Every finding on record at Willapa Harbor Care

Based on interview and record review, the facility failed to ensure a thorough investigation was conducted for 1 of 2 sampled residents (Resident 1) reviewed for accident and incident investigations. This failure placed residents at risk for abuse and neglect, inappropriate corrective actions, and a diminished quality of life.Findings included . Record review of the facility policy, titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, dated 08/2022, documented, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review and investigate all allegations of abuse, neglect, exploitation, mistreatment, injuries of an unknown source, and misappropriations of resident property using the Risk Management electronic incident report in Point Click Care [electronic medical record system] and components of a thorough investigation to include resident interview, resident observation, staff interviews, other resident interviews etc. Resident 1 admitted to the facility on [DATE]. Review of Resident 1's 5-day Minimum Data Set, an assessment tool, dated 07/16/2025, documented Resident 1 was cognitively intact. Record review of a reported complaint received on 07/29/2025 at 6:36 PM, showed it was alleged Resident 1 threatened staff and another resident (Resident 2) with a butterknife. Record review of the facility's Accident and Injury log failed to document the encounter. A review of Resident 1's progress note, dated 07/28/2025, documented, [Resident 1] was having some heightened behaviors. Refusing Meds, throwing things, trying to pull the fire alarm, verbal threats to everyone around him and some physical contact with Aides. This writer came to the facility and sat with him until about 2230 [10:30 PM]. We just talked until he got tired. He agreed to take his meds and went to sleep. When this writer arrived at the building 23-2 [Resident 1] had calmed down. 23-1 [Resident 2] had been moved to room [ROOM NUMBER] to keep him out of the activity. No harm to 23-1. The following day I asked 23-1 (now 11) if he had any issues from the night before. He wasn't able to recall anything and was in a very good mood. In an interview on 08/21/2025 at 10:27 AM, Staff A, Administrator, said there was an incident with Resident 1 late 07/28/2025 going in to 07/29/2025 where he was watching news about wildfires and believed he was going to burn. Resident 1 started pulling fire alarms and was going after the staff and his roommate, Resident 2. Staff A said Resident 2 was separated from Resident 1 at this time. Staff A said Resident 1 had a butterknife he took from his meal tray and hit the window with the butterknife. Staff A said Resident 1 had made threats about cutting people and Resident 2 was there when the threats were made. Staff A said an incident report was not filed regarding this incident. Staff A said verbal abuse would be considered a reportable incident, but did not believe Resident 2 had been verbally abused. In an interview on 08/21/2025 at 11:25 AM, Staff A said she had asked staff members to write witness statements regarding the 07/28/2025 incident. Staff A said she did not ask any residents to write witness statements. Staff A said monitoring Resident 2 for possible harm did not occur. Staff A said while she talked to Resident 2 the next day, a documented evaluation to determine if Resident 2 felt safe in the facility did not occur. Staff A said she did not do what she would consider to be a full investigation. Reference WAC 388-97 -0640 (6)(a)(b).

Based on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 2 kitchen refrigerators, reviewed for food storage. This failure placed residents at risk for food borne illness, and a diminished quality of life.Findings included .During an observation on 08/04/2025 at 10:03 AM, the kitchen refrigerator on the left, was observed with the following expired, opened items: 1. Metal Tupperware Jar of Butter Pasta- labeled with use by date of 08/03/20252. Metal Tupperware Jar of Meatballs - labeled with use by date of 08/02/20253. Metal Tupperware Jar of Diced Carrots - labeled with use by date of 08/03/20254. Plastic Ziplock bag of Bulk Ham- labeled with use by date of 07/25/20255. Plastic Ziplock bag of Deli Ham- labeled with use by date of 07/29/20256. Plastic Ziplock bag of Parmesan Cheese- labeled with use by date of 08/02/2025In an interview on 08/04/2025 at 10:05 AM, Staff M, Dietary Manager, said the items in the refrigerators should be kept until the use by date, and then disposed of. Staff M stated, they should be tossed out, and proceeded to throw away the expired items. In an interview on 08/07/2025 at 10:26 AM with Staff B, Director of Nursing, said she expected food items in the refrigerators and freezers to be discarded by the use by date. Reference WAC 388-97-1100 (3) & 2980

Based on interview and record review, the facility failed to revise a resident care plan for 1 of 3 sampled residents (Resident 37) reviewed for activities of daily living (ADL). This failure placed residents at risk for unmet needs and inappropriate plans of care.Findings included.Record review of the facility's policy titled, Care Planning Process, revised date 05/19/2023, stated the care plan must be reviewed and revised according to the RAI (resident assessment instrument) process at a minimum upon admission, quarterly and with significant change in condition and services provided or arranged must be consistent with each resident's written Care Plan.Resident 37 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS), an assessment tool, dated 06/25/2025, documented Resident 37 was dependent with oral care, and needed substantial/maximal assistance with personal hygiene. Resident 37 was moderately cognitively impaired.Review of Resident 37's ADL self-care performance deficit care plan, revised date 08/23/2022, documented, Personal Hygiene/Oral Care: The resident requires set up assist of (1) staff for personal hygiene and oral care.During an interview on 08/06/2025 at 2:17 PM, Staff I, Certified Nursing Assistant (CNA), said dependent meant the staff provided the full care doing everything for the resident with personal care and teeth. Staff I said personal care was head to toe, brush hair, teeth, dress and wash face and hands. Staff I said partial/moderate assistance was setting up and helping residents with something the residents could not do themselves. During an interview on 08/06/2025 at 2:55 PM, Staff C, Infection Preventionist/Registered Nurse, said partial assistance meant staff should encourage residents to do as much of their own care as possible. Staff C said if the MDS documented a resident was dependent with ADLs the care plan should be updated to reflect the change. During an interview on 08/06/2025 at 3:02 PM, Staff B, Director of Nursing/Registered Nurse, said if the resident's care needs changed the MDS should reflect the change, and the care plan should be updated. During an interview on 08/06/2025 at 3:10 PM, Staff B said she spoke with the CNA and was told Resident 37 did have a change with her care needs. Reference WAC 388-97-1020(2)(c)(d)

Based on observation, interview and record review, the facility failed to complete an accurate comprehensive dental/oral assessment for 1 of 1 resident (Resident 8) reviewed for dental status. This failure placed the residents at risk for unmet care needs and a diminished quality of life.Findings included .Resident 8 was admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set (MDS), an assessment tool, dated 02/17/2025, documented the resident was alert and oriented.Record review of Resident 8's oral/dental status MDS assessment, dated 02/17/2025, documented Resident 8 did not have broken or loose natural teeth. In an observation on 08/04/2025 at 10:48 AM, Resident 8 was observed to have broken and loose teeth.In a joint observation on 08/06/2025 at 10:44 AM, Staff G, Licensed Practical Nurse, assessed Resident 8's mouth and stated, his teeth are loose, and he has broken teeth. Resident 8 was observed to be able to push his front teeth back and forth using his tongue. In an interview on 08/07/2025 at 9:37 AM, Staff C, Infection Preventionist/Registered Nurse reviewed the oral/dental status MDS assessment dated [DATE]. Staff C said Resident 8 did have broken teeth therefore the MDS assessment was incorrect. Staff C said it was the expectation that an accurate physical assessment was completed and documented in the MDS assessment. Reference WAC 388-97-1000 (1)(b)(2)(K)

Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and/or behaviors) for 1 of 5 sampled residents (Resident 14) reviewed for unnecessary medications. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.Findings Included . Review of the facility's policy titled, Psychoactive [a drug affecting the mind] Medication Management, revised 08/2024, documented, .10. Complete the Psychopharmacologic [drugs used to treat mental health conditions] Medication Information Evaluation with the resident/resident representative. a. Review the Psychopharmacologic Medication Information Evaluation with the resident/resident representative when psychoactive medication is prescribed. Resident 14 was admitted to the facility on [DATE] with multiple diagnoses including depression and dementia. The End of PPS (Prospective Payment System) Minimum Data Set, an assessment tool, dated 06/20/2025, documented Resident 14 was severely cognitively impaired, taking antidepressant (used to treat depression) medication, and an antipsychotic (a class of psychotropic medications used to treat symptoms of various mental disorders) medication. Record review of Resident 14's physician orders, dated 05/12/2025, documented Resident 14 was prescribed Sertraline (a medication used to treat depression) 50 mg (milligrams) daily. The August 2025 Electronic Medication Administration Record (EMAR) showed Resident 14 was receiving Sertraline 50 mg daily. Review of Resident 14's Electronic Health Record (EHR) Psychopharmacologic Medication Informed Consent, dated 05/30/2025, showed Resident 14's representative gave consent for Sertraline on 05/30/2025, 18 days after the medication was started. Record review of Resident 14's physician orders, dated 05/12/2025, documented Resident 14 was prescribed Bupropion (a medication used to treat depression) 150 mg two times a day. Further review of Resident 14's EHR, showed the Bupropion dose ordered and administered was decreased to 100 mg two times a day starting 06/12/2025, decreased to 50 mg two times a day on 07/12/2025, and decreased to 25 mg two times a day on 08/02/2025. Review of Resident 14's EHR Psychopharmacologic Medication Informed Consent, dated 05/12/2025, showed Resident 14 gave consent for Bupropion on 05/12/2025. Review of Resident 14's EHR did not show documentation of consent or notification of change in dose from the resident or resident's representative for dose changes of the Bupropion on 07/12/2025 and 08/02/2025. In an interview on 08/07/2025 at 8:48 AM, Staff C, Infection Preventionist/Registered Nurse (RN) said they got consent from the resident and/or the resident's representative prior to administering psychotropic medications. Staff C said if there was a dosage change to psychotropic medications; they would notify the resident and/or the resident representative. When asked about Resident 14's Sertraline consent signed on 05/30/2025, Staff C said it was signed late, it should have been signed before Resident 14 started the medication. Staff C said she did not see a consent signed prior to starting Sertraline. When asked about Resident 14's Bupropion consent, Staff C said the original consent should not have been signed by Resident 14, it should have been signed by a representative or power of attorney (POA), stating, Her BIMS [Brief Interview for Mental Status, a screening tool used to assess cognitive function) is so low. Staff C said she did not find documentation Resident 14's representative was notified for the start of Bupropion and the dose changes on 07/12/2025 and 08/02/2025. In an interview on 08/07/2025 at 9:39 AM, Staff B, Director of Nursing/RN, said it was her expectation consents were signed by the resident or POA prior to the start of psychotropic medications. Staff B said the resident and/or the POA needed to be notified, and it documented in the EHR, if there was a change in dose for psychotropic medication. Staff B said if a resident had a low BIMS score, they needed to get consent from the POA for psychotropic medications. Reference WAC 388-97-0260 (1)-(3)

Based on observation, interview and record review, the facility failed to provide resident centered activities that incorporated the resident's preferences for 1 of 3 residents (Resident 37) reviewed for activities. This failure placed residents at risk for a diminished quality of life.Findings included .Resident 37 was admitted to the facility on [DATE]. The Annual Minimum Data Set, an assessment tool, dated 06/25/2025, documented it was very important for Resident 37 to listen to music she liked. Resident 37 was moderately cognitively impaired. Review of The Life Enrichment quarterly progress notes dated 02/15/2025 and 03/21/2025, documented music became more important to her. Review of Resident 37's care plan, revised date 02/12/2025, showed Resident 37 prefers the following TV channels: news, sports, drama, etc. Resident 37 sometimes joins in a JW (Jehovah's Witness) meeting on Zoom [a platform that provides video and audio conferencing and online meetings]. Review of Resident 37's Planned Activities task, dated 07/08/2025 to 08/05/2025, documented Resident 37 had five of 27 days of one-on-one visits. No other activities were documented. In an observation on 08/05/2025 at 9:27 AM, Resident 37 was lying in bed, eyes closed head slightly turn to left shoulder. The TV was on. In an observation on 08/05/2025 at 10:08 AM, Resident 37's eyes were closed, her head slightly turned to her left. Resident 37 did not respond to knocks on the door or calling out to her. In an interview on 08/06/2025 at 11:10 AM, Resident 37 said she loved country music. When asked if she listened to music here, she stated no! Resident 37 said if they had music television she would listen to it, but she preferred a radio. In an interview on 08/06/2025 at 2:25 PM, Staff J, Life Enrichment Director, said if a resident had a preferred activity, they would do what they could to meet that resident's preferences. Staff J said they had two cd (compact disc) players and a variety of music to include country. Staff J said they did not have any radios. Staff J said he had offered Resident 37 the opportunity to use the cd player a few times, but she declined. Staff J said they don't document how often residents decline or refuse. In an interview on 08/06/2025 at 3:12 PM, Staff A, Administrator, said if a resident refused a program staff should document. Reference WAC 388-97-0940 (1)(2)

Based on interviews and record review, the facility failed to initiate bowel interventions for 3 of 6 residents (Resident 1, 3 & 30) reviewed for quality of care. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included . Record review of the facility policy, titled, “Management of constipation,” revision date, November 2023, documented, “when a resident is identified with no/small BM (bowel movement) documented for 64 hrs (hours), the LN (licensed nurse) will assess the resident and determine if the bowel protocol will be initiated.” The facility policy outlined standard bowel protocol based on providers’ orders which included: “Milk of magnesia 30 ml (milliliters) PO (by mouth) HS (at hour of sleep) after eight shifts of no BM. Bisacodyl Suppository rectally if no results from the milk of magnesia. Fleets Enama rectally if no results from the Bisacodyl Suppository.” Resident 1 Resident 1 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 07/30/2025, documented the resident was alert and oriented. Review of Resident 1's the Bowel Movement (BM) task sheet, undated, showed documentation of Resident 1’s BM activity on 07/13/2025 at 2:48 PM. Resident 1’s next BM was documented on 07/18/2025 at 06:42 AM, approximately 118 hours since the last BM. Record review of Resident 1’s physician’s order, dated 06/22/2025, documented, “Milk of Magnesia [MOM- medication for constipation] Suspension 400 MG [Milligrams]/5ML [Milliliters] (Magnesium Hydroxide) Give 30 ml by mouth every 8 hours as needed for Constipation Give at bedtime or at resident preferred time if no BM on 3rd day.” Review of Resident 1’s physician’s order, dated 06/22/2025, documented, “Dulcolax Suppository (Bisacodyl) [medication for constipation] Insert 1 suppository rectally every 24 hours as needed for Constipation If no results from MOM after 12 hours.” Review of Resident 1's Electronic Medication Administration Record (EMAR), dated July 2025, did not show documentation of medication intervention for no BM after 64 hours from 07/13/2025 to 07/18/2025. Review of Resident 1’s physician’s order, dated 06/22/2025, documented, “Fleet Enema Enema 7-19 GM [Grams]/118ML (Sodium Phosphates) Insert 1 application rectally every 24 hours as needed for Constipation If no results from Dulcolax in 4-6 hours. If no results from enema, notify MD [Doctor].” Resident 3 Resident 3 was admitted to the facility on [DATE]. The Medicare 5-day MDS, an assessment tool, dated 06/27/2025, documented the resident was alert and oriented. Record review of the Bowel Movement task sheet, undated, showed documentation of Resident 3’s BM activity on 07/22/2025 at 12:08 PM. Resident 3’s next BM was documented on 07/27/2025 at 01:55 PM, approximately 121hours since the last BM. Record review of Resident 3’s physician’s order, dated 06/23/2025, documented, “Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth every 8 hours as needed for Constipation Give at bedtime or at resident preferred time if no BM on 3rd day.” Record review of Resident 3’s physician’s order, dated 06/23/2025, documented, “Dulcolax Suppository (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for Constipation If no results from MOM after 12 hours.” Record review of Resident 3’s physician’s order, dated 06/23/2025, documented, “Fleet Enema Enema 7-19 GM(grams)/118ML (Sodium Phosphates) Insert 1 application rectally every 24 hours as needed for Constipation If no results from Dulcolax in 4-6 hours. If no results from enema, notify MD.” Record review of Resident 3’s Electronic Medication Administration Record (EMAR), dated July 2025, did not show documentation of medication intervention for no BM after 64 hours from 07/25/2025 to 07/26/2025 In an interview on 08/06/2025 at 1:39 PM, Staff B, Director of Nursing Services/Registered Nurse (RN), said the bowel protocol should be initiated 64 hours after the last BM. Staff B said after reviewing the medical records the bowel protocol for Resident 3 had not been initiated 64 hours after the last BM on 07/22/2025. Resident 30 Resident 30 was admitted to the facility on [DATE]. The Medicare 5- Day MDS, dated [DATE], documented the resident was alert and oriented. Review of Resident 30's Bowel Movement task sheet, undated, showed documentation of Resident 30’s BM activity on 07/23/2025 at 5:21 AM. Resident 30’s next BM was documented on 07/28/2025 at 03:21 PM, approximately 130 hours since the last BM. Record review of Resident 30’s physician’s order, dated 07/22/2025, documented, “Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth every 8 hours as needed for Constipation Give at bedtime or at resident preferred time if no BM on 3rd day.” Review of Resident 30’s physician’s order, dated 07/22/2025, documented, “Dulcolax Suppository (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for Constipation If no results from MOM after 12 hours.” Review of Resident 30’s physician’s order, dated 07/22/2025, documented, “Fleet Enema Enema 7-19 GM(grams)/118ML (Sodium Phosphates) Insert 1 application rectally every 24 hours as needed for Constipation If no results from Dulcolax in 4-6 hours. If no results from enema, notify MD.” Review of Resident 30’s EMAR, dated July 2025, did not show documentation of medication intervention for no BM after 64 hours from 07/23/2025 to 07/28/2025. In an interview on 08/07/2025 at 10:03 AM, Staff N, Licensed Practical Nurse stated, “There should be something in the records from that stretch of time. There are no BM interventions for both.” In an interview on 08/07/2025 at 10:26 AM, Staff B, said it was her expectation to follow the bowel protocol. Staff B stated, “we have a problem with documentation. That is unacceptable to not have started the bowel protocol.” Reference WAC 388-97-1060 (1)(3)(c)

Based on observation, interview and record review, the facility failed to ensure an order was in place prior to the administration of oxygen, for 1 of 2 sampled residents (Resident 30) reviewed for respiratory services. This failure placed residents at risk for complications in respiratory health and a diminished quality of life. Findings included . Record review of the Facility's Oxygen Management Policy, revised on 12/2022, documented, The center requires that a physician's order be obtained prior to the administration of oxygen. Resident 30 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease making it difficult to breathe) and pulmonary fibrosis (condition in which scare tissue builds up in the lungs, making it difficult to breathe). The Medicare 5- Day Minimum Data Set, an assessment tool, dated 07/22/2025, documented Resident 30 was alert and oriented. In an observation on 08/04/2025 at 1:06 PM, and at 3:23 PM Resident 30 was observed in bed with continuous oxygen on. Record review of Resident 30's physician order, dated, 08/05/2025, documented, 2lpm [liters per minute] n/c [nasal canula] oxygen continuously. Review of Resident 30's Electronic Health Records (EHR) did not contain any documentation of physician's order for oxygen prior to 08/05/2025. In an interview on 08/07/2025 at 12:21 PM, Staff C, Infection Preventionist/Registered Nurse, said Resident 30 had been using oxygen since her admission on [DATE]. Staff C stated, she has been on it ever since she has been here. In an interview on 08/07/2025 at 12:36 PM, Staff C stated, Yes, she admitted with oxygen. We checked and there was no order in until the 5th. In an interview on 08/07/2025 at 2:08 PM, Staff B, Director of Nursing Services, said that oxygen must be ordered by a physician. Staff B said she would expect oxygen to be administered per facility policy. Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to ensure medications were administered by professional standards of practice for 1 of 5 residents (Resident 20) reviewed for medication administration. This failure placed residents at risk for medication errors, negative outcomes, and a diminished quality of life.Findings Included. Review of the facility's policy titled, Medication Administration, revised 12/2024, documented, .15. Remain with the resident until all medication is taken. Resident 20 was admitted to the facility on [DATE]. The End of PPS (Prospective Payment System) Part A Stay Minimum Data Set, an assessment tool, dated 07/08/2025, documented Resident 20 was cognitively intact. In an observation and interview on 08/04/2025 at 10:47 AM, Resident 20 was observed lying in bed with no staff present in the room. A medication cup with 9 pills in the cup was observed in front of Resident 20 sitting on the bedside table. When Resident 20 was asked about the pills in the cup, she said she wasn't ready to take them when the nurse brought them in. Resident 20 said she was still sleepy, so the nurse left them there for her to take. Resident 20 said she did not know what they all were for. Resident 20 said some were for nausea, dizziness, and some for high blood pressure. Record review of Resident 20's electronic health record did not show a self-medication administration evaluation had been completed. In an interview on 08/04/2025 at 10:51 AM, Staff B, Director of Nursing/Registered Nurse, said she did not think there were any residents on a self-medication program. Staff B said medications should not be left at the bedside if a resident was not on a self-medication program. In an observation and interview on 08/04/2025 at 10:55 AM, Staff B went to Resident 20's room to observe the medication cup at bedside. Resident 20 was observed to be swallowing and then set the empty medication cup down on bedside table. Resident 20 said she just swallowed her medications. When asked if the nurse left the medications there for her, Resident 20 stated, Yes. In an interview on 08/04/2025 at 11:01 AM, Staff B said Resident 20 was not on a self-medication program. Staff B said she talked to Resident 20's nurse. Staff B said Resident 20's nurse said she handed Resident 20 her pills and thought Resident 20 would take them, so she left the room. Staff B said the nurse should have stayed and watched Resident 20 take her medications. Reference WAC 388-97-1300 (1)(b)(i), (3)(a)

Based on observation and interview, the facility failed to distribute resident meal trays in a sanitary manner in 1 of 2 hallways reviewed for infection control. This failure placed residents at risk of infection transmission and a diminished quality of life.Findings included .In an observation on 08/04/2025 at 12:46 PM, Staff F, Certified Nurse Assistant, was observed carrying a meal tray from the food cart into room [ROOM NUMBER] and placed it on a bedside table. room [ROOM NUMBER] had an orange-colored sign at the room entrance indicating the resident in room [ROOM NUMBER] was on enhanced barrier precautions (infection control precautions). Resident in room [ROOM NUMBER] declined the meal tray. Staff F proceeded to pick up the tray from the bedside table and returned it into the meal cart in the hallway which had other meals trays due to be served. In an interview on 08/04/2025 at 1:01 PM, Staff F was asked where she would keep residents meal trays if the resident refused it. Staff F stated, we typically put them back in the meal cart. In an interview on 08/07/2025 at 9:36 PM, Staff C, Infection Preventionist/Registered Nurse, said it was the expectation when a resident declined their meal tray, staff were expected to leave the meal tray in the room and not return the tray into the meal cart thus preventing contamination of the other trays in the cart. Reference WAC 388-97-1320 (1)

Based on interview and record review, the facility failed to ensure nursing hours were accurately posted and updated daily for 30 of 31 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.Findings included.Record review of the Daily Nursing Staffing Report postings, prior to being edited, from 07/05/2025 to 08/04/2025 were not provided for review. Review of the Daily Nursing Staffing Report postings provided by the facility, from 07/05/2025 to 08/04/2025, showed changes for every day, except for 07/21/2025, to columns titled Hours Scheduled, Staffing Total, and Actual Hours Worked daily.In an interview on 08/05/2025 at 11:05 AM, Staff H, Staffing Coordinator, said she had only done staffing since May and was still learning. Staff H said she had not been updating the staffing numbers for each shift on the posted Daily Nursing Staffing Report. Staff H said yesterday's updated staffing did not get added to the daily posting during the day and that happened a lot.In an interview on 08/07/2025 at 9:49 AM, Staff B, Director of Nursing/Registered Nurse, said staffing was a new role for Staff H and she was still learning the process. Staff B said Staff H would only post the daily staffing numbers that were scheduled. Staff B said Staff H did not know she had to update the postings with changes each shift, and Staff H did not have a process to update them. Staff B said they would need a process to figure out who would be updating them. Staff B said the Daily Nursing Staffing Report needed to be updated with changes throughout the day.In an interview on 08/07/2025 at 10:42 AM, while looking at the Daily Nursing Staffing Reports provided by the facility with Staff H, Staff H said the postings provided to the surveyors had changes to them because she reviewed and corrected the postings the next day after they were taken down. Staff H said she would take the previous posted day down, review and correct it, and post a new one for the current day. Staff H said she did not know it needed to be updated to reflect current staffing throughout the day.No WAC Reference

Based on observation and interview, the facility failed to provide a safe dining environment by ensuring the floorboard heater was not hot to the touch in 1 of 1 dining room reviewed for environment. This failure had the potential to place residents at risk of burns and a diminished quality of life. Findings included . On 07/21/2024 at 12:45 PM, the dining room floorboard heater was observed radiating heat. The floorboard heater was hot to the touch and made this observer's hand move quickly away when touched. At 12:47 PM, Staff D, Maintenance Director, said the floorboard heater had to be manually turned on. Staff D touched the floorboard heater, removed his hand quickly and stated, It's pretty hot. At 12:51 PM, Staff D was observed using a thermometer which read 100 degrees. Staff D said it was hot and would be turned down. Reference WAC 388-97-0880 (1)

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan addressing wounds for 1 of 5 sampled residents (20) reviewed for comprehensive care plans. This failure placed residents at risk for continued decline and decreased quality of life. Findings included . Resident 20 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 04/17/2024, documented Resident 20 was cognitively intact and was at risk of developing skin breakdown. On 07/21/2024 at 3:08 PM, Resident 20 was observed lying in bed and had a darkened skin impairment to his left great toe. Resident 20's comprehensive care plan did not address the skin impairment on his left great toe. On 07/24/2024 at 10:17 AM, Staff E, Infection Preventionist and Licensed Practical Nurse, said Resident 20's electronic health record did not have a specific care plan for the left great toe skin impairment. At 2:07 PM, Staff B, Director of Nursing Services and Registered Nurse, said it was the expectation that if a new skin impairment developed, a care plan would be implemented to address the skin impairment's care. Staff B said there was not a care plan for the left great toe skin impairment in Resident 20's comprehensive care plan. Reference WAC 388-97-1020 (1)(2)(a)

Based on observation, interview, and record review, the facility failed to obtain an evaluation assessment, consent, and physician order for full length bolsters on both sides of the bed for 1 of 2 sampled residents (7) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included . Resident 7 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 05/16/2024, documented Resident 7 was moderately cognitively impaired. On 07/21/2024 at 3:28 PM, Resident 7 was observed lying in bed on an air mattress with bolsters on the upper and lower full length left and right side of the bed. On 07/22/2024 at 12:54 PM, Resident 7's bed was observed with an air mattress with bolsters on the upper and lower full length left and right side of the bed. At 1:47 PM, Resident 7 was observed lying in bed on an air mattress with bolsters on the upper and lower full length left and right side of the bed. Record review of Resident 7's Electronic Health Record did not show an evaluation assessment, consent, or physician's order related to a bolstered air mattress. On 07/23/2024 at 9:12 AM, Resident 7 was observed lying in bed on an air mattress with bolsters on the upper and lower full length left and right side of the bed. At 2:26 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, said an assessment, physician's order, and consent, signed by the resident or family member, was needed for use of a bolstered mattress. Staff E said she could not find an assessment, physician order, or consent for Resident 7's bolsters on the mattress and it should have been done. At 3:22 PM, Staff B, Director of Nursing Services and Registered Nurse, said she expected evaluation assessments, consents, and physician orders were completed for use of safety devices such as bolsters on mattresses. Reference WAC 388-97-0620 (1)(a)(b)(4)(a)(b)

Based on interview and record review, the facility failed to ensure Registered Nurse (RN) supervision was provided at least eight hours daily for 3 of 30 days reviewed. This failure placed residents at risk for not receiving needed care and supervision of care. Findings included . The Aging and Long-Term Support Administration (ALTSA) Staffing Pattern, and the facility's Daily Nurse Staffing Forms, showed the facility did not have an RN on duty for any of their three shifts (day, evening & night) on 06/30/2024, 07/07/2024 and 07/14/2024. On 07/24/2024 at 2:24 PM, Staff A, Administrator, said they were trying to hire nurses from using a hiring software; however, they mostly got Licensed Practical Nurse applicants. Staff A said if they were short on RNs they would pull from their management team and use staff from another facility whenever they could. Reference WAC 388-97-1080 (3) .

Based on observation, interview, and record review, the facility failed to ensure restorative services were provided for 1 of 2 sampled residents (12) reviewed for range of motion (ROM) and mobility. This failure placed residents at risk for avoidable decline and diminished quality of life. Findings included . Resident 12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 07/22/2024, showed Resident 12 was cognitively intact, had impairment on one side of the body, and did not show the resident was on a restorative therapy program. The care plan, dated 06/19/2023, showed Resident 12 had limited physical mobility related to stroke and weakness. There were no interventions for maintaining ROM or function in the care plan. The care plan showed Resident 12 required extensive assistance x2 (two person) for bed mobility, and repositioning, and transfers with 2 staff members with a mechanical lift. On 07/21/2024 at 11:31 AM, Resident 12 said her hand did not open, and the resident demonstrated the limited mobility of her hand. Resident 12 indicated she did not recall staff ever performing range of motion to the left hand. On 07/23/2024 at 12:20 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, stated, We do not have any patients with contractures. When asked what they would do if they had a resident with a contracture, Staff E said they would have a diagnosis and a care plan. Staff E said they were in the process of getting a restorative program back up and running. At 3:45 PM, Staff B, Director of Nursing Services and Registered Nurse, stated, I would have to check with the MDS nurse to see if any patients had contractures. When asked about Resident 12, Staff B observed Resident 12's left hand and stated, Well, it looks like it is contracted. Staff B said no restorative program was in place. Reference WAC 388-97-1060 (3)(d)

Based on observation, interview and record review, the facility failed to provide resident centered activities incorporating the resident's preferences for 1 of 1 sampled resident (285) reviewed for activities. This failure placed residents at risk for a diminished quality of life. Findings included . Resident 285 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 05/06/2024, showed Resident 285 was moderately cognitively impaired and had an activity preference of going outside to get fresh air when the weather was good. The May 2024, June 2024 and July 2024 Activity Participation reports did not have documentation Resident 285 had been offered, refused, or had gone outside while at the facility. On 07/22/2024 at 8:52 AM, Resident 285 said it would be nice to go outside. On 07/24/2024 at 9:25 AM, Staff C, Life Enrichment Director, said she did an initial assessment to learn Resident 285's choices. Staff C said she invited residents outside if the weather permitted. Staff C said they had invited Resident 285 to go outside but was not sure if the resident had been outside. At 1:44 PM, Staff B, Director of Nursing Services and Registered Nurse, said resident preferences should be offered. At 2:24 PM, Staff A, Administrator, said he expected activities staff to document what they were doing and how long. Staff A said documenting refusals was weak. Reference WAC 388-97-0940 (1)(2)

Based on observation, interview, and record review, the facility failed to ensure grooming assistance was provided for 1 of 2 sampled residents (12) reviewed for activities of daily living (ADLs). This failure placed residents at risk for unmet care needs, poor hygiene, and a diminished quality of life. Findings included . Resident 12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 07/22/2024, showed Resident 12 was cognitively intact and had an impairment on one side (left) of the upper extremity. Resident 12's care plan, dated 06/19/2023, showed Resident 12 required extensive assistance with personal hygiene and did not have specific interventions for nail care. On 07/22/2024 at 11:31 AM, Resident 12 was observed to have long unkept fingernails on both hands. Resident 12 said it was her preference for her fingernails to be shorter. The electronic medical record did not reflect any nail care was offered and/or refused from 06/30/2024-07/22/2024. On 07/23/2024 at 10:30 AM, Staff F, Nursing Assistant, said nail care was completed on shower days. Staff F said shower days were two times weekly, and nail care refusal should be documented. At 12:20 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, said nail care was offered with shower or skin assessment. Staff E said nail care refusals would be documented just like a shower refusal in the electronic medical record or on a paper shower sheet. At 3:50 PM, Staff B, Director of Nursing Services and Registered Nurse, said nail care should be completed on shower days and any refusal should be documented. Staff B observed Resident 12's nails and indicated they were long and unkept. Reference WAC 388-97-1020 (2)(a)(i)

Based on interview and record review, the facility failed to ensure staff received dementia training and/or abuse/neglect training for 3 of 5 sampled staff (F, G & H) reviewed for nurse aids in-service trainings. This failure placed residents at risk for receiving necessary care from unskilled staff. Findings included . Staff F, Certified Nursing Assistant, was hired on 06/18/2023. No training records or in-services provided showed Dementia or Abuse/Neglect training was completed since hire. Staff G, Certified Nursing Assistant, was hired on 12/02/2022. No training records or in-services provided showed Dementia or Abuse/Neglect training was completed since hire. Staff H, Certified Nursing Assistant, was hired on 11/07/2022. No training records or in-services provided showed Abuse/Neglect training was completed since hire. On 08/08/2023 at 3:15 PM, Staff A, Administrator, said staff should have at least one Dementia training per year. Reference WAC 388-97-1680 (2)(b)

Based on interview and record review, the facility failed to ensure informed consents were obtained prior to administration of psychotropic medications (medications affecting the mind) for 2 of 5 sampled residents (16 & 31) reviewed for rights to be informed about care and treatment related to unnecessary medications. This failure placed residents at risk of not knowing the effects of medications, medication side effects, and a decreased quality of life. Findings included . 1) Resident 16 was admitted to the facility on [DATE] with diagnoses including depression. Resident 16's admission Minimum Data Set (MDS), an assessment tool, dated 06/26/2023, documented the resident was moderately cognitively impaired. A physician's order, dated 06/19/2023, documented Resident 16 was ordered Trazodone, an anti-depressant medication. A physician's order, dated 06/20/2023, documented Resident 16 was ordered Venlafaxine, an anti-depressant medication. A physician's order, dated 06/20/2023, documented Resident 16 was ordered Diazepam, an anti-anxiety medication. Resident 16's August 2023 Medication Administration Record documented the resident received Trazodone, Venlafaxine, and Diazepam on a routine basis. Resident 16's electronic medical record (EMR) did not show informed consents were completed explaining the risk and benefits of the psychotropic medications. On 08/08/2023 at 1:18 PM, Staff B, Director of Nursing Services and Registered Nurse, said psychotropic medications included medications such as antidepressants and anxiolytics (anti-anxiety medications). Staff B said residents were educated on the risks and benefits to psychotropic medications by informed consent forms containing information on the prescribed medications. Staff B said floor nurses were responsible for obtaining informed consents for psychotropic medications. Staff B said she could not find the consents for Resident 16's Trazodone, Venlafaxine, and Diazepam medications, and there should be consents in place for the medications. 2) Resident 31 was admitted to the facility on [DATE] with diagnoses including depression. The admission MDS, dated [DATE], documented the resident was moderately cognitively impaired. A physician's order, dated 06/28/2023, documented Resident 31 was prescribed Sertraline, an antidepressant medication. A physician's order, dated 06/28/2023, documented Resident 31 was prescribed Mirtazapine, an antidepressant medication. Resident 31's EMR did not show informed consents were completed explaining the risk and benefits of the psychotropic medications. On 08/09/2023 at 10:57 AM, Staff B said there were no informed consents in Resident 31's medical record for the psychotropic medications and there should have been. Reference WAC 388-97-0180 (1-4)

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment, intended to mitigate the risk and spread of coronavirus (a highly contagious virus which causes COVID-19 infections), was consistently implemented in one of two halls (West Wing-COVID-19 quarantine unit) for 16 of 32 sampled residents (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, & 16) reviewed for quarantine with known exposure to COVID-19. This failure placed residents and staff at risk for contracting COVID-19 during a global pandemic. This failure resulted in an Immediate Jeopardy when staff did not know how to implement PPE on a unit with known exposure to COVID-19 and increased the likelihood of serious illness or death due to the spread of COVID. Removal of the IJ immediacy was validated effective 03/02/2021 with an on-site visit on 03/03/2021 ensuring PPE was properly and consistently used, isolation precaution signage was in place, and staff were educated on hand hygiene, transmission and preventing the spread of COVID-19. Findings included . Center for Disease Control (CDC) guidelines, updated 11/20/2020, entitled Preparation for COVID-19 in nursing homes . documented, Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Healthcare provider) should wear an N-95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. The facility's Infection Prevention and Control Program (IPCP) policy, dated 11/2017, documented when a resident was placed on transmission-based precautions, signage that clearly identified the type of precautions and appropriate PPE (personal protective equipment) to be used, should be posted in a conspicuous place outside the resident's room. On 02/25/2021 at 11:10 AM, four personal protective equipment (PPE) face shields were observed laying on various surfaces at the nurses station. One face shield laid on top of the refrigerator the facility used for resident snacks and supplements. Three of the face shields had unidentifiable names written on sides of the shields, and two had no identification marks. When asked about the face shields placed around the nursing station and on top of the refrigerator, Staff A, Assistant Director of Nursing Service and Infection Control Preventionist (ADNS/ICP), said she would assume the shields were dirty. Staff A said all staff were to keep their PPE in their assigned cubbies at the facility entrance door. At 11:15 AM, the double doors leading into the West wing (COVID quarantine unit) were observed to be closed with two red stop signs alerting persons to check with nursing prior to entry. 16 residents (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 & 16) resided on the West wing. At 11:15 AM, after entering the West wing the following observations and interviews were made: --room [ROOM NUMBER] was observed to be occupied by Resident #1 and Resident #2. Staff C, Hospitality Aide, was observed sitting behind a bedside table across from Resident #1. Resident #1 was observed wearing a face mask, and no other PPE. Staff C said in an interview immediately following the observations, Staff C said he provided supervision only as Resident #1 was a fall risk. There were no precautions signs observed on room [ROOM NUMBER] doors or walls indicating a need for transmission based precautions. --Staff D, Registered Nurse (RN), was observed outside room [ROOM NUMBER]. When asked about the staff in room [ROOM NUMBER], Staff D said Staff C was a hospitality aide, and did not provide direct care and did not need full PPE. Staff C let other staff know if the residents needed anything. When asked about PPE worn on the unit, Staff D said when residents were released from the designated COVID unit, staff were to wear mask, shield, gloves, and gowns for 14 days. Staff D said four residents (#3, 4, 13 & 14) were recently released from the COVID unit and were under precautions. Staff D said signs were available and showed in Rooms 20-22, staff were to wear PPE. --room [ROOM NUMBER] was observed occupied by Resident #3 and Resident #4 (recently released from the COVID unit). room [ROOM NUMBER] did not have posted precaution signs or instructions for PPE needed prior to entering. --A brown three drawer cart was observed outside of room [ROOM NUMBER], occupied by Resident #6. The cart contained masks, gloves, gowns, and did not contain disinfectant wipes. There were no signs on the Resident #6's door, or wall leading into his room, identifying the need for PPE or identified transmission precautions staff were directed to follow. When asked about Resident #6's cart outside his door, Staff D, RN, said Resident #6 had a [DIAGNOSES REDACTED]. When asked if there were additional precautions needed for persons with [DIAGNOSES REDACTED], Staff D said no. (Centers for Disease Control current guidance recommends gown, gloves, hand hygiene whenever entering room). When asked about care for Resident #6, Staff E, Nurse Aide (NA), said the resident had C.diff, and staff were to wear a gown and gloves. Staff E said she did not know if the resident was on droplet or any other precautions. --room [ROOM NUMBER] was observed to be occupied by Resident #5 and had a quarantine precautions sign on her door. The front of the precaution sign showed staff were to perform hand hygiene on entry to room, and wear mask (N-95 with aerosolizing procedures), eye protection and gown and glove when providing direct resident care. Additional instructions provided information regarding using disposable or dedicated equipment, and cleaning and disinfecting shared equipment. The back of the sign showed the header Quarantine Precautions and directly beneath noted if resident has diarrhea and/or C.difficle add Contact [MEDICATION NAME] Precautions. Additional information instructed staff in placement of sign, use of dishes, equipment, waste and linen management, private room recommendations, room cleaning, transport and diagram on how to donn and doff PPE. --room [ROOM NUMBER], occupied by Resident #14, showed no signs posted. --Staff E, NA, was observed outside room [ROOM NUMBER], occupied by Resident #11, donning a gown. Staff F, NA, approached Staff E and was overheard telling Staff E she did not need to gown up for that particular room. room [ROOM NUMBER] was observed with a cart placed beside the room door. No quarantine signs were posted. --When asked about residents with precautions, Staff F said residents with precautions had carts with drawers in front of their rooms. Staff F said the two residents in room [ROOM NUMBER] (Resident #13 and Resident #14) came over to the West wing two days ago, room [ROOM NUMBER] (Resident #11) was not on precautions, one of the residents in room [ROOM NUMBER] (Resident #15 and Resident #16) had a cough, and there was plenty of PPE on the wing. --room [ROOM NUMBER], occupied by Resident #13 and Resident #14 who had just transferred two days ago, was observed without a posting showing instructions to staff on precautions. The posting observed was only the back side of the Quarantine poster previously noted on room [ROOM NUMBER]. --room [ROOM NUMBER], occupied by a resident with a cough, was observed with signage of only the front of the Quarantine sign posted outside the door and no additional isolation precautions (droplet) were posted indicating special precautions. At 11:45 AM, Staff G, Therapist, was observed in room [ROOM NUMBER] with Resident #14. Staff G transferred the resident from her chair to bed. Staff G wore a face mask, shield and gown. No gloves were observed on Staff G's hands. Prior to exiting the room and washing her hands, Staff G opened several of the cart drawers looking for an item. Upon exiting room [ROOM NUMBER], Staff G was asked if she had used gloves during care. Staff G said no. Staff G said there were none in the cart that were her size and she did not want to remove her gown and go get the size she needed. Staff G said she was looking in the cart for bleach wipes. Staff G said she knew she should have removed her gown, retrieved gloves in her size prior to working with the resident. At 11:50 AM, upon exiting West wing, the double doors showed an additional Quarantine sign had been posted alongside the stop signs previously observed at 11:15 AM. At 11:50 AM, Staff H, NA, was observed going through the doors and entering the West wing. When asked about COVID in the facility, Staff H said positive cases started on the West wing 10 days prior, and the facility tested everyone every Tuesday and Friday. Staff H said if there were positive cases they would probably be from the West wing. When asked about how she would know when to wear PPE, Staff H said she would wear gowns with residents that had carts in front of their doors. Staff H said she did not see the signs on the entrance doors leading to the West wing. At 12:05 PM, after talking about the previous observations and interviews about the West wing, Staff B, Director of Nursing Services, said the doors to the West wing were closed due to exposure of COVID to all residents residing on the wing. Staff B said all residents were on contact precautions. Staff were to wear gowns, gloves for everyone, and it applied to the whole unit. Staff B said [MEDICAL CONDITION] residents should have [MEDICATION NAME] precautions and it had been awhile since there was a need for the sign to be used. Staff A said the whole wing was quarantined and she would expect when staff were providing direct care to wear gowns. Staff A said gowns were not necessary if there were no hands on, and referred to hospitality aide, Staff C. Staff A said currently there were no residents on special precautions. If droplet, there would be a pink sign; and staff would gown up. Staff A said residents were quarantined from exposure, and West wing staff were not allowed to work on the other end of building to limit movement back and forth. At 12:58 PM, the West wing was observed. Staff C was observed in room [ROOM NUMBER], seated at a bedside table. Staff C wore a mask, and no other PPE was observed. room [ROOM NUMBER] did not have a sign on the door indicating a need for precautions. At 1:00 PM, when asked about COVID positive residents, Staff H, RN, said Resident #17 and Resident #18, now on the COVID unit, were not new admissions. The exposure occurred about one to two weeks prior. Staff H said when the residents became positive, they were moved to the COVID unit. Staff H said Resident #17 and Resident #18 were not roommates. Staff H said they were roommates with Resident #1 and Resident #2, who were supervised by Staff C in room [ROOM NUMBER]. Record review of the facility's infection control line listing showed the COVID-19 outbreak started on 01/30/2021 when a staff member tested positive for COVID-19 and had worked on the West Wing. As of 02/25/2021 a total of seven residents and eight staff from the West wing had tested positive for COVID-19, with the most recent facility staff reported positive on 02/23/2021. Record review, completed on 03/03/2021, showed six residents were on isolation/droplet precautions related to possible COVID-19 exposure, and included Resident #1, Resident #2 and Resident #11 on the West wing. A staff tested positive for COVID-19 on 03/03/2021. Reference WAC 388-97-1320(1)(a)(2)(a)

Based on observation, interview and record review, the facility failed to ensure acceptable parameters of nutrition were maintained for 5 of 5 current sampled residents (#59, 23, 64, 63, & 24) reviewed for nutrition, when the facility failed to monitor weights, notify the Registered Dietician (RD) and/or Physician of weight loss, and implement recommended interventions. This failure resulted in a severe weight loss for Residents #59, 23 and 64 and placed all residents at risk for malnutrition and a decline in health status. Findings include: The facility's Weight Assessment and Intervention Policy, dated September 2008, documented, The nursing staff will measure resident weights on admission, the next day and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 1) Resident #59 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 8/2/17, documented that resident was rarely or never understood and required extensive assistance with Activities of Daily Living (ADLs). Resident #59's care plan, dated 7/26/17, documented the resident was at nutritional risk due to his [DIAGNOSES REDACTED]. A Nutritional Evaluation, dated 8/6/17, documented a goal to prevent unplanned significant weight changes, with interventions to offer snacks and be evaluated by the dietician as needed. On 9/11/17, Resident #59's care plan documented Resident #59 was at risk for weight loss due to frequent sleeping late and choosing not to get up and eat. The resident was observed sleeping in his bed multiple times from 11/7/17 to 11/16/17 during meal time. On 9/15/17, the previous Consulting Dietician (CD) documented, Discussed meal intake and weights with dietary director and resident is receiving added calories, protein and fluids via supplements three times a day to help promote weight maintenance. No documentation was found in the resident's chart to show the resident was actually receiving supplements or the amount the resident was taking. On 10/18/17, a Nutritional Evaluation documented the most recent weight of 181 pounds, taken three months prior, on 8/20/17, and listed a goal to sustain the weight of 181 pounds or greater. On 11/8/17 at 3:33 p.m., Resident #59's Power of Attorney (POA) stated, I'd like him to be weighed. I am curious if he is losing weight. It looks like he has. On 11/13/17 at 12:38 p.m., Resident #59 was observed in the dining room with his eyes closed. Resident #59's meal intake form documented the resident refused his meal 25 times between 10/15/17 and 11/13/17. Resident #59's medical record documented the following weights: 7/26/17 184 pounds 7/28/17 185 pounds 8/20/17 181 pounds On 11/13/17 at 11:53 a.m., when asked if Resident #59 had been weighed since 8/20/17, Licensed Nurse (LN) A, a Registered Nurse, stated, I don't see a weight for September, October, or November. When asked if she would expect there to be a weight for Resident #59 for these months, LN A stated, I don't know if he is supposed to have a weight. I know he is not a daily weight. If a resident is not a daily weight, then we just weigh them on admit and maybe when needed for the MDS. When asked how the dietician was informed of weight loss, LN A stated, I don't know. The dietician comes in and I don't really correspond with her. The dietician would ask if she needed a weight. I think she comes in once a month. I don't prepare a weight list. On 11/13/17, upon request of the surveyor, Resident #59 was weighed. The weight was entered in the chart as 166 pounds, which was a 15 pound loss, resulting in a severe weight loss of 8.28%. On 11/13/17, a Nutritional evaluation documented, Resident has had a significant weight loss over the past quarter of about 8.5%. This is faster weight loss than is desirable. Resident is not eating enough of his meals (only about 36.6%) and not drinking enough to meet minimum nutrition or hydration needs at time of this writing .resident is at risk for continued weight loss related to [DIAGNOSES REDACTED]. The facility failed to obtain weights for resident per standards of practice, assess his nutritional status accurately, provide nutritional interventions, and caused harm when they failed to prevent a severe weight loss for Resident #59. 2) Resident #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented the resident was moderately cognitively impaired and required extensive assistance with ADLs. On 11/14/17 at 9:03 a.m., Resident #23 was observed sitting in his wheelchair in the hall and appeared thin and frail. A Nutritional Evaluation, completed by the Previous Consulting Dietician (CD), dated 9/15/17, documented a goal of preventing unplanned significant weight changes and to offer snacks and follow up with the RD as needed. There was no documentation that showed the resident received snacks between meals per the RD's recommendation. The resident's medical chart documented the resident weighed 137 pounds on 9/10/17 and 135 pounds on 9/17/17. No other weights were taken until 11/15/17, when the resident weighed 123 pounds. Resident #23 experienced an unplanned and undetected weight loss of 14 pounds, resulting in a severe 10 % weight loss and a BMI of 18.7%. The facility failed to obtain weights according to current standards and the facility's policy and failed to implement interventions to prevent severe weight loss, causing harm to Resident #23. 3) Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented the resident was rarely or never understood and required limited assistance with ADLs. A Nutritional Evaluation, dated 9/15/17, documented the resident's meal and snack intake varied and the resident was to receive health shakes three times a day with meals, be offered snacks and be referred to the Registered Dietician (RD) as needed. There was no documentation in the resident's chart showing the resident had received health shakes or snacks. On 11/15/17 at 10:08 a.m., Nursing Assistant (NA) A said she did not regularly pass out snacks to any resident in particular. At 10:11 a.m., Resident #64 said he did not receive any regular snacks from staff. The resident's care plan, dated 9/29/17, documented the resident had a nutritional problem and was at risk for weight loss and skin break down. The care plan listed a goal to not have a significant weight loss of 5% in 30 days. Interventions included reporting signs or symptoms of malnutrition to the doctor, including a three pound weight loss in one week, greater than five % weight loss in one month or greater than 7.5% in three months. Interventions also included serving snacks and supplements and contacting the RD for diet change recommendations. The resident's medical chart documented the resident weighed 143 pounds on 9/7/17 and weighed 130 pounds, one month later, on 10/8/17, resulting in a weight loss of 13 pounds and 9% severe weight loss, causing harm to Resident #64. There was no documentation in the chart showing the RD or physician was contacted about the weight loss. 4) Resident #63 was admitted to the facility on [DATE] with a fracture and nutritional deficiencies including [MEDICAL CONDITION]. The MDS, dated [DATE], documented the resident was severely cognitively impaired and required extensive assistance with ADLs. On 8/25/17, the resident weighed 122 pounds. A nutritional evaluation, dated 9/10/17, documented the resident should receive health shakes with meals twice a day and be offered snacks. The resident's medical chart showed an order for [REDACTED]. On 11/13/17 at 12:50 p.m., the Dietary Manager (DM) provided a list of residents receiving health shakes with meals. Resident #63 was not on the list. On 11/15/17 at 3:06 p.m., the DM reviewed Resident #63's tray card and said health shakes were not listed. She said that was an error and added health shakes to his card. On 11/15/17 at 3:12 p.m., when asked about snacks, Resident #63 said, They don't come around and ask about snacks. The resident said he would need to ask for a snack. At 3:13 p.m., the ADNS said if the RD recommended snacks, nursing should write an order for [REDACTED]. 5) Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], documented the resident was cognitively intact and required extensive assistance of two persons with ADLs. On 11/7/17 at 5:00 p.m., Resident #24 was observed siting up in his bed and appeared frail and thin. A Nutritional Evaluation completed by the RD, dated 10/27/17, documented, He is a very high nutrition risk related to recent weight loss and eating and drinking less than enough to meet minimum nutrition and hydration needs at this writing . An admission weight had not been taken and the RD requested staff obtain a weight to be used in her nutrition assessment of Resident #24. The resident weighed 147 pounds and had a BMI (body mass index) of 19%. The RD recommended Resident #24 be given snacks between meals and at bed time. There was no documentation in the residents chart showing he had been receiving snacks. On 11/15/17 at 2:18 p.m., the RD said, His BMI is horrible. He needs calories. The RD said she was not aware of the resident's unstageable pressure wound. At 3:49 p.m., The DM verified the recommended snacks were not ordered or identified on Resident #24's MAR and said Resident #24 was not on a list of residents to receive snacks. The DM said, It looks like that one was missed. <Staff Interviews Regarding Weight Loss and Nutrition> On 11/13/17 at 12:44 p.m., the Assistant DNS said she was not sure how often the RD came in, or who the RD's contact person in the facility was, and she was not aware of any regular scheduled meeting to discuss weight loss and interventions. At 12:49 p.m., the DM said they had a new RD. She was unsure of the exact date the RD would be at the facility and said, She leaves me notes if I am not here. At 1:58 p.m., the DNS said the DM had been overseeing weights and responsible for contacting the RD when weight loss had occurred. At 2:01 p.m., the DM stated she and/or nursing would call the RD if weight loss was identified. When asked about the extent of weight loss that would require the facility to contact the RD, the DM said, Three pounds in a week or five pounds in a month. The DM said if she knew the RD was coming in a day or two, she would notify her at that time, but would otherwise call her to report identified weight loss. At 4:38 p.m., the DNS said, I know the system is broke. At 5:05 p.m., the RD stated she had been working with the facility for one month and had not received any calls from the facility about resident weight loss during that time and said, I will let the DNS know it is my expectation to weigh residents at least monthly. On 11/14/17 at 9:09 a.m., the DNS stated, We're trying to get things back on track and to following the regulations. On 11/15/17 at 3:49 p.m., when asked how RD recommendations to provide snacks were implemented, the DM said snacks were stocked in the nurse's refrigerator each evening and said the nurse's knew who needed to be offered a snack. The DM was not able to produce a list of residents who were recommended to receive snacks. At 3:50 p.m., the Medical Records Staff said she unsure if there was a list of residents who had been recommended to receive a snack. The facility's Weight Assessment and Intervention Policy, dated September 2008, documented, Any weight change of 5% or more .will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The facility failed to accurately monitor weights per their policy and per standards of practice, failed to have a functioning system in place to identify and report weight loss to the RD and/or physician and failed to consistently implement recommended interventions. Reference: (WAC) 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with the resident's advanced directives and professional standards for 1 of 3 former sampled residents (#27) reviewed for death in the facility. This failure caused harm to Resident #27 when an emergent medical evaluation was not received, and contributed to his decline. The facility also failed to assess for neurological changes after unwitnessed falls for 1 of 3 current sampled residents (#15) reviewed for accidents. This failure placed residents at risk of a delay in treatment and intervention. Findings include: 1) Resident #27 was admitted to the facility on [DATE] at 11:55 a.m., with multiple medical [DIAGNOSES REDACTED]. A hospital discharge summary, dated 8/22/17, documented the plan as, He will have (Physical therapy) evaluate and treatment with no weight bearing on the right leg. Continue oxygen at 2 liters per minute via nasal cannula due to hypoxemia (low oxygen in blood) and [MEDICAL CONDITION]. Turn every 2 hours as needed to attempt to decrease risk of [MEDICAL CONDITION] (blood clots) and pressure ulcers. There was no documentation in the hosptial records that indicated the resident was going to the nursing home on comfort measure or hospice care. A nursing note, dated 8/22/17, at 1:01 p.m., documented, Resident had a POLST form - DNR with comfort measures. Resident #27's Physician order [REDACTED]. Do not use intubation or mechanical ventilation. May use less invasive airway support (e.g. [MEDICAL CONDITIONS]). Transfer to hospital if indicated, avoid intensive care if possible. No comfort care orders were found in Resident #27's medical record. Physician orders, dated 8/22/17, documented to keep oxygen saturations above 90%. A nursing note, dated 8/22/17, at 11:00 p.m., documented, (Oxygen saturations) were 78% on 2.5 liters oxygen at 7:50 p.m. Oxygen was increased to 4 liters before (saturations) were above 90%. An Oxygen Saturation Summary, dated 8/23/17, at 8:00 a.m., documented an oxygen saturation of 76%. Resident #27's Medication Administration Record [REDACTED] A nursing note, dated 8/23/17, at 9:02 a.m., documented, Resident found without vital signs. No documentation was found in the resident's medical chart that indicated the family or physician was consulted regarding the resident's change in condition. On 11/16/17 at 2:52 p.m., the Director of Nursing (DNS) confirmed the resident's POLST did not indicate comfort measures only, nor did she see an order for [REDACTED].#27 should have been sent to hospital as the POLST directed. Resident #27's POLST directed that he wanted to be transferred to a hospital, if indicated, and would want airway support. The resident had significantly low oxygen saturations on at least two occasions during the 21 hours he was in the facility. The resident's doctor was not notified or consulted and resident was not transferred to a higher level of care. This failure to include the physician in care decisions and treatment options contributed to the resident's decline in condition which caused harm to Resident #27. 2) Resident #15 was admitted to the facility on [DATE]. The resident's MDS, dated [DATE], documented the resident was rarely or never understood and required extensive assistance of two persons for ADLs. The facility's Neurological Assessment Policy, dated October 2010, documented, Neurological assessments are indicated: following an unwitnessed fall .3) Perform neurological checks with the frequency as ordered or per falls protocol. 4) Determine resident's orientation to time, place and person. 5) Observe resident's patterns of speech and speech clarity. 6) Take temperature, pulse, respirations, blood pressure .7) Check pupil reaction . The facility's neurological observation form, dated January 2006, indicated neurological checks should be completed every 15 minutes for the first hour, every 30 minutes for the next hour, every hour for the next four hours, and every four hours until 24 hours has passed. On the second day, neurological checks should be completed every eight hours. A nursing progress note, dated 7/7/17, documented Resident #15 fell from his wheel chair on 7/7/17 at 7:25 p.m. A nursing progress note, dated 9/29/17 at 10:18 a.m., documented Resident #15 was found lying on his right side in his room. A nursing progress note dated 10/9/17, documented Resident #15 was found lying on his side on the floor beside his bed on 10/8/17 at 7:10 p.m. Progress notes indicated the falls had been unwitnessed. Neurological checks were not found in the resident's chart or investigative documentation for the three unwitnessed falls. On 11/16/17 at 3:25 p.m., the DNS said neurological checks should be done for any unwitnessed fall. At 3:33 p.m., the Assistant DNS (ADNS) said neurological checks should be done if they hit their head and stated, If the fall was unwitnessed, you can ask them. If someone is alert, they would know if they hit their head. When asked if Resident #15 could reliably tell you if he hit his head, the ADNS said, It depends on the day. At 4:18 p.m., the ADNS looked in Resident #15's chart and found neurological checks from 2016. At 4:25 p.m., the ADNS she said, I didn't find any other neuros. Reference: (WAC) 388-97-1060 (1)

Based on interview and record review, the facility failed to implement policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of property when it failed to screen out 1 of 5 facility employees (Staff A) reviewed for background checks. The facility failed to follow CFR §483.12(b)(1) and its own internal policy when Staff A was found to have a substantiated finding of abuse and/or neglect which precluded the employee from working with vulnerable adults. Staff A worked unsupervised with vulnerable adults from December 2013 until May 2017, despite two background checks which disclosed the finding of abuse and/or neglect. This failure placed all residents at risk for abuse and/or neglect, which constituted an Immediate Jeopardy. Findings include: According to the facility's Abuse Policy and Procedure (undated but provided by the facility on 5/22/17), The facility will protect the resident from abuse by adhering to established procedures related to screening and training of employees, prevention, identification of potential abuse, investigation of potential abuse, protection of residents and reporting of suspected abuse. Under the Screening section of the policy, If any of the pre-employment screening indicates a criminal or licensing/credentialing board history of abuse, neglect, misappropriation of property or unsatisfactory work history, the applicant will not be considered for employment. The policy further provides, If during the course of employment of an individual, (the facility) becomes aware of an ensuing criminal or licensing/credentialing board finding of abuse, neglect or misappropriation of property the information will be forwarded to Corporate Human Resources for processing and investigation. The individual will be removed from the schedule until cleared. On 5/22/17 at 4:04 p.m., Staff A stated he/she was hired by the facility in late December of 2013 as a certified nurse aide (CNA) and had worked at the facility for about four years. When asked about background checks, Staff A stated, As far as I know, my background's good. When asked if he/she was aware that his/her background check contained a finding of abuse, Staff A stated he/she was not aware of any problem or any dings on my record, and did not remember any incident where he/she would have been reported. When asked, Staff A stated he/she had never received a copy of his/her background check report, and no one from the facility had ever spoken to him/her about it. Staff A reviewed the 5/2/17 Notification of Background Check Result and verified it contained Staff A's correct name and birthdate. On 5/22/17 at 4:30 p.m., the Director of Nursing Services (DNS) stated that Staff A had been taken off the schedule and the State agency that substantiated the finding of abuse and/or neglect would be contacted the next day for more information. On 5/22/17 at 4:52 p.m., the Administrator stated he knew the facility had hired Staff A, but did not recall anything wrong. When asked about Staff A's background check, the Administrator said, I don't remember if I've seen it. The Administrator explained the process had been when a background check came back as cleared, it did not go to the corporate office. If a background check came back that indicated further review was required, he would review the background check and either sign it, or write no which indicated the applicant was not to be hired. If the background check came back as not cleared, the Administrator said it would be reviewed to determine whether it was either a mistake or needed a suitability review. The Administrator said, The company now reviews all the background checks. On 5/23/17 at 2:20 p.m., the Administrator said in the past the facility did not have the same checks and balances. The Administrator referenced a new policy which went into effect earlier in the year which showed all new hire background checks go through the central office. On 5/23/17 at 2:20 p.m., when asked about the process for an existing employee whose background check was returned with a finding, the facility's Regional Vice President said if it comes back negative, the facility is supposed to be notifying the recruiting department. According to the facility's New Hire Policy and Procedure, dated January 2017, Recruiting will inform the candidate that the background check, drug screen, 2-step TB, physical (if applicable) and reference checks must be completed before the candidate is 'cleared' to start working. The New Hire Policy and Procedure documented, If you have not received a 'cleared' result from your Onboarding Coordinator, DO NOT allow the employee to work. Review of Staff A's employment records at the facility contained an Application for Employment for a position as a CNA signed by Staff A on 12/17/13. On 12/17/13, Staff A signed a Background Authorization which permitted the facility to request a background check prior to beginning employment. According to facility payroll records, Staff A began work at the facility as a CNA on 12/18/13. On 12/24/13, the State Background Check Central Unit faxed the background check results for Staff A to the facility which documented Staff A had a substantiated finding of abuse and/or neglect. Review of the Department Secretary's List of Crimes and Negative Actions, referenced in the background check result, documented individuals may not work in a position that involves unsupervised access to minors or vulnerable adults if he or she has been convicted of or has a pending charge for one of the several crimes, including abuse or neglect. On 5/7/17, a Notification of Background Check Result was faxed to the facility which documented Staff A's background contained a substantiated finding of abuse and/or neglect. The notice displayed in large type and bold print, DISQUALIFY. The notice explicitly documented, This means the applicant cannot have unsupervised access to children or vulnerable adults. Review of Staff A's employment portfolio did not contain documentation of review of either background check result by the facility administrator or the facility's corporate office. The facility employed Staff A as an unsupervised direct caregiver from 12/18/13 until 5/22/17. The facility received two notifications of a substantiated finding of abuse and/or neglect on the staff member's background check but did not act on the finding to protect residents according to regulation or policy. WAC 388-97-0640(2)(a)(b), (9) .

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potentially affected all residents in the facility. Failure to ensure compliance represented Immediate Jeopardy for Resident #5 and #6 referenced in F 223, F 225 and F 226 and harm to Resident #1 referenced in F 314. Findings include: 1) Refer to 42CFR 483.12 - F 223 Free From Abuse/Involuntary Seclusion for facility failure to protect Resident #5 and #6 when staff failed to recognize sexual abuse and implement measures to protect the residents. This constituted Immediate Jeopardy. 2) Refer to 42CFR483.12(a)(3)(4)(c)(1)-(4) - F 225 Investigate/report Allegations/individuals for facility failure to recognize sexual abuse and take immediate measures to protect the residents; report the incident to ensure staff immediately reported witnessed sexual contact between residents to Administration and the State Agency for Resident #5 and #6 and constituted Immediate Jeopardy. 3) Refer to 42CFR483.12(b)(1)-(3), 483.95(c)(1)-(3) - Develop/implement Abuse/Neglect, Etc. Policies, F 226 for facility failure to develop and implement policies and procedures to protect 2 of 2 current residents (#5 and #6) from witnessed unlawful sexual abuse and take immediate measures to protect the residents from repeated occurrences. This failure constituted Immediate Jeopardy. 4) Refer to 42CFR483.25 (b)(1) -Treatment/services to Prevent/heal Pressure Sores F 314 for facility failure to document, monitor and prevent the development of pressure ulcers and resulted in harm to Resident #1 and placed all residents at risk for skin injuries. The administration failed to ensure there was sufficient policies and procedures in place to protect residents from abuse, to ensure residents did not develop skin injuries that resulted in harm, and were readily available for staff related to abuse, neglect and skin issues. This resulted in resident harm, and placed all residents at risk the same/similar failed practice. .

Based on observation, interview and record review, it was determined the facility failed to protect 2 of 2 sampled residents (#5, #6) reviewed for unlawful sexual abuse. The facility permitted the Residents to continue to reside in the same room after the facility witnessed sexual contact between related residents and failed to intervene. This failed practice created an unsafe environment for these residents and placed all residents at risk of the same/similar deficient practice and constituted Immediate Jeopardy. Findings include: Resident #5 was admitted to the facility on [DATE] with multiple health conditions including dementia. The resident used a wheelchair for mobility but was able to ambulate and self-transfer independently. Resident #6, a relative of Resident #5, was admitted to the facility on [DATE] with multiple health conditions including dementia and a cognition level of 3 out of 15 score on a mental status exam. A score below 7 indicates severely limited cognition/ability to understand. Review of a hand-written note by Nursing Assistant (NA) A dated 1/5/17 at 7:30 p.m., indicated she witnessed sexual contact between Residents #5 and #6 who were also roommates. The residents are related within the definition of RCW 9A.64.020. The NA did not report the incident as required but did ask NA B what to do. NA B advised for her to write a note to leave for the Director of Nursing Services (DNS). During interview with Registered Nurse (RN) A on 1/25/17 at 6;10 p.m., she stated no one informed her of the witnessed abuse and when she did find out about it, she said the residents were back sleeping in their own beds. She said she did not report the event to the DNS or anyone else because she got busy and forgot. She did not feel any harm occurred because the residents were related. On 1/12/17, the facility modified each resident's care plan to close the residents' door and provide privacy when engaging in sexual contact. The Director of Nursing Services (DNS) conducted in-service education to staff regarding residents' right to privacy. As of 1/25/17 at 7:00 p.m., both residents remained in the same room without interventions in place to prevent repeated abuse. Refer to F 225; 226. .

Based on observation, interview and record review, it was determined the facility failed to ensure an allegation of sexual abuse was immediately reported to the facility administrator/designee and to other officials in accordance with State law and 42 CFR 483.12(c)(1),(2),(3) and (4). Failure to recognize the allegation as abuse prevented initiation of necessary protective/corrective actions aimed at protecting residents until a thorough investigation into the allegations had been concluded for 2 of 2 Sampled Residents (#5, #6) reviewed for abuse. This failure constituted Immediate Jeopardy. Findings include: On 1/25/17, during interviews with the Director of Nursing Services (DNS), facility Nurse Manager (NM), Nursing Assistants (NA) A and B and Registered Nurse (RN) A between 1:00 p.m. and 7:30 p.m., it was learned the facility did not have written abuse prohibition policies and procedures. The DNS stated the facility used the State's Purple Book (PB, Nursing Home Guidelines, 6th Edition, Partners in Protection, October 2015). Page 30 of the PB: The nursing home's 1st priority is to protect the victim/resident and other residents from harm or further harm. Pages 6-7 of the PB: Immediate telephone reporting is required when there is reasonable cause to believe abuse .has occurred and .An incident of physical assault between residents always has to be reported to the department via telephone and reporting log . Page 15-16 and 20 of the PB: Individual mandated reporters must immediately report to the Department's hotline: when there is a reasonable cause to believe an incident is abuse .a belief that the incident probably happened .as soon as the resident is protected .if a crime has been committed against a resident, must report to the Department and to Law Enforcement within two (2) hours .If you are unsure, Report it. Resident #5 was admitted to the facility on [DATE] with multiple health conditions including dementia. The Minimum Data Set (MDS), a comprehensive admission assessment dated [DATE], indicated Resident #5 had a score of 12 out of 15 on a mental status exam which indicated good understanding/comprehension. Resident #6, a relative of Resident #5, was admitted to the facility on [DATE] with multiple health conditions including dementia and cognitive deficiency. On 1/3/17 the facility assessed Resident #6 with a cognition score of 3 out of 15 on the Brief Interview Mental Status (BIMS) exam. A BIMS score below 7 indicates severe impairment. On 1/12/17, review of the required reporting log failed to show the facility reported the witnessed sexual contact immediately to the Department on 1/5/17 and it was not documented on the reporting log. Witness statements from staff related to the allegation were not obtained except for the hand-written note left for the DNS on 1/5/17 at 7:30 p.m. by witness NA A. During interview on 1/25/17 at 2:15 p.m. regarding the event between Resident #5 and #6 (validated on a hand-written document dated 1/5/17 at 7:30 p.m. by NA A), NA A stated: I heard a yelp or ooooh, the door was open so I peeked in . The NA stated she observed both residents in what was described as sexually intimate contact and I didn't know what to do so I walked away, then heard one of the residents say, 'She is going to tell on us.' I did not know what to do, so I walked away .I was unsure how to deal with this so I left. She stated: .it was the residents' right as long as it's consensual (sexual contact). During interview at 3:00 p.m. with NA B she stated NA A told her about the incident and she told NA A to write a report and leave it for the DNS. When asked why she did not report to the hotline immediately she stated: We use chain of command .tell the DNS .I didn't see anything. NA B said no one interviewed her for a witness statement about the incident. At 5:45 p.m., during interview with the Nurse Manager (NM) for the facility, she stated: It (the witnessed event) was mentioned in report the following morning and that she had no other knowledge about the incident. During interview with RN (Registered Nurse) A at 6:12 p.m., she stated she found out about the sexual contact around 10:00 p.m. and .in my opinion, this behavior has been going on for a long time. She stated she knew Resident #6 was mentally challenged .had cognitive deficiencies .I didn't believe it was harm because they were related. RN A said she did not inform the DNS or report to the state hotline immediately when she found out because she got very busy and forgot. She said no one interviewed her for a witness statement about the incident. During all interviews with staff, they stated they would report to the DNS and no one stated they would call the state hotline as noted in the Purple Book because it was a right to priavcy issue, not abuse. The DNS stated she had a phone conversation with a psychologist who recommended calling APS on 1/9/17. The incident was not reported to DSHS hotline by any staff at the facility, the investigation was not started immediately and not logged within 5 days. On 1/26/17 at 9:00 a.m., during interview with others not associated with the facility, it was learned the DNS and former interim administrator were informed on 1/13/17 that what had occurred between Resident #5 and #6 was a crime .and if they continued to keep the residents together they could be abetting (aiding/accessory to) a crime. Refer to F 223 and F 226.

Based on observation, interview and record review, it was determined the facility failed to develop and implement policies and procedures to protect 2 of 2 current residents (#5 and #6) from witnessed unlawful sexual abuse. The failure of the facility to identify actual and/or potential sexual abuse, immediately protect residents from repeated occurrences, implement effective interventions to prevent further unlawful, sexual behavior between related residents and immediately report the occurrence and begin an investigation of the witnessed sexual contact constituted an Immediate Jeopardy. Findings include: On 1/25/17, during interviews with the Director of Nursing Services (DNS), facility Nurse Manager (NM), Nursing Assistants (NA) A and B and Registered Nurse (RN) A between 1:00 p.m. and 7:30 p.m., it was learned the facility did not have written abuse prohibition policies and procedures. The DNS stated the facility used the State's Purple Book (PB, Nursing Home Guidelines, 6th Edition, Partners in Protection, October 2015). Page 1 of the PB: This document contains guidelines for the protection of nursing home residents along with guidelines for preventing, investigating, determining and reporting incidents of abuse .including reporting reasonable suspicion of a crime .these guidelines are intended to assist facilities in developing and implementing principles and procedures to help prevent resident abuse of all types . Page 6-7 of the PB: Immediate telephone reporting is required when there is reasonable cause to believe abuse .has occurred. Page 47 of the PB: PROTECT, INVESTIGATE, REPORT, CORRECT, PREVENT. In general, there is a presumption that abuse occurred whenever there has been some type of impermissible, unjustifiable, harmful, offensive, or unwanted contact with a resident . During interview on 1/25/17 at 2:15 p.m. regarding the event between Resident #5 and #6 on 1/5/17 at 7:30 p.m., NA A stated: I heard a yelp or ooooh, the door was open so I peeked in .and saw Resident #6 sitting up on the edge of the bed with Resident #5 sitting on top of Resident #6's lap. The NA stated she observed both residents in what was described as sexually intimate contact and Yes, I knew they were related .I didn't know what to do so I walked away, then heard one of the residents say, 'She is going to tell.' I did not know what to do, so I walked away .I was unsure how to deal with this so I left. When NA A was asked about training related to the incident, she stated a recent inservice (could not remember the date) was presented by the DNS that it was the residents' right as long as it's consensual (sexual contact). The NA was not able to verbalize what she knew about consent for sexual contact between residents. Resident #5 was admitted to the facility on [DATE] with multiple health conditions including dementia. The Minimum Data Set (MDS), a comprehensive admission assessment dated [DATE], indicated Resident #5 had good cognition. The resident used a wheelchair for mobility and was able to ambulate and self-transfer. At 1:30 p.m. during interview, Resident #5 could verbalize issues about life and family but had trouble remembering specific events. The resident did remember previous enjoyable relationships. When asked about the witnessed interaction between Resident #5 and Resident #6, Resident #5 stated: I don't know what you are talking about .that is (expletive) and added: I used to think (Resident #6) was a good (person) until this happened. When asked what happened, Resident #5 would not respond and wanted to go back to the room. Resident #6, a relative of Resident #5, was admitted to the facility on [DATE] with multiple health conditions including dementia and cognitive impairment. According to the admission assessment dated [DATE] for determining cognitive status (ability to understand/comprehend), Resident #6's score was 3 out of 15 on the Brief Interview Mental Status (BIMS) exam. A BIMS score below 7 indicates severe impairment. At 2:00 p.m. during interview, Resident #6 was able to converse and was not willing to participate in any conversation related to the event on 1/5/17 involving Resident #5. During interview at 3:00 p.m. with NA B she stated NA A told her about the incident and she said she told NA A to write a report and leave it for the DNS. When asked why she did not report to the hotline immediately she stated: We use chain of command .tell the DNS. When asked about what she was told by NA A, she stated: I know they (residents) have rights and I didn't feel they were in any danger . When NA B was asked what the nurses do in situations of sexual contact like this, NA B stated: I was shocked .I cannot judge them .They are both consenting adults. NA B was aware the residents were related. During interview with RN (Registered Nurse) A at 6:12 p.m., she/he stated no staff members reported the incident to her. She stated at around 10:00 p.m. on 1/5/17 she asked the NAs what they were discussing prior to leaving their shift. She asked about the note NA A was leaving for the DNS and asked to see it. She stated the note revealed NA A witnessed Resident #5 and #6 engaged in sexual contact. When asked what she did upon learning of the sexual contact, RN A said she did not assess either resident because they were both back in their own beds and sleeping. She acknowledged Resident #6 was cognitively impaired but she did not inform the DNS or report to the state hotline immediately because she got very busy and forgot. RN A acknowledged knowing both residents were related and would have considered this to be sexual abuse but in my opinion, this behavior has been going on for a long time. She stated she knew Resident #6 was mentally challenged .cognitive deficiencies. RN A stated: I didn't believe it was harm because they were related. On 1/12/17 and 1/25/17, no documentation could be found to indicate the residents were protected and that interventions were immediately in place to protect both vulnerable residents. As of 1/25/17 both residents still resided in the same room. Both NAs and the RN stated if they found the residents in this act in the future, they were instructed by the DNS to close the door and allow privacy as this is their right. All stated this activity must have been occurring for a long time and was therefore, consensual. Review of the Staff Inservice report after this event and provided by FAX from the facility on 1/13/17 indicated: All residents have the right to privacy. Residents may choose to close their door, unless assessed to be a high fall risk for the sake of their own privacy. Staff will respect when a resident's door is closed. If at all possible, return at a later time. If care must be performed at that time or a resident's safety is in question, staff must knock and wait for a response. If no response and you are concerned with the resident's safety, the staff may then enter the room. Review of the clinical records failed to provide any documentation about the witnessed sexual contact in the progress notes, reporting log or the residents' care plans. According to the DNS on 1/12/17, this documentation was kept out of all clinical records and in a separate file to protect Resident #5 and #6's right to privacy. The DNS felt both residents were able to consent to sexual contact because neither had been declared legally incompetent and it was not against the law. She said no resident in the facility was declared legally incompetent. If two consenting adults then we would provide privacy. When asked how she determined residents' competency to understand/comprehend even when the two residents were related to include the legal consequences of sexual contact, she felt she was being put on the spot and explained: If they (residents) are not declared incompetent and they can make their basic needs known and touch is a basic need . As of 1/25/17 at 7:00 p.m. the residents still resided in the same room with the door closed. According to RN A, the door should be left open to observe for falls and closed for when residents' needed time together. During all interviews with staff, none stated their first responsibility would be to immediately protect the residents from any harm/potential harm but would close the door for their right to privacy. .

Based on interview and record review, it was determined the facility failed to document, monitor and prevent the development of pressure ulcers for 1 of 6 sample residents (#1) reviewed for skin injuries. On 12/6/16 former Resident #1 was assessed on arrival at a hospital with pressure injuries that the facility failed to identify, document, treat and monitor to provide needed care and services. These failures resulted in harm to former Resident #1 due to the development of pressure ulcers and created the potential for development of pressure injuries to other residents in the facility. Findings include: Former Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, diabetes and kidney disease. At the facility, former Resident #1 continued on antibiotic treatment for [REDACTED]. The Minimum Data Set (MDS), a formal assessment tool dated 11/29/16, documented former Resident #1 was severely limited with cognition and communication and was dependent on staff for activities of daily living (ADLs), including repositioning in bed and transferring in and out of bed to a chair. The skin section of the MDS identified the resident was at risk for pressure ulcers, currently had no unhealed pressure ulcers, and listed interventions such as the use of chair and bed pressure relieving devices. Review of weekly skin assessments between admission on 11/22/16 and 12/6/16, the day former Resident #1 was transferred to the hospital, failed to identify any pressure injuries at Stage 1 (redness that is relieved with repositioning) or higher and no areas of excoriation (reddened, inflamed skin). On 1/12/17 at 2:13 p.m., Licensed Nurse (LN) A, who had provided care for former Resident #1 stated he had some redness to his bottom in the past but it had resolved. The LN stated former Resident #1 had no skin issues before he went to the hospital. On 1/12/17 at 2:31 p.m., LN B stated former Resident #1 had no skin issues prior to transferring to the hospital. The LN stated that moisture barrier cream was applied to the resident's bottom preventatively but there were no open areas. According to the record, during the early morning of 12/6/16, former Resident #1 became short of breath and his respiratory condition deteriorated. At 5:15 a.m., he was transported to the hospital. On arrival to the local emergency room (ER) on 12/6/16 at 6:50 a.m., nursing notes documented the presence of skin breakdown in former Resident #1's perineal area (skin most affected by elimination). Photographs taken in the ER of former Resident #1's skin showed small stage 2 (breaks in the skin) pressure injuries on his coccyx (tailbone area) and scrotum. The time between when former Resident #1 left the faciity on [DATE] at 5:23 a.m. and when the skin breakdown was first documented in the ER at 6:50 a.m. was approximately one hour and 27 minutes. The facility failed to show adequate assessments and care provided to prevent, monitor and document Resident #1's skin condition prior to the pressure injuries being found on arrival at the hospital ER. .