Every finding on record at Washington Veteran Home-Retsil

Based on observation, interview, and record review the facility failed to ensure the safety of 2 out of 3 residents (Resident 1 and Resident 2) reviewed for the right to be free from abuse. This failure caused both Resident 1 and Resident 2 to sustain minor injuries at the hands of Resident 3 and placed other residents at risk for harm and a diminished quality of life.Findings included.An Abuse and Neglect policy, dated 12/18/2024, defined abuse as the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment of a vulnerable adult.Resident 1 admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 04/17/2026, showed Resident 1 was severely cognitively impaired and had a history of Dementia. The Behavioral Care Plan, dated 06/23/2023, showed Resident 1 had the potential to be physically abusive to staff and other residents. Resident 2 admitted to the facility on [DATE]. The admission MDS showed Resident 2 was severely cognitively impaired and had a history of Vascular Dementia (decline in thinking skills caused by conditions that block blood flow to the brain). The Behavioral Care Plan, dated 05/20/2026, showed Resident 2 had a behavioral problem related to Dementia with severe agitation. Resident 3 admitted to the facility on [DATE]. The quarterly MDS showed Resident 3 was severely cognitively impaired and had a history of Alzheimer's. The Behavioral Care Plan, dated 08/21/2025, showed Resident 3 had the potential to be physically abusive to staff and other residents. Resident 1, Resident 2, and Resident 3 all resided in the secured memory care unit in the facility.An Incident Report, dated 06/20/2026, documented at 12:25 that day, Resident 3 approached Resident 2 by the nurse's station and punched them in the left shoulder and left neck. Resident 3 then approached Resident 1 and punched them in the mouth causing their lower lip to bleed. It documented the aides were busy getting other residents ready for lunch.On 07/20/2026 at 2:50 PM, Staff B, Certified Nursing Aide, said staffing had been good, but it was still difficult to always anticipate and intervene when altercations broke out between the residents.On 07/20/2026 at 3:00 PM, Staff C, Recreation Therapist, was observed in a gathering area about 10 feet from the entrance to the memory care unit. A person from an outside agency was engaged in guiding 9 residents through breathing exercises. There were no nurses or certified nursing aides around the area. When asked what they would do if any altercation were to suddenly break out, Staff C said they would try to intervene by removing one of the residents but could not provide any care as they were not licensed. When asked if they had a radio or a phone to call for help, Staff C said the facility did not provide those at that time.On 07/20/2026 at 3:33 PM, Staff A, Director of Nursing Services, said these types of incidents were unfortunate but hard to avoid as there isn't enough staffing for each resident to have their own staff member monitoring them. Reference WAC 388-97-0640(1)

Based on observation and interviews, the facility failed to have sufficient staff to ensure residents received timely call light responses during mealtimes. This failure placed residents at risk for accidents, injuries and diminished quality of life.Findings included .Staff InterviewsObservation and interview on 05/11/2026 at 11:01 AM, showed no Certified Nursing Assistants (CNA) on the A hall. Five residents were observed in their rooms. Staff G, LPN (Licensed Practical Nurse), stated during mealtimes CNA's were assisting with feeding residents in the dining room and on the hall. Staff G stated they were responsible for responding to call lights for the duration of the mealtimes (approximately an hour). Staff G stated a resident who required two staff for care during that time were told they would need to wait until mealtime was over.During an interview on 05/11/2026 at 1:03 PM, Staff S, CNA, stated I leave my hall at 11:35 AM to assist with dining in the dining room, that leaves one CNA on the hall to pass trays and then they come to assist with feeding in the dining room. The nurse on the hall answers lights and if a resident requires cares in pairs or two-person assist during that time they tell them they will have to wait until additional staff is back on the floor which is between 12:45-1:30 PM.Observation and interview on 05/11/2026 at 12:45 PM, showed no CNA's on the B-hall. Staff R, LPN, stated, We currently don't have any CNAs on the hall they are assisting with feeding in the dining room. The CNA's leave at 11:45 AM and usually get back on the hall at 12:40 PM, I answer all the call lights during that time.During an interview on 05/11/2026 at 1:08 PM, Resident 126 stated, I have waited over an hour and a half for a brief change at times. I turned on my call light at 12:30 PM and as you can see my light is still on. I think there is usually one staff on the hall from 11:45 AM until who knows when.Resident InterviewsResident 5During an interview on 05/05/2026 at 11:04 AM, Resident 5 stated in the past two weeks the longest amount of time they had to wait for their call to be answered was a couple hours.Resident 98During an interview on 05/04/2026 at 1:11 PM, Resident 98 stated, One time I thought I was having a heart attack, and I went to the end of the hallway, and nobody was around. I even called 911 and they arrived before staff responded to my call light. Sometimes the nurse on my hall has to take care of another hall, they are short staffed.Resident 105During an interview on 05/05/2026 at 10:29 AM, Resident 105 stated, During meals it can take staff some time to respond to my call light.Resident 135During an interview on 05/04/2026 at 3:11 PM, Resident 135 stated, I have waited an hour many times, I got back from lunch put on my call light and waited an hour. There is only one person on the hallway during mealtimes.Resident 4During an interview on 05/04/2026 at 2:04 PM, Resident 4 stated, I have waited over an hour for my call light to be answered on more than one occasion because they were waiting for staff from another floor or the staff were in training. JustDuring an interview on 05/11/2026 at 4:57 PM Staff B, Director of Nursing, stated during mealtimes the licensed nurse (LN) was the only member of staff on the halls and was responsible for answering call lights. Staff B stated CNA's were assisting with feeding in the dining rooms during mealtimes. Staff B stated the expectation was if a resident required 2 members of staff during mealtime the LN would go to the dining room to request assistance from a CNA.Reference WAC 388-97-1080(1), 1090(1).

Based on observation, interview and record review, the facility failed to maintain proper refrigerator, freezer and dishwasher temperatures logs for 1 of 1 kitchen and 4 of 4 serveries (AC, ABCD, EG, EFGH serveries) and prevent contamination during meal preparation services for 1 of 1 serveries (AC) reviewed for food service safety. The failure to maintain documented refrigerator/freezer and dishwasher temperature logs and prevent cross contamination placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life. Findings included .Cross contaminationOn 05/06/2026 at 12:00 PM, Staff J, Lead Food Services worker, started plating lunch meals in the AC servery with gloves on. Staff J reviewed the resident's meal card tickets, that were wrapped in a plastic sleeve, before they grabbed a plate warmer and a plate. Staff J placed the hot food required by meal type on the plate and then placed the meal card on the tray and then retrieved the required items like pea salad cup, ambrosia cup or requested meal items. Staff J then would pass the meal tray to the Certified Nursing Assistant standing on the other side of the steam table and proceed with the next tray. On 05/06/2026 at 12:04 PM, Staff J, with a gloved hand, touched the pork to cut it and then wiped their hand on the rag sitting on the steam tray table next to them and continued to dish lunch meal plates. On 05/06/2026 at 12:06 PM, Staff J, with a gloved hand, touched the pork to cut it and then wiped their hand on the rag sitting on the steam tray table. Staff J plated multiple more plates before changing their gloves at 12:07 PM and started dishing plates again. On 05/06/2026 at 12:08 PM, Staff J, with a gloved hand, touched the pureed vegetables and mashed potatoes. Staff J immediately donned (put on) a new pair of gloves. On 05/06/2026 at 12:10 PM, the alternative meal, liver and onions, arrived at the servery. Staff J took the temperature of the liver and onions (touching the thermometer and did not change their gloves) and continued to dish lunch meal plates. On 05/06/2026 at 12:14 PM, Staff J, donned a new pair of gloves, touched the vegetarian patty to cut it, and continued to dish more plates. On 05/06/2026 at 12:16 PM Staff J, wiped down the steam table countertop with the rag, that they had been using to wipe their hand with after touching the meat/protein. Staff J was still wearing the same gloves from previous meat touching and continued to dish lunch meal trays. On 05/06/2026 at 12:24 PM, Staff J, with gloved hand, touched a vegetarian hotdog to cut it. Staff J then wiped their gloved hand on rag (used previously to wipe down countertop). Staff J was still wearing the same gloves from previous meat touching and continued to dish lunch meal trays. On 05/06/2026 at 12:26 PM, Staff J, with a gloved hand, touched the pork on the plate, to move it back on the plate. On 05/06/2026 at 12:27 PM, Staff J, with a gloved hand, touched the pork to cut it and then wiped their hand on the same rag sitting on the steam tray table. Temperature LogsOn 05/06/2026, Staff M, Food Services Manager, provided a stack of refrigerator, freezer and dishwasher logs about 5-6 inches tall. The top two pieces of paper were reviewed: AC Refrigerator/Freezer temp log and AC Dish Machine Temperature Log March 2026 AC Refrigerator/Freezer Temperature Log was missing entries on the 6th, 7th, 8th, 9th, 20th, 21st, 22nd, 27th, 28th-no temp recorded, only an X marked. March 2026 AC Dish Machine Temperature Log was missing entries on the 4th dinner, 5th dinner, 6th lunch and dinner, 7th lunch and dinner, 10th dinner, 11th dinner, 12th breakfast, lunch and dinner, 14th lunch and dinner, 17th, lunch and dinner, 18th dinner, 19th dinner 20th lunch, 21st lunch and dinner, 22nd breakfast and lunch, 23rd dinner, 24th dinner, 25th lunch and dinner, 27th breakfast and lunch. On 05/06/2026 at 1:15 PM, when asked the process for missing dates on temperature logs, Staff K, Food Services Manager, with Staff L, Administrative Assistant and Staff M, Food Services Manager present, said if there were missing dates, they would contact the staff working that day and question them why it was not filled out. Reviewing March 2026 AC Refrigerator/Freezer Temperature Log and March 2026 AC Dish Machine Temperature, all three staff members acknowledged the missing entries on the March 2026 refrigerator/freezer and dishwasher temperature logs and said the missing entries should have been filled in. When asked if touching food was allowed, Staff K said food was not supposed to be touched with bare hands, staff should be using gloves or utensils for Ready to Eat foods. When observations were explained about Staff J, Lead Food Services worker, touching the food, cleaning supplies (dirty rag) and environmental surfaces (meal ticket cards, thermometer, refrigerators), Staff K, Staff L and Staff M said Staff J should not have touched the food, they should not have touched the food (purposely repeated themselves), the cleaning rag or other environmental surfaces. Staff K said Staff J should have changed their gloves, washed their hands before touching anything else and should not have used the same rag. Reference WAC 388-97 -1100 (3), -2980

Based on record review and interview, the facility failed to ensure psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) included adverse side effects and target behaviors were thoroughly documented and monitored, that as needed psychotropic medications limited to 14 days was reassessed, and Abnormal Involuntary Movement Scale (AIMS, a standardized, clinician-administered assessment designed to observe, quantify, and track involuntary movements in patients, especially those taking long-term antipsychotic medications) testing was completed within required timeframes for 4 of 5 sampled residents (Resident 19, 2, 121 & 13) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medication usage, increase in side effects without interventions, and a diminished quality of life. Findings included.Resident 19 Resident 19 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbances and anxiety (the specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss), bipolar disorder (a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes), and generalized anxiety (intense, excessive and persistent worry or fear). The Quarterly Minimum Data Set (MDS, an assessment tool) dated 03/20/2026, documented Resident 19 was unable to complete interviews, was severely cognitively impaired and relayed on staff for some cares. A physician's order, dated 07/04/2025, documented Resident 19 was prescribed quetiapine (an antipsychotic) for bipolar with psychosis daily at bedtime. A physician's order, dated 11/04/2025, documented Resident 19 was prescribed sertraline (an antidepressant) for depression (persistent feelings of sadness and loss of interest) daily in the morning. Resident 19 had no diagnoses of depression. A physician's order, dated 02/11/2026, documented Resident 19 was prescribed lorazepam (an antianxiety) every 4 hours as needed (PRN) for terminal anxiety for 90 days. A physician's order, dated 02/04/2026, documented Resident 19 was ordered to have an Abnormal Involuntary Movement Scale (AIMS, a standardized, clinician-administered assessment designed to observe, quantify, and track involuntary movements in patients, especially those taking long-term antipsychotic medications) test completed on the 16th of the month. Resident 19's Mood State care plan, dated 03/03/2025, documented Resident had one target behavior listed under Behavior Tracking for quetiapine; paranoid statements (no details provided) and one target behavior under Behavior Tracking for sertraline; tearfulness (no other details provided). AIMS testing Review of the electronic health record (EHR), on 05/05/2026, showed no documentation an AIMS test was completed on 02/16/2026 or thereafter. Psychotropic medication over 14 days An encounter (physician's) note, dated 02/12/2026, documented Resident 19 was on comfort focused care, after they returned to the hospital with a diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI, where a coronary artery is partially blocked, leading to reduced oxygen supply to the heart muscle). The encounter note documented to start comfort care orders including pain medication and antianxiety as needed, discontinue nonessential mediations. The EHR showed no 14-day reassessment for the antianxiety medication. Monitoring of side effects and target behaviors Review of the EHR on 05/05/2026, showed no documentation of side effect monitoring for the antipsychotic, antidepressant or the antianxiety PRN. The EHR also showed no documentation of target behaviors for the antianxiety medication. On 05/08/2026 at 9:08 AM, Staff G, Licensed Practical Nurse (LPN), said Resident 19 was mostly nonverbal, needed cueing for some tasks and liked to be independent with care. Staff G said Resident 19 originally had a lot of behaviors including exit seeking, yelling out and crying, but Resident 19 had a decrease in all his behaviors, and they have not seen any of those behaviors in about 3-4 months. Staff G confirmed Resident 19's behaviors had decreased enough last month the facility assessed the resident no longer require a wander guard (a wearable or system-based solutions designed to prevent wandering and elopement in residents with dementia or cognitive impairments) and it was removed. On 05/08/2026 at 9:21 AM, Staff H, Registered Nurse/Neighborhood Coordinator, said in order to administer any psychotropic medication the facility must obtain a diagnosis (justification for use), consent and an order from the physician. The facility must also monitor target behaviors and side effects of the medication(s). Staff H reviewed the EHR and confirmed there was no side effect monitoring for any of the antipsychotic or antidepressant and no side effect or target behaviors for the antianxiety medication. Staff H said there should have been side effect monitoring and target behaviors for all the psychotropic medications. Staff reviewed Resident 19's Medication Administration Record (MAR) and said the target behaviors were listed there and under tasks. Staff H reviewed the MAR and the tasks and confirmed only one target behavior was associated with the antipsychotic (paranoid statements) and the antidepressant (tearfulness). When asked if tearfulness met the criteria for justification on use for an antidepressant, Staff H could not answer. Staff H said there should have been more target behaviors listed for Resident 19 and it was undetermined what target behavior correlated to what medication, it should have been more specific. Staff H was asked to find the AIMS test completed in February 2026. Staff H was unable to locate the AIMS test in February 2026 and confirmed no AIMS test had been completed since. Staff H said the AIMS should have been completed. When asked about psychotropic medication as a PRN, Staff H said, Resident 19 was located on another hall, he had experienced a lot of behavior issues and then was transferred to the memory care unit for a higher level of care. Staff H said earlier this year, Resident 19 received a diagnosis of cardiac disease and started displaying behaviors that included anxiousness, pacing, nervousness, facial grimacing/concerns, tearfulness and crying out (none of these were listed as target behaviors on the MAR or care plan, except tearfulness). When Resident 19 was diagnosed with the cardiac disease the physician placed Resident 19 on comfort care and ordered antianxiety medication. Staff H said PRN psychotropic medications were to be prescribed for 14 days and then reassessed for continual use. Staff H confirmed the medication was prescribed for 90 days, no 14-day reassessment was completed. Staff H said the antianxiety should have been assessed if needed. Staff H said over the past few months Resident 19 had shown a decrease in target behaviors. On 05/08/2026 at 12:22 PM, when asked to locate the side effect and target behavior monitoring orders, Staff B, Director of Nursing Services (DNS), confirmed there was no side effect monitoring for any of the psychotropic medications, no target behaviors listed for the antianxiety medication and said there should have been. Staff B reviewed the MAR, tasks and care plan for target behaviors related to the antipsychotic and antidepressant. Staff said there was one target behavior listed for each medication, antipsychotic-paranoid statements, and the antidepressant -tearfulness. When asked if tearfulness met the criteria for justification on use for an antidepressant, Staff B stated, I see where you are going with this and acknowledged that all of Resident 19's associated target behaviors should have been listed under each medication type on the MAR and on the care plan and it was not person centered. Staff B was asked to locate the AIMS test completed in February 2026. Staff B was unable to locate the AIMS test in February 2026, confirmed no AIMS test had been completed since and said the AIMS should have been completed. When asked about PRN psychotropic medications, Staff B said if psychotropic medication was being used PRN it required a 14-day order, then to be reassessed by the provider for continual use. If the medication was extended past the original 14 days, it needed justification for use. Staff B reviewed the antianxiety medication ordered (for comfort care) and confirmed there was no original 14-day order and the provider had not reassessed the need for the medication, only prescribed the 90-day PRN. When it was explained that Resident 19 had a decrease in target behaviors and never received a dose of the antianxiety medication, Staff B said it should have been reassessed. Resident 2 Resident 2 was admitted on [DATE] with diagnoses that included major depressive disorder, unspecified dementia, unspecified severity with agitation, anxiety disorder and unspecified psychosis not due to substance or known, physiological conditions (a diagnosis given when a person exhibits clear psychotic symptoms, such as hallucinations or delusions, but the symptoms do not fully match any specific psychotic disorder). The Quarterly MDS, dated [DATE], documented Resident 2 was severely cognitively impaired and able to make needs known. A physician's order, dated 02/18/2026, documented Resident 2 was prescribed Lorazepam every 4 hours PRN for terminal anxiety for 90 days. On 05/08/2026 at 9:21 AM, Staff H, Registered Nurse/Neighborhood Coordinator, reviewed the EHR and confirmed there was no side effect monitoring or target behavior for the antianxiety said there should have been side effect monitoring and target behaviors. On 05/08/2026 at 12:22 PM, when it was explained Resident 2 had been prescribed an anxiety medication and there was no side effect monitoring or target behaviors, Staff B, DNS, said there should have been. Staff B also confirmed there was no original 14-day order, and the provider had not reassessed the need for the medication, only prescribed the 90-day PRN. Resident 121 Resident 121 was admitted to the facility on [DATE] with diagnoses of major depressive disorder and anxiety disorder. The Quarterly MDS, dated [DATE], documented Resident 121 was cognitively intact. Resident 121 had two orders for psychotropic medications as follows: 1) Buspirone (anti-anxiety medication) two times daily for anxiety, dated 10/29/2025.2) Fluoxetine (antidepressant medication) every morning for Major Depressive Disorder (MDD), dated 10/29/2025. Review of the MAR and the Treatment Administration Record (TAR) from 04/01/2026 through 04/30/2026 and 05/01/2026 through 05/05/2026, showed that adverse side effects were not monitored for the medication Buspirone. Review of Resident 121's care plan, initiated 10/29/2025, listed target behaviors as 1. Psychomotor agitation (restlessness, fidgetiness, calling out, etc.) 2. Self-report or observed sad affect. The care plan did not differentiate which of the target behaviors were to be observed for which medication prescribed. Review of the Certified Nursing Assistant task documentation showed there were two different behavior monitors where nursing assistant staff could document behaviors exhibited by Resident 121. One monitor was for psychomotor agitation (restlessness, fidgetiness, calling out, etc.). The second monitor was for self-report or observed sad affect. The documentation did not specify which target behavior was being monitored for which medication. On 05/08/2026 at 10:57 AM, Staff B, DNS, when asked their expectations for identifying target behaviors for psychotropic medications said that they were to be given for behaviors and staff would be monitoring for those behaviors. Staff B said behavior monitoring should be in place for each psychotropic medication. After reviewing the two medications Resident 121 was prescribed, Buspirone for anxiety and fluoxetine for MDD, Staff B was asked what specific target behaviors were being monitored and for which medication. Staff B said the target behaviors were not specific to the medications and the target behaviors overlapped for Resident 121. When asked how it would be determined if the medications were necessary if the target behaviors were not specific to the medications, Staff B said I see what you are going with that and said the EHR was not set up to differentiate between the specific medications and the target behaviors. When asked which medication sad affect was treating Staff B said it had not been indicated. When asked if documented target behavior of sad affect met criteria for MDD, Staff B said it was part of Resident 121's symptoms, Staff B did not elaborate on what other symptoms of MDD Resident 121 displayed. During this same interview Staff B said she expected adverse side effects to be monitored for psychoactive medications. When asked if adverse side effect monitoring was in place for Resident 121's Buspirone, Staff B looked in the EHR and said she did not see adverse side effect monitoring in place, and it should have been. Resident 13 Resident 13 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment, diagnoses of dementia with behavioral disturbance, anxiety disorder and depression, received antipsychotic and antianxiety medication, and there was physician documentation, dated 02/25/2026, that a gradual dose reduction (GDR) of the resident's antipsychotic medication was contraindicated. Record review showed Resident 13 had orders for the following psychotropic medications.a) Quetiapine (an antipsychotic medication) which the resident received from 09/19/2025- 03/16/2026 for a diagnosis of psychosis with hallucinations. On 03/17/2026 the diagnosis for the use of quetiapine was changed to dementia with behavioral with other behavioral disturbance.b) Buspirone (an antianxiety medication) initiated on 03/03/2025 for anxiety.c) Lorazepam (an antianxiety medication) initiated on 03/20/2025 for advanced dementia with severe agitation. Review of Resident 13's EHR showed an AIMS assessment was completed on 02/16/2026. There was no documentation to show staff completed a baseline AIMS assessment at the time Resident 13 was started on quetiapine (09/19/2025). In an interview on 05/11/2026 at 9:58 AM, Staff B, DNS, said an baseline AIMS assessment should have been completed when Resident 13's was started on quetiapine. When asked if one was completed Staff B stated, No. A Behavioral Symptom care plan, revised 01/22/2026, showed Resident 13 had diagnoses of dementia, depression, post-traumatic stress disorder (PTSD) and anxiety disorder. It documented a history of the resident using abusive language, such as yelling, screaming and threatening others, as well as a history of physical behaviors towards staff that included kicking, hitting, pushing and grabbing. Interventions included administering anti-anxiety medication for the target behaviors (TB) of restlessness, agitation, and aggression (verbal or physical), non-pharmacological interventions/approaches included: 1. Ensure safety of the resident and peers, creating space if needed and reapproaching after a few minutes. 2. Identify possible needs (pain, toileting, hunger, discomfort, overstimulation) and offer assistance. 3. Provide reassurance and supportive presence, allowing the resident to talk or express distress as needed. 4. Listen calmly and validate feelings, helping reduce fear, confusion, or frustration. 5. If agitation escalates, step back briefly to reduce stimulation and allow the resident space. 6. Reapproach calmly after a short interval, using reassurance and simple communication. A Mood care plan, revised 04/07/2026, documented the resident had issues with mood secondary to diagnoses of dementia, depression and PTSD which manifested as sleep challenges. A goal of will continue to function at current level with no signs and symptoms of depression was identified and the interventions were to encourage the resident to express feelings, provide support and reassurance, and perform psychotropic medication reviews per facility policy. Resident 13 comprehensive care plan did not identify or address the resident's psychosis, hallucinations, use of antipsychotic medication, or indicate what behaviors the quetiapine was initiated to target. Review of the March, April and May 2026 MAR showed there was no identification or monitoring of target behaviors or adverse side effects related to Resident 13's use of quetiapine, buspirone or lorazepam. During an interview on 05/11/2026 at 10:30 AM, when asked for documentation to show nurses were monitoring for adverse side effects associated with the use of lorazepam, buspirone and quetiapine Staff B, DNS, said no, not that's documented. When asked if the specific TBs each medication was initiated to treat, had been identified and were being monitored Staff B indicated agitation was a TB for all three medications and behavior monitoring was done by nurse aides in Point of Care (POC, a computer program where nurse aides chart). Review of Resident 13's behavior monitor in POC for May 2026 showed the following behavior monitors were in place.a) TB 1- Notice 1st signs: agitation &/or aggression: verbal or physical.b) TB 2- Upset, pacing, accusatory to staff.c) TB 3- Anxious mood exhibited by poor safety awareness (interacting w/ others) -Aggressive speech/ actions.d) TB 4- Resident pushing items: moves chairs, tries to push (fellow residents) in wheelchairs, or carts.e) TB 5- Target Behaviors: 1. Restlessness 2. Agitation (verbal or physical) 3. Aggression 4. Worsening symptoms in late afternoon or evening.f) TB 6- Notice 1st signs: pacing &/or irritability. The behavior monitors did not identify what TBs were associated with which medications. During an interview on 05/11/2026 at 12:30 PM, Staff B, DNS acknowledged staff did not identify specific TBs for the use of each psychotropic medication. When asked how the facility could assess the effectiveness of each medication and the need for continued use if all three psychotropic medications had the same TBs Staff B, said I see your point. Gradual Dose ReductionsReview of Resident 13's falls care plan, revised 01/22/2026, documented 4/5/26 Intervention- failed GDR will be placed back on prior dosage. The care plan did not indicate what medication had a failed GDR, or how it was determined (e.g. increased TB behaviors etc.) A 03/16/2026 provider note documented Gradual dose reduction of the patient's antipsychotic medication was recommended or ordered during this visit.Decrease Seroquel 12.5 mg to once daily for paranoia and agitation 2/2 [secondary to] dementia. A 04/03/2026 provider note documented, Decreased Seroquel 12.5 mg to once daily for paranoia and agitation 2/2 dementia, tolerating well, continue current dose and follow up in 2 weeks. A 04/06/2026 provider note documented, Seen and examined per nurse supervisor request for potentially failed Seroquel GDR. He has advanced dementia and does not answer questions appropriately. Nurse manager reports he has been extremely agitated and ramming his wheelchair into things, combative with care, and hard to redirect, all since Seroquel dose reduction. She does not believe he is hallucinating but hard to tell. He's calm at the moment, but I have seen him easily agitated and somewhat confrontational at times. The provider wrote an order to increase Resident 13's quetiapine to 25 mg every afternoon for paranoia and agitation secondary to dementia. Review of Resident 13's EHR showed no documentation to support the resident had demonstrated any increased agitation, combativeness, or difficulty being redirected. Nor was there documentation to support the resident had rammed his wheelchair into anything since 03/16/2026, when the quetiapine dose was reduced. Review of the progress notes from 03/16/2026 - 04/05/2026 showed no behaviors were documented. During an interview on 05/11/2026 at 4:12 PM, when asked if there was any documentation to support Resident 13 demonstrated increased behaviors or any behaviors at all after the GDR of the quetiapine on 03/16/2026 to support the determination that it was a failed GDR Staff B, DNS, indicated she saw one behavior documented in a progress note. Staff B said the documentation Does not support a failed GDR. Reference WAC 388-97-0620 (1)(a)

Based on interview and record review, the facility failed to develop and implement a system that ensured copies of advanced directives (written instruction, such as a living will or durable power of attorney for health care) were requested from residents who indicated they had one, and/or to provide information and assistance to residents who expressed an interest in formulating one for 6 of 6 residents (Resident 105, 121, 135, 148, 10 & 232) reviewed for advanced directives. These failures placed residents at risk of not having their healthcare choices honored and/or detracted from residents' ability to have their healthcare preferences known. Findings included .Resident 105Resident 105 was admitted to the facility on [DATE]. Review of the resident's admission agreement showed they had a durable power of attorney (DPOA) for healthcare but had not provided a copy to the facility.Review of the electronic health record (EHR) showed there was not a copy of Resident 105's DPOA for healthcare, nor was there documentation of staff attempts to obtain a copy. Resident 121Resident 121 was admitted to the facility on [DATE]. Review of the resident's admission agreement showed the resident did not have an advanced directive but wanted further information and/or assistance formulating one. Review of the EHR showed there was no documentation that staff provided the resident with further information about advanced directives or assisted the resident with the process of formulating one.Resident 135Resident 135 was admitted to the facility on [DATE]. Review of the resident's admission agreement showed the resident did not have an advanced directive but wanted further information and/or assistance with formulating one. Review of the EHR showed there was no documentation that staff provided the resident with further information about advanced directives or assisted the resident with the process of formulating one.Resident 148Resident 148 was admitted to the facility on [DATE]. Review of the resident's admission agreement showed they had a DPOA for healthcare but had not provided a copy to the facility.Review of the EHR showed there was not a copy of Resident 105's DPOA for healthcare, nor was there documentation to show staff attempted to obtain a copy. Resident 10Resident 10 was admitted to the facility on [DATE]. Review of the resident's admission agreement showed they did not have an advanced directive but wanted more information and/or assistance with formulating one. Review of the EHR showed there was no documentation that staff provided the resident with further information about advanced directives or assisted the resident with the process of formulating one.Resident 232Resident 232 was admitted to the facility on [DATE]. Review of the resident's admission agreement showed the resident had a durable power of attorney (DPOA) for healthcare but had not provided a copy to the facility.Review of the EHR showed there was not a copy of Resident 105's DPOA for healthcare, nor was there documentation of staff attempts to obtain a copy. On 05/07/2026 at 8:20 AM, Staff A, Administrator, and Staff B, Director of Nursing Services, were asked to provide documentation of staff attempts to obtain copies residents' advanced directives who indicated they had them, and/or documentation showing facility staff provided further information about advanced directives and/or assisted with the process to formulate one for the above identified residents who had requested it. On 05/07/2026 at 10:53 AM, Staff A, Administrator, confirmed the above requested documentation was not present in the residents' records. Staff A explained that there had been some confusion with the advanced directive process and indicated facility staff social services were following up with the identified residents who had a DPOA for healthcare to obtain a copy and were in the process of providing further information about advanced directives and/or assistance with formulating one for the above residents that had requested it.Reference WAC 388-97-0300(1)(b)(3)(a)-(c)

Based on interview and record review, the facility failed to ensure all residents with personal funds accounts had access to their accounts after business hours and on the weekends for 7 of 10 sampled residents (Resident 121, 135,15, 3, 232, 4 & 14) reviewed for personal funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life. Findings included.On 05/05/2026 at 12:34 PM, Resident 121 said I can get money whenever I want except Saturday and Sunday. The doors were locked on the weekends.On 05/04/2026 at 3:08 PM, Resident 135 said they were told they could withdraw money on the weekend and get up to $100 by going to the front desk, but no one's ever there on the weekend so you really can't and during the week you could only withdraw money before 3 pm.On 05/04/2026 at 10:53 AM, Resident 15 said they could withdraw their money only during normal business hours because there was no one in the administrative area to withdraw money at night. Resident 15 said, they don't need the money at night and would withdraw earlier if they think they would need money after hours.On 05/05/2026 at 10:27 AM, Resident 3 said they could only access their money Monday through Friday from 8 AM to 4 PM and when asked about access to their money on Saturday and Sunday, Resident 3 said the office door was closed and there was no access.On 05/04/2026 at 2:20 PM, Resident 232 said, I can plan ahead if I need money on the weekend.On 05/04/2026 at 2:24 PM, Resident 4 said they could not access their money on Saturday or Sunday because the cashier doesn't work weekends and if they go up there on a Friday night, they could not get money after 3:00 PM. On 05/04/2026 at 11:26 AM, Resident 14 said they could only withdraw money during business hours, and they could plan ahead if they needed money on the weekends. On 05/07/2026 at 6:10 AM, Staff N, Registered Nurse 2, was asked what their process was when a resident came to them on their shift at night and wanted to withdraw money from their personal fund account and Staff N said, we don't have access. We used to have access but now lately we don't. Staff N said they would have to inquire more about it and would advise the resident to talk to social work to withdraw money.On 05/07/2026 at 6:09 AM, Staff O, Licensed Practical Nurse 2, was also asked the procedure to withdraw money out of a trust account at night and they said, We don't have access on night shift [to the trust money]. I would tell them to wait until morning when the office opens. Unfortunately, I am pretty new still and I have not had that happen.On 05/07/2026 at 9:12 AM, Staff P, Administrative Assistant 5, said the evening and night shift supervisors were aware of the process for accessing resident personal funds after hours. Staff P said we need to do more training. The staff needed to know how and where the funds were kept and how to check to see if a resident has money in their account. Staff P said there were new nurses and they would coordinate with the Director of Nursing Services to train the new staff, so they were aware of the process.On 05/11/2026 at 9:09 AM, Staff A, Administrator, said the residents should have access to their funds after hours and on weekends. Staff A said the evening and night shift supervisors were aware of the process and he wanted to make sure all the staff know what to do. Staff A said they have already provided staff training, on the evening and night shifts, to make sure the residents have access to their funds if they requested it.Reference WAC 388-97-0340(1)(2)(3)

Based on interview and record review, the facility failed to provide bowel care in accordance with the facility's bowel protocol for 3 of 8 residents (Resident 3, 8 & 29) reviewed for bowel management. This failure placed residents at risk for nausea/vomiting, abdominal pain/discomfort, decreased appetite, and other negative health outcomes associated with untreated constipation.Findings included . Resident 3 Resident 3 was admitted to the facility on [DATE]. Review of the Quarterly minimum data set (MDS, an assessment tool), dated 02/11/2026, showed the resident was cognitively intact. On 05/05/2026 at 10:47 AM, Resident 3 said he had been struggling with constipation. Review of the April 2026 bowel record showed Resident 3 went from 04/15/2026 - 04/21/2026 (7 days), without a bowel movement (BM). Record review showed Resident 3 had the following as needed bowel care orders:a) Miralax as needed, for no BM for 48 hours, dated 02/25/2022.b) Milk of Magnesia once daily as needed for constipation, dated 01/04/2026c) Bisacodyl- administer two tablets once daily, as needed, for constipation not relieved by milk of magnesia, dated 03/20/2025.d) Bisacodyl Suppository every 24 hours, as needed for constipation not relieved by milk of magnesia, dated 02/25/2022.e) Mineral Oil Enema administer every 24 hours, as needed for Constipation, dated 02/25/2022. Review of the April 2026 Medication Administration Record (MAR) showed Resident 3 was not provided as needed bowel medication until 04/20/2026, the sixth day without a BM. On 05/11/2026 at 4:44 PM, when asked if Resident 3 was provided as needed bowel care in accordance with provider orders or the facility's bowel protocol Staff B, Director of Nursing Services (DNS), stated, No. Resident 8Resident 8 was admitted to the facility on [DATE]. A review of the Annual MDS, dated 03/092026, showed the Resident 8 was cognitively intact. A review of Resident 8's electronic medical record showed the following orders: a) Lactulose Solution given every 24 hours as needed for constipation Once daily dated 04/07/2026 b) Lactulose Solution given every 12 hours as needed for constipation dated 09/12/2025c) Senna Tablet Give 2 tablet by mouth at bedtime for prevent constipation dated 03/05/2025d) Docusate Sodium Give 1 capsule by mouth three times a day for Bowel Management ordered dated 03/14/2025e) Milk of Magnesia Suspension Give 30 ml by mouth as needed for constipation once daily dated 03/12/2025f) Bisacodyl Give 2 tablet by mouth as needed for constipation not relieved by milk of magnesia. Once daily dated 03/21/2025 g) MiraLax Oral Powder Give 1 scoop by mouth in the morning for constipation dated 07/11/2025h) Bisacodyl Suppository give 1 suppository rectally as needed if no Bowel movement after Miralax (notify provider if no results from suppository) dated 07/06/2025 A review of Resident 8's bowel record from 04/07/2026 - 05/05/2026 showed no bowel movement from 04/12/2026 – 04/16/2026 (5 days). A review of April 2026 MAR showed Resident 8 refused:-Miralax on 04/13/2026-Senna on 04/12/2026-Docusate sodium on the evening of 04/12/2026 And no other as needed bowel medications were documented as given or refused on the April 2026 MAR during that time peiod. On 05/08/2026 at 9:40 AM, Staff Q, Registered Nurse 3, said they would liked to see more documentation on the medication refusals, specifically that the staff went back to check in and offer again to Resident 8. Staff Q said Resident 8 had the right to refuse. On 05/11/2026 at 9:29 AM, Staff B, DNS, said the nursing staff should have initiated the bowel protocol on the 15th. Staff B said after 72 hours of no Bowel Movement the Bowel Protocol should have been initiated. Resident 29 Review of the electronic health record (EHR) showed Resident 29 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), depression (mood disorder) and constipation. Resident 29 was able to make needs known. Review of Resident 29's task section in the EHR for bowel and bladder elimination showed no BM on 04/22/2026, 04/23/2026, 04/24/2026, 04/25/2026, 04/26/2026, 04/27/2026 and 04/28/2026. The EHR showed documentation that the resident was administered Milk of Magnesia Suspension, Dulcolax Suppository (Bisacodyl) and MiraLAX on 04/29/2026. During an interview on 05/11/2026 at 9:41 AM, Staff B, DNS, stated the expectation was that the facility's bowel protocol should have been implemented within the stated time frame and documented whenever a resident had no BM for 3 days. Reference WAC 388-97-1060(1) .

Based on interview and record review, the facility failed to provide timely incontinent care for 1 of 2 residents (Resident 11) reviewed for activities of daily living (ADL) for dependent residents. This failure placed dependent residents at risk for skin breakdown, poor hygiene and diminished quality of life.Findings included .Review of the electronic health record (EHR) showed Resident 11 admitted to the facility on [DATE] with diagnoses that included overactive bladder, depression (mood disorder), chronic right heart failure and hemiplegia and hemiparesis affecting right side (partial loss of strength and near complete loss of voluntary movement). Resident 11 was dependent on staff for toileting hygiene.During an interview on 05/04/2026 at 12:02 PM, Resident 11 stated they were often left in a soiled (feces and urine) brief for long periods of time during mealtimes when they became a Hoyer transfer requiring two staff. Resident 11 stated they had developed sore areas that were painful. Resident 11 stated they purchased their own wipes for facility staff to use because washcloths had become too painful.Observation and interview on 05/11/2026 at 11:01 AM, showed no Certified Nursing Assistants (CNA) on the A hall. Five residents were observed in their rooms. Staff G, LPN (Licensed Practical Nurse), stated during mealtimes CNA's were assisting with feeding residents in the dining room and on the hall. Staff G stated they were responsible for responding to call lights for the duration of the mealtimes (approximately an hour). Staff G stated a resident who required two staff for care during that time were told they would need to wait until mealtime was over.During an interview on 05/11/2026 at 1:03 PM, Staff S, CNA, stated, I leave my hall at 11:35 AM to assist with dining in the dining room, that leaves one CNA on the hall to pass trays and then they come to assist with feeding in the dining room. The nurse on the hall answers call lights and if a resident requires cares in pairs or two-person assistance during that time they inform the resident they will have to wait until additional staff were back on the hall which is between 12:45-1:30 PM.Review of a Revision to Care Plan Order, dated 04/02/2026, signed by Physical Therapy showed, Resident 11 was downgraded from using a sit to stand to a Hoyer lift for transfers from bed to chair.Review of the providers orders showed Resident 11 was prescribed Ozempic (a medication used for blood sugar regulation) on 03/26/2026 which has a common side effect of diarrhea.Review of Weekly Skin assessment dated [DATE] showed, no open areas or redness.Review of Weekly Skin assessment dated [DATE] showed, no open areas or redness.Review of Weekly Skin assessments dated 04/11/2026, 04/18/2026, 04/25/2026, 05/02/2026 showed, Multiple red rashes on buttocks, inner thighs, and peri-area. No open areas noted. Applied Calmoseptine + Vit [vitamin] A&D ointment.Review of Weekly Skin assessments dated 05/09/2026 showed, On-going with multiple red rashes on buttocks, inner thighs, and peri-area. No open areas noted. Dimethicone applied as ordered. On-going with discoloration bilaterally, redness/rash on upper thighs.Review of a progress note, dated 05/09/2026, showed, Resident entire peri area front and back, inner thigh and abdominal folds with red rashes and sensitive to touch, peri area, vaginal area, labia very red raw, painful to touch when powder and cream applied. Right inner thigh with open area 2cm [centimeters] long x 0.3cm.Review of the EHR showed on 05/09/2029, Resident 11 requested to go to the emergency room for increased pain, burning, itching and rash to vaginal area. Resident 11 was diagnosed with a urinary tract infection and prescribed antibiotics for ten days.During an interview on 05/11/2026 at 4:57 PM, Staff B, Director of Nursing Services, stated during mealtimes the licensed nurse (LN) was the only member of staff on the hall and was responsible for answering call lights. Staff B stated the expectation was if a resident required two members of staff during mealtime the LN would go to the dining room to request assistance from a CNA.Reference WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 3 residents (Residents 4) reviewed for limited range of motion. Facility nurses demonstrated a pattern of falsely documenting the application of bilateral wrist splints, that were not applied. This failure resulted in a resident losing trust in assigned nursing staff and placed residents at risk of contracture formation/progression, loss of independence and/or increased dependence on staff and a diminished quality of life. Findings included .Resident 4 Resident 4 was admitted to the facility on [DATE]. Record review showed a provider order, dated 09/17/2024, that directed staff to assist with the application of Resident 4's bilateral wrist splints every morning and to assist with the removal of the wrist splints at bedtime.On 05/04/2026 at 2:08 PM, 05/06/2026 at 10:48 AM and 05/07/2026 at 11:58 AM, Resident 4 was observed without wrist splints in place.On 05/07/2026 at 12:00 PM, when asked about the wrist splints Resident 4 stated, I don't wear wrist splints. Several years ago, I did. They had me wear them for a short period after I got my casts off. To clarify, in the past three months you have not worn or had your wrist splints applied? Oh, no. It's been much longer than that. I don't even remember what they look like, that's how long it has been. Resident 4 allowed this writer to look though the dresser drawers to see if any wrist splints present in the resident's room. None were found.Review of the March, April and May 2026 Treatment Administration Records (TARs) showed from 03/01/2026 - 05/08/2026 (69 days) Resident 4's bilateral wrist splints were signed off as having been applied as ordered on all 69 days by 17 of 17 nurses who worked. On 05/08/2026 at 3:13 PM, when asked about Resident 4's bilateral wrist splits Staff E, Registered Nurse/Neighborhood Coordinator, said she did not recall ever seeing Resident 4 wearing wrist splints since she started working at the facility (hire date 10/16/2024). Staff E reviewed Resident 4's TAR and confirmed facility nurses had signed they assist with application of Resident 4's bilateral wrist splints daily as ordered and stated, That's concerning. Staff E said it was the expectation that nurses only sign for tasks that they completed or validated was complete. Reference WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i)

Based on observation, interview, and record review the facility failed to develop, implement and/or ensure residents' comprehensive care plans accurately reflected care needs for 3 of 34 sampled residents (Resident 19, 13 & 4) reviewed for care plans. These failures placed residents at risk for unidentified and/or unmet care needs, medical complications and a diminished quality of life.Findings included .Resident 19 Resident 19 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbances and terminal anxiety (the specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss), Bipolar disorder (a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes), and generalized anxiety (intense, excessive and persistent worry or fear). The Quarterly Minimum Data Set (MDS, an assessment tool) dated 03/20/2026, documented Resident 19 was unable to complete interviews, was severely cognitively impaired and relied on staff for some cares. A physician's order, dated 07/04/2025, documented Resident 19 was prescribed quetiapine (Seroquel, an antipsychotic) for Bipolar with psychosis daily at bedtime. A physician's order, dated 11/04/2025, documented Resident 19 was prescribed sertraline (an antidepressant) for depression (persistent feelings of sadness and loss of interest) daily in the morning. Resident 19 had no diagnoses of depression. A physician's order, dated 02/11/2026, documented Resident 19 was prescribed lorazepam (an antianxiety) every 4 hours as needed (PRN) for terminal anxiety for 90 days. Resident 19's Mood State care plan, dated 03/03/2025, documented Resident 19 had one target behavior listed under Behavior Tracking for quetiapine; paranoid statements (no details provided) and one target behavior under Behavior Tracking for sertraline; tearfulness (no other details provided). Resident 19 had no Comfort Care care plan, only a mention under Nutrition care plan that documented, weights are at risk to decrease. On 05/08/2026 at 12:22 PM, when asked to locate the side effect and target behavior monitoring orders for Resident 19, Staff B, Director of Nursing Services, confirmed there was no side effect monitoring or no target behaviors listed for the antianxiety medication and said there should have been. Staff B said there was one target behavior listed for each medication, antipsychotic-paranoid statements, and the antidepressant -tearfulness on the care plan. Staff B acknowledged that all of Resident 19's associated target behaviors should have been listed under each medication type on the Medication Administration Record and on the care plan and the care plan was not person centered. Resident 4 Resident 4 was admitted to the facility on [DATE]. Record review showed a provider order, dated 09/17/2024, that directed staff to assist with the application of Resident 4's bilateral wrist splints every morning (donning) and to assist with the removal (doffing) of the wrist splints at bedtime. An alteration in musculoskeletal status care plan, revised 04/14/2026, documented that the resident would wear bilateral wrist splints at night and that Staff will assist resident in donning black wrist braces when he goes to bed and doffing braces when he gets up in the morning. A potential for pressure ulcers care plan, revised 04/14/2026, documented The resident is dependent upon one person to apply protective splints to hand/wrist at night (bilateral) Check skin when donning and doffing. Both care plans indicated Resident 4 was to wear bilateral wrist splints at night, in direct conflict with the provider order, which directed staff to assist with application in the morning and removal at bedtime. On 05/04/2026 at 2:08 PM, 05/06/2026 at 10:48 AM and 05/07/2026 at 11:58 AM, Resident 4 was observed without wrist splints in place. On 05/07/2026 at 12:00 PM, when asked about the wrist splints, Resident 4 stated, I don't wear wrist splints. Several years ago, I did. They had me wear them for a short period after I got my casts off. I don't even remember what they look like, that's how long it has been. Resident 4 allowed this writer to look in drawers to see if there were wrist splints present in the resident's room. None were found. On 05/08/2026 at 3:13 PM, Staff E, Registered Nurse/Neighborhood Coordinator, said she did not recall ever seeing Resident 4 wearing wrist splints. When informed of Resident 4's report that he wore the splints several years prior, Staff E said Resident 4's care plans needed to be updated/revised. Resident 13Resident 13 was admitted to the facility on [DATE]. Record review showed the resident received quetiapine (an antipsychotic medication) from 09/19/2025 - 03/16/2026 for a diagnosis of psychosis with hallucinations. Review of the resident's comprehensive care plan, initiated 01/13/2025, showed it did not address the residents use of an antipsychotic medication, diagnosis of psychosis, the history of hallucinations/what was hallucinated. Nor did the care plan identify what specific behaviors the quetiapine was initiated to target or identify and instruct staff that an Abnormal Involuntary Movement Scale (AIMS, a standardized, clinician-administered assessment designed to observe, quantify, and track involuntary movements in patients, especially those taking long-term antipsychotic medications) was required at least every six months. On 05/11/2026 at 9:58 AM, Staff B, Director of Nursing Services (DNS), said the residents use of quetiapine, diagnosis of psychosis, history of hallucinations and what the hallucinations were of and the specific target behaviors the quetiapine was implemented to treat should have been care planned but acknowledged they were not. A 03/16/2026 provider note, documented Decrease Seroquel 12.5 mg to once daily for paranoia and agitation 2/2 [secondary to] dementia A 04/06/2026 provider note, documented Increase Seroquel 25 mg to in the afternoon/evening time, daily for paranoia and agitation 2/2 dementia. Review of Resident 4's comprehensive care plan, initiated 01/13/2025, showed the facility failed to develop and implement a plan that addressed the resident's paranoia and associated behavioral manifestations. On 05/11/2026 at 10:24 AM, Staff B, DNS, said a plan that addresses Resident 4's paranoia and associated behavioral manifestations should have been care planned. Reference WAC 388-97 -1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to ensure minimum data set (MDS) assessments accurately reflected residents' health status and/or care needs for 1 of 34 sample residents (Resident 13) reviewed. The failure to accurately code resident active diagnoses, placed residents at risk for unidentified and unmet psychosocial and/or behavioral care needs. Findings included . Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI, a manual that directs staff on how to accurately assess and code the status of residents) version 1.20.1, dated October 2025, once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have been documented in the last 60 days and have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look back period. Nursing Monitoring includes clinical monitoring by a licensed nurse. Listing a disease/diagnosis on the resident's medical record problem list is not sufficient for determining an active diagnosis. Resident 13 was admitted to the facility on [DATE]. Review of the hospital history and physical and Discharge summary, dated [DATE], showed the resident had provisional diagnoses (temporary or working diagnoses made by a healthcare professional based on an initial evaluation. It represents their best educated guess of a patient's condition at the current time, used when there is not yet enough information to make a final or definitive diagnosis.) of psychotic disturbance, mood disturbance and anxiety. No diagnosis of depression was found.Review of Resident 13's electronic health record (EHR) showed the following orders:a) Quetiapine (an antipsychotic medication) for psychosis with hallucination, from 09/19/2025 - 03/16/2026. On 03/16/2026 the diagnosis for the use of quetiapine was changed to unspecified dementia with behavioral disturbance.b) Melatonin at bedtime for insomnia, with nurse monitoring of the resident's hours of sleep, dated 01/23/2025.c) Trazadone (an antidepressant) for insomnia from 02/01/2025 - 03/03/2025. Resident 13's EHR showed after 03/03/2025 they received no further antidepressant medications and no behavior monitoring for target behaviors for depression had occurred since the resident was admitted . Review of all mood assessments completed with the resident's MDSs since admission (three by resident interview on 01/20/2025, 07/08/2025 and 10/16/2025, and one completed by staff assessment on 04/21/2025) assessed the resident had a depression score of 0.Review of Resident 13's 10/16/2025 Quarterly, MDS showed the resident had diagnoses of anxiety and depression and received antipsychotic and antianxiety medications during the assessment period. Resident 13 did not receive an antidepressant medication, and psychosis and insomnia were not coded as active diagnoses. Review of Resident 13's 01/16/2026 Annual MDS showed the resident had diagnoses of anxiety and depression and received antipsychotic and antianxiety medications during the assessment period. Resident 13 did not receive an antidepressant medication, and psychosis and insomnia were not coded as active diagnoses. Review of Resident 13's 04/14/2026 Quarterly MDS showed the resident had active diagnoses of anxiety, depression and unspecified dementia with behavioral disturbance, and received antipsychotic and antianxiety medications during the assessment period. Resident 13 did not receive an antidepressant medication and insomnia was not coded. On 05/13/2026 at 10:08 AM, Staff Y, MDS Coordinator, indicated they did not see Resident 13's psychosis diagnosis for the use of quetiapine and said it should have been coded 10/16/2025 and 01/16/2026 MDSs. On 05/11/2026 at 10:18 AM, when asked if Resident 13 was actively being treated with medication for insomnia and if nurses were monitoring the resident's hours of sleep at the time of the above referenced MDSs Staff Y, MDS Coordinator, said yes, and acknowledged insomnia was a active diagnosis. On 05/13/2026 at 10:32 AM, when asked why depression was coded on the 10/16/2026, 01/16/2026 and 04/14/2026 MDSs Staff Y said depression was listed as a diagnosis in provider notes within 60 days of each MDS. Staff Y acknowledged Resident was not being treated for depression (e.g. medication, counseling, behavior monitoring etc.) Documentation was requested to show how depression affected Resident 13's care or functional, cognitive, mood or behavior status during the assessment periods. No documentation was provided. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to identify allegations of abuse or neglect for 2 of 4 sampled residents (Resident 11 and 98) reviewed for abuse. This failure placed residents at risk for unidentified and repeated potential abuse, neglect, or mistreatment, and a diminished quality of life.Findings included .Review of the facility's policy titled, Abuse and Neglect-Resident Abuse Prevention, revised December 18, 2024, showed, NEGLECT: A pattern of conduct or inaction by a person or entity with a duty of care that fails to provide the goods and services that maintain physical or mental health of a vulnerable adult, or that fails to avoid or prevent physical or mental harm or pain to a vulnerable adult. In a Washington State Veterans Home, neglect also means a failure to provide a resident with the goods and services necessary to avoid physical harm, mental anguish, or mental illness. All incidents of alleged or suspected abuse, neglect, personal and/or financial exploitation, abandonment, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported and investigated in accordance with established federal and state rules.Resident 11Review of the electronic health record (EHR) showed Resident 11 admitted to the facility on [DATE] with diagnoses that included overactive bladder, depression (mood disorder), chronic right heart failure and hemiplegia and hemiparesis affecting right side (partial loss of strength and near complete loss of voluntary movement). Resident 11 was able to make needs known.During an interview on 05/04/2026 at 12:02 PM, Resident 11 stated they were often left in a soiled (feces and urine) brief for long periods of time during mealtimes which started when they became a hoyer transfer requiring two staff. Resident 11 stated they had developed sore areas that were painful. Resident 11 stated they purchased their own wipes for facility staff to use because washcloths had become too painful.During an interview on 05/07/2029 at 11:10 AM, Staff B, Director of Nursing Services (DNS), was made aware of the information Resident 11 provided about incontinent care.Review of a progress note, dated 05/08/2026, documented the Social Work met with the resident that day related to wellbeing post discussion the day prior about sitting in feces and long wait times for toileting. A date was set to meet again the following day to address a formal grievance related to staffing.During an interview on 05/11/2026 at 9:13 AM, Staff U, Registered Nurse/Investigation Nurse, stated Resident 11 reported during breakfast staff were not available to assist the resident with timely transfers and incontinent care. Staff U stated Resident 11 was not concerned about abuse or neglect and was urged to complete a grievance related to the situation which would be handled by the Social Work department.Review of the facility's updated Accident and Incident Log provided on 05/11/2026 for May 2026, showed no incident logged related to Resident 11's allegations related to incontinent care or rough handling.During an interview on 05/11/2026 at 9:41 AM, Staff B, DNS, stated based on Resident 11's response in the interview of not feeling abused or neglected the facility did not believe the incidents were allegations of abuse or neglect.During an interview on 05/11/2026 at 11:04 AM, Staff F, Social Work, stated Resident 11 was interviewed 48 hours after the incident was reported to the Administrator. Staff F stated during the interview Resident 11 reported their brief was not changed timely due to Certified Nursing Assistants (CNAs) not being available during mealtimes. Resident 11 also reported on their shower day staff requested the resident to stay in bed in a soiled brief until a shower could be provided. Resident 11 additionally reported rough handling by staff to Staff F during the interview. Resident 98Review of the facility's policy titled, Abuse and Neglect-Resident Abuse Prevention, revised December 18, 2024, showed, Mental abuse means a willful verbal or nonverbal action that threatens, humiliates, harasses, coerces, intimidates, isolates, unreasonably confines, or punishes a vulnerable adult. Mental abuse may include ridiculing, yelling, or swearing. All incidents of alleged or suspected abuse, neglect, personal and/or financial exploitation, abandonment, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported and investigated in accordance with established federal and state rules.Review of the EHR showed Resident 98 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), heart failure and chronic obstructive pulmonary disease (damaged lungs). Resident 98 was able to make needs known.During an interview on 05/04/2026 at 1:04 PM, Resident 98 stated they were recently involved in a verbal altercation with another resident who threatened to whip my a**. Resident 98 stated staff intervened and there were no further issues with the resident.During an interview on 05/06/2029 at 9:43 AM, Staff A, Administrator was made aware of the information Resident 98 provided related to the altercation.Review of a progress note dated 05/06/2026, showed Staff F, Social Work documented Resident 98 reported another resident yelled at them on their hall. Resident 98 reported two CNAs were present and did their best to break up the disagreement. Resident does not wish to file a grievance stating, there's not much you can do. Resident requested that staff communicate better as the event took place about 1.5 weeks ago.Review of the facility investigation dated 05/06/2026, showed the verbal altercation took place on 04/15/2026. Staff member X, CNA, was interviewed as a witness and one of the staff present during the altercation.Review of the facility's Accident and Incident Log for April 2026, showed no incident logged related to Resident 98's resident to resident altercation.During an interview on 05/11/2026 at 5:09 PM, Staff B, DNS, stated when staff witnessed a resident-to-resident altercation the expectation was to keep the residents safe, complete an incident report, complete an investigation and report to the hotline when there was abuse or neglect.Reference WAC 388-97-0640(5)(a)

Based on record review and interview the facility failed to initiate a grievance for 1 of 2 sampled residents (Resident 215) reviewed for missing personal property. This failure placed the resident at risk of unmet needs, personal loss and a diminished quality of life. Findings included. Review of the facility policy titled Missing Items, effective date 04/03/2025, showed the process for reporting and handling residents' missing property, including money was when a resident and/or resident's representative brought to the attention of a staff member a concern that money or a personal possession is missing the staff member to whom the loss was reported should check areas the item may have been misplaced. If the item could not be located, the staff member to whom the concern was reported was instructed to complete a grievance on the same day. Resident 215 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/03/2026, documented Resident 215 was moderately cognitively impaired. On 05/04/2026 at 11:10 AM, Resident 215 told Staff C, Registered Nurse, that their stereo equipment was missing in an elevated voice. Staff D, Certified Nursing Assistant, entered the room, and Resident 215 said their stereo was gone. Staff D asked what was missing and Resident 215 said in a loud voice it was a Bose Stereo. At 11:18 Staff D, looked in the cupboard for the missing item, but did not locate it. Resident 215 said the stereo looked like an old-fashioned stereo, but it was new, they had told staff that morning it was missing and they were not sure when it went missing. On 05/06/2026 at 10:57 AM, Staff E, Registered Nurse/Neighborhood Coordinator, said when a resident reports a missing personal item staff would talk with the social worker and the social worker would talk with the resident and fill out a grievance if needed. Staff E said it was her expectation that staff would alert the neighborhood coordinator and the social worker. On 05/06/2026 at 11:10 AM, Staff F, Social Worker, said her expectation of staff, if a resident reported missing property, was for them to look for the item and if not found to initiate a grievance, and if it was a valuable item to initiate the grievance immediately. Staff F said whoever took the complaint should initiate the paperwork. Regarding Resident 215's report of a missing stereo to 2 staff members, Staff F said this had not been reported to her and that the staff should have told her even if only by email. Staff F said she was in charge of resolving missing items but whoever heard about it should have initiated a grievance. When asked if she had received an email or grievance regarding Resident 215's reported missing stereo, Staff F looked in the electronic health record and said she did not see a progress note, email, or grievance about the reported missing stereo. Staff F said Resident 215 would make allegations because of a previous head injury, but that should not stop staff from following procedure. On 05/07/2026 at 1:24 PM, Staff F, when asked if it met her expectations that staff had not reported the missing stereo and had not filed a grievance, said it did not meet her expectations, that there should have been a note under her door, or an email or the charge nurse should have said something, staff should have followed up. Reference WAC 388-97-0460

Based on observation, interview, and record review, the facility failed to ensure personal privacy was protected for 2 of 2 sampled residents (Residents 25 and 75) reviewed for resident rights. This failure placed the residents at risk for embarrassment, a violation of their privacy, and a diminished quality of life.Findings included .Resident 25Review of the electronic health record (EHR) showed Resident 25 was admitted to the facility on [DATE] with diagnoses that included chronic pain, diabetes (too much sugar in the blood) and hypokalemia (low potassium). Resident 28 was able to make needs known.Observation on 05/04/2026 at 11:01 AM, showed Resident 25 had an [NAME] (electronic virtual assistant device) on their bedside table. Review of Resident 25's EHR showed no documentation of consent to the recording device in their room.Review of the Care Plan showed no documentation related to the [NAME].Resident 75Review of the EHR showed Resident 75 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (movement disorder of the nervous system), high blood pressure and Aphasia (impairs ability to communicate due to damage to the language areas of the brain). Resident 75 had unclear speech and sometimes understood others.Observation on 05/04/2026 at 12:56 PM, showed Resident 75 had an [NAME] with a screen (electronic virtual assistant device) on their bedside table. Review of Resident 75's EHR showed no documentation of consent to the recording device in their room.Review of Resident 75's Care Plan showed an intervention to encourage resident to call family member on their Alexa device.During an interview on 05/07/2026 at 8:51 AM, Staff T, Licensed Practical Nurse (LPN), stated Resident 75 had an [NAME] in their room because family liked to look in on the resident. Staff T stated they were unaware if there was a special process staff followed when providing care to ensure the resident had privacy.During an interview on 05/11/2026 at 2:33 PM, Staff B, Director of Nursing Services, stated the expectation was for a consent to be signed by the resident or resident representative and roommate if applicable prior to the use of the recording device. Staff B stated the electronic device should have been care planned so staff were aware to turn the screen when providing care to the resident.Reference WAC 388-97-0360, 0500(1)

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Residents 11) was consistently offered/received services to maintain or prevent declines in mobility when reviewed for range of motion (ROM). This failure placed the residents at risk of decreased motion, mobility and a diminished quality of life.Findings included.Review of the electronic health record (EHR) showed Resident 11 admitted to the facility on [DATE] with diagnoses that included overactive bladder, depression (mood disorder), chronic right heart failure and hemiplegia and hemiparesis affecting their right side (partial loss of strength and near complete loss of voluntary movement). Resident 11 was able to make their needs known.During an interview on 05/04/2026 at 12:14 PM, Resident 11 stated they recently requested to start participating in restorative or physical therapy due to declining mobility. Resident 11 stated in the past they had medical issues that interfered with their ability to participate in therapy but said they were never reapproached by staff and restorative was not offered consistently.Review of a progress note dated 03/11/2026 showed, Resident requested to see LN to raise concern of increasing weakness of bilateral lower extremity, it's more difficult to stand and move now. I don't want to be stuck on sit-to-stand, I'm scared. Referral sent to PT/OT to assess and treat bilateral lower extremity weakness affecting ability to transfer.Review of a progress note from a different licensed nurse, dated 03/12/2026, showed resident was feeling like they were losing strength, a review of the restorative program was completed and resident was agreeable for more aggressive form of exercise that in room exercises and LN was awaiting guidance from restorative nurse. Review of a progress note, dated 04/04/2026, showed resident was transferred via hoyer.During an interview on 05/07/2026 at 9:27 AM, Staff V, Restorative Coordinator, stated Resident 11's restorative program was discontinued on 03/23 due to refusals. Staff V stated Resident 11 requested to restart her program and had been evaluated by therapy on 04/02/2026. Staff V stated Resident 11's restorative program was restarted on 05/06/2026.During an interview on 05/08/2026 at 1:57 PM, Staff W, Rehabilitation Director, stated Resident 11's evaluation was completed on 04/02/2026. Resident 11 was assessed to participate in therapy three times per week for four weeks. Staff W stated Resident 11's insurance required a steep copay/participation fee which Resident 11 stated they were unable to pay and therefore did not receive therapy. Staff W stated the business office was responsible for obtaining authorization and had not communicated with the therapy department on the status of the approval. Staff W stated they should have referred Resident 11 back to restorative therapy while waiting for the insurance approval but did not. Staff W stated the lack of coordination between the business office, therapy and restorative did not meet their expectations.During an interview on 05/11/2026 at 2:58 PM Staff B, Director of Nursing Services stated the expectation was that Resident 11 was offered some type of functional maintenance program or restorative program in the process of waiting for the approval. Staff B stated there was a communication breakdown between restorative and therapy and ultimately the facility realized Resident 11 had double coverage and was never responsible for a participation fee.Reference WAC 388-97-1060(3)(d)

Based on record review and interview, the facility failed to ensure non-pharmacological interventions (NPIs, non-medication interventions) were attempted prior to the administration of as needed (PRN) pain medications for 2 of 5 residents (Residents 2 & 121) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life. Resident 2 Resident 2 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 05/01/2026, documented Resident 2 was severely cognitively impaired and was able to make needs known. A physician's order, dated 03/23/2021, documented, Pain Non-Pharmacological Codes: 1) Remove to calmer space 2) Ambulate resident 3) Refer to nurses note 4) Read material/coloring 5) Return to room [ROOM NUMBER]) Toileting 7) Provide food/snack 8) Give fluids 9) Change position 10) Adjust room temp 11) Back rub 12) 1 on 1 Conversation 13) Send to activities 14) Other were to be attempted prior to PRN pain medication administration. A physician's order, dated 04/28/2026, documented Resident 2 was prescribed oxycodone PRN every 6 hours for chronic pain. Review of the April and May 2026 Medication Administration Record (MAR), documented Resident received oxycodone on 04/30/2026 pain level 9; 05/02/2026 pain level 0; 05/03/2026 pain level 10, 05/06/2026 pain level 5. No NPI's were attempted prior to the administration of the PRN pain medication. On 05/08/2026 at 9:21 AM, Staff H, Registered Nurse/Neighborhood Coordinator, said NPI's were to be attempted prior to the administration of the PRN pain medication. Staff H reviewed the listed dates above in the electronic health record (EHR), confirmed no NPI's were attempted and said they should have been. On 05/08/2026 at 12:22 PM, Staff B, Director of Nursing Services (DNS), reviewed the EHR and confirmed Resident 2 had received PRN pain medication without NPI's having been attempted and said NPI's should have been attempted prior to administration. Resident 121 Resident 121 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/04/2026, documented Resident 121 was cognitively intact. Review of Resident 121's orders for April and May 2026, showed they had orders in place for acetaminophen-codeine (narcotic pain medication) to be given PRN for pain. Resident 121 had another order, dated 10/29/2025, for monitoring and assessing pain instructing staff to document what non-prescription (non-medication) interventions were provided with 0=none, 1- verbal reassurance, 2- change in location/environment, 3- warm blanket, 4 – reposition, 5- food and/or drink, 6- rest, 7- heat, 8-cold, 9- music, and 10- massage. This order was not associated with the PRN acetaminophen-codeine orders. Review of the MAR, from 04/01/2026 through 04/30/2026, documented the PRN acetaminophen-codeine had been given 26 times in April with no NPIs attempted. Review of the MAR from 05/01/2026 through 05/05/2026, showed acetaminophen-codeine had been administered six times with no NPIs attempted. On 05/08/2026 at 10:57 AM, Staff B, DNS, said her expectations for NPIs as they related to PRN pain medications were that NPIs be offered prior to pharmacological (medication) interventions. Staff B reviewed the 04/2026 and 05/2026 MARs and confirmed that NPIs had not been attempted prior to the administration of PRN pain medication on the dates reviewed. Staff B said she did not see anything in Resident 121's progress notes regarding NPIs being attempted. Staff B said this did not meet her expectations. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview and record review, the facility failed to thoroughly assess resident risk for elopement and provide the level of supervision required to prevent residents from eloping (exiting the facility without the required supervision) for 1 of 4 residents (Resident 1) reviewed for accidents. This failure placed residents at risk for inadequate supervision, elopement and potential of life-threatening situations. Findings included.Review of the facility policy titled, Missing Resident, dated 08/23/2024, showed the facility would identify residents at risk for elopement and they would be monitored to ensure their safety. Review of the facility policy titled, Wandering, Unsafe Resident, Revised August 2014, showed the facility would identify residents at risk for wandering/elopement, assess for correctable risk factors, and assess residents at risk for appropriateness of the use of a wander guard (specialized, wearable-based security solution to protect residents with cognitive deficits from wandering). Review of the facility policy titled, Wander guard Wander Management System, dated 10/01/2024, showed that the device would be placed to protect residents as risk for elopement and/or unsafe wandering and would be reviewed quarterly. The procedure did not include a process of evaluating the potential discontinuance of the wander guard. Resident 1 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS), an assessment tool, dated 02/02/2026, showed Resident 1 had severe cognitive impairment, and was independent with dressing, sitting, standing, and was able to ambulate (walk) 150 feet without staff assistance. The care plan focus for elopement risk, dated 04/14/2025, showed the resident was at risk for elopement related to history of attempts to walk outside and unable to find way back and impaired safety awareness. Review of the Physician's Order, dated 04/14/2025, showed a wander guard was ordered for resident use for safety.Review of the Wander risk assessment, dated 08/05/2025 by Staff E, Registered Nurse (RN), showed Resident 1 was at moderate risk for wandering. Review of the progress note, dated 08/19/2025 at 1:37 PM by Staff C, RN, Resident Care Manager (RCM), showed that the wander guard alarm was discontinued.Review of the Wander Guard Event report for the bracelet #586896 in use for Resident 1 prior to being discontinued on 08/19/2025 showed 76 entries between 04/14/25 and 08/01/2025, with alarms at three different doors and the most recent entry was 08/01/2025. Review of the facility investigation report, dated 02/08/2026, showed that Staff F, RN, had observed a gentleman at the bottom of the hill entrance of the facility property at 11:55 AM, the staff member inquired if the man was ok and they replied they were just going for a walk. At 12:30 PM, the staff member inquired of Staff H, Nursing Assistant Lead (NAL), if the man observed was a resident. They confirmed it sounded like one of their residents and they attempted to locate him, and could not find them, the report also indicated Staff H, NAL, thought the resident had a wander guard. At 12:44 PM, Staff F, RN, left to attempt to locate the resident, stopping at local business along the way. The resident was located by Staff F, RN, at 1:15 PM in front of a music store (located 1.7miles away). The resident was safely brought back to the facility. The facility investigation report also showed that Resident 1 had a previous elopement on April 13, 2025.On 04/06/2026 at 1:05 PM, Staff E, RN, said they had completed the wander risk assessment on Resident 1 and that if the facility was going to discontinue the wander guard, they would expect them to review how many times the resident had exit seeking behaviors. Staff E said that Staff D (MDS RN) had reviewed that, and Resident 1 had not had any exit seeking behaviors for the previous six months and thought it was ok to DC the wander guard. On 04/06/2026 at 1:52 PM, Staff D, MDS RN, said wander risk assessments were completed on admission, quarterly, and as needed for changes. The care team revisited all devices in use by the residents quarterly and when they reviewed Resident 1 in August, the team felt it was appropriate to discontinue the wander guard. Staff D said that wandering and exit seeking would be similar risks and they were not aware of how they could determine if there had been exit attempts by the resident that were not part of the resident record. Staff D said they did not know how to attain the wander guard event report for a resident, and if they had that information available, they would not have recommended the wander guard to be discontinued. On 04/06/2026 at 2:09 PM, Staff C, RN/RCM said Resident 1 was observed by staff prior to lunch and staff became aware he was missing after lunch, but staff were able to locate the resident, and he was returned to the building. Staff C said that Staff D, MDS RN initiated the discontinuation of the wander guard and that the resident had not exited the building in months. She evaluated the residents' continued need for the wander guard by reviewing the progress notes. Staff C said they did not review the alarm event report to determine if the resident had exit seeking behaviors that were not part of the resident record, because they did not have access to that information, only Staff B, Director of Nursing (DNS) and Staff G, RN, Investigative Nurse, have access. Staff C said if the wander event report showed the resident was still exit seeking, the wander guard should not have been discontinued. On 04/06/2026 at 2:51 AM, Staff G, RN, Investigative Nurse, said the incident occurred on a weekend; one of the nurses was coming back to the facility and saw Resident 1 at the end of the driveway, and he told her he was just out for a walk, they asked other staff about the resident and they identified him as Resident 1, and began the search for them. Staff G did not believe staff were aware he was missing prior to Staff F, RN inquiring about the resident. Staff G believed there was enough staff to supervise the residents. Staff G said residents are assessed for wander risk on admission and quarterly and as needed for changes. Staff G was not aware of a way staff could assess for exit seeking that was not part of the resident record, if staff were hearing the wander guard alarm, they were not sure the resident was placed on alert, if they were exit seeking, they would expect them to be placed on alert. Staff G said sometimes the resident just walks by the door or gets too close and it will alarm. Staff G said reviewing the wander guard event report is not part of risk assessment, that they were aware of. Staff G said if the wander guard event report showed the resident was still triggering the alarms at various doors they should probably not have discontinued the wander guard. On 04/07/2026 at 4:42 PM, Staff A, Administrator said that residents are assessed at risk for wandering/elopement and they have a wander guard system in place. Staff A was not aware of the process for removal of the wander guard device for a resident identified at risk for wandering. Regarding Resident 1, he was not aware the device had been discontinued until after the event, it was reinstated after his safe return to the facility. Staff A said he thought it would make sems for staff to review the wander alarm event report as part of the decision process to discontinue the safety device. Staff A said they should have had a better system in place; they were evaluating that. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse/neglect/mistreatment for 1 of 6 residents (Resident 3) reviewed for allegations of abuse/neglect. Failure to thoroughly investigate the allegations of abuse/neglect placed the residents at risk for continued mistreatment, unmet needs, and diminished quality of life.Findings included .According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), all incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. A thorough investigation is a systematic collection of review/evidence/information that describes and explains an event or a series of events to determine what occurred and make necessary changes to resident's plan of care and services to prevent reoccurrence. The investigation should include the who, what, when, where, why and how, of the incident and establish a reasonable cause within 24 hours of the incident.Review of the facility's policy titled, Resident Abuse Prevention, dated 12/18/2024, showed that staff were trained regarding how to report allegations of abuse and that an investigation would be conducted for reported allegations. Resident 3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/05/2025, showed the resident had moderate cognitive impairment, displayed rejection of care, and was medically complex. A progress note, dated 05/22/2025 at 11:47 AM, by Staff L, RN, Neighborhood coordinator, showed that during a visit to update the resident about upcoming appointments the resident continued to have multiple complaints about staff not caring for his needs pertaining to his wound/skin treatment.Review of Resident 3's Treatment Administration Record for May 2025 showed Staff I, Registered Nurse (RN), was the nurse who performed the dressing change on 05/22/2025.Review of Resident 3's progress note, dated 05/24/2025 at 1:19 PM, showed that the resident was upset with multiple care related concerns and the administrator, nurse practitioner, management, supervisor and social worker was notified. Review of Resident 3's progress note, dated 05/25/2025 at 6:41 AM, by Staff I showed that the Staff I was told by Staff J, Licensed Practical Nurse (LPN) that the resident did not like him and reported if Staff I came in there ever again he would punch him. Staff I could no longer provide care to Resident 3. Review of Resident 3's progress note, dated 05/29/2025 at 5:21 AM, by Staff I showed Staff I attempted to assist Resident 3, and the resident was quoted as saying, Get f*ck out of here or I will bust your ass. Shift supervisor was notified, and email was sent to manager and social worker.Review of Department records on 05/29/2025 at 1:33 PM, showed a State Agency Complaint Intake was reported that during the early morning of 05/22/2025, a male night shift nurse allegedly treated Resident 3 rough during an abdominal dressing change and the dressing was placed on a windowsill and then replaced the same dressing back on. The resident reported this to the charge nurse, the social worker, and the Director of Nursing. During an interview on 06/11/2025 at 1:22 PM, Resident 3 said that on the early morning of 05/22/2025, a male nurse treated him rough during a dressing change. Resident 3 said the staff member asked if the resident could hold his abdomen up while they cleaned and redressed the area. Resident 3 said he could not assist him, and the nurse manipulated his abdomen in a painful way and placed the dressing which included previously placed ointment on it, on the windowsill and then replaced it back to his groin. Resident 3 said after the shift change, he requested to speak to the nurse and reported it to her. Resident 3 said he reported the incident to multiple nurses and multiple nursing assistants, and he asked that Staff A come speak with him. He believed multiple staff were aware and no one had done anything to follow up. The situation left him feeling, uncomfortable and questions the care every time someone comes in. Resident 3 said he had not seen the same staff member again.Review of a Social Worker Note, dated 05/30/2025, by Staff N, Social Worker, showed that a referral from nursing was received and reported that Resident 3 was planning on going to the nearest police station to file a complaint that he was not being properly cared for. Staff N met with Resident 3 to ask about his concerns and the resident reported he did not need any follow up, it was being taken care of.Review of a Social Worker Note, dated 05/31/2025 at 11:10 AM, by Staff M, Social Worker, showed they received an email at 9:40 AM from Resident 3 asking to see him, when they arrived the resident reported he no longer needed to speak with them. Review of the facility incident log for 05/17/2025 to 06/11/2025 showed no entry for reported care concerns to being rough handled and treatment care concerns on 05/22/2025. The facility was unable to provide an investigation/incident report for the alleged allegations from 05/22/2025. Review of the facility grievance log for 05/11/2025 through 06/11/2025 showed no entries for Resident 3. During a joint interview with Staff K, LPN and Staff L, RN, Unit Coordinator (Manager), on 07/10/2025 at 3:05 PM, Staff K did not recall Resident 3 reporting care related concerns to her on the morning of 05/22/2025. She recalled that the resident reported the care provided was rough and the dressing was placed on the windowsill after it was removed and then put back. She did not consider this to be an allegation of abuse; her focus was to replace the dressing and make the resident happy. Staff L said Staff I was the nurse who worked with the resident the previous shift. Staff K said she did not report the allegation, but the information was given to Staff L. During an interview on 07/11/2025 at 9:11 AM, Staff I, RN, said he recalled performing care to Resident 3 on 05/22/2025 and the resident was in his recliner and the resident asked him if it was ok to clean the abdominal folds and change the dressing. Staff I said he was not rough with Resident 3 and did not place the dressing on the windowsill he set it up on the side table. Staff I said later he heard about the allegation of being rough with the resident from Staff J and made a progress note about it [on 5/25/2025] and sent emails regarding to Staff A, Administrator and Staff L. During an interview on 07/11/2025 at 12:40 PM, Staff M, Social Worker, said that the facility staff had been emailing social workers regarding allegations and the social workers would email nursing. They have recently updated the policy so that the staff member that heard it reported it. Staff M said she was not aware of Resident 3's allegation on 05/22/2025, but that the resident had recently filed one on 07/04/2025 regarding care in May, and she interviewed the resident. When asked what that was pertaining to, Staff M said it was that the caregiver rough handled him and lifted his abdomen up, causing pain, and placed the same dressing back. The resident reported the way the Staff member handled his abdomen, the first time it hurt, but the second time it was assault. Staff M said the resident did allege mistreatment and she did consider the allegation of abuse. She would expect the allegation to have been reported and investigated at the time of occurrence.During an interview on 07/11/2025 at 1:02 PM, Staff L said she heard about the allegations regarding care on 05/22/2025, about a week, week and a half later. They were meeting with the resident to discuss other things like appointments, and he brought it up. When asked what the allegation was, Staff L said that the care was rough, and the dressing was reused. Resident 3 was not able to identify the staff member. She reviewed the progress notes, and it indicated more that the resident was yelling at the staff. Staff L interviewed Staff I, and Staff I reported he used a flat hand when lifting the abdomen up. When asked if she considered it an allegation, she said she felt it was more of a grievance.During an interview on 07/11/2025 at 1:40 PM, Staff H, Investigative Nurse, said she was working on a current reported concern from Resident 3 regarding care in May 2025. Resident 3 had alleged mistreatment during a treatment causing pain when his pannus (lower abdomen) was lifted and the treatment was not done correctly. Staff H said she had not had time to interview the staff yet and if the resident reported it to staff, she would expect them to report it to the state and that it would have been investigated.During an interview on 07/11/2025 at 2:36 PM, Staff B, RN, Director of Nursing, was not able to recall receiving information regarding Resident 3's allegation on 05/22/2025. After reviewing Resident 3's progress notes, Staff B said there was a progress note on 05/23/2025. When asked if he reported that he was rough handled during care and staff replaced a soiled dressing after laying it on the windowsill, would that have been a reportable allegation, Staff B said yes, if the resident felt that way, Staff B would have expected it to be reported, investigated and logged. When asked if the facility staff use email to communicate allegations, Staff B said sometimes there was email communication in regard to residents and staff, and if an investigation had not been started there would be more eyes on it. On 07/11/2025 at 4:48 PM, Staff A, Administrator said he was not aware of a staff trend of emailing the neighborhood coordinator and social worker regarding resident reported allegations, but if they did, it did not alleviate them from reporting. Staff A said if a resident felt they were mistreated; it should be called in and investigated and he would expect it to be on the facilities incident log. Reference WAC 388-97-0640 (6)(a)(b)

Based on observation, interview and record review, the facility failed to provide the level of supervision required to prevent residents from eloping (exiting the facility without the required supervision) or attempting to exit the facility for 2 of 6 sampled residents (Resident 1 and 2) reviewed for accidents and failed to timely correct the wander guard system in place. These failures placed residents at risk of significant injury and a decreased quality of life.Review of the facility policy titled, Missing Resident/Elopement, dated 09/22/2023, showed that residents would be identified for risk of wandering and/or elopement and those at risk would be monitored and staff were to take necessary precautions to ensure resident safety. Resident 1 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS) an assessment tool, dated 05/05/2025, showed Resident 1 had severe cognitive impairment, required the partial/ moderate assistance with the use of a manual wheelchair, and a wander/elopement alarm was used daily. The care plan focus for elopement, initiated 11/06/2024, showed Resident 1 was an elopement risk related to previous attempts to leave the facility and interventions included that staff were to distract the resident from wandering by offering diversion, activities, food, television or books and Wander guard (an electronic alarm system that alerts staff when the resident approaches a door) placement. The wandering risk assessment, dated 05/06/2025, indicated Resident 1 was at low risk of wandering.Resident 2 was admitted to the facility on [DATE], the MDS dated [DATE], showed the resident was cognitively intact, independent with ambulation, and was careplanned to ambulate outside on the extensive campus independently. The wandering risk assessment, dated 02/11/2025, indicated Resident 2 was a low risk of wandering.A facility investigation report, dated 06/11/2025, showed Resident 1 triggered the alarm on floor 2 at door 8 (F2 courtyard) at 5:20 PM and the alarm was turned off at 5:25 PM. The resident then triggered the alarm on floor 2 at door 6 (main lobby) at 5:28 PM and the alarm was turned off at 5:29 PM. The resident then triggered the alarm on floor 1 at door 20 at 5:32 PM and the alarm was turned off at 5:33 PM. At 5:50 PM, Resident 1 was observed in his wheelchair being pushed by Resident 2 off of facility property, approximately 0.25 miles from the front entrance of the facility. The residents were observed on the side of the road by Staff E, Transportation, as he was returning to the facility. Staff E arrived at the facility and contacted Staff C, Registered Nurse and they both intercepted the residents who had made it approximately 0.50 miles from the main entrance of the facility. Staff C remained with the residents, while Staff E returned with the facility van. Resident 2 reported he was helping Resident 1, who reported he was going to another town.On 07/02/2025 at 4:22 PM, Resident 1 approached and asked if The Department staff could help him, to go someplace. Resident 1 was asked where he needed to go and he replied, across the street. Facility staff intervened and escorted the resident to the outside courtyard. In an interview on 07/09/2025 at 11:50 AM, Staff D, Registered Nurse (RN), Memory Care Neighborhood Coordinator, said that when a resident triggered the door alarm, staff should turn off the alarm and redirect the resident. Some redirection techniques could be to offer to go outside with them or activities or possibly assess if they needed to be toileted. Staff D said Resident 2 now resided in the memory care unit and had access to locked outside space. In an interview on 07/09/2025 at 1:19 PM, Staff F, Nursing Assistant (NA), said that they knew what residents were at risk of wandering/elopement by the use of a wander guard or if it was identified on the run sheets. Staff F said that if a resident was exit seeking, and triggering the alarm, staff should redirect the resident, maybe offer a snack and let the nurse know. Staff F said she was not aware Resident 1 had left the facility property. In an interview on 07/09/2025 at 2:17 PM, Staff G, RN, Neighborhood Coordinator, said when residents triggered the wander guard alarm, staff should reset the alarm and redirect the resident back to their unit.In an interview on 07/09/2025 at 2:33 PM, Staff C, RN, said she was in her office when Staff O came to her and reported he saw Resident 1 and 2 off of facility property. They went in staff O's private vehicle, and she stayed with the residents while Staff O returned with the facility van. Staff C said that Resident 1 stated he wanted to go home, and Resident 2 said he was taking him home. Staff C said she was not sure how Resident 1 exited the building, or if Resident 2 helped, but believed it was on the first floor. In an interview on 07/11/2025 at 4:38 PM, Staff C said nursing staff were not aware Resident 1 was missing on 06/11/2025. In an interview on 07/11/2025 at 1:40 PM, Staff H, RN, Investigative Nurse, said when a resident triggered the alarm staff were to respond to the alarm and redirect the resident or determine if they had any unmet needs; if they were not able to locate the residents, they should call all of the units to do a head count. Staff H said there was only one door that did not lock when the wander guard alarms and that was door 20 on the first floor. There were no staff in that first-floor area after 5 PM. Pharmacy staff were there until 6 PM but the door was closed. Staff H said pharmacy staff were interviewed, and they did not hear the alarm. Staff H said Resident 2 confirmed they went out through door 20 on the first floor. Staff H then demonstrated the door 20 alarm and the sound was not of a volume indicative of an alarm. Staff H said they were working on a system to send the wander guard alarms to all med cart laptops, but did not know when that would be completed.In an interview on 7/11/2025 at 2:36 PM, Staff B, RN, Director of Nursing, said when a resident triggered an alarm, staff were expected to turn the alarm off and redirect the resident. If they could not find the resident, they should look for the resident. Staff B said the door 20 [the door by the clinic] alarms but she was not sure it did not lock; she had not tested it. Staff B said they were working on getting an alert system to all of the laptops when a wander guard triggers.In an interview on 07/11/2025 at 3:12 PM, Staff A, Administrator, said they use a wander guard system to prevent wandering and elopement of cognitively impaired residents. Staff A said that the alarm to door 20 was set to the loudest it could be, and they were in the process of getting a new alert system to alarm on all of the laptops. He anticipated that to be completed, In about a week or two. Staff A reported Information Technology (IT) had been there on 07/09/2025 to work on the new system. In an interview on 07/11/2025 at 4:00 PM, Staff A said he was contacting the (IT) department and Wander guard company and believed he could get the new system in place in about 15 minutes.During an observation on 07/11/2025 at 4:23 PM, the wander guard alert system operating on laptops of Hall C and E. Alert provided both a visual and audio alert that notified staff of the resident and location. Staff A said they were now working on all medication cart laptops.Reference WAC 388-97-1060 (3)(g).

Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines during the use of a mechanical lift and the lift sling for 2 of 3 residents (Residents 1, 5) reviewed for falls. The facility failed to assess, evaluate the root cause, and implement fall prevention interventions specific to resident needs for 4 of 6 sampled residents (Residents 1, 2, 3, and 4) reviewed for accidents. In addition, the facility failed to follow manufacturer instructions for routine, documented inspection of the mechanical lift slings. Resident 1 experienced harm when they sustained a hip fracture when transferred with a mechanical lift and sling in a manner inconsistent with the manufacturer instructions. These failures placed all residents that required mechanical lift transfer at risk for avoidable falls, physical injuries, functional decline, and diminished quality of life. Findings included . <Mechanical lift sling> <Resident 1> Resident 1 was admitted to the facility on [DATE]. The quarterly minimum data set (MDS), dated [DATE], documented that the resident had no cognitive impairment and was dependent on staff for activities of daily living (ADLs). Resident 1 had no recent history of falls. The care plan, dated 12/21/2023, documented Resident 1 was at risk for falls due to chronic debility and decreased sensation to bilateral low extremities. Staff would use a two-person transfer with a mechanical lift and a medium red toileting sling, ensuring flaps were not bunched underneath the resident. On 06/17/2025 at 10:25 AM, Resident 1 was observed in their room, in bed. In a concurrent interview at that time, the resident reported they were recovering from a hip fracture and things were going well so far. The resident said they remembered the fall. Resident 1 said they didn't hook it up to the Hoyer [mechanical lift] the right way. Resident 1 did not see how the staff hooked her up because she was not watching but felt that way because there was never a problem with the sling before. The facility investigation, dated 06/01/2025, documented Resident 1 fell during a transfer with the mechanical lift. The staff were transferring the resident from the bed into the wheelchair when the resident slid through the mechanical lift sling, bottom first, falling to the floor. Resident 1 hit their head on the bar of the mechanical lift resulting in a head laceration. Resident 1 was transported to the hospital. Witness statements noted staff used the red toileting sling to transfer the resident. The resident was noted to be secured appropriately with the legs crossed underneath both resident's legs. The investigation conclusion was noted as unable to determine the root cause of this fall and found the resident was transferred out of bed according to the care plan. Review of the Vancare Hygiene Sling Instruction Sheet, undated, documented strap of the legs should be crisscrossed between the legs of the resident and in front of the resident. Progress notes, dated 06/11/2025, documented Resident 1 was found to have a right hip fracture from the fall to the floor. During an interview on 06/04/2025 at 2:25 PM, Staff F, nursing assistant (NA), said she assisted Resident 1 with the transfer which resulted in the fall out of the mechanical lift. Staff F said they were getting the resident up into the wheelchair. They hooked the resident up like they normally did. They used the red toileting sling, hooking both straps to the top of the mechanical lift. They bucketed the straps on the resident's legs describing this as both straps going under the legs but not crisscrossed in-between the legs. As they lowered the resident into the chair, the resident slid through the straps and fell to the floor. One of the resident's legs remained hanging in the sling and the other fell to the floor. Staff F said it was like the resident fell through a trap door. Staff F said she used the sling how she was trained. She said, the sling is not safe, but did not know of any other incidents with the sling, just close calls. During an interview on 06/04/2025 at 3:00 PM, Staff K, NA, and Staff L, NA, said they bucket the red toileting sling when transferring residents. Both Staff K and Staff L said they were trained to use the red toileting sling this way. Staff K said the sling is safe if you use it right. During an interview on 06/04/2025 at 3:33 PM, Staff H, NA, said he was trained to bucket the red toileting sling when transferring residents. Staff H said there were no safety issues with the sling if you use it right. During an interview on 07/02/2025 at 4:19 PM, Staff C, Registered Nurse and Investigation Nurse, said the staff reported they crisscrossed the straps under the legs but not between the legs. Staff C did not investigate the manufacturer instructions to determine if the leg straps were used appropriately. Staff C could not state how the red toileting sling should be used. Staff C said the care plan did not note how the leg straps should be placed. Staff C said she was unsure if this was the appropriate sling for the resident due to the resident's lack of core strength and weight carried in their midsection. Therapy had recommended the red toileting sling at some point, but a recent reassessment was conducted, and a new sling was chosen. During an interview on 07/02/2025 at 5:29 PM, Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), said she did not know the correct way to use the red toileting sling and could not say if staff used the red toileting sling appropriately. During an interview on 07/30/2025 at 5:04 PM, an email communication from Staff B documented training and education was started related to the proper use of the red toileting sling. <Resident 5> Resident 5 was admitted to the facility on [DATE] with diagnosis of renal failure and multiple sclerosis. The annual MDS, dated [DATE], documented Resident 5 had no cognitive impairment and was dependent on staff for ADLs. During an observation on 06/04/2025 at 3:37 PM, Staff H positioned the red toileting sling around Resident 5's back with the assistance of Staff L. The staff adjusted the sling and wrapped it around Resident 5's waist and clipped it. They positioned the chair in a reclining position to position leg straps under the resident. The sling's straps were bucketed under both legs, not in-between the resident's legs. Staff H opened the legs of the mechanical lift and positioned the chair between legs. The staff hooked the straps on the top hook and the bottom hooks. Both staff support the resident as they lifted and transferred the resident into bed. They lowered the resident into bed and remove the lift, then sling. During an interview on 07/02/2025 at 4:19 PM, Staff C could not state how the red toileting sling should be used. During an interview on 07/02/2025 at 5:29 PM, Staff B, DNS and RN, said she did not know the correct way to use the red toileting sling. During an interview on 07/30/2025 at 5:04 PM, an email communication from Staff B documented training and education was started related to the proper use of the red toileting sling. <Fall investigation & Assessment of Preventative Measures> <Resident 1> Resident 1 was admitted to the facility on [DATE]. The quarterly minimum data set (MDS), dated [DATE], documented the resident had no cognitive impairment and was dependent on staff for ADLs. Resident 1 had no recent history of falls. The facility investigation, dated 06/01/2025, documented Resident 1 fell during a transfer with the mechanical lift. The staff were transferring the resident from their bed into their wheelchair when the resident slipped out of the mechanical lift sling, falling to the floor. Resident 1 hit their head on the bar of the mechanical lift resulting in a head laceration. Resident 1 was transported to the hospital. Witness statements noted staff had used the red toileting sling to transfer the resident. The resident was noted to be secured appropriately with the legs crossed underneath both resident's legs. The investigation conclusion is noted as unable to determine the root cause of this fall and found the resident was transferred out of bed according to the care plan. During an interview on 07/02/2025 at 4:19 PM, Staff C, said she completed the investigation on Resident 1's fall. The staff reported they crisscrossed the straps under the legs but not between the legs. Staff C did not investigate the manufacturer instructions to determine if the leg straps were used appropriately. Staff C could not state how the red toileting sling should be used and was not aware the manufacturer guidelines directed staff to crisscross between their legs. Staff C said the care plan did not note how the leg straps should be placed. Staff C said she did not evaluate other residents using the sling and did not watch residents transferred with the sling. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], documented the resident had moderate cognitive impairment and required substantial/maximal assistance from staff for ADLs. Resident 2 had two or more falls in the recent past/look back period with no injury and two or more falls with injury. The care plan, dated 06/29/2025, documented Resident 2 had actual falls due to Huntington's disease (a neurological disease which affects thinking ability, movements, and mental health) and an unsteady gait. The resident is noted as having 15 falls since January 2025. On 06/17/2025 at 11:05 AM, Resident 2 was observed lying in bed. The wheelchair was observed to have no anti-roll device. The fall investigation, dated 03/13/2025, documented Resident 2 fell on the floor in front of his wheelchair. The resident sat in wheelchair without waiting for staff to sit. Intervention included an anti-roll back wheelchair. The fall investigation, dated 03/13/2025, documented Resident 2 was sitting on the floor at the entrance of his room. Water was on the floor. It appeared he had been washing his hands. Poor lighting and improper footwear were noted. No documentation of prior toileting assistance was noted. No staff interviews related to the fall were noted. The care plan, dated 03/14/2025, documented the resident would be assisted with washing their hands. The investigation did not assess for prevention interventions related to the poor lighting, improper footwear, or the last time the resident was assisted with toileting. The fall investigation, dated 03/14/2025, documented Resident 2 fell when they stood up abruptly from the chair in their room then fell and hit their head. Staff were present in the room. The resident pointed to their fingernails and staff determined they wanted their fingernails cut. Portions of the investigations fall assessment were left blank. The root cause was gait imbalance. No interventions were documented. The fall investigation, dated 03/14/2025, documented Resident 2 had an unwitnessed fall in their room. The resident was found on the floor by the recliner. The resident wanted to use the bathroom. Portions of the investigations fall assessment were left blank. The investigation did not determine the last time the resident was assisted with toileting or if the resident fell from the bed, recliner, or wheelchair. The care plan, dated 03/14/2025, documented a referral for therapy to consider an anti-roll back wheelchair. The fall investigation, dated 04/12/2025, documented Resident 2 was found on the floor next to the bed. The investigation noted the resident did not use a call light. Portions of the investigations fall assessment were left blank. The investigation did not determine the last time the resident was assisted with toileting and what type of footwear the resident was wearing. The root cause determined is Resident 2's impulsiveness and self-transfers. The intervention was to add a soft touch call light to Resident 2's room. The fall investigation, dated 04/16/2025, documented Resident 2 was found sitting next to their bed on the floor. The resident did not use the call light. The care plan, dated 04/14/2025, documented Resident 2 needed a soft touch call light. The fall investigation, dated 06/03/2025, documented staff heard a loud bang and found Resident 2 on the floor next to the recliner. The resident sustained a cut to the right temple measuring 1.5 centimeters (cm) x 0.5 cm. A predisposing factor was listed as furniture but did not include how the furniture contributed to the fall. The resident had improper footwear on at the time of the fall. The investigation did not determine the last time the resident was assisted with toileting, whether the resident used the call light or within reach, or where the resident was prior to the fall. The root cause determined Resident 2 may have taken themselves to the bathroom or may have been sleeping and fallen out of bed. No care plan interventions were noted in the investigation or care plan. The fall investigation, dated 06/04/2025, documented Resident 2 was found sitting in the hall in front of his room with the food cover from their food tray next to him. The investigation did not determine the last time the resident was assisted with toileting, whether the resident used the call light or within reach, or where the resident was prior to the fall. The root cause determined the resident was trying to return the food cover to staff. The care plan, 06/05/2025, document staff will remove the food cover from the food trays. During an interview on 07/02/2025 at 4:19 PM, Staff C said the staff did not place the soft touch call light timely. <Resident 3> Resident 3 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], documented the resident had severe cognitive impairment and required substantial/maximal assistance from staff for ADLs. Resident 2 had no recent falls. The care plan, dated 06/27/2025, documented Resident 3 was at risk for falls due to Parkinson's disease, generalized weakness and decreased mobility. Resident 3 had 11 falls since January 2025. On 06/17/2025 at 11:48 AM Resident 3 was observed in their wheelchair. No anti-roll devices were noted on the wheelchair. The fall investigation, dated 03/20/2025, documented Resident 3 was found on the floor in the hallway holding their shoe. The assessment of the fall was blank in some sections and there were no staff interviews related to the fall. The root cause of the fall was self-shoe removal. The resident was to be assessed for anti-roll back wheelchair. The fall investigation, dated 04/28/2025, documented Resident 3 was in the shower area of the bathroom, on the floor and was likely standing using [shower] bar when lost balance. The resident's cell phone was on the ground. One brake was locked on the wheelchair. The investigation assessment was blank in some sections and there were no staff interviews related to the fall. The section noting last time toileted or brief check or change was left blank. The root cause and interventions included follow up for a urinary tract infection (UTI). The care plan, dated 04/28/2025, documented request urine analysis. The fall investigation, dated 05/23/2025, documented Resident 3 was found sitting on the floor facing the sink. The resident had toileted themselves. The investigation did not include interviews from staff or the last time the resident was assisted with toileting. Portions of the investigation assessment were incomplete or missing. The root cause was attempting to toilet on his own. The care plan, dated 05/27/2025, documented Resident 3 was sent the resident to the emergency room (ER). The fall investigation, dated 05/24/2025, documented Resident 3 attempted to grab a coke out of their fridge and fell. The wheelchair brakes were not locked. The assessment of the fall was blank in some sections and there were no staff interviews related to the fall. The intervention noted was to continue the same plan of care. The fall investigation, dated 05/24/2025, documented Resident 3 fell out of bed. The investigation assessment was blank in some sections and there were no staff interviews related to the fall. The investigation does not mention when staff last saw the resident or when they last toileted the resident. The intervention was to send to the ER. The investigation lacked a root cause of the fall. During an interview on 07/02/2025 at 4:19 PM, Staff C said Resident 2 and Resident 3 did not currently have an anti-roll back chairs and there was a long wait to get one. Staff C said no other interventions were implemented in its place. Staff C said there were pieces missing in each Resident's investigations. The unit coordinators were supposed to be gathering all the information, but it was done inconsistently. All fall investigations should be thoroughly investigated including an assessment of the fall and details before and after, root cause of the fall, and a care plan intervention. <Resident 4> Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident had no cognitive impairment and was dependent on staff for ADLs. Resident 2 had one recent fall with no injury. The care plan, dated 05/27/ 2025, documented Resident 4 was at risk for falls due to a disease of the nervous system causing muscle weakness and loss of control. The resident would be reminded to use the call light, encouraged to be active, and ensure they are wearing the proper footwear. The fall investigation, dated 05/24/2025, documented Resident 1 fell to the floor while reaching their glasses. The investigation noted staff will assess for an eyeglasses strap. No follow up in the investigation or care plan noted if the eyeglasses strap was obtained. During an interview on 07/02/2025 at 4:19 PM, Staff C said the resident did get an eyeglass strap but was not in the care plan. <Sling care> Review of the Vanderlift Operating Manual, November 2017, documented that nurse or professional rehabilitation staff must inspect all slings at least once a month for signs of damage, lose and missing stitching and/or tears or excessive wear that may cause the sling to fail. Slings that are damaged or excessively worn must be removed from service. A permanent record of each inspection and action taken should be kept by the facility. During an interview on 07/02/2025 at 5:29 PM, Staff B said they did not keep a record of the sling inspections. Reference WAC 388-97-1060(3)(g) .

Based on interview and record review, facility failed to ensure the care plan for safe transfers with a mechanical lift was followed for one of three residents (Resident 1) and failed to ensure one of three residents (Resident 2) was assessed for safe transfer with a mechanical lift after sustaining a head injury during a fall. Failure to follow the care plan for safe transfers caused harm to Resident 1 when he fell and fractured his lower leg during a transfer performed without the use of the mechanical lift. Failure to ensure priority assessments after Resident 2 sustained a head injury during a fall placed the resident at risk for further injury when he was transferred in a mechanical lift. Findings included . The American Nurses Association cited the Nursing Process as the common thread uniting nursing. The Nursing Process is the systematic collection and synthesis of data consisting of assessment, nursing diagnosis, planning, implementation and evaluation. Nursing standards include communication of the patient's status to appropriate members of the interdisciplinary team and documentation of the nursing care provided and the response to that care. According to the [DATE] Agency for Healthcare Research and Quality (AHRQ) guidance, if the head was hit during the fall the patient should not be moved until it was safe to do so as evidenced by assessment. AHRQ guidance included that cervical spine should be examined and if there was any indication of injury the cervical spine (neck area) should be immobilized and physician called. AHRQ guidance also listed the following priority assessments that should take place after a fall: assessment of circulation, airway and breathing, neurological observations, basic vital signs, and cleaning and dressing wounds. < Resident 1 > Resident 1 was admitted [DATE] with diagnoses including history of falling. Minimum Data Set, an assessment, dated [DATE], documented Resident 1 required extensive assistance of two staff with transfers. Care Plan for transfers, last revised [DATE], documented Resident 1 was to be transferred by two staff using a Hoyer lift, a mechanical device with a sling. Progress notes, dated [DATE], documented Resident 1 sustained a fall when he was transferred by two staff using a stand and pivot transfer instead of the Hoyer lift. Physician notes, dated [DATE], documented Resident 1 had a fall on [DATE] and subsequent imaging showed that there was a fracture of the left leg and the physician ordered the resident transferred to the hospital. On [DATE] at 12:00 PM, Staff D, Registered Nurse (RN), stated the facility's investigation of the fall showed the aides did not follow the care plan for safe transfer and instead transferred Resident 1 without use of the Hoyer lift. Staff D stated one aide floated from another unit to help and should have checked the care plan for Resident 1. Staff D said instead of consulting the care plan, the aide relied upon the information received from another aide who also did not check the care plan for Resident 1. Staff D was asked if there was a staffing problem on the unit the day Resident 1 fell and Staff D responded that staffing was a challenge that day with staff calling off and one staff member leaving because of illness. < Resident 2 > Resident 2 was admitted [DATE] with diagnoses including repeated falls. Resident 2's Fall Risk Assessment, dated [DATE], noted the resident was at moderate risk for falls. Progress note, dated [DATE], showed Resident 2 was found face down on the floor next to his bed and was assisted back to bed via a Hoyer lift (mechanical device with sling). The progress note documented there was a bump and abrasion on Resident 2's forehead. Resident 2 was quoted as explaining he was reaching for something. There was no documented assessment of Resident 2's cervical spine. Movement of extremities, ability to follow commands and cleansing and/or dressing of the wound on Resident 2's forehead were not documented. Movement of extremities and ability to follow commands were not documented as assessed. The progress note documented the physician for Resident 2 was contacted. Physician note, dated [DATE], documented the provider saw Resident 2 on video per a telehealth visit and stated the resident had a large bruise of his forehead and ordered resident to be transferred to the hospital. Hospital Death Summary, dated [DATE], documented Resident 2 died on [DATE] at 6:40 AM with manner of death stated as natural and the immediate cause of death was fracture of first and second cervical vertebrae. On [DATE] at 4:50 PM, Staff E, Registered Nurse (RN), indicated that after a resident falls, the nurse should conduct a head-to-toe assessment beginning with level of consciousness, airway, breathing, circulation, pain, bleeding, bruising, signs or symptoms of fracture, and if a resident had a head injury, the nurse should carefully assess the neck. Staff E stated that generally if there was a potential cervical spine injury the nurse would not want to use a Hoyer lift (mechanical device with sling for transferring) to transfer the resident from the ground to another surface. Staff E indicated it was important to know if it was safe to move the resident. At 5:12 PM, Staff B, Director of Nursing Services (DNS) indicated the expectation was that licensed nurses follow the nursing process after a resident's fall. Staff B indicated the nurse did not document a complete assessment prior to using the Hoyer lift to assist Resident 2 from the floor to bed. Staff B indicated that moving Resident 2 with the Hoyer lift would not be contraindicated if the nurse conducted appropriate assessments to determine if it was safe. Staff B indicated nurses should conduct and document relevant assessments and appropriate interventions after a fall. Staff B indicated that assessment and documentation of changes in resident condition were subjects of a recent and ongoing performance improvement project with education aimed at nurses' critical thinking and the nursing process. Reference WAC [DATE](3)(g).

Based on interview and record review, facility failed to ensure care planned interventions to prevent falls for one of three sampled residents (Resident 1) reviewed for avoidable falls were implemented and failed to ensure staff were oriented to facility policy regarding use of transfer gait belts (belts used around resident's waist for support during a transfer from one surface to another). Failure to follow care planned interventions and orient staff for transferring resident with a gait belt resulted in harm to Resident 1 who sustained a femur (thigh bone) fracture and endured severe pain. Facility Policy, Equipment- Transfer/Gait Belt, dated 09/17/2008, documented staff were to use a gait belt for resident transfers that did not involve the use of a mechanical lift. The policy documented the facility would train staff during new employee orientation regarding proper use of gait belts. The Policy documented that the care plan for residents who required assistance with transfers would provide directions for use of the gait belt. Facility Policy, Documentation - Resident Care Plan, dated 10/12/2010, documented the Resident Care Plan was the guide for all care and interventions on behalf of the resident, with problem areas to be addressed included safety and falls. Findings included . Resident 1 was admitted [DATE] with diagnosis of trauma to the spine causing some paralysis. The Minimum Data Set, an assessment, dated 02/02/2022, documented Resident 1 had a history of falls and needed extensive assistance to transfer between surfaces including from bed to chair. Progress Note, dated 04/25/2022, documented Resident 1 was 6 feet tall, weighed 243 pounds, and had right-sided paralysis. Care plan, dated 02/02/2022, documented Resident 1 should be transferred from bed to chair with extensive assistance and use of gait belt. Progress note, dated 04/12/2022, documented Resident 1 was found lying on floor and was not wearing a gait belt. The progress note documented Staff H, Certified Nursing Assistant and Temporary Agency Staff Member, were trying to transfer resident from the bed to chair and did not use a gait belt. Progress note documented Resident 1's pain level to right hip area was assessed 7-8 out of 10 on the pain scale. Progress note documented Resident 1 was sent to the hospital for evaluation. Hospital record, dated 04/18/2022, documented Resident 1 fractured the right thigh bone during the fall and had surgery to repair and stabilize the bone. Facility Incident Report Root Cause Analysis (determination of reason an incident occurred), dated 04/15/2022, documented the root cause of Resident 1's fall with injury was that Staff H relied on the resident's confirmation of morning routine instead of following the plan of care that instructed staff to use a gait belt for transfer. On 04/19/2022 at 3:36 PM, Staff E, Registered Nurse (RN) and Educator, stated Staff H did not receive orientation to the facility's policy for transferring residents and using gait belts. On 04/28/2022 at 3:30 PM, Staff F, Occupational Therapist, stated staff should have used a gait belt to transfer Resident 1. On 05/12/2022 at 11:12 AM, Staff B, Director of Nursing, stated the expectation was staff would follow the care plan and use a gait belt if it was care planned. At 11:15 AM Staff A, Administrator, stated the gait belt policy had been added to the orientation program for temporary agency staff members. At 2:15 PM Staff A stated the fall prevention program was a facility priority. Reference (WAC) 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to conduct thorough individualized assessments/reassessments and identify all risk factors with use of air mattresses, and/or develop specific care plans to assure resident safety during provision of care for three of five residents ( #s 1, 2 & 3), reviewed for air mattresses and falls from beds. Resident #1 rolled off the opposite side of the bed onto the floor during care provided by one staff, and experienced harm due to resulting pain and distress, which required emergency transport to the hospital for evaluation and treatment. Findings included: RESIDENT #1 Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Care plan for deficit in self-care performance showed the resident had activity intolerance and [DIAGNOSES REDACTED]. Intervention dated 03/29/19 included use of an alternating pressure mattress with setting to maximize comfort, function and safety. The care plan also showed staff initiated two person transfers with a mechanical lift on 10/16/18 and a tilt in space wheelchair on 04/12/19. A care plan for bowel incontinence initiated 10/16/18 showed Resident #1 required total assistance for incontinence care and used briefs. A nursing aide Kardex (care directives) included separate instructions for bed mobility and grooming/hygiene. Instructions under bed mobility did not state specifically how many staff needed to turn Resident #1 in bed to assure safety when providing incontinence care. Directives showed 1-2 staff could provide extensive to total assistance with personal hygiene and did not specify under what circumstances the resident would need one staff, or when two staff were needed. A facility fall investigation showed on 12/08/19 at 6:20 PM, one staff rolled the resident away from the side she was on and provided incontinent care for large amount of loose stool. The air mattress had a slippery cover and Resident #1 slid off the opposite side of the air mattress onto knees on the floor while holding the mobility bar. The investigation showed after knees hit the floor, the resident flipped onto her back and legs were crossed Indian style. The resident could not state what happened, complained of pain and stated, It hurts everywhere. When nursing attempted to move legs, the resident grimaced and moaned. Nursing note dated 12/08/19 showed Resident #1 received 911 transport to the hospital at 7:00 PM. A Hospital Emergency Department report dated 12/09/19 11:32 PM, showed Resident #1's final [DIAGNOSES REDACTED]. During an interview on 12/12/19 at 8:30 PM, Staff D, Certified Nursing Assistant (CNA), who provided care to Resident #1 at the time of the fall, stated she checked the care directive before assisting the resident, which showed one staff could provide personal care. Staff D stated she rolled the resident in the opposite direction because she would not be able to reach over to clean the resident if rolled toward her. During observation and interview with Staff D CNA on 12/12/19 at 3:46 PM, Staff D demonstrated how Resident #1 lay in bed on her side before the fall. Staff D stated the resident got uncomfortable when cleaned, started to fidget and moved upper leg forward. Staff D stated when the resident's upper leg moved off the edge of the bed, she reached over to try to stop the resident from falling but could not. During an interview on 12/12/19 at 8:50 PM, Staff C, Registered Nurse, stated that she saw Resident #1 on the floor of the room and asked if she could move her legs, and the resident stated that she had pain all over. Staff C also stated that three medics arrived and when they straightened the resident's leg, the resident moaned. Staff C stated, my impression was the resident seemed weaker and needed glass of water held when giving medications. Staff C also stated she later found out Resident #1 was sick and I did not know it. Resident #1 was on alert for potential change in condition. The record did not show licensed nursing staff reassessed the resident's current ability to assist with safe turning on an air mattress while observing for potential change in condition to assure adequate number of staff were present to ensure safety during care. CARE PLAN/AIDE DIRECTIVES NOT SPECIFIC The care plan did not provide parameters when one or two staff were needed to provide incontinence care and the facility allowed nursing assistants to make the decision. During an interview on 12/12/19 at 8:40 PM, Staff F, Licensed Practical Nurse stated that if Resident #1 was weak, two staff should provide care. Staff F stated nursing assistants knew if the resident was weak to ask for help. During an interview on 12/12/19 at 8:18 PM, Staff E, Certified Nursing Assistant (CNA) stated the aide kardex did not specify when one or two staff were needed to provide care. During an interview on 12/19/19 at 9:45 AM Staff B, Registered Nurse, stated the care plan should have clear measurable parameters to identify when a resident required two staff for care. Staff B confirmed Resident #1's care plan did not specify when two staff should provide care and not one. Staff differed what terminology on the aide directive showed how to provide incontinence care. During an interview on 12/12/19 at 8:40 PM, Staff F, Licensed Practical Nurse stated that personal hygiene listed in the directive applied to staff directions for incontinence care. During an interview on 12/19/19 at 3:41 PM, Staff M Certified Nursing Assistant (CNA) stated that personal hygiene on the aide directive meant brush hair, brush teeth and wash face. Staff M stated that toileting instructions on directives included incontinence care and changing briefs. AIR MATTRESS SAFETY ASSESSMENT Resident #1's record did not show staff conducted an individualized assessment for air mattress use that identified all potential risk factors. The record did not show staff assessed ability of Resident #1 to reposition self and control bodily movements during care, or level of assistance needed to turn and control lower extremities to prevent sliding off the mattress with one staff present. During an interview on 12/19/19 at 1:40 PM, Staff B, Registered Nurse, could not locate a safety assessment for use of an air mattress for Resident #1. DETERMINATION FOR ONE TO TWO PERSON CARE During an interview on 12/12/19 at 9:38 PM, Staff G, Certified Nursing Assistant (CNA) stated that if a resident was alert enough to follow directions, two staff did not need to provide care. During an interview on 12/09/19 at 8:55 am, Staff A, Director of Nursing (DON) stated that care directives showed one staff was needed if the resident was strong and two staff if residents were weak. Staff A also stated that if a resident needed more help with care, aides were expected to ask for help. During an interview on 12/19/19 at 2:25 PM, Staff K, Registered Nurse (RN) stated that nursing assistants assessed the situation and decided if one or two staff should provide care. Staff K stated that if a resident had a large stool, became tired, showed signs of agitation, or had an infection, two staff should give care. During an interview on 12/19/19 at 3:11 PM, Staff L, Licensed Nurse (LN), stated that a resident needed to be able to roll back and forth in bed in order for one staff to be able to provide care. During an interview on 01/07/20 at 1:40 PM, Staff N, Registered Nurse, stated that if a resident could not hang onto the bed bar or assist with turning in bed, had behaviors or resistive with care or had a change in condition, two staff should provide care for safety. Staff N also stated if a resident could hold onto a bed rail one person could provide care. During an interview on 01/07/20 at 1:00 PM, Staff N, MDS Coordinator, Registered Nurse (MDS, RN) stated that a risk factor for use of an air mattress could be falls. If a person could hold onto a mobility bar they were considered a one person. If residents did not have ability to turn in bed they needed two staff to provide care. Resident #1 held onto the bar when her lower body slid off the mattress. The resident could not maintain physical control of lower extremities and the resident fell on to the floor, resulting in pain. The record did not contain a thorough assessment to determine amount of staff assistance the resident required to remain safe when turning in bed. RESIDENT #2 A facility [DIAGNOSES REDACTED].#2 has [DIAGNOSES REDACTED]. An Annual MDS dated [DATE] showed Resident #2 had functional limitation in range of motion of both lower extremities and required extensive assistance from one staff to turn in bed and two staff to assist with transfers. A care plan for self-care deficit performance due to left sided weakness showed the resident had an alternating pressure mattress initiated 06/07/18. During observation and interview on 12/19/19 at 3:43 PM, Resident #2 had an air mattress with raised sides on the bed and mobility bars on each side of the bed. Resident#2 stated that he once woke up and decided it was time to get out of bed and kept scooting toward the edge of the bed and fell . The resident denied physical injury. A facility investigation dated 11/17/19 showed Resident #2 stated he slid off the bed during a bad dream and previously slid out of bed on 10/28/19 during attempt to reposition self. A facility Safety Device/Enabler assessment dated [DATE] listed check boxes for risk factors of multiple assistive devices that included bilateral bed handles, recliner and alternating pressure mattress. Risks included memory, impaired decision making; body control problems, poor body alignment, partial ability to balance, history of falls, medications, sensory deficits and incontinence. Resident #2's medical record did not include individualized assessments for each device that included analysis of risks and benefits supported with observations. The assessment did not identify if and how staff determined the mattress contributed to falls. During an interview on 12/19/19 at 1:40 PM, Staff B Registered Nurse (RN) stated that the assessment (11/28/19) reviewed for potential restraint. During an interview on 01/07/20 at 12:25 PM, Staff B RN stated that assistive device assessments could often combine use of multiple devices, such as low beds and mobility bars. If staff added another device later, it could be assessed separately. RESIDENT #3 A facility Resident Dashboard showed on 11/08/19, Resident #3 admitted with [DIAGNOSES REDACTED]. An Admission MDS assessment dated [DATE] showed the resident had impaired memory and history of fall in month prior to admission. During observation on 1219/19 at approximately 3:00 PM, Resident #2 lay in bed on an air mattress with the bed in the lowest position. The resident was non-verbal. A family member stated the resident would get confused and try to get up out of bed. Facility investigations showed staff found Resident #2 on the floor next to the bed lying on a fall mat on 12/14/19 and 12/16/19. The record did not contain evidence staff conducted a safety assessment for use of an air mattress to rule out as a contributing factor for falls out of bed. During an interview on 01/07/20 at 2:55 PM, Staff A, Director of Nursing (DON) stated that the air mattress did not contribute to the falls. Staff B RN, stated that although there was no formal assessment, although she looked to rule out the air mattress as a contributing factor for falling. Following a meeting on 11/07/20 at 3:00 PM, the facility did not provide further evidence staff conducted and documented a risk/benefit analysis for air mattress use for Resident #1, Resident #2 and Resident #3 that included how the air mattress affected physical functioning limitations with turning in bed and maintaining control of body positioning during care. Assessments were not found that showed the facility assessed air mattress use with mobility bars and risks/benefits for entrapment and falling out of bed. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to thoroughly and accurately monitor wounds for two of 10 residents (Resident #s 49 and 137) reviewed for skin related injuries and failed to ensure proper support and wheelchair positioning for one of six residents (Resident #133) reviewed for positioning and mobility. In addition, the facility failed to monitor changes in condition after a fall for two of 13 residents (Resident #s 149 and 215) when reviewed for accidents. These failures placed residents at risk for medical complications, unmet needs, unmet needs, discomfort and pressure-related skin impairments. In addition, these failures resulted in harm to Resident #149 when a fracture and change of condition was identified after a fall two days later. RESIDENT #149 Refer to F610 for additional information and resident history. Review of the quarterly Minimum Data Set (MDS, a required assessment tool), dated 04/02/19, showed Resident #149 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was alert, had short term memory loss and impaired judgement. The MDS further showed that Resident #149 was given antipsychotic, antidepressant and opioid medications. Review of the care plan dated 04/15/19 showed Resident #149 had an alteration in comfort related to cervical stenosis (abnormal narrowing of the spinal canal that can result in neck/back pain, weakness, numbness or burning sensation in the shoulders/arms/legs and gait impairment). The goal was for the resident to be able to verbalize or indicate adequate pain relief with current pain intervention. Interventions included: Increased agitation may be related to having pain/discomfort in neck and/or shoulders; If the resident complained of pain, the Licensed Nurse (LN) will assess and use pain management form tool; Monitor for possible adverse side effects of pain medications including constipation, over-sedation, respiratory depression and notify the physician. The 04/15/19 care plan further showed that Resident #149 had an alteration in communication and cognition (confusion, delusion, paranoia) related to dementia and post-traumatic stress disorder ([MEDICAL CONDITION]). Interventions included that the resident's speech was clear and understands what is being communicated and can make himself understood; Has episode of confusion, delusions and paranoia- at these times, he may have trouble understanding what is being said and communicating his needs; The LN will assess when any changes in the resident's ability to communicate or increased confusion and make a referral as needed. Review of the (MONTH) 2019 Incident and Accident Log showed Resident #149 sustained a fall with a fracture on 05/14/19. Review of the incident report of the fall that occurred on 05/14/19, showed there were two incident reports for the same incident, one that resulted in no injury, and the other in at latent injury: a left [MEDICAL CONDITION]. The incident reports showed Resident #149 was found on the floor in his room at 5:00 AM, laying on his right side, and was fairly anxious. Resident #149 complained of left hip pain and later left shoulder pain. Staff SS, RN2, responded and assessed the resident has having no injuries. The incident report further showed that an addendum was made on 05/16/19, Sent to ER (emergency room ) for decreased L[NAME] (level of consciousness), drowsy, Fx (fracture) L (left) ischial tuberosity ([MEDICAL CONDITION]) found on x-ray on 05/16/19. The incident report did not identify if the pain Resident #149 felt was usual, unusual or worse than normal. The incident report also did not include a full skin assessment to see if there were any reddened areas or bruises that may have developed from the fall or any latent bruising/changes. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The resident did not receive any doses from 05/01/19 to 05/13/19. Review of nursing progress dated 05/14/19 at 8:48 AM showed Resident #149 complained of pain in his hips and shoulders after the fall. Staff SS, Registered Nurse 2 (RN2), assessed the resident and determined there were no injuries. Staff SS, RN2, gave the resident [MEDICATION NAME] and Quetiapine (antipsychotic) were given with effect. The progress note further showed the resident was placed on alert charting. Review of nursing progress notes dated 05/14/19 at 9:41 AM and 7:24 PM, showed Resident #149 denied pain, resumed his usual routine, neurological assessments were within normal limits, and would continue to monitor. Review of nursing progress notes dated 05/15/19 at 4:24 AM, showed Resident #149 was awake at 3:30 AM, was incontinent of urine, denied pain but noticed discomfort in his left hip when he was repositioned. [MEDICATION NAME] was given and continued to monitor. Review of nursing progress notes dated 05/15/19 at 9:03 AM, showed Resident #149 complained that his left arm was still painful. The resident was given PRN (as needed) pain medication. Review of nursing progress notes dated 05/15/19 at 11:48 AM, showed an order was received for an x-ray of his left shoulder, left hip and left knee related to falls and pain. At 9:23 PM, the x-rays to the left shoulder and hip were negative for fracture and dislocation from the fall. The resident requested to stay in bed that shift. Received PRN [MEDICATION NAME] for left shoulder pain. Review of nursing progress notes dated 05/16/19 at 2:01 AM and 8:58 AM, Resident #149 was sleeping on and off in wheelchair and no behaviors were observed. Nursing progress note dated 05/16/19 at 10:16 AM, showed Resident sent via ambulance at this time (to the hospital) . related to resident's change in condition in L[NAME], very drowsy, pale, jerking movements, 110/50, HR (heart rate) 49, R (respirations) 24 . Review of nursing progress notes dated 05/16/19 at 9:33 PM, Resident #149 returned from the hospital with a [DIAGNOSES REDACTED]. A 2 centimeter (cm) x 2 cm bruise was found on his right buttock, possibly latent bruise from the fall. Review of hospital record dated 05/16/19 showed, (Resident #149) was sent from (facility) for evaluation of altered mental status and worsening speech clarity over the last 2 days since an unwitnessed fall . The patient complains of pain to his 'legs' on both sides and localized pain to his 'hips'. The nursing progress notes did not identify any assessment or evaluation related to increased pain or potential changes in condition between the fall on 05/14/19 and 05/16/19. In an interview on 06/10/19 at 10:16 AM, Staff UU, Investigative Nurse/RN3 (IN/RN3), was asked why it took two days to identify a fracture and change of condition and the reason for Resident #149's decreased L[NAME], Staff UU, IN/RN3, stated she was not certain, as it was not documented. In an interview on 06/13/19 at 8:30 AM, Staff B, Director of Nursing Services (DNS), stated that she would have expected documentation to explain why Resident #149 was drowsy on 05/16/19 and was not sure why it took until 05/16/19 to identify the change in condition and the fracture. RESIDENT #215 Review of the admission MDS, dated [DATE], showed that Resident #215 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was alert, had short term memory loss, impaired judgment, was hard of hearing, had difficulty communicating needs/wants and understanding others, had impaired vision, and demonstrated behaviors including rejecting care and wandering. The resident required two-person physical assistance for transfers with unsteady gait/balance, toileting, and one-person physical assistance for dressing and bathing. Review of the (MONTH) 2019 Incident and Accident Log showed Resident #215 sustained an unwitnessed fall on 05/13/19. Review of the 05/13/19 incident report showed Resident #215's blood pressure was elevated at 160/96. It was unclear if this was normal for Resident #215 or if there was a medical concern at the time. The issue was not addressed in the investigation. Review of the nursing progress notes dated 05/13/19 at 11:52 PM, showed Resident #215 sustained an unwitnessed non-injury fall at 4:30 PM, but did not mention the elevated blood pressure or physician notification related to the elevated blood pressure. Review of the nursing progress notes dated 05/14/19 at 12:16 AM and 05/16/19 at 10:01 PM, showed no mention of Resident #215's elevated blood pressure, the possible cause, or recommendations from the resident's physician. RESIDENT #49 Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 03/07/19, showed that Resident #49 readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS showed that Resident #49 had an indwelling catheter (a tube that drains urine from the bladder into a bag outside the body), was at risk for developing pressure ulcers and received application of ointments/medications and nonsurgical dressing treatments. Resident #49 was able to make needs known. Review of Resident #49's document titled, Alteration in Skin Condition Record, showed the wounds to the right upper thigh were first observed was 04/15/19. In addition, it showed that Resident #49 had multiple open areas; however, there were no measurements of the wounds nor did it indicate how many wounds Resident #49 had. Multiple dates (04/22/19, 04/29/19, 05/06/19, 05/13/19, 05/20/19, 05/27/19 and 06/03/19) showed incomplete documentation which did not include: description of the wound, drainage type and amount of drainage, current treatment, special interventions, pain and progress of wound healing. During an interview on 06/06/19 at 2:52 PM, when asked if Resident #49's alteration in skin condition record met her expectations, Staff B, Director of Nursing Services (DNS), stated, No. Staff B, DNS, further stated that there should have been measurements and descriptions for every single open area, as well as the surrounding skin areas, and a drawing of the wounds if possible. RESIDENT #137 Refer to F-610 for addition information Review of the annual MDS dated [DATE] showed that Resident #137 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS further showed Resident #137 had a skin impairment and memory deficits. Review of the Alteration in Skin Condition records for Resident #137 showed skin impairment to the left side of the foot. Entries on 05/09/19, 05/10/19, 05/17/19, 05/24/19 and 05/31/19 showed incomplete documentation to include: measurement, description of the wound, drainage type and amount of drainage, special interventions required, current treatment, pain and progress of wound healing. Review of the medical records on 06/10/19 at 11:00 AM showed that on 10/05/18 a skin tear was found to the side of the left foot by the pinky toe, which is located over a boney prominence. Observation on 06/10/19 at 9:38 AM of Resident #137 with both Staff G, Registered Nurse 3 (RN3), and Staff H, Licensed Practical Nurse (LPN), showed that Resident #137 had skin impairments on the outside of the left foot by the pinky toe and two small areas on the left great (big) toe. During an interview on 06/10/19 at 10:08 AM, Staff G, RN3, stated that she knew that the wound started out as a skin tear on 10/05/18 and had not healed. When asked what type of wound it was (i.e. abrasion, pressure, vascular, arterial or diabetic ulcer), Staff G, RN3, stated that she was unable to determine what type of wound it was and had not consulted the doctor to make that determination. In addition, Staff G, RN3, stated that the expectation was that the alteration in skin condition record documentation should be completely filled out. RESIDENT #133 Review of the quarterly MDS dated [DATE], showed that Resident #133 admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS further showed that Resident #133 was dependent on others for her daily care needs, was wheelchair-bound and had limited range of motion on both sides of her body. Observation on 05/29/19 at 1:48 PM showed that Resident #133 was in her wheelchair in her room, tilted back approximately 45 degrees. Her head was not resting on the head rest, and she appeared to be holding it forward. Observation and interview on 06/03/19 12:41 PM showed that Resident #133 was in her wheelchair in her room, with the right side of her head resting against a metal bar that ran alongside the headrest of the wheelchair. The headrest appeared to be positioned too far back for Resident #133 to rest her head against it. When asked how her neck felt, Resident #133 stated, Ok. When questioned about any discomfort related to how she held her head up, Resident #133 stated, It hurts sometimes, but there's nothing I can do about it. When asked about the right side of her head resting against the metal bar, she stated, Yes! That's hard. In an interview on 06/03/19 at 12:47 PM, Staff G, RN3, stated that the Therapy Department was responsible for ensuring proper fit for specialized wheelchairs, and that a request for a wheelchair to be re-assessed would be made if staff were to find that there were changes in the resident that would impact the fit of the wheelchair, or if staff observed that the resident did not appear to fit properly. In an interview on 06/03/19 at 1:02 PM, Staff OO, Physical Therapist (PT), stated that she knew it had been a concern that Resident #133's head did not rest on the headrest. Staff OO, PT, further stated that a therapy evaluation had not been requested for Resident #133's wheelchair headrest. Reference WAC 388-97-1080 (3)(b)

Based on observation, interview and record review, the facility failed to ensure a safe resident environment and failed to provide increased supervision for Resident #1 who had possession of a gun and other weapons and had a known history of suicidal thoughts and having a plan to commit suicide. This failure placed Resident #1 at risk for acting on his suicidal thoughts, and potentially causing self harm, or death. Additionally, this failure placed staff and other residents at risk of being victims of violence or witnessing a violent act with use of the weapons in the facility. The facility also failed to immediately investigate and increase supervision of an alleged gun transaction (buy and sell) between Resident #s 2 and 3 in the facility. The facility demonstrated serious disregard for consequences of the likelihood for serious injury and harm, placing all residents at the facility in an immediate jeopardy situation. Immediate Jeopardy was identified on 03/07/19. Findings included: SAFE ENVIRONMENT/INCREASED SUPERVISION A Review of facility incident report provided by Staff C, Investigative Nurse, on 03/07/19 at 4:42 PM, showed Staff A's, Superintendent, statement describing weapons and assorted bullets/casings located in Resident #1's room on 03/01/19. The description included a loaded gun found on the resident's bed while he was out in the community. The gun was dismantled by Staff A, and locked up at the facility at 1:38 PM. A room search completed by the facility staff on the same day found a knife set, two boxes of .22 caliber bullets, each with 50 shells and casings from blanks. The police department was not notified about the gun incident on 03/01/19. According to Staff A, Superintendent, during an interview on 03/07/19 at 6:45 PM, he indicated it was not necessary to contact the police. Staff A chose not to inform direct care staff about the incident. Staff A, Administrator, was notified of Immediate Jeopardy (IJ) on 03/07/19. Review of police report dated 03/07/19 at 7:40 PM, six days later, showed Resident #1 spoke with the officer on duty and stated he knew weapons were not allowed in the facility. Resident #1 said he did not know why he bought the gun. Resident #1 told the officer he did not purchase any guns recently because he realized that due to his history alcohol use and his [DIAGNOSES REDACTED]. In the same report it showed Staff A, Superintendent, told the resident that from now on his room will be checked when he returns from community outings On 03/07/19 between 1:00 PM and 4:00 PM eight direct care Staff M, I, N, S, R, T, Y, & P, (Nursing Assistants and/or Licensed nurses) reported they worked with Resident #1 between 03/01/19 and 03/07/19. The staff reported they did not know about the gun incident on 03/01/19 and did not receive guidance for increased supervision. Staff P, Anonymous, said if staff had known that a resident had a gun they would have increased safety rounds and checked on the nurse and the aid. Staff P said the facility did not inform staff of finding weapons and staff did not know, and were not directed, to increase supervision after the incident occurred. Staff Z, Licensed Nurse, interviewed on 03/07/19 at 3:10 PM, stated he was on duty on 03/01/19. Staff Z said there was no increase in supervision after firearms were found in Resident #1's room. The facility did not increase supervision following the incident on 03/01/19 as evidenced by not informing direct care staff about the incident and/or updating the care plan, and initiate alert monitoring. Refer to F657 for failure to update care plan Refer to F684 for failure to initiate alert charting RESIDENT #1 Record review showed Resident #1 signed admission document titled: WASHINGTON STATE DEPARTMENT OF VETERANS AFFAIRS ADMISSION AGREEMENT on 02/05/16. Page 3 of this document informed the resident that firearms and the edged weapons (a device that has a sharp enough edge to cut, slash or stab, such as a knife, axe or sword) were prohibited on the premises. If firearms were found on a person and/or their belongings, the items would be turned over to the police. Resident #1 admitted to the facility on [DATE] according to quarterly Minimum Data Set (MDS, a required periodic assessment) dated 01/03/19. The MDS assessment dated [DATE] showed the resident was cognitively intact and was able to walk by himself inside and outside of the facility. Resident #1 had [DIAGNOSES REDACTED]. According to a physician note dated 11/11/18, Resident #1's medical history included liver [MEDICAL CONDITION], end stage liver disease, long history persistent nausea/vomiting and chronic pain related to disease of the digestive system. The same note showed the resident experienced persistent [MEDICAL CONDITION] spasms and pain. On 01/15/19 Staff F, Social Services (SS), documented a request for Psychiatry Consult. The same note read Can you please assess for [MEDICAL CONDITION] (Post Traumatic Stress Syndrome) diagnosis? Resident met criterion for [MEDICAL CONDITION] do you want to give him a [MEDICAL CONDITION] diagnosis? Record review did not find evidence that the [DIAGNOSES REDACTED]. On 03/12/19 at 12:30 PM, during an interview Resident #1 said he experienced daily pain in his throat and stomach after his esophagus ruptured over three years ago. Resident also experienced daily nausea and had chronic vomiting. The resident said he felt embarrassment when he vomited in public. Resident said he was frustrated with his facility care givers because they repeatedly asked about his physical problems when they couldn't help his problem. During interview on 03/07/19 at 6:30 PM, Staff F, Social Services (SS) described Resident #1 as very active and out in the community all day long. Between 03/01/19 and 03/13/09 Resident #1 left the facility eleven times totaling being out of the facility for 38 hours, according to the Resident sign out/in log. Interviews were conducted with Staff S, Licensed Nurse (LN), Staff T, LN, Staff R, Nursing Assistant (NA), U, NA, P, and Staff V, Medical Doctor between 03/07/19 4:40 PM and 03/21/18 at 3:30 PM. Direct care staff described Resident #1 frequently demonstrated behaviors towards staff including; anger, screaming, throwing things, verbal aggression, hostility, and that he was volatile and unpredictable. Staff P, anonymous, said nursing staff did not go into Resident #1's room unless they had to due to his history of anger and aggression. Staff P said when nursing staff needed to go into Resident #1's room to give medications, he/she would find a second staff member to go into the room with them to stand by the nurse in case the nurse needed protection from Resident #1. Staff P, said the Resident #1 became volatile at things that were not commonly bothersome to other people. Review of a Social Worker annual assessment note dated 01/03/19 showed the resident's mood declined when he had increased health problems. During interview on 03/12/19 at 2:04 PM, Staff B, Director of Nursing, stated there was no need for all staff to know about the situation because the resident was seen by social services and was determined by them as not currently suicidal. According to Staff B, DNS, since Resident #1 was not suicidal, staff were not directed to increase awareness of his room or increase supervision of his daily activities because she did not want staff to treat Resident #1 differently than other residents in the facility, such as being more closely monitored than others. Review of Resident #1's care plan on 03/12/19 showed it did not include information clarifying use of knifes or sharp edges items. Refer to F552 for additional information. RESIDENT #3 According to MDS assessment dated [DATE], Resident # 3 did not have memory problems and was able to make independent decisions. On 03/06/19 at 12:07 PM Social Services, SS, note showed that Resident #3 allegedly was purchasing weapons from Resident #2. The Resident #3 volunteered his room for immediate search. The social worker declined the invitation. On 3/11/19 a social services note showed a knife was found in Resident #3's room, in a drawer on 03/08/19. Resident #3 was unavailable for an interview. RESIDENT #2 Resident #2 admitted on [DATE] with [DIAGNOSES REDACTED]. The notes revealed Resident #2 experienced ongoing agitation, anger, verbal and physical aggression. The behaviors occurred without a stimulus or provocation. On 03/08/19 at 1:00 PM Resident #2 was observed in a wheelchair while reminiscing about his military career. On 03/08/19 at 12:40 PM, Social Services (SS) note revealed Resident #2 was asking someone to bring a 22 pistol. The social services note stated, He was direct in that he was selling a gun, but denied it was any residents at the facility. On 03/13/19 at 9:37 AM, a behavioral note showed that several days ago Resident #2 was overheard talking about selling guns to another resident the unit. The same note stated This same subject has been addressed with this resident multiple times. In December, (YEAR) resident was having conversations with other residents about selling guns. This was the second note in less than a week which showed staff were aware Resident #2 was seeking a gun to sell while in the facility. The facility did not have evidence showing increased supervision for Resident #2 and Resident #3 when facility staff became aware of conversation about buying/selling guns on 03/06/19. The facility failed to adequately increase supervision of residents who were identified by staff as actively seeking weapons, or actually having weapons in his/her possession. This failure placed all staff, residents and visitors at potential risk of being victims or witnesses to violent acts. The IJ was removed on 03/14/2019 as a result of findings during an onsite verification visit the same day. WAC REFERENCE 388-97-3220(1)

Based on observation, interview and record review, the facility failed to ensure Resident #1, who had a history of [REDACTED]. This failure placed Resident #1 at risk of increased thoughts of self harm and potentially acting on them, thus causing self harm and/or death. The facility failed to acknowledge and assess the underlying causes of the ongoing expressions of emotional distress and/or suffering related to multiple factors including cyclical exacerbation of physical illness. Additionally, the facility did not have a system in place for collecting data of target behaviors in order to identify indicators of emotional distress, which are known to be contributing factors for self harm or suicidal thoughts. The combination of these failures constituted an Immediate Jeopardy situation identified on 03/11/19 and the facility's Administrator was informed on that date. Findings Included . RESIDENT #1 Resident #1 was admitted to the facility in (MONTH) (YEAR) according to the quarterly Minimum Data Set (MDS, a required periodic assessment) dated 01/03/19. Resident #1 was cognitively intact and was able to walk without assistance. His [DIAGNOSES REDACTED]. Further record review showed a Preadmission Screening and Resident Review (PASRR) in (MONTH) (YEAR), revealed Resident #1 had an episode of suicidal ideation and had a plan to harm himself. According to a facility psychiatry request form on 12/16/16, Resident #1 had suicidal thoughts and a specific plan to end his life. Resident #1 wanted to put himself out of misery and described his plan to the provider. A facility incident report provided on 03/07/19 at 4:42 PM, revealed a loaded gun, an assortment of bullets/casings, and other sharp edged items were found in Resident #1's room on 03/01/19. The incident report indicated the gun was purchased in (MONTH) (YEAR). On 03/08/19 at 10:08 AM, a social services note referred to a document within the resident's chart. The document dated 03/01/19, described some of Resident #1's stressors: - A traumatic experience after witnessing significant other dying and still being haunted by it. - Distraught feelings after a major organ ruptured leaving resident suffering unpleasant daily physical symptoms and inability to work, travel and loss of career qualifications which was very important to the resident. -The document showed resident suffered tremendous physical pain as a result of the disease condition. It also described that resident had to live with this every day and night. Following discovery of a loaded gun in the resident's room on 3/01/19, the facility failed to timely identify and thoroughly evaluate all potential indicators that may contribute to Resident #1 having returning thoughts of self harm or suicide, including but not limited to: -Review of care guide on 03/07/19 showed the resident was giving away belongings -resident had a history of [REDACTED]. -Resident #1 suffered from chronic pain, intractable nausea/vomiting and problems sleeping. -Multiple hospitalization s. The last hospitalization in (MONTH) (YEAR) resulted in Resident #1 needing kidney [MEDICAL TREATMENT] due to severe dehydration related to exacerbation of chronic medical condition. -Emotional disturbances as evidenced by ongoing behaviors noted in the nursing notes from (YEAR)-2019. On 3/22/19 at 9:10 AM, during an interview, Resident #1's physician, Staff W stated that Resident #1 had 11 hospitalization s, and described him having impulsivity and poor insight. Resident #1's medical problems affected his psychological state. On 3/12/19 at 12:30 PM, Resident #1 was observed sitting on the bed. During an interview at this time, the resident did not maintain eye contact. Resident #1 said he experienced painful [MEDICAL CONDITION] spasms nausea/vomiting, and throat pain. The resident said he experienced this pain daily. Resident #1 reported his average pain level is eight to ten based on a one to ten scale (severe pain) daily. Resident #1 indicated prescribed treatments had resulted in minimal relief of his symptoms. Resident #1 said this had been going since (YEAR). The resident said he had constant nausea, frequent vomiting and at sometimes vomited blood. Resident #1 said he was embarrassed when he vomited in public. Resident #1 also stated feeling frustrated when staff repeatedly asked him about his physical problems when they knew they could not do anything to fix it. Resident #1 explained he felt the nursing staff saw him for just for his physical problems and said he did not feel people saw him as a normal person. Resident #1 said, they only ask me about nausea and offer medications. Resident #1 said when he feels the spasms he is not able to swallow medications. Resident #1 said sometimes he vomits right after getting the medications, therefore, the medication comes up and is not effective in treating his nausea. Resident #1 said he takes most medications by mouth. When asked if anyone approached him about using alternative routes for pain or anti-nausea medications, such as injections or under the tongue, he replied no. During the same interview, Resident #1 indicated that he likes going out into the community and gets frustrated when he is sick and not able do that. Resident #1 said he wanted to have counseling but there had been transportation problems in the past, so he was not able to go. Resident #1 also mentioned he used to see an acupuncturist approximately a year ago and it helped. The resident said he was not sure why the treatment was stopped and no one explained to him if it was an insurance issue or if there was another reason why he no longer was receiving the treatment. Review of acupuncture appointment notes dated (MONTH) (YEAR), confirmed the acupuncturist reported the treatment was beneficial. The same record review showed there was no evidence in the record if interdisciplinary team discussed trying using medications using alternative routes. Interviews were conducted with Licensed Nurses and Nursing Assistants: Staff S, T, R, U, P, and Staff V, physician, between 03/07/19 4:40 PM and 03/22/18 9:00 AM. According to the interviews, Resident #1 frequently demonstrated inappropriate behaviors towards staff including: anger, screaming, throwing projectiles, verbal aggression, hostility, volatility and unpredictability. Staff said they did not go into his room unless they had to. Staff said the resident became volatile at things other people didn't usually get upset with. A Social Services Annual Assessment note dated 01/09/19, showed Resident #1's mood fluctuated over the past year and his mood declined when he experienced increased health problems. The assessment indicated Resident #1 was having trouble sleeping. There was no evidence resident's hours of sleep were monitored. A note by Staff F, Social Services, SS, dated 01/15/19, showed that there was a request for a psychiatric consultation after completing screening tool (PCL 5, an assessment that indicates the presence and severity of [MEDICAL CONDITION] symptoms) the note showed the resident met the criterion for [MEDICAL CONDITION]. The note showed Staff F, SS, asked the physician if he/she wanted to list [MEDICAL CONDITION] as a [DIAGNOSES REDACTED]. A physician's note showed an assessment related to the resident's condition after finding the gun on 03/01/19. The note was dated 3/12/19, eleven days following the incident. The resident reported to the physician his pain was 10/10. The note identified Resident #1 is often out of the facility and misses scheduled medications to treat his pain and digestive symptoms. The note indicated Resident #1 was using marijuana which could have contributed to recurring vomiting. The note did not address ruling in or ruling out [MEDICAL CONDITION] diagnoses. A behavior team/GDR (Gradual Dose Reduction) meeting note, dated 01/22/19 and signed on 3/14/19, did not include evidence that the underlying causes of Resident #1's behaviors and emotional distress were reviewed. The note did not reflect whether team evaluated what triggered the resident's behaviors. The care plan did not include specific steps staff could implement to de-escalate behaviors and/or acknowledge his feelings when he demonstrated anger and frustration In an interview on 3/12/19 at 4:12 PM, Staff C, provided documentation of facility monitoring Resident #1's behaviors of anger/aggression prior to him purchasing the gun in (MONTH) (YEAR) and after staff found a gun and ammunition on 03/01/19. Staff C, showed that target behaviors being monitored did not match the behaviors listed in the care plan and did not match those identified in the psychosocial assessments. Staff C reported the daily behaviors were documented by the nursing assistants, not licensed nursing staff. In an interview on 3/20/19 at 9:25 AM, Staff H, RN, said that prior to the electronic medical record (EMR) implementation in (MONTH) (YEAR), the nurses tracked resident behaviors daily. When EMR was rolled out, nurses lost daily tracking records. Staff H said, We no longer track behaviors. On 3/20/19 at 2:54 PM, Staff D, Corporate consultant, explained that a problem with the target behavior monitoring system was identified and the facility was in the process of improving the system. Review of resident roster showed at least 38 other residents had actual [DIAGNOSES REDACTED]. The lack of a systematic approach to managing veteran's/resident's emotional well-being, especially when they had trauma and/or [MEDICAL CONDITION], increased the risk of suicidal thoughts not being identified timely and created avoidable emotional suffering. The IJ was removed on 03/14/2019 as a result of findings during an onsite verification visit the same day. Refer to F689 for information on lack of supervision for Resident #1. Refer to F684 for additional information related to lack of initiating alert monitoring for Resident #1. Refer to F552 for additional information related to updating the care plan for Resident #1. Refer to F610 for information related to lack of thorough investigation for Resident #1. Refer to F609 for not reporting the incident on 03/01/19. WAC REFERENCE 388-97-1060(3)(e).

Based on observation, interview, and record review, the facility failed to ensure staff conducted a transfer with a mechanical lift in a safe manner to prevent an avoidable fall for 1 of 3 sampled residents (#1) reviewed who transferred with mechanical lifts. Staff did not report the fall to nursing staff until two days later when X-rays were obtained and identified the resident sustained [REDACTED]. Failure to ensure safe transfer technique during a transfer, resulted in harm for this resident. Findings include: Refer to F 225 for failure to immediately report Resident #1 to nursing and administrative staff. Refer to F 157 for failure to immediately report changes in condition for Resident #1. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A care plan dated 7/5/10 for Alteration in Safety, identified Resident #1 had a potential for falls, weakness of lower extremities, poor safety judgement, periods of restlessness with attempts at independent transfers/crawling out of bed, impulsive behavior with periods of confusion related to dementia. A Self-Care Deficit Care Plan dated 7/5/10 included staff interventions to obtain two persons to assist with care if the resident became agitated and care must be provided, or to re-approach if care could wait and report to the licensed nurse. The care plan also stated for two staff to use a mechanical lift to transfer the resident on and off a shower chair. Nursing Care Directives updated 10/26/16 identified Resident #1 required extensive assistance for showers; hygiene; dressing and to turn in bed. Directives identified the resident used a tilt in space wheelchair to meet positioning and comfort needs; had some difficulty making needs known and understanding others, especially when agitated; was slightly hard of hearing and had poor vision. Aide directives included interventions found in the Self Deficit Care Plan regarding management of resident behaviors and the need for two person care when the resident became agitated or combative. During observation on 1/19/17 at 1:05 p.m., Resident #1 sat with eyes closed in a reclined position in a tilt wheelchair in front of the television. The resident had knees bent and legs extended and wore a knee brace on the right leg. The resident wore a foam boot on the left lower leg with the lower portion of the leg and foot exposed. Multiple lengths of tape were visible extending from the top of foot by toes up the resident's leg beneath clothing. The left foot appeared swollen and top of toes were discolored light purple. The resident did not respond when spoken to at this time. Two staff approached and repositioned Resident #1's left leg foam boot. One staff held the resident's left ankle and foot in position and Staff M slid the boot to straighten it. The resident verbalized ow when staff repositioned the foot in the boot. Staff M reported the resident had more pain than before the accident. FALL 1/8/17 A facility incident report signed 1/13/17 identified on 1/8/17 at 3:30 p.m., Staff H and Staff J informed facility nursing staff, Resident #1 slid and fell three feet from a sling during transfer out of a shower chair using a Vander-Lift (type of mechanical lift). The investigation noted Staff H reported the resident complained of an upset stomach during the shower and wrote in a statement, the resident was moving around a lot during the shower. The facility investigation noted on 1/10/17, staff informed Provider K, Resident #1 kicked during the shower. During an interview on 1/19/17 at 9:50 a.m., Staff C confirmed two staff were required to transfer Resident #1 to and from a shower chair and one staff could shower Resident #1. Staff C reported Staff H showered the resident after initial transfer and stated the resident's behavior did start in the shower. Staff C stated if the resident started kicking during the shower, Staff H should have stopped. Staff C stated the care plan contained an approach, if the resident became resistant during care, to make sure the resident remained safe and leave alone; or if not able to leave alone, to get a second person. Staff C reported staff stated the resident kicked during the shower and could not confirm further details of the resident's behavior. During an interview on 1/19/17 at 12:25 p.m., Staff M reported, Resident #1 had episodes of behaviors of grabbing, hitting and mainly lashing out arms and being verbal. Staff M stated, if the resident became combative during a transfer we make sure the resident is safe, use the call light, and wait for staff to come or use an emergency call switch when in the shower room. Staff M also reported the resident had not had leaning issues in the past while seated. The investigation report identified Staff J reported to staff on 1/11/17, as Staff H raised the lift, Resident #1 turned to his/her left side and slid out of the sling hitting left knee on floor. Staff H reported the sling was not balanced under the resident and there was too much sling on the right side and it was 'short' on the left side making it easier for the resident to slide out. Following the fall, the investigation identified Staff H and Staff J used the lift to place the resident from the floor into a wheelchair. Neither staff reported the fall to a nurse when it occurred. During an interview on 1/19/17 at 9:50 a.m., Staff C stated Staff J reported the resident was not centered in the sling. Staff C stated, approximately two thirds of the sling covered the right side of the resident's body and one third of the sling covered the left side, and when the resident turned to the left side, legs slipped out. During an interview on 1/19/17 at 12:25 p.m., Staff M reported, if we notice the sling off when lifting we need to put the resident down. Staff M also stated lift transfers were always done by two staff to buddy up and double check each other. Vander-Lift's Operating Manual provided by the facility on 1/19/17, identified, during a transfer from a chair, the center of the sling should be over the patient's spine with the head support at, or a few inches above, the top of the patient's head. The manual also identified use of a crossed leg method to apply the sling, (creating a bucket to cradle the lower body), could be used as long as there were enough staff members present to prevent the patient from injuring themselves or staff. The investigation contained a statement written by Staff Z that documented, after the shower, staff brought Resident #1 to the common area, the resident yelled out in pain. Staff Z wrote Staff H informed him/her the resident was combative during the shower and complained of pain. Staff Z wrote Resident #1 reported pain in abdomen and then vomited (emesis) a large quantity of undigested food. Staff Z's statement identified medication for nausea and anxiousness were administered and the resident stated he/she felt better. Provider Staff K examined Resident #1 on sick call 1/10/17 at 11:00 a.m., for a nursing report of bruising of left foot and ankle and right knee. The note documented the resident had pain when touched and complained of pain with movement in bed of back. The note indicated Resident #1's right knee grossly swollen compared to the left knee and the left ankle and foot discolored. On 1/10/17 at 11:30 a.m., the Provider K ordered portable x rays of the right knee and left foot to rule out fractures. The physician also increased the dose of the resident's fentanyl patch and ordered a pad and boot to the ankle as tolerated. The provider noted Resident #1 as non-weight bearing status. X-ray reports dated 1/10/17 identified Resident #1 had a fractured bone on the outside aspect of the left ankle and a displaced fracture just above the right knee. On 1/12/17 the physician ordered a right knee immobilizer or hinged knee brace to be worn 24 hours a day for six weeks except for bathing and dressing. On 1/13/17 the physician ordered the left ankle taped and management by physical therapy staff. During a telephone interview on 1/27/17 at 9:30 a.m., following review of the details of this incident involving the Vander-Lift, Vander Lift Collateral Contact AA reported, if using a VanCare sling on a VanderLift, and instructions were followed correctly, such as using the correct size sling and applying and attaching the sling correctly, you just won't fall out. Collateral Contact AA stated, someone is making a mistake. Some step was overlooked in the process. You just cannot fall out of a sling during transfer. It just cannot happen. During a telephone interview on 1/30/17 at 3:00 p.m., Staff B stated, because the resident fell , something didn't go right. Staff H failed to obtain assistance when Resident #1 displayed behaviors during the shower. Treatment records also did not identify Licensed Staff Z conducted a routine skin check when the resident showered 1/8/17. Both failures prevented licensed staff from having an opportunity to assess the resident's behaviors in the shower and determine if completing the shower and transfer, or if change in approach of care, were required to maintain resident safety. Staff H and Staff J also failed to either apply the sling, or follow manufacturer's instructions to conduct the transfer, to prevent Resident #1 from falling during transfer and fracturing the left ankle and right leg, resulting in harm for this resident.

Based on observation, interview, and record review, the facility failed to ensure staff immediately reported a fall and bruises of unknown origin to Administration and the State agency, for 1 of 3 sampled residents (#1) reviewed for falls. Failure to report potential abuse and neglect, delayed protection of residents, initiation of an investigation, assessment of Resident #1 and [DIAGNOSES REDACTED].#1. The facility also failed to ensure background checks were timely screened for disqualifying criminal histories for 8 of 11 Contracted Staff (Staff O, P, S, T, Q, U, X & Y) and 1 of 5 Facility Staff (Staff G) reviewed for background checks. These failures placed all residents at risk for unsupervised contact with staff who had disqualifying criminal records. Findings include: RESIDENT #1 Refer to F 323 for medical history and additional information related to a fall in the shower and monitoring change in medical condition for Resident #1. A facility investigation signed 1/13/17 identified on 1/8/17 at 3:30 p.m., Staff H and Staff J transferred Resident #1 following a shower with a mechanical lift. The investigation noted the resident slid to the floor out of the sling and fell about three feet. Both staff then used the mechanical lift to transfer the resident into a wheelchair and did not report to nursing staff the resident fell . Nursing documentation written 1/8/17 through 1/10/17 identified nursing staff monitored Resident #1 for emesis that began shortly after the shower, determined to be related to an adverse reaction to [MEDICATION NAME] and monitored for pain. The facility investigation identified licensed nursing staff were not aware the resident experienced a fall and did not know they needed to assess the resident or initiate an investigation immediately following the incident. On 1/19/17 at 2:15 p.m., Staff C reported, Staff H informed Staff L on 1/10/17, Resident #1 fell in the shower 1/8/17. Staff H reported the fall two days after it occurred. The investigation also identified the facility interviewed Staff J on 1/11/17. Staff J reported Resident #1 did fall out of the mechanical lift sling (on 1/8/17) and did not notify the nurse due to concerns with getting in trouble. Staff J reported he/she was aware of facility policy to report falls immediately before moving a resident. Staffing schedules for 1/8/17 and 1/9/17 identified Staff H and Staff J continued to work the rest of the shift on 1/8/17 after failing to report Resident #1 fell from a mechanical lift. Schedules also identified Staff H also worked 1/9/17, the following evening. The facility report identified on 1/10/17, two days after Resident #1 fell , Staff H and Staff J were removed from duty, and the facility reported the incident to the State agency and initiated a full investigation of events related to the resident's injuries. BRUISING AND POTENTIAL INJURY NOT REPORTED TIMELY A nursing note written 1/9/17 at 12:10 p.m. the day following the fall, Staff D documented Resident #1 had bruises to the left knee and right foot and toe area. Staff documented on facility Non-Ulcer Evaluation Forms the resident had a bruise on the right knee (not left knee) and on the left foot toe area (not right foot). Later on 1/9/17 during evening shift, Staff N documented in nursing notes Resident #1 had swelling to the right knee, pain with movement and right knee was warm to touch. Resident #1's medical record did not identify Staff D or Staff N reported bruises or potential injury of unknown origin to administration or initiate an investigation to determine potential cause. During an interview on 1/19/17 beginning 9:50 a.m., Staff C reported it became obvious something happened when bruising appeared on Resident #1's right leg and then started an investigation for injury of unknown origin. Staff C also reported nursing staff should have reported Resident #1's bruising discovered during night shift on 1/9/17. During an interview on 1/19/17 at 2:15 p.m., Staff E reported bruises of unknown origin were investigated at the time they were noticed. Staff E stated he/she would have liked to have known when staff found bruises on Resident #1 on 1/9/17 so an investigation could have been started. Staff E also stated, if he/she had been aware the resident had bruises, statements from all staff who worked with Resident #1 in the preceding 72 hours would have been requested right away. The facility policy and procedure titled Incident Reporting identified upon becoming aware of any unusual occurrence or incident which involves a resident . the resident or residents must be protected from further harm. The policy also identified for staff to immediately notify the Director and/or Assistant Director of Nursing, the Neighborhood Coordinator or the Nursing shift Supervisor and to the State, of allegations of abuse and neglect. Two staff who were involved in care at the time Resident #1 fell on [DATE] and two staff who observed potential injuries on 1/9/17, failed to follow facility policy and procedure to immediately report and investigate. BACKGROUND CHECKS On 1/19/17 at 9:55 a.m. Administrative Staff A reported the facility just recently started processing background checks for contracted employees and did not know until recently they were not being done timely by the outside contractor. Staff A also reported the facility had not obtained copies of contracted employee background checks at the facility from the contractor. A list provided by the facility in 1/19/17 identified 11 contracted employees currently worked in the facility. All contracted staff were hired between 11/1/2009 through 5/2/2016. On 1/19/17 at 12:10 p.m., multiple contracted staff were present in the therapy room. During an interview on 1/25/17 at 9:44 a.m., Staff O reported eight contracted staff worked in the facility on 1/19/17. The facility policy and procedure for Abuse and Neglect identified steps taken for abuse prevention included criminal background checks to protect residents from contact with persons who had convictions of a felony violation or gross misdemeanor. During a meeting and interviews on 1/19/17 beginning 4:15 p.m., Staff A reported the facility thought the outside provider completed background checks. Staff A stated the contract between the facility and the provider indicated the outside provider would be in compliance with all federal and state requirements. The facility client service contract with the outside provider signed 10/6/14, for performance period dated 10/1/14 through 6/30/17, identified staff working for the contractor were fully licensed and and followed all applicable State and Federal Therapy guidelines. Washington State Administrative Code 388-97-1800 regarding criminal history disclosure and background inquiries states: (2) The nursing home must: (a) Have a valid criminal history background check for any individual employed, directly or by contract, or any individual accepted as a volunteer or student who may have unsupervised access to any resident; and (b) Repeat the check every two years. Non Contracted Facility Staff: Review of personnel files on 1/19/17 revealed the facility hired facility Staff G on 1/25/2010. Per Washington State requirements, repeat criminal background checks are required every two years. On 1/19/17 at 4:15 p.m. Staff A reported Former Human Resource Staff F submitted a request for a repeat background check for Staff G on 7/6/16. Staff A stated the background check had not been returned and did not know for sure why follow up had not been done.

Based on observation, interview and record review, the facility failed to adequately assess and identify all safety risks and adequately supervise and implement planned interventions to ensure safe smoking practices were in place for 1 of 19 Sampled, Residents # 1, reviewed for smoking. This failure resulted in a resident sustaining third degree burns to his face when his beard caught fire, and a subsequent hospitalization for care and treatment related to the burns. Findings include: A record review of Resident # 1's incident report on 4/16/16 at 1:15 p.m., revealed Resident #1 sustained facial and neck burns while the resident was attempting to light a cigarette inside a smoking shelter on the facility campus. Resident # 1 was alone in the shelter at the time with three other facility residents located adjacent to the smoking shelter, when flames were first seen on the resident. Resident # 1 had a current admitted [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1 smoked 1 pack per day of cigarettes. The last MDS, an assessment tool, dated 3/08/16 documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. Resident # 1's smoking assessments and progress notes dated between 3/10/2015 and 4/16/16 revealed the following: resident reminded to safely discard smoking supplies and partially smoked cigarettes, a burned left thumb nail sustained during a smoking episode and a violation of the facility's smoking policy which occurred after an allegation of possible cigarette sharing with another resident. Additionally the resident's smoking assessment from 3/2015 to 4/2016 did not address within the narrative assessment the resident's excessive beard, mustache growth or any use of adaptive equipment (cigarette extender). A record review of the Washington Veterans Home - Resident Smoking Agreement dated 3/10/15 and 11/10/15 revealed Resident # 1 agreed with the information contained in this agreement. The agreement was reviewed by the resident or it had been reviewed and explained by the facility representative. Resident #1 was assessed as an independent smoker, no record of a smoking apron used or adaptive equipment (cigarette extender). Resident # 1 could retain smoking products and smoke without any staff interventions. Resident # 1 was care planned for self-care deficit related to CVA. Staff was to trim the resident's mustache and beard specifically around his mouth to keep the beard as short as possible, to prevent it from being cinged when smoking. The resident's care directive revealed staff provided total one person assistance for personal hygiene due to a history of mustache being cinged while smoking, and to assist as needed with use of smoking apron. Resident # 1 was additionally care planned for an alteration in health maintenance related to nicotine dependence with a goal to smoke safely and follow smoking rules and an alteration in thought process due to cognitive deficits related to current diagnoses. Resident #1 had additional documentation in his medical record related to impulsive behavior, poor safety decision making, and resistance to care. Record review of the Certified Nurse Assistant (CNA) assignment record between 12/01/15 and 04/01/16 revealed, staff were directed to document number of times per shift the resident refused care, document a brief description of what happened, and notify the license staff (LN). the majority of entries revealed, the resident accepted care with rare documentation of any refusals. In interview on 4/19/16 at 1:45 p.m., Staff I stated the nursing aides revealed Resident #1 had refused many times to allow for his beard and mustache to be trimmed and it had gotten bigger since admission to this facility. I have told my nurse manager about his refusing to have his beard trimmed. I think that the facility should not allow smoking because the policy (smoking) is not consistently enforced across the board. I have told my supervisors verbally and in an email about my concerns with the resident's safety during smoking. In interview on 4/21/16 at 1:30 p.m., Staff F stated from reviewing the assignment record, there was a lack of documentation of Resident # 1's refusal of care, and revealed the resident was independent related to smoking assessment, however, he had refused many times to have his beard trimmed. In interview on 4/21/16 at 1:45 p.m., Staff G stated, Resident # 1 has never allowed me to trim his beard since his admission and stated another staff was able to trim just the lower part of his beard and not around the mouth or mustache. The beard has actually gotten much longer and bushier than when he first arrived last year. I have never seen him use any smoking apron. In interview on 4/21/16 at 2:25 p.m., Staff H said he/she was the only staff Resident # 1 had allowed to trim his beard, and Staff H said it was trimmed twice in the last two years. According to Staff H, the resident refused most of the time and the beard has gotten bigger and bushier, with food stuck a lot of times in his beard. I told him that I needed to trim around his lips and mustache because it is a safety issue. We are supposed to tell the nurses if he refuses and document on the assignment record. An assignment record documentation dated 4/6/16, revealed Staff H's note stating resident likes long beards and that he needed trimmed for his safety. Observation on 4/19/16 at 12:30 p.m., revealed one of the four approved facility outside smoking shelter. The structure appeared to be constructed of steel supports and walls with several large clear windows, a fire extinguisher with pin intact, last check 4/2016, had full pressure and attached to the interior wall of the structure. A medium size commercial grade cigarette disposal container, chimney style, enclosed, Smokers Cease-Fire Receptacle was located within the shelter. In interview on 4/21/16 at 1:35 p.m. Staff F stated, There is no policy currently in place for any facility staff to supervise residents who use these structures. Residents who smoke at these places can call for help on their cell phone, they can yell for help from other residents that may be nearby of if staff happen to walk by the structure Staff F provided a document created after Resident #1's cigarette burn incident titled Smoking Companions Needed, related to the need for staff to cover shifts around the clock, seven days a week, for smoking companions. In interview on 4/21/16 at 3:30 p.m. Staff A stated, The resident was deemed to be a responsible smoker but was irresponsible in his actions. This resident had a feature that made him unsafe (his beard) that he insisted on and was adamant about having it. If we were to restrict him from smoking because of his beard he would have went off and smoked at another location on the facility campus where we could not see him. Modification of Environment Record review of the facility's Washington Veterans Home Resident Incident report (WVH 001) logged 4/18/16 regarding Resident #1's 4/16/16 smoking incident revealed, there were two witnesses (residents) one ran inside the facility to get staff help when they saw Resident # 1 had caught his beard and clothing on fire while smoking. The second resident extinguished the flames on Resident # 1 with a hat. Facility staff arrived upon the scene after a resident went inside the building and yelled for help. First aid was administered by staff, 911 emergency services were called and the resident was transported to an area hospital for further inpatient treatment. Smoking shelters Observations on 4/19/16 at 11:45 a.m., revealed four smoking shelters located around the campus, outside the facility. Each shelter had 1 fire extinguisher mounted on the inside wall of the shelter, a broom, and a dustpan. Each shelter had one chimney (enclosed) ashtray inside the shelter, and one outside the shelter. On 4/19/16 at 11:45 a.m., Resident #2 sat in a power wheelchair outside of the smoking shelter located in the front of the facility, smoking a cigarette. There was a sign posted on the inside wall: Practice fire safety- extinguish your cigarette. Let staff know of any concerns right away. No emergency call system was in place in the smoking shelter. No other fire safety equipment was located in the shelter. In Interview on 4/19/16 at 11:50 a.m., when asked how s/he would get help if it was needed while outside at the smoking shelter, Resident #2 stated Hopefully someone comes along I could ask. Observation on 4/19/16 at 12:00 p.m., revealed a smoking shelter on the north side of the building had 1 fire extinguisher mounted on the inside wall, a broom, and a dustpan. No signs were posted. No other fire safety equipment or emergency call system was in place. In interview on 4/19/at 1:00 p.m., Staff E stated smoking assessments were done with the initial assessment then quarterly. If a resident showed decreased safety then they would be reassessed. Only residents who are independent smokers go out to smoke and supervised smoking for residents had been stopped 1-1 ½ years ago. When asked how residents let staff know if assistance was needed when in a smoking shelter, Staff E stated a resident may tell someone to come help him or another resident may come in and say there was a problem outside. In interview on 4/21/16 at 1:30 p.m., Staff C stated residents go outside independently to smoke. If a resident needed help when out, they would come back in or ask someone outside for assistance. Some residents have cell phones and will call the nurses station if they need assistance outside. In interview on 4/21/16 at 1:40 p.m., Staff D stated if a resident needed help then usually a staff member would see them or another resident would get help. S/he further stated there was no call system in any of the smoking shelters and sometimes residents used cell phones to call for help. In interview on 4/21/16 at 3:30 p.m., Staff A stated We can't spend or use state money on these smoking shelters is the reason why there is no emergency call light in these smoking shelters. The facility did not ensure a resident who smoked was adequately assessed and supervised. In addition safety risks and interventions that were previously identified were not being addressed. This failed practice resulted in harm to the resident requiring emergency medical treatment and inpatient hospitalization for servere burns. The facility failed to modify the environment to reduce risks of hazards to the residents, when there were no call systems installed in or around the smoking shelters for residents to get help fast in an emergency situation. When Resident #1 caught on fire, there was no way to call for staff to assist.

Based on observation, interview and record review it was determined the facility failed to ensure staff safely transferred according to the care plan to prevent falls for one of four residents sampled (#1). As a result, harm occurred when the resident fell on the floor during a mechanical lift transfer and fractured a hip. Failure to not follow hip precautions had the potential to compromise healing from recent hip surgery. Findings include: An Admission Face Sheet Record identified Resident #1 previously admitted to the facility on [DATE] with a lung condition, spinal condition and depressive disorder. A Hospital Discharge Summary dated 9/1/15 identified the resident had a surgical procedure on 8/30/15 to treat a fractured left hip. The summary included physician orders [REDACTED]. A required Significant Change assessment dated [DATE] identified Resident #1 needed total assistance from two staff to transfer and extensive assistance from two staff to assist with bed mobility. A Nursing Care Directive reviewed by staff 7/8/15 directed two staff to provide total assistance to transfer the resident using a Hoyer lift. FAILURE TO FOLLOW CARE PLAN FOR TRANSFER On 9/14/15 at 10:15 a.m. Resident #1 lay in bed on back and reported an incident occurred when he/she dropped out of the Hoyer and fractured a hip. The resident reported one staff assisted during the transfer and not two, which was not typical. A Hoyer mechanical lift uses a hydraulic mechanism to rise and lower residents while positioned in a sling. The sling is attached to the lift with four different loops. Movement from a bed to wheelchair and back requires suspending a resident in the sling above the floor to complete a transfer. Resident #1 stated the incident created a myriad of feelings and had more anxiety since the fall and more fear that it could happen again. The resident also stated my depression has gotten worse. A facility incident investigation documented on 8/29/15 at 2:30 p.m., Resident #1 fell during a mechanical lift transfer from bed to wheelchair when one of the loops from the sling came off the hook causing the resident to fall. The investigation stated Staff E did not get assistance from a second aide due to everyone doing their last rounds. The investigation identified the back rear caster wheel spun under the base of the lift and got stuck while Resident #1 was lifted in the sling. The investigation stated Staff E believed when jerking the lift to get it unstuck, it caused the resident's left shoulder sling loop to slip off the lift hook and the resident slid onto the floor. The resident complained of pain to left hip. The physician sent the resident to the emergency room and had surgery to treat the condition the following day. On 9/14/15 at 9:20 a.m., Staff F reported two staff should transfer Resident #1 with a Hoyer lift to ensure the resident stayed safe. Staff F also reported staff should not do the transfer if they couldn't find a second person to help. On 9/14/15 at 10:05 a.m. Staff G reported, during the incident, one of the loops of the sling slipped off and the back wheel of the lift wobbled. Staff G also reported if residents needed two staff for transfers one of my roles as a nurse was to ensure the equipment was good and staff followed the care plan. On 9/14/15 at 11:25 a.m., when asked if Resident #1's fall and fracture was avoidable, Staff A reported he/she could not confirm if the (sling) loop on the (Hoyer) hook was seated properly or not. On 9/14/15 at 11:35 a.m., Staff B reported the aide jerked the lift back and forth to get the wheel unstuck and the loop came off the lift. Staff B also reported there were no previous identified mechanical problems with the Hoyer lift used and the facility had a process in place to routinely inspect lifts. Although maintenance records identified a system to routinely inspect mechanical lifts, the maintenance record system the facility used, did not identify the specific date maintenance conducted the safety check on the lift for Resident #1, prior to the time of the fall. Facility policy and procedure titled Equipment - Mechanical Devices for Transferring Residents stated The mechanical lift is used by all nursing personnel depending on the type of the lift and specific resident requirements. The Care Plan and nursing care directives will indicate if one or two staff needs to be present during transfer. Facility investigation findings stated staff failed to follow the plan of care when transferring Resident #1 without a second person. The report also stated the wheel that got stuck was a contributing factor to the fall causing the staff to have to jerk the lift during transfer possibly causing the sling loop to slip off the lift hooks. Failure to ensure staff followed the plan of care to transfer Resident #1 with two staff while using a Hoyer lift prevented a second staff from visually monitoring the process to identify if safety concerns, such as, monitoring of sling loops that held the resident in suspension, remained securely in place and did not dislodge during movement or to provide assistance when a maintenance concern with the lift developed.

Based on observation, interview, and record review it was determined that the facility failed to implement interventions consistent with the resident's needs, plan of care, and current standards of practice in order to reduce the risk of an accident for 1 of 3 residents (#1) reviewed for accidents. This failure caused harm when Resident #1 rolled off the bed during incontinent care, and sustained facial laceration and abrasions, and a femur fracture. Findings include: Resident #1 admitted to the facility with multiple [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS), an assessment tool, dated [DATE] and the discharge assessment MDS dated [DATE] documented the resident required total assistance of two people for bed mobility (how resident moves to and from lying position, turns from side to side etc.) and toileting (how the resident used the toilet room, commode, bedpan etc.). The care plan with a start date of [DATE] and a discontinued date of [DATE], documented the resident required two person assist to turn and position in bed. The care plan and the care directive (a care guide for nursing assistants) documented the resident required "2 person extensive assist to turn to the right side and total assist of two to turn towards the left and to scoot up in bed." Although the MDS documented the resident required total assist of two people for toileting, the care directive documented the resident required ",[DATE] person assist to clean after using the bed pan or when changing the resident's incontinence pad." The facility's "Resident incident report" documented Resident #1 fell on [DATE] and sustained a 4 x 5 cm swollen laceration to the forehead, abrasion to the bridge of the nose and left side of neck/jowl, and a fracture to her left distal femur. The resident expired on [DATE]. The nursing assistant (Staff D) turned the resident in bed to perform incontinence care as a one person assist. According Staff D's witness statement, the resident stated, "it would be better to turn me (the resident) towards the window". Staff D documented she rolled up a brief in an under pad and positioned it to slip under the resident as she rolled the resident. Staff D documented she held the resident with her left hand and turned the resident with her right, and the resident kept rolling, she (Staff D ) lost her grip and the resident rolled off the bed onto the floor. Although the care directive (a care guide for nursing assistants) directed staff to use the assistance of two when turning the resident to the right or left side, the facility's investigation concluded Staff D was following the care plan when she turned the resident to the side to provide incontinence care, because the care directive directed staff to use ,[DATE] people when providing incontinence care. On [DATE] at 2:30 p.m., during an interview with the investigation nurse (Staff A) reported therapy, the neighborhood nurse and MDS nurse are responsible to assess residents and determine if they are a 1 or 2 person assist for bed mobility and incontinence care. When asked, Staff A confirmed the care directive did not provide clear direction to the nursing assistants on when to use the assist of one person or two when providing Resident #1 with incontinence care. On [DATE] at 2:02 p.m., during an interview, the nursing assistant (Staff B) stated some aides will care for Resident #1 as a one person assist and some will provide care as a two person assist. Staff B stated it just depends on how comfortable the aide is with providing care, but most times it is with the assist of two people. Staff B stated she explained this to Staff D when she was orienting Staff D on how to care for Resident #1. In addition, the current standards of practice is to turn the resident towards the caregiving staff in order to reduce the risk of an accident. Staff B looked at the care directive with the complaint investigator and confirmed the care directive was not clear if the resident required the assist of ,[DATE] people or the assist of 2 two people for turning to provide incontinence care. Although the MDS and care plan documented the resident required the assist of two for bed mobility and turning, On [DATE] at 3:05 p.m., during an interview, the MDS nurse (Staff C) stated staff were to have two people present when the resident became accusatory, which was why the care plan documented 1 or 2 when providing care. Staff C also stated that the resident would get impatient when waiting for 2 staff to provide care, and making the resident a 1 or 2 person assist allowed staff to provide the assist of 1 person when the resident would become impatient. The MDS documented the resident required total assist of two for bed mobility and toilet use. The care directive documented the resident required ,[DATE] person assist to cleanse the resident after using the bed pan or when changing the resident's incontinence pad. The care directive also documented the resident required total assist of two for turning. The facility failed to provide clear direction to the nursing assistants when providing care to Resident #1. The facility failed to implement interventions consistent with the assessed needs, plan of care, and current standards of practice, which caused harm to Resident #1 when the resident was assisted by one nursing assistant (Staff D) with turning the resident away from the staff while providing incontinence care, and rolled off of the bed, onto the floor, sustaining facial abrasions and a fracture to the femur.