 hrs (hours) as tolerated. Remove for meals. Check for redness, swelling, pain, indentation and report to OT. The ordered frequency was Everyday. The listed goal was To maintain hand ROM for functional use of hands. Review of the 04/02/17 Limited mobility CP listed the goal and intervention as written above, not assigned to the RA, but to the Licensed Nurse and/or Nursing Assistant on a PRN (as needed) basis. In an interview on 09/12/17 at 10:44 a.m. Staff P said, palm protectors are a nursing task, assigned to nursing assistant and Licensed Nurse, not the RA. In an interview on 09/07/17 at 10:23 a.m. Staff G (Registered Nurse) said, Resident #71 had contractures of the shoulder, wrist, hands and fingers. According to Staff G, the resident received ROM services by Restorative staff, but had no splint. In an interview on 09/13/17 at 10:01 a.m. when asked about the palm protectors, Staff G said, the resident had gloves, but she was not aware of palm protectors, adding, I'll have to check on that. No further information was provided. Resident #71 was observed not wearing palm protectors at any time during the survey, including, but not limited to 09/06/17 at 11:44 a.m., 09/07/17 at 10:10 a.m., 10:41 a.m., 1:59 p.m., 09/08/17 9:12 a.m., 09/12/17 at 8:49 a.m., 9:32 a.m., 11:29 a.m., 09/13/17 at 10:32 a.m. Review of the P(NAME) documentation revealed, staff documented application of palm protectors in: May 2017 on eight of 31 days, June 2017 four of 30 days, July 2017 on six of 31 days, August 2017 on eight of 31 days and in September 2017 on six of eleven days. The palm protectors were not documented as applied on 09/06/17 or 09/07/17 which was consistent with observations. In an interview on 09/12/17 at 10:44 a.m. Staff P said, the RCMs were supposed to be reviewing the RA programs quarterly with the MDS notes. In an interview on 09/13/17 at 10:01 a.m. the Resident Care Manager, Staff G said, she started the job in July 2017 and had not done a quarterly review for Resident #71. Staff G said, the quarterly reviews she had completed, included ADLs, mobility, but not specifics related to the RA program. Review of the resident's record revealed, no quarterly restorative evaluations. The evaluations were requested, and none provided. In an interview on 09/12/17 at 10:44 a.m. Staff P said, contracture monitoring was completed by skilled therapists. In an interview on 09/12/17 at 12:10 p.m. Staff Q said, on a quarterly basis we get orders from the care managers for those residents with quarterly MDS'. We evaluate/reassess their ROM based on what the MDS looks at for the contracture. If no real change, we just monitor. If a sudden change, or decline in ROM we may pick up for a little bit. Review of the 05/19/14 Limited mobility CP a PT/OT referral was to be completed quarterly and PRN. Review of Contracture Monitoring documents revealed, it was not completed quarterly as planned. It was done 09/15/16 and not again until 04/12/17, seven months later. On 09/15/16 the resident's left wrist extension was WFL (within full limits). On 04/12/17 the resident's left wrist extension was not measured. On the following contracture measurement dated 08/16/17 the resident's left wrist extension was limited to -20 degrees, which per the contracture key was indicative of fully contracted. In addition, the resident's left and right elbow flexion was measured as WFL on 05/04/16, 09/15/16, and 04/12/17. On 08/16/17 the resident's right elbow flexion was limited to -25 degrees, and the left -28 degrees. A note written on the contracture monitoring form dated 8/16/17 elbow flex contracture related to body habitus. In an interview on 09/12/17 at 12:10 p.m. when asked about body habitus, Staff Q replied, I'm not sure what she means, the OT wrote that. In an interview on 09/12/17 at 12:10 p.m. when asked about Resident #71's worsening ROM, Staff Q replied, she is being seen by OT, she is currently on caseload by OT, they are working on her shoulder. Review of the 08/16/17 OT evaluation revealed, no ROM goals or treatment plan. When questioned, Staff Q said, the resident had one appointment with OT since 08/16/17, we are waiting for the wheelchair. When asked if Resident #71 was being seen by therapy for ROM or splinting, Staff Q replied, No, is currently on a Restorative program. Failure of facility staff to provide the restorative services that the resident was assessed to require resulted in development of contractures to Resident #71's right and left elbows and left wrist. RESIDENT #18 Resident #18 admitted to the facility on [DATE]. According to the 08/17/17 Quarterly MDS, the resident had functional limitations in ROM to bilateral lower extremities, one upper extremity, and received restorative active/passive ROM on six of seven days. No splint program was provided. Review of the Impaired mobility due [MEDICAL CONDITION](stroke) . CP, with goal date of 11/07/17, listed goals of: Maintain ROM to R(ight) UE; Will remain free of any complications due to immobility including further or new contractures .; and to maintain ROM and strength to upper extremity. Interventions included: Wear R(ight) hand splint 6 hours daily; and to provide AROM to bilateral upper extremities with a one pound wt as well as AROM to bilateral lower extremities 10 repetitions, times two sets, six days a week. Review of the restorative flowsheets for the last 30 days (08/12/17 to 09/10/17) revealed, the resident had received the ROM program 20 times in 30 days and splinting only eight times in 30 days with one refusal. On 09/12/17 at 12:36 p.m., Staff P stated, it was the expectation that residents who were assessed to require splinting daily, or ROM six days a week, receive it at that frequency. When asked why this was not occurring, Staff P stated, They do not have the staff, they do not have the restorative aides to do it .I am aware they are not getting done .there are currently 123 residents on restorative programs with one, two or three programs each. Staff P indicated, at 15 minutes a program, it was not possible to complete all the programs with the current number of restorative aides. Failure of the facility to provide restorative services as the resident was assessed to require placed the resident at risk for declining ROM, progression of and/or further contracture formation. RESIDENT #86 Similar findings for Resident #86, who admitted to the facility on [DATE]. According to the 07/06/17 Quarterly MDS, the resident had functional limitation in ROM to upper and lower extremities on one side, and received no restorative services. An At risk for decline in ROM CP listed goals as: Pt (patient) will maintain ambulation with SBQC (small base quad cane); and maintain ROM BUE/LE. Review of the Restorative programs revealed, the resident was to receive AROM to the right upper extremity, to all planes as tolerated, with direction to staff to Apply splint after ROM. No frequency was included. The resident's ambulation program, which was reinstated on 08/09/17, directed staff to ambulate the resident 100-200 feet with SBQC and CGA (contact guard assistance) times 15 minutes six days a week. On 09/12/17 at 12:37 p.m. Staff P stated, Splints should be done daily . Review of the restorative flowsheets for the past 30 days (08/12/17 to 09/10/17) revealed, Resident #86 received the ambulation program 14 times in 30 days and the ROM/splint program 15 times in 30 days. On 09/12/17 at 1:00 p.m. When asked if he was aware that restorative programs were not consistently being done Staff B (Director of Nursing) stated, Yes .the plan is to have four restorative aides, but that is not always possible, sometimes we have three or two or one. We are trying to address it. RESIDENT #90 Similar findings were identified for Resident #90. Review of restorative documents for June, July, and August 2017 revealed, the resident's ROM program was not consistently provided six times a week as directed. Reference: WAC 388-97-1060(3)(d)

Based on observation, interview, and record review, the facility failed to ensure two (#1, #2) of five sample residents reviewed for accidents received adequate supervision, when staff left the residents unattended. This failure resulted in harm to the residents when they experienced falls sustaining substantial injuries. Findings include: RESIDENT # 1 According to the Admission Minimum Data Set (MDS) assessment, dated 06/02/17, Resident #1 admitted to the facility on [DATE]. She had medically disabling conditions that included dementia. This MDS identified the resident had severely impaired cognition and required extensive, 2 person physical assistance for transfers and mobility. Review of the Incident Investigation report dated 06/16/17 revealed, Resident #1 experienced a fall when she was left alone in the day room. The investigation revealed, there was no staff present at the nurse's station or in the hall way close to the day room. Review of the resident's Care Area Assessment (CAAs), dated 06/02/17, revealed the resident's room was to be kept close to the nurse's station and common areas to ensure consistent monitoring of the resident to ensure her safety. On 06/22/17, in an interview when staff Staf D, the assigned nurse was asked what consistent monitoring meant? she sated Consistent monitoring meant to always have the resident in line of sight of staff to prevent her from falling. Staff left the resident alone in the day room contraly to the Fall Care Plan which instructed staff to always be in line of site of the resident when she attempted to get up. On 06/26/17 at 4:00 p.m., in an interview, the resident's family member said she went to visit Resident #1, when she found the resident on the floor screaming for help. The resident's family member further stated that Resident #1 was alone in the day room, and there was no presence of staff at the nurse's station or in the halls at the time of the incident. On 06/22/17 at approximately 4:00 p.m., Staff D, the assigned License Nurse (LN), stated that she had left the nurse's station for a few minutes to answer another resident's call light when she heard someone calling out for help in the day room. When Staff D approached the dayroom, she noted the resident had fallen from the wheel chair and was on the floor. Staff D, acknowledged and staed that staff the resident should not have been left without any staff in her line of sight. On 06/22/17 at 11:30 a.m., in an interview, Staff G, a Certified Nurse's Aide (CNA) stated that she toileted the resident and left her in the day room and proceeded to assist other residents. The CNA further stated that she was checking on the resident occasionally, but not all the time because she had to assist other residents. The facility did not ensure staff implemented the fall prevention care plan to ensure the resident was always in the line of sight of staff when the resident was left alone which resulted in a fall and serious harm when the resident sustained [REDACTED]. RESIDENT #2 Observation on 06/22/17 at 9:00 a.m., found Resident #2 propelling himself in a wheel chair. The resident was observed with multiple sutures to the back of the head. On interview, Resident #2 stated he fell in the bathroom when attempting to transfer from the toilet to the wheel chair. According to the annual Minimum Data Set (MDS) assessment dated [DATE], Resident #2 admitted to the facility in 06/03/16 after an acute hospitalization when he experienced a stoke at home. The resident had medically disabling conditions that included left sided weakness and dementia. This MDS identified the resident had an impaired cognition and required extensive, 2 person physical assistance for most activities of daily living (ADL's), including transfers and toileting. Review of the resident's care plan, dated 03/23/16, revealed the resident required assist to toilet and anticipation of needs for ADL assist. The resident was identified as a fall risk with unsteady gait, and attempted to self-transfer. The resident's care plan directed staff not to leave the resident unattended while toileting. Review of the Incident Investigation report dated 06/16/16 revealed, Resident #2 experienced a fall in the bathroom when Staff F and staff H assisted the resident to use the toilet. The facility investigation revealed the staff members left the resident on the toilet unattended, and proceeded to assist other residents. Contrary to the Fall Prevention Care Plan, which instructed staff to wait with the resident when toileting, due to the resident's impaired cognition and attempts to self transfer. Resident#2 fell in the bathroom when he was left unattended. As a result of the fall, the resident sustained [REDACTED]. On 06/22/17 at 10:30 a.m., in an interview, Staff F, stated that he had assisted Resident #2 with the assistance of Staff H, but then both staff left Resident #2 on the toilet unattended, and proceeded to answer other residents' call lights. When Staff F returned, he found the resident had fallen in the bathroom. Staff F, further stated If I had not left the resident alone on the toilet he would not have fallen. In an interview, on 06/22/16 at approximately 10:30 a.m., Staff B, the Assistant Director of Nursing (ADNS), was asked if the facility's licensed staff had implemented the care plan to ensure the resident's safety. Staff B stated No. Staff B further stated that staff should have waited with the resident until the resident was completely finished with toileting to ensure his safety. Reference: 388-97-1060 (3) (g)

Based on interview and record review, it was determined the facility failed to prevent falls and injuries for one (#2) of three residents reviewed for recurrent accidents/ falls. Failure to provide clear and concise direction to caregivers related to the resident's need for assistance with transfers and toileting and to revise interventions after each fall resulted in Resident #2 experiencing a fall with injury and a subsequent laceration to the lower extremity during a transfer. Findings include: According to the Minimum Data Set (MDS) assessment, dated 01/25/16, Resident #2 admitted to the facility 01/19/16 after experiencing a fall with a fracture at home. She also had medically disabling conditions that included muscle weakness, cellulitis and abscess of left leg. This MDS identified the resident had moderately impaired cognition and required extensive, 2 person physical assistance for most activities of daily living (ADLs), including transfers and toileting. Subsequent MDS assessments revealed the resident had an unplanned discharged to the hospital 03/19/16, returned to the facility 03/23/16, was again discharged to the hospital 06/12/16 and returned 06/15/16. According to the 03/29/169 MDS, Resident #2 required 1 person, extensive physical assistance with toileting and 2 person, extensive physical assistance with transfers. Review of an undated Care Guide, with an admitted [DATE], revealed the resident required assist to toilet and anticipation of needs for ADL assist. The resident was identified as a fall risk and staff were directed to instruct res(ident) to call for assist for toilet needs. In addition, the Care Guide directed the resident was to be transferred with a gait belt and assistance of 1 and 2 staff. There were no directions that instructed staff when one person versus two should be used for transfers. Review of the Incident Investigation report dated 04/03/16 revealed Resident #2 experienced a fall in the bathroom when Staff C assisted her to use the toilet and left her unattended. Further review of the Incident Investigation report revealed the facility identified the resident's poor safety awareness contributed to the fall. A Rehab status [REDACTED]. There was no indication of changes to the resident's plan of care, except the therapist recommended a sign be posted in the bathroom to remind the resident to use the call light. Review of the Incident Investigation report dated 04/06/16 revealed a staff member was attempting to transfer the resident when Resident #2's legs gave out and she was lowered to the floor. The Incident Investigation report revealed the resident's weight bearing status/ability had decreased due to her medical conditions and refusal to participate in the rehabilitation program. The only recommendation following this second fall was Continue to encourage res(ident) participate in her ADLs/Transfers. There was no clarification when one or two staff should assist the resident with transfers. According to the Incident Investigation report, on 06/12/16, Resident #2 experienced another fall. The report related Resident #2 fell after Staff D assisted her onto the bedside commode, then stepped away and pulled the privacy curtain, blocking the resident from Staff D's view. Staff D gave the resident the call light and instructed her to use it when she was finished. A few minutes later, (Staff D) heard a noise and immediately pulled the curtain and noticed that the resident had fallen off the commode and hit her head. The Fall Investigation indicated the resident was forgetful (can't remember) prior to the fall. The report indicated the resident is a 1-2 person assist with transfers. The resident sustained [REDACTED]. She was transferred to the hospital, via 911, due to the head injury, where she remained for three days. Record review found Resident #2 re-admitted to the facility on [DATE] from the hospital after treatment of [REDACTED]. On 07/04/16, Resident #2 sustained a 7.5 centimeter laceration to the left leg when Staff E transferred her from the bedside commode to the bed. According to the Incident Investigation Report, the resident's left leg got caught against the edge of the bed. Review of the At Risk for Fall or Injury care plan, with a print date of 04/09/16, indicated the resident required 1 person assist for transfers. The care plan was updated, print date of 04/18/16, to indicate 1-2 person assist for transfers. Neither this care plan or the Care Guide provided any direction to caregivers to determine when the resident might require one versus two staff. Despite several falls and injuries, including one that required hospitalization , neither was updated to provide the staff with specific information required to assess how to appropriately transfer the resident safely. In an interview on 07/11/16 at approximately 4:00 p.m., Staff B, the Director of Nursing, was asked if preventative interventions were revised to ensure the resident's safety and prevent accident reoccurrences. Staff B stated No. Staff B stated that the plan of care should have been more specific to direct caregivers on safe transfers. In an interview on 07/11/16 at approximately 4:10 p.m., Staff A, Administrator, stated the care plan should have been revised and more specific to ensure the safety of the resident.

Based on observation, interview and record review the facility failed to provide adequate assistance and supervision to 1 of 2 sample residents (Resident #1) reviewed for falls with injury from a census of 131. This resulted in the resident rolling out of bed onto the floor, sustaining injuries to her eye and knee. Findings include: Observation 2/24/15 at 08:07 a.m. found Resident #1 lying on her right side wearing a hospital gown. The resident had pressured speech and starting listing multiple concerns about her care and staff. The resident's listing was disrupted by transport to a medical appointment. Record review found Resident #1 was admitted to the facility 12/19/12 with medically disabling conditions and generalized anxiety disorder. Symptoms of the anxiety disorder included food, treatment and care refusal and frequent accusations against and reporting of staff to authorities regarding perceived lack of care. Records show Resident #1 received psychiatric screening as required but declined all medications and psychiatric care. Resident Resident #1's annual minimum data set (MDS) assessment dated [DATE] identified the resident was totally dependent on 2 staff for bed mobility, transfers and toileting. A fall risk assessment completed 12/3/14 scored Resident #1's fall risk level as 16 (any score over 10 is high risk for falls). Resident #1's care plan dated 1/7/15 identified 2 staff assistance with transfers. The care plan directed assist with bed mobility. The care plan identified an every 2 hour check and change program for bowel and bladder incontinence. There was no direction regarding how many staff was to assist with bed mobility or incontinence care. Resident #1's care directive (to nursing assistants) listed 2 person assist with mechanical lift, and 2 person assistance with incontinence care. There was no date to indicate when these interventions were initiated. Facility incident report documented on 1/21/14 at 1:45 p.m., Staff A was providing incontinence care to Resident #1 in bed. After cleaning the front side, she rolled Resident #1 towards the opposite side. The resident was holding onto the edge of the mattress but rolled out of bed onto the floor. The left side of Resident #1's body hit the floor. The resident sustained [REDACTED]. Resident #1 was transported to the hospital for evaluation and received 3 sutures to the cut above her eye. Facility incident report documented follow up to the resident's fall and injury included using 2 persons assist with changing because the resident refused any other offered intervention. Follow up also included retraining certified nursing assistants (NAC) how to keep residents in the middle of the bed during repositioning and providing care in the bed. Staff A's statement dated 1/21/15 documented she performed incontinence care for Resident #1 by turning the resident from side to side and kept her in the middle of the bed. Staff A documented she had a restorative aide stand by the door while performing care. On interview 2/24/15 at 9:20 a.m. Staff A stated she could give care to Resident #1 by herself except for Resident #1's allegations against staff. Staff A then said 2 people are required to turn and care for Resident #1 due to the resident's pain during turning. Staff A stated on 1/21/15 she could not find another staff person to help her so she had someone stand by the door so there would be 2 people present (in case of accusations). Staff A stated she did not wait for a second person to help her with Resident #1's care because Resident #1 was yelling and demanding care immediately. On interview 2/24/15 at 10:55 a.m. Staff B (MDS assessment nurse) stated Resident #1 really required 1 person extensive assistance with bed mobility, transfers and toileting. Staff B stated he assessed Resident #1 as needing 2 persons on the MDS because the resident requested 2 persons for all care. Staff B said the second person didn't really have to be helping with care but was present so they can come and help for safety if Resident #1 feels she will fall. On interview 2/24/15 at 11:00 a.m. the director of nursing services (DNS) stated prior to the 1/21/15 fall out of bed, Resident #1 was a 1 person assist with toileting. The DNS stated after the fall, she added to the NAC care directive that 2 staff would assist with Resident #1's care.

The facility failed to report an acute femur fracture in a resident (Resident #1) to the doctor, resulting in a three-day delay in treatment. The delay in treatment resulted in acute blood loss as well as pain and discomfort over the three-day period. This delay placed the Resident at considerable risk for the development of other complications, which had the potential to result in loss of life. Findings include: The facility admitted Resident #1 on 02/27/2014 with a [DIAGNOSES REDACTED]. She was also receiving [MEDICATION NAME], a blood-thinning agent that placed her at high risk for bleeding. She was assessed to be at high risk for falls. On 08/10/2014 she suffered a fall in her room. The facility investigation showed she was being assisted by the nursing assistant when she started to feel weak in both legs and was lowered to the floor. She complained of pain in the left knee. The physician was called and an X-rays was ordered. The X-ray report came in two pages to the facility by fax. Page one of the report revealed no [MEDICAL CONDITION]. At the end of the first page the report states " continued on page 2. " The second page of the report showed the Resident had a displaced left femur fracture. Documentation on the report showed the nurse on the unit called the results to the physician on the same date. It was later learned that the nurse failed to read page two to the physician. A review of the nursing documentation for 08/10-08/12/2014 revealed the Resident had pain with movement of her leg and on 08/11/2014 rated her pain as 9/10 (severe pain). The records showed that she remained in bed and her intake was poor. She was " grimacing when moving or applying pressure to the BLE (bilateral lower extremities). " On 08/12/2014 at 03:36 PM, the nurse assessed the resident ' s complaint of " generalized discomfort " . She noted that the Resident had an area of " purplish bruising to her right dorsal foot and great toe " with pain when touched. An X-ray was obtained showing a fracture of her right great toe. The nurse also noted the Resident had " increased [MEDICAL CONDITION] (swelling) to her right thigh area and lower extremity " . On 08/13/2014 at 08:30 PM, the facility was notified by the lab that the Residents hematocrit (blood count) was low at 17.7 (normal is 40-50). The doctor was called and the Resident was sent to the emergency department. The hospital records showed that upon arrival to the hospital on [DATE], she was found to have a left distal femur fracture (a [MEDICAL CONDITION] bone just above the knee). She was diagnosed with [REDACTED]. She required a transfusion of 2 units of blood to correct her low blood count. In addition, her INR (measurement of clotting time) was "supratheraputic at 4.2 " (blood was taking too long to clot) which increased her blood loss. As she was on [MEDICATION NAME] to thin her blood, it was stopped and vitamin K was required to reverse the effects of the [MEDICATION NAME]. She was also given four units of fresh frozen plasma to help her blood clot. Due to the need for a blood transfusion, the Resident suffered from acute [MEDICAL CONDITION], requiring the use of [MEDICATION NAME] (a diuretic to manage excessive fluid in the body) with use of additional [MEDICATION NAME] after discharge. The facility determined that the injury was missed because the nurse who received the initial X-ray report on 08/10/2014 failed to read the entire X-ray report to the doctor over the phone. In an interview with Staff A, the Director of Nursing on 09/08/2014 at 03:30 PM, he verified the fracture was not found until the chart was reviewed on the following Monday. He stated that now the facility also requires that results be called to both the nurse on the unit and the director of nursing. There was no established mechanism to communicate results directly to the physician. Failure to establish a system to ensure lab, X-ray, and other test results are communicated to the physician in an accurate, direct and timely manner places residents at risk for delays in care and potential decline in their condition. .