Every finding on record at Woodland Convalescent Center

Based on observation, interview and record review, the facility failed to ensure that food items were stored in accordance with professional standards for food safety; and failed to maintain required temperature for 1 of 1 kitchen dishwasher reviewed for kitchen task. These failures placed residents at risk for food borne illness and decreased quality of life.Findings included.Food Storage During an observation and interview on 08/03/2026 at 10:19 AM, two unlabeled bottles of Gatorade drinks, one with no lid, and a plastic bottle of water partially consumed were observed in the meat freezer. When asked, Staff Q, Cook, was unable to identify whom the drinks belonged to. During an observation and interview on 08/03/2026 at 10:26 AM, an open brown paper packaging containing dry food items was observed on the floor in the storage room. When asked what the food item on the floor was, Staff Q identified the dry food item as panko (flaky breadcrumbs) and said it should have been stored in a food storage bin. Dishwasher TemperatureDuring an interview on 08/03/2026 at 10:38 AM, Staff Q, said the kitchen dishwasher was a high temperature dishwasher. Record review of May 2026, June 2026 and July 2026 Dish Machine Temperatures logs documented, REPORT ANY WASH TEMPERATURES BELOW 160 DEGRESS OR RINSE TEMPERATURES UNDER 180 DEGREES TO MAINTENANCE/OR DIETARY MANAGER/PIC [person in charge]. The following listed temperatures were outside the required temperature ranges:May 2026: 7 of 31 days Wash below 160 degrees May 2026: 31 of 31 days Rinse below 180 degreesJune 2026: 6 of 30 days Wash below 160 degreesJune 2026: 30 of 30 days Rinse below 180 degrees July 2026: 13 of 31 days wash below 160 degreesJuly 2026: 31 of 31 days Rinse below 180 degreesDuring an interview on 08/06/2026 at 2:45 PM, Staff R, Dietary Supervisor, reviewed the Dish Machine Temperature logs for May 2026, June 2026 and July 2026 and identified dates when the wash and rinse temperatures were out of range. When asked about the rinse temperatures, Staff R said the temperatures below 100 degrees may have been recorded from a broken gauge instead of the temperature booster. Staff R was unable to account for the rinse temperatures above 100 degrees but below 180 degrees. Staff R said staff should have notified them or the maintenance director of any out-of-range temperatures.Reference WAC 388-97-1100 (3)

Based on interview and record review, the facility failed to ensure facility staff received Dementia training for 2 of 2 staff (Staff J, and Staff P) reviewed for staff in-service training. This failure placed residents at risk for not receiving necessary care from unskilled staff. Findings included. Staff J, Nursing Assistant, was hired on 05/29/2019. No in-services or training records were provided indicating Dementia training was completed over the past year for Staff J. Staff P, Nursing Assistant, was hired on 09/04/2025. No in-services or training records were provided indicating Dementia training was completed over the past year for Staff P. During an interview on 08/06/2026 at 2:12 PM, Staff I, Infection Preventionist/Licensed Practical Nurse, said she was not able to find abuse prevention training for Staff J or Dementia training for Staff J or Staff P. At 3:10 PM, Staff M, Human Resource Director, said they were only able to find Staff J's abuse prevention training from 2019. Reference WAC 388-97-1680(2)(b)

Based on observations, interviews and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP, extra protection steps with gloves and gowns during certain care tasks to stop tough germs from spreading in long-term care settings) were implemented for 5 of 5 sampled residents (Residents 1, 3, 5, 43, and 60) reviewed for infection prevention and control. These failures placed the residents, staff, and visitors at risk for contracting infectious diseases and a decreased quality of life. Findings included. Record review of the facility's policy titled, Enhanced Barrier Precautions, reviewed 03/08/2026, documented: 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when: a. A resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained; b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and c. Contact precautions do not otherwise apply. 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs. 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and j. wound care (any skin opening requiring a dressing). 16. Staff are trained prior to caring for residents on EBPs. 17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. 18. Personal protective equipment and alcohol-based hand-rub are readily accessible to staff. 19. Residents, families, and visitors are notified of and educated about the implementation of EBPs. Resident 3 was admitted to the facility on [DATE] with multiple diagnoses to include quadriplegia. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 07/11/2026, documented Resident 3 was alert and oriented, had an indwelling catheter (a flexible tube that goes into your bladder to help it drain urine out of your body), one Stage 3 pressure ulcer (a deep skin injury that has gone through the top layers of skin and into the layer of fat under the skin), and one Stage 4 pressure ulcer (a deep skin injury that has gone through skin, fat, muscle, and possibly bone or other deep tissues). During an observation on 08/03/2026 at 2:22 PM, Resident 3 did not have an EBP sign posted on the door or wall outside their room that communicated the type of precautions and personal protection equipment (PPE) that was required. Resident 3's hall (Long Hall) did not have a PPE cart readily accessible to staff. Resident 3 was sitting in his room and had a catheter bag hanging under his wheelchair. In an interview on 08/03/2026 at 2:26 PM, Staff J, Certified Nursing Assistant (CNA), said staff knew a resident needed EBP's if there was an EBP sign outside their room and a PPE cart outside their door. When asked specifically about Resident 3's room, she said she was familiar with that resident having a catheter, but thought staff would only need to wear gloves when providing care. Resident 1 was admitted to the facility on [DATE] with multiple diagnosis to include urinary retention (a condition where you cannot empty all or any of the urine from your bladder). The admission MDS, dated [DATE], documented Resident 1 had an indwelling catheter. During an observation on 08/03/2026 at 10:39 AM, Resident 1 did not have an EBP sign posted on his door or wall outside his room indicating the type of precaution needed while giving care. Resident 5 was admitted to the facility on [DATE] with multiple diagnosis to include urinary retention. The Quarterly MDS, dated [DATE], documented Resident 5 had an indwelling catheter. During an observation on 08/03/2026 at 10:41 AM, Resident 5 did not have an EBP sign posted on his door or wall outside his room indicating the type of precaution needed while giving care. Resident 43 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 43 was alert and oriented and had a pressure ulcer. Record Review of Resident 43's skin observation tool, dated 07/18/2026, documented Resident 43 had a pressure ulcer. During an observation on 08/03/2026 at 10:52 AM, Resident 43 did not have an EBP sign posted on his door or wall outside his room indicating the type of precaution needed while giving care. In an interview on 08/03/2026 at 2:40 PM, Resident 43 said she had a wound on her back. When asked if staff wore protective gowns and gloves when caring for her wound Resident 43 said staff did not. Resident 43 said her wound care was done every day by the nurses. During an observation and interview on 08/04/2026 at 9:13 AM, a nurse's aide was observed going into Resident 43's room without donning PPE. When asked what care the nurse's aide had provided, Resident 43 stated, she came in and changed me [changed Resident 43's soiled brief]. Resident 43 said the nurse's aide did not don PPE when providing care. Resident 60 was admitted to the facility on [DATE] with multiple diagnosis to include endocarditis (inflammation of the inner lining of the heart). During an interview and observation on 08/03/2026 at 2:03 PM, Resident 60 was observed to have a PICC (Peripherally Inserted Central Catheter, used as a central line) to his right upper arm. Resident 60 said that staff used the PICC line to administer his intravenous medication. Resident 60 did not have an EBP sign posted on his door or wall outside his room indicating the type of precaution needed while giving care. In an interview on 08/03/2026 at 2:32 PM, Staff I, Infection Control Nurse/Licensed Practical Nurse, said residents with feeding tubes (a way to give food and fluids directly to the stomach or small intestine when eating by mouth isn't possible or safe), indwelling catheters, wounds and central lines (a long, flexible tube that goes deep into a big vein to help give medicines, fluids, and nutrition), should be on EBP's, should have an EBP sign at their door and should have a PPE cart by their room. WAC 388-97-1320 (2)(a)(b)

Based on observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment was maintained for 1 of 2 sampled shower rooms (Horseshoe shower room) when a sharps container (a puncture-resistant, leak-proof container intended to safely collect and dispose of used medical instruments that can puncture or cut skin, like needles, syringes, and other sharp tools) was observed above the full line. This failure placed residents and staff at risk for injury, potential exposure to diseases, and a diminished quality of life.Findings Included . In an observation on 08/06/2026 at 10:42 AM, the Horseshoe shower room door was open in the Horseshoe hallway. The red sharps container mounted on the wall inside of the Horseshoe shower room showed sharps instruments inside of the container one inch above the fill line that said, do not fill above this line. A razor was observed inside the sharps container sticking out of the top obstructing the lid from opening and closing all the way. In a joint observation and interview on 08/06/2026 at 10:46 with Staff I, Infection Preventionist/Licensed Practical Nurse, the Horseshoe shower room sharps container was observed over the fill line. Staff I said it was over the fill line, and the sharps container should have been emptied. In an interview on 08/06/2026 at 1:26 PM, Staff B, Director of Nursing/Registered Nurse, said she expected sharps containers were changed out before they were over the fill line. Reference WAC 388-97-3220 (1)

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I, a screening tool used to identify mental health needs, was requested upon a significant change of condition for 1 of 5 residents (Resident 5) reviewed for PASARR. This failure placed the residents at risk of unidentified mental health needs, and a diminished quality of life.Findings included . Record Review of the facility's policy, titled, Resident Assessment- Coordination with PASARR Program, revised August 2025, documented, .8. Any level II resident who experiences significant change in status will be referred promptly to the state mental health or intellectual authority for additional review . d. A resident whose significant change is physical, but has behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living. Resident 5 was admitted to the facility on [DATE], with multiple diagnoses to include major depressive disorder (mood disorder characterized by persistent, depressed mood), anxiety disorder (disorder characterized by excessive fear and worry), and post-traumatic stress disorder (mental disorder caused by experiencing a traumatic event). The Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/23/2026, showed Resident 5 was alert and oriented. Record review of Resident 5's Electronic Health Record, documented Resident 5 was assessed for change of condition on 11/25/2025, but did not show documentation that a new PASARR referral was completed upon Resident 5's significant change of condition. In an interview on 08/05/2026 at 10:06 AM, Staff D, Social Service Director, said the facility's practice was to complete a new PASARR following a significant change in mental health condition, and confirmed there was no new PASARR referral completed for Resident 5. Staff D stated, We do a new PASARR if they had a significant change in depression, or anxiety, but not necessarily for a physical change. In an interview on 08/06/2026 at 1:13 PM, Staff B, Director of Nursing and Registered Nurse, said it was the facility's practice to send new PASARR referrals following a significant change in condition. Staff B said Resident 5's new PASARR referral was not completed as should have been. Reference WAC 388-97-1915 (4)

Based on observation, interview, and record review, the facility failed to develop and/or complete a comprehensive care plan for an individualized activities preference care plan for 1 of 4 residents (Resident 12) reviewed for Activities, for 1 of 4 residents (Resident 45) reviewed for physical restraints, and for 2 of 6 residents (Resident 7 and 16) reviewed for Unnecessary Medications and/or Insulin (a medication used to help regulate blood sugar levels and treat diabetes mellitus [DM, a chronic health condition where your blood sugar levels are too high]). This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included. Activities Resident 12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) an assessment tool, dated 06/15/2026, indicated Resident 12 was cognitively impaired. The MDS indicated listening to music and being outside was somewhat important; and being around animals such as pets and doing things with groups of people were very important. The Activity Interview for Daily and Activity Preferences, dated 06/12/2026, indicated: 2. how important is it to you to listen to music you like? 2. somewhat important 3. how important is it to you to be around animals such as pets? 1. very important 5. how important is it to you to do things with groups of people? 1. very important 7. how important is it to you to go outside to get fresh air when the weather is good? 2. somewhat important Review of Resident 12's care plan interventions, revision dated 05/26/2023, did not show his preferences for being around groups of people or being around animals. The following care plan intervention are system generated (not resident specific): Encourage ongoing family involvement. Invite Resident's family to attend special events, activities, meals. Invite Resident 12 to scheduled activities. Ensure that the activities Resident 12 is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate. Be conscious of his position when in groups, activities, dining room to promote proper communication with others. Avoid activities that involve bending, lifting. Revision 03/27/2024 Give Resident 12 as many choices as possible about care and activities. Revision 06/05/2024 Resident 12 will continue to make choices r/t [related to] to attendance at group activities Date Initiated: 11/27/2024 During an interview on 08/06/2026 at 9:13 AM, Staff L, Activities Director, said activity interest and preference were added to the care plan by the Resident Care Manager (RCM). During an interview at 9:31 AM, Staff K, RCM/Registered Nurse (RN), said the activities director was responsible for individualizing the activities care plan. During an interview at 10:30 AM, Staff B, Director of Nursing/RN, said the activities care plan should have residents individualized likes and preferences. Bed Against the Wall Resident 45 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 06/29/2026, indicated that Resident 45 was severely cognitively impaired. Observation on 08/03/2026 at 1:45 PM, Resident 45's bed was observed against the wall. During an interview 08/03/2026 at 3:04 PM, Resident 45's Guardian said they discussed the bed against the wall last week. Review of the progress note, dated 07/26/2026, documented, Bed set up changed with one side of bed against wall able to view hall way [sp] and TV easily. Review of the care plan, dated 08/03/2026, did not have intervention documentation for the bed was against the wall. During an interview on 08/06/2026 at 10:30 AM, Staff B, Director of Nursing/Registered Nurse, said they would assess, get consent from the resident and/or guardian, and may get an order from the physician for the use of a potential restraint. Staff B said they would develop a care plan for the use of the bed against the wall. Unnecessary Medications and/or Insulin Review of the facility's policy titled, Nail Care, date revised 03/06/2026, documented . 2. Identify conditions that increase risk for foot or nail problems, such as diabetes . 6. b. Only licensed nurses shall trim or file fingernails of residents with diabetes. Toenails of residents with diabetes or circulation problems shall be filed only. Resident 7 was admitted to the facility 05/13/2025 with multiple diagnosis to include DM. The Quarterly MDS, dated [DATE], documented Resident 7 was cognitively intact, had DM, and was on insulin (a prescription medication used to lower blood sugar levels). Record review of Resident 7's .ADL [Activities of Daily Living] self-care performance deficit. care plan, date revised 05/14/2025, documented an Intervention, BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Further review of the care plan showed Position for the Intervention to include CNA (certified nursing assistant). Resident 16 was admitted to the facility on [DATE] with multiple diagnosis to include DM. The Quarterly MDS, dated [DATE], documented Resident 16 was cognitively intact and had DM. Record review of Resident 16's .ADL self-care performance deficit. care plan, date initiated 01/31/2025, documented an Intervention, BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Further review of the care plan showed Position for the Intervention to include CNA. In an interview on 08/06/2026 at 11:38 AM, Staff C, RCM/RN, said nurses did nail care for diabetic residents. When asked about the ADL care plans for nail care for Resident 7 and Resident 16, Staff C said it should not specify for the CNAs to do nail care. Staff C said it should only have been the nurse to do nail care for diabetic residents. In an interview on 08/06/2026 at 1:26 PM, Staff B, Director of Nursing/RN said CNAs were not supposed to cut diabetic residents' nails. Staff B said they would need to have care plans direct the nurses to do nail care for diabetic residents. Reference WAC 388-97-1020(1)(2)(a), 1060 (1), and 0620 (1)(b)

Based on observation, interview and record review, the facility failed to ensure the shower room floor was maintained in good condition for 1 of 3 shower rooms (small flagship hall shower room) and failed to ensure resident rooms did not have unused medical equipment for 1 of 1 resident (Resident 41) reviewed for clean and homelike environment. This failure placed residents at risk of a diminished quality of life and a less home-like environment. Findings included. During an observation on 08/05/2026 at 1:56 PM, the floor of the small flagship hall shower room was observed to have two areas that were chipped measuring approximately 5 inches by 5 inches and 3 inched by 3 inches. During an interview on 08/06/2026 at 9:01 AM, Staff C, Resident Care Manager/Registered Nurse, observed the small flagship hall shower room floor and said the floor chipping had been an issue. During an interview on 08/06/2026 at 9:03 AM, Staff F, Nurse Assistant Certified (NAC) said facility staff assisted residents with showers in the small flagship hall shower room. During an interview on 08/06/2026 at 10:19 AM, Staff G, NAC said the small flagship hall shower room floor had been chipped for some time but was unable to say for how long. Staff G said residents received showers in that shower room. During an interview on 08/06/2026 at 10:30 AM, Staff B, Director of Nursing/Registered Nurse, said the shower room would be closed to resident use that morning. Resident 41 was admitted to the facility on [DATE]. The admission/5-day Minimum Data Set, an assessment tool, dated 07/04/2026, indicated Resident 41 was alert and oriented. During an observation and interview on 08/03/2026 at 11:05 AM, an oxygen concentrator was observed near the upper left side of Resident 41's bed. When asked if she was on oxygen Resident 41 said she was not. Resident 41 said they brought the oxygen into her room after she admitted , and it had been there since. Resident 41 said she didn't really want it in her room because she had never used it. Review of Resident 41's electronic health record did not show Resident 41 had a current or discontinued oxygen order. During an interview and record review on 08/06/2026 at 10:03 AM, Staff C, Resident Care Manager/Registered Nurse, said Resident 41 did not have a current or discontinued order for oxygen. Staff C said the oxygen concentrator should not be in Resident 41's room. WAC Reference 388-97-0880 (1)

Based on observation, interview, and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 1 sampled resident (Resident 4) reviewed for urinary catheter (foley catheter, a flexible tube used to drain urine from the bladder and collect it in an external bag), and 1 of 3 sampled residents (Resident 4) reviewed for respiratory care. This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included. Resident 4 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and re-admitted to the facility on [DATE] with multiple diagnosis to include acute respiratory failure (medical emergency where the lungs cannot get enough oxygen into the blood), dated 08/01/2026, and retention of urine (inability to completely empty the bladder), dated 08/01/2026. The admission Minimum Data Set, an assessment tool, dated 05/28/2026, documented Resident 4 was cognitively intact. Urinary Catheter Record Review of Resident 4's progress notes, dated 08/01/2026, documented, [Hospital] nurse called with report to d/c [discharge] res [resident] back to [facility].Tried removing foley 2 days ago, but still retained urine. D/c with foley. Record review of Resident 4's physician orders, dated 08/03/2026, showed Resident 4 was ordered a foley catheter for urinary retention. In an interview and observation on 08/04/2026 at 9:03 AM, Resident 4 said he had an infection in his bladder and had a urine catheter put in while in the hospital. A urine catheter drainage bag was observed hanging off the right side of Resident 4's bed frame. In an observation on 08/05/2026 at 10:31 AM, Resident 4 was observed lying in bed with a urine catheter drainage bag hanging off the right side of the bed. Record review of Resident 4's bowel and bladder care plan, date revised 06/02/2025, did not show a Need, Goal, and/or Interventions area related to a urinary catheter. Respiratory Care Record review of Resident 4's physician orders, dated 08/01/2026, showed Resident 4 was ordered oxygen (O2) therapy via nasal cannula every shift for oxygen therapy. Record review of Resident 4's progress notes, dated 08/03/2026, documented, .He does not consistently keep his O2 nasal cannula on.Staff are reinforcing/reminding him of the importance of keeping his O2 cannula on. In an observation on 08/04/2026 at 9:08 AM, Resident 4 was observed lying in bed with oxygen on per nasal cannula. In an observation on 08/05/2026 at 10:24 AM, Resident 4 was observed lying in bed with oxygen on per nasal cannula. Record review of Resident 4's care plan, titled, [Resident 4] has potential for altered respiratory status/difficulty breathing r/t [related to], date revised 06/02/2025, did not show a diagnosis of acute respiratory failure or a Need, Goal, and/or Interventions area for use of oxygen. In an interview on 08/06/2026 at 11:05 AM, when asked about Resident 4's urinary care plan and catheter, Staff C, Resident Care Manager/Registered Nurse (RN), said Resident 4's care plan should have been updated to include the foley catheter when he returned from the hospital. Staff C said Resident 4's respiratory care plan should have been updated to include the diagnosis of acute respiratory failure and his oxygen use. In an interview on 08/06/2026 at 1:26 PM, Staff B, Director of Nursing/RN, said it was the expectation that care plans were updated to reflect foley catheter, oxygen use, and respiratory issues. Staff B said they have had issues with care plans. Reference WAC 388-97-1020 (2)(a)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 1 of 1 sampled resident (Resident 16) reviewed for Insulin (a medication used to help regulate blood sugar levels and treat diabetes mellitus [DM, a chronic health condition where your blood sugar levels are too high]). This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.Findings included. Resident 16 was admitted to the facility on [DATE] with multiple diagnosis to include DM. The Quarterly MDS, dated [DATE], documented Resident 16 was cognitively intact, had DM, and did not receive injections and/or insulin injections in the last seven days. Review of Resident 16's June 2026 Electronic Medication Administration Record (EMAR), documented Resident 16 received Insulin Lispro Injection Solution (a type of rapid-acting injected insulin) on 06/03/2026, 06/04/2026, 06/05/2026, 06/06/2026, 06/07/2026, 06/08/2026, and 06/09/2026. Review of Resident 16's June 2026 EMAR documented Resident 16 received Insulin NPH Subcutaneous (placed directly under the skin) Suspension (a type of intermediate-acting injected insulin) on 06/03/2026, 06/04/2026, 06/05/2026, 06/06/2026, 06/07/2026, 06/08/2026, and 06/09/2026. In an interview on 08/06/2026 at 11:46 AM, Staff C, Resident Care Manager/Registered Nurse (RN), when asked about Resident 16's MDS coded for no injections and/or insulin injections, Staff C looked at Resident 16's Electronic Health Record and said it was marked as no injections. Staff C said injections should have been marked as yes on Resident 16's MDS. In an interview on 08/06/2026 at 1:26 PM, Staff B, Director of Nursing/RN, said she expected the MDS was coded correctly to reflect the medications a resident was taking. Reference WAC 388-97-1000 (1)(b), (2)(n)

Based on interview and record review, the facility failed to notify the Office of the State Long Term Care Ombudsman (LTCO) of the transfer to hospital from the facility for 1 of 2 sampled residents (Resident 17) reviewed for hospitalization. This failure placed residents at risk of not knowing their rights during hospital transfer and a diminished quality of life.Findings included.Resident 17 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set, an assessment tool, dated 06/22/2026, indicated Resident 17 was moderately cognitively impaired.Record review of Resident 17's electronic health record (EHR) documented Resident 17 was transferred to the hospital on [DATE] and returned on 06/20/2026. Resident 17 was also transferred to the hospital on [DATE] and returned on 07/06/2026Record review of Resident 17's EHR showed no documentation that the facility had notified the Office of the State Long Term Care Ombudsman of Resident 17's hospital transfers. In an interview on 08/05/2026 at 1:34 PM, Staff D, Social Service Director, said the facility did not notify the LTCO of hospital transfers.In an interview on 08/06/2026 10:39 AM, Staff B, Director of Nursing/Registered Nurse, said the facility typically notified the LTCO of residents' discharges but did not notify the LTCO of hospital transfers. Reference WAC 388-97-0120 (5)(b)(i)

Based on observation and interview, the facility failed to secure medications in 1 of 2 sampled treatment carts (Flagship treatment cart) reviewed for medication storage. This failure placed residents at risk of misappropriation of medication and a diminished quality of life. Findings included . Record review of the facility policy, titled, Medication Labeling and Storage, date revised March 2026, documented, .Medication Storage. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. In an observation on 08/05/2026 at 11:00 AM, the Flagship treatment cart was observed in the Flagship Hall unlocked. A sign was taped on top of the cart that showed, did you lock it???? No nursing and/or facility staff were observed in the hallway or within view of the treatment cart. Surveyor was able to open five drawers of the unlocked treatment cart with access to multiple tubes and bottles of creams, ointments, gels, and powders; to include prescription labelled medications of nystatin topical powder (a prescription antifungal medication), silver sulfadiazine cream (a prescription topical antibiotic), and triamcinolone cream (a prescription cream used for various skin conditions). In an interview on 08/05/2026 at 11:04 AM, Staff H, Registered Nurse (RN), was asked to observe the unlocked Flagship treatment cart. Staff H said the cart should have been locked. Staff H held up a set of keys from her pocket and said they had keys to unlock the treatment carts. In an interview on 08/05/2026 at 3:13 PM, Staff B, Director of Nursing/RN, said she expected the treatment carts were kept locked when no staff were around the cart. Reference WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to provide resident centered activities that incorporated the resident's preferences for 1 of 1 resident (Resident 12) reviewed for activities. This failure placed residents at risk for a diminished quality of life. Findings included.Resident 12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/15/2026, indicated Resident 12 was cognitively impaired. Review of Resident 12's Activity Interview for Daily and Activity Preference, dated 06/12/2026, indicated it was very important for him to be around animals such as pets, do things with groups of people, and somewhat important to get fresh air and listen to music. Review of Resident 12's One on One task, review dated 08/06/2026, showed Resident 12 had participated in one event on 08/05/2026, over the past 30 days. No other entries were noted on the form.Review of Resident 12's events/parties, review dated 08/06/2026, showed Resident 12 participated in one event on 07/31/2026, over the past 30 days. No other entries were noted on the form. Review of Resident 12's other activities task, dated 08/06/2026, did not have any entries for arts and crafts, bible study/church, bingo, book club, bus rides, cooking/baking, exercise, food committee/resident council, games/cards, gardening, memory/reminisce, movie, music/entertainment, painting, pet therapy, or science for seniors and shopping; over the past 30 days.During an interview on 08/06/2026 at 9:13 AM, Staff L, Activities Director, said the resident activity assessment was reviewed, for long-term resident, quarterly and annually. Staff L said if a resident had a specific preference they would put it in the care plan. Staff L said the Resident Care Manager would put preferences on the care plan. While reviewing Resident 12's activities, Staff L said Resident 12 was at a party last week and was in the TV room yesterday. Staff L said she could not see any other activities or refusals documented for Resident 12. Staff L said they should be charting activities Resident 12 was participating in and charting his refusals. Reference WAC 388-97-0940 (1)(2)

Based on interview and record review, the facility failed to administer medication as ordered for 1 of 1 sampled resident (Resident 43) reviewed for quality of care. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included. Review of facility policy titled, Administering medication, dated March 2026, documented, 4. Medications are administered in accordance with prescriber orders, including any required time frame.Resident 43 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 06/27/2026, documented Resident 43 was alert and oriented. In an interview on 08/03/2026 at 2:40 PM, Resident 43 said she was supposed to get a Vitamin B12 injection (a vitamin the body uses) monthly but had not had one in July 2026. Record review of Resident 43's electronic health record showed a physician's order, dated 06/24/2026, for Cyanocobalamin Injection Kit (form of vitamin B12) 1000 micrograms/milliliter to be administered every 28 days on day shift. Record review of Resident 43's July 2026 Electronic Medication Administration Record (EMAR) showed Resident 43 was scheduled to receive the Cyanocobalamin Injection on 07/22/2026 but there was no documentation that Resident 43's received the injection. In an interview and record review on 08/05/2026 at 10:19 AM, Staff C, Resident Care Manager/Registered Nurse (RN), reviewed Resident 43's EHR and verified the physicians' order for cyanocobalamin. Staff C reviewed Resident 43's July 2026 EMAR and said there was no documentation that cyanocobalamin was administered as scheduled. Staff C said it was the expectation that the medication was administered as ordered. In an interview on 08/06/2026 at 10:30 AM, Staff B, Director of Nursing/RN it was the expectation that nurses administer medications as ordered. Reference WAC 388-97-1060(3)(i)

Based on interview and record review, the facility failed to ensure residents were receiving restorative services for 1 of 3 residents (Resident 28) reviewed for rehabilitative services. This failure placed residents at risk of a diminished quality of life when not receiving the necessary services to maintain or increase their muscle weaknesses.Finding included.Resident 28 was admitted to the facility on [DATE]. The significant change Minimum Data Set, an assessment tool, dated 06/26/2026, indicated Resident 28 was alert and oriented. During an interview on 08/03/2026 at 2:09 PM, Resident 28 said she was admitted for rehabilitation but had not received any therapy. Review of Resident 28's care plan, dated 07/30/2026, NURSING REHAB/RESTORATIVE: ACTIVE ROM [range of motion] Program #1 Omnicycle [a motorized bicycle used in therapy] for bilateral Lower Extremities setting 1-2 for 15 - 20 minutes daily . NURSING REHAB/RESTORATIVE: Walking Program #2ambulate 50 feet or great with 2 staff. FWW [front-wheeled walker], gait belt and wheelchair follow.Review of Resident 28's omnicycle task form, dated 08/05/2026, documented Resident 28 refused on 08/04/2026. No other documentation for services offered, completed, or refused on other days. Review of Resident 28's walking task form, dated 08/05/2026, did not have any documentation of services being offered, completed, or refused.During an interview on 08/05/2026 at 11:19 AM, Staff C, Resident Care Manager/Registered Nurse, was receiving restorative services for range of motion with the omnicycle and a walking program with her FWW with a wheelchair to follow. While reviewing the restorative task sheet, Staff C said it looked like Resident 28 refused the omnicycle on 08/04/2026. Staff C said Resident 28 had not received any services for the walking program.WAC Reference 388-97-1280 (1)(a) and (2)

Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 1) received the pneumococcal vaccine (a vaccination used to help prevent certain bacterial infections such as pneumonia, an infection of the lungs) and/or provide information and education regarding risks, benefits, and potential side effects associated with the influenza vaccine, for 1 of 5 sampled residents (Resident 5) reviewed for unnecessary medications. These failures placed residents at risk for developing respiratory related complications, and a diminished quality of life.Findings included.Pneumococcal Vaccine Record review of facility policy titled, Pneumococcal Vaccine, Revised 03/07/2026, documented, 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 05/15/2026, documented Resident 1 was alert and oriented. Record review of Resident 1's vaccine consent form, dated 05/13/2026, documented that Resident 1 consented to receiving the pneumococcal vaccine. Record review of Resident 1's Electronic Health Record (EHR) did not show documentation that Resident 1 received his pneumococcal vaccine. Influenza VaccineRecord review of facility policy titled, Influenza Vaccine, Revised 03/15/2025, documented, 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized.Resident 5 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 5 was alert and oriented. Record review of Resident 5's EHR did not have documentation of information and/or education provided, nor record of an influenza vaccination offered and/or declined or medically contraindicated.In an interview on 08/06/2026 at 9:19 AM Staff I, Infection Preventionist/ Licensed Practical Nurse, said licensed nurses obtained consents from residents to administer immunizations and document if the resident consented or refused. When asked if there was documentation that Resident 5 refused his influenza vaccine, Staff I reviewed Resident 5's EHR and said no. In an interview on 08/06/2026 at 3:00 PM, when asked if Resident 1 received his pneumococcal vaccination, Staff I reviewed Resident 1's EHR and could not find documentation that Resident 1 received his pneumococcal vaccination. Staff I said it was the expectation that Resident 1 received his vaccination per his consent. Reference WAC 388-97-1340 (2)

Based on interview and record review, the facility failed to ensure medications were administered for 1 of 4 residents (Resident 1) reviewed for medication errors. This failure placed residents at risk for complications and decline in health status. Findings included . Record review of the facilities policy and procedure titled, Admission/re-admission Checklist, undated, documented the faco;oty was tp Activate/Confirm all physician orders in Point Click Care, the facilities electronic medical record. Resident 1 was admitted to the facility on [DATE] at 6:45 pm with diagnosis including nontraumatic subarachnoid hemorrhage, (a type of stroke involving sudden bleeding into the space between the brain and the skull), type 2 diabetes mellitus, (a chronic condition in which the body doesn't produce enough insulin causing elevated blood sugar levels, and essential hypertension (high blood pressure without a single identifiable medical cause). Record review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 04/25/2026, documented Resident 1 had no short-term memory loss and moderately impaired cognitive skills for daily decision making. Record review of Resident 1's nursing progress note, dated 04/25/2026 at 8:24 am, documented, Resident on alert for new admit post brain aneurysm. Resident arrived to the facility yesterday evening. Medications and orders were delayed due to late evening admission. Upon arriving to my shift, the resident had a bad headache and pain in his R [Right] hip rated around 8/10. 10mg (milligrams) PRN (as needed) oxycodone (pain medication) was given as well as the scheduled 1000 mg of Tylenol (pain medication) for the evening that he did not receive per orders. 2 units of insulin (medication to manage blood sugar levels) lispro (sliding scale 206 units of insulin for CBG [capillary blood glucose] and 8 units NPH (evening scheduled) insulin were given per orders. Lidocaine cream applied to painful R hip. Upon reassessment resident voiced relief in both the headache and pain in R hip, although still rated around 3-4/10 on pain scale. Resident calm, polite, and cooperative with care. BP [blood pressure]: 140/64 charted at 0700 [7:00am]. Record review of the Facility Resident Incident Review, Assessment, and Action Report, dated 04/26/2026, documented Resident 1 was not given medications as ordered on the evening of admission on [DATE]. Name of medication(s) and dose(s) that were missed on the evening of admission [DATE]:Irbesartan 300mg, a medication used to treat high blood pressure, give 1 tab at hour of sleep.Clonidine, a medication used to relax blood vessels or calm the central nervous system, 0.1 mg 2 times a day. Evening dose at 9:00 pm.Check blood glucose at 9:00 pm.Metformin HCL ER, a medication used to manage blood sugar levels in Type 2 diabetes, give 1000mg at 9:00 pm.Polyethylene Glycol, a laxative used to treat occasional constipation, give 17 gm (grams) at 9:00 pm.Acetaminophen, a pain medication, give 500 mg 2 tabs at 9:00 pm.Gabapentin, a medication used to treat nerve pain, give 100mg 1 cap at 9:00 pmInsulin Lispro, a subcutaneous medication used to lower blood glucose, administer according to directions given for sliding scale at 9:00 pm. The Facility Administrative Summary, dated 04/26/2026, documentedThe Resident Care Manger assigned to Resident 1 failed to follow facility procedure for admissions process of ensuring diagnosis and admissions orders were entered into the medical record prior to his admission which occurred on evening shift.The evening shift Licensed Nurse (LN) assigned to Resident 1 did not initiate the admissions process and did not ask the other unit nurse for guidance or call a Nurse Manager or the Director of Nursing Services.Medication Errors: Due to the above failures Resident did not receive his routine medications that should have been administered by the licensed nurse on evening shift. During an interview on 05/12/2026 at 1:00 PM, Staff C, Registered Nurse (RN) and Resident Care Manager (RCM), said Staff D, RN, was a new nurse and a recent new hire to the facility. Staff C said Staff D had completed four weeks of orientation and the admissions process was part of the facility orientation. Staff C said when Staff D was notified of Resident 1's medication errors and questioned as to why the admission process had not been implemented, she said she was unaware it was her responsibility to do so. Staff C said Staff D should have initiated the admission process and if unsure of the process ask another nurse or contact an RCM or the Director of Nursing Services (DNS). During an interview on 05/14/2026 at 9:58 AM, Resident 1's spouse said she was aware that her husband went several hours without his ordered medications. The nurse on duty was new and didn't have a clue about the admissions process. Of more concern to her was the hospital discharging her husband so soon. When she went to visit him the next morning her was wrapped in sheets and blankets shivering and unable to respond to her. She had requested the facility call 911. During an interview on 06/09/2026 at 1:30 PM, Staff E, RN/RCM, said she had been the RCM on duty the day Resident 1 had admitted . Staff E said she had given Staff D report regarding the pending admission. Staff E said she was surprised to hear that the admissions process had not been initiated. Staff E said that to prevent this from happening again she is now completing the order portion of the admission process before going home for the day. During an interview on 06/09/2026 at 2:44 PM, Staff F, RN/RCM, said when expecting an admission on evening shift she gives report to the charge nurse who works 10:00 AM to 6:00 PM. Staff F said it's facility policy to have two nurses present to double check physicians orders before recording them on the medication administration sheet. Staff F said there should be no reason why orders were not verified and noted. During an interview on 06/09/2026 at 4:00 PM, Staff C, RN and Director of Nursing Services, said it was an expectation for nurses to follow admissions procedures when residents were admitted on an evening shift. They know they can call her if they have questions regarding process or need assistance. She said the nurse on duty when Resident 1 was admitted was a new nurse and was probably overwhelmed. The Director of Nursing Services and the RCM's have a process in which they place the admissions orders from the hospital in a queue prior to a resident's actual admit. Once the resident arrived, the nurses were educated to check the queue, verify the orders using two nurses, and then note the orders and order medications from the pharmacy. WAC Reference 388-97-1060[3][k][iii]

Based on observation, interview, and record review, the facility failed to ensure a safe transfer during the use of a mechanical (hoyer) lift for 1 of 4 residents (Resident 1) reviewed for accident hazards. Resident 1 experienced harm when the hoyer lift sling detached during a mechanical lift transfer resulting in a fall; the resident sustained injuries to the head, rib fractures, and fractures of the lumbar vertebra (spine) that required hospital evaluation and treatment. Findings included.Record review of the facility policy and procedure revised in July 2017, and reviewed on 12/15/2025, titled, Lifting Machine, Using a Mechanical, documented the following: Steps in the Procedure:12. Attach sling straps to sling bar, according to manufacturer's instructions.a. Ensure the sling is securely attached to the clips and that it is properly balanced.b. Check to make sure the resident's head, neck and back are supported.c. Before resident is lifted, double check the security of the sling attachment.d. Examine all hooks, clips or fasteners.e. Check the stability of the straps.f. Ensure that the sling bar is securely attached and sound. Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including osteoarthritis (a degenerative joint disease caused by a breakdown of protective cartilage, leading to pain, stiffness, and reduction in mobility), spondylosis of cervical and thoracic regions of the spine (a wearing of the vertebral disks of the neck and mid spine), and Alzheimer's Disease ( a progressive, incurable brain disorder). The Minimum Data Set, an assessment tool, dated 02/28/2026, documented Resident 1's cognitive skills for daily decision making was severely impaired. Record review of Resident 1's care plan, dated 06/04/2025, showed Resident 1 required the assistance of two people during hoyer lift transfers.Record review of an incident report for Resident 1, dated 02/19/2026, showed Resident 1 was being transferred by two Certified Nursing Assistants (CNA's) when a corner of the hoyer sling she was being transferred in became disengaged from the hoyer lift and she fell approximately four feet to the ground landing on her buttocks, bouncing, and then falling backward striking her head on the leg of the hoyer lift. Record review of Resident 1's hospital records, dated 02/19/2026, showed as a result of the fall from the hoyer sling, Resident 1 sustained an abrasion to the back of head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra ( largest vertebra at the base of the spinal cord which support the rest of the spine and withstand body weight and movement). On 02/24/2026, at 3:00 PM, Staff D, Certified Nursing Assistant (CNA), said she and another CNA were present during the transfer when Resident 1 fell. They were attempting to get her up for dinner. They had placed the sling beneath her and attached the loops at each corner of the sling top and bottom to the mechanical (Hoyer) lift. They had just raised her off the bed and had gotten her in the space between the bed and wheelchair when the bottom left corner of the sling came loose from the lift and Resident 1 dropped to the floor. Record review of an email from Staff C, Registered Nurse (RN), dated 02/26/2026 at 7:30 PM, showed Staff C said that after research the facility had decided to replace all the hoyer slings and each resident who required transfers using hoyer lifts would have their own slings labeled with their names. On 03/27/2026, at 2:39 PM, Staff F, Licensed Practical Nurse (LPN), said she was called to Resident 1's room by one of the CNA's present when Resident 1 fell. Staff D said when she entered the room, she first assessed the resident, then when looking at the Hoyer lift, she noted one of the loops of the sling had become disengaged. The CNA's told her when they raised Resident 1 from the bed everything had been fine. It wasn't until they had moved her from the bed toward the wheelchair that the sling had come undone. Staff F said she had assessed the sling after the incident, and it had looked like it was in good condition. Staff F had taken the Hoyer lift and sling used to transfer Resident 1 out of rotation until it could be assessed by the Maintenance Department. On 03/27/2026, at 3:07 PM, Staff E, CNA, said when she and Staff D had transferred Resident 1 on the evening of the fall, the loops of the sling were securely fastened. We had barely lifted her up and off the bed when the bottom left loop became disconnected and she fell. We were really shocked and couldn't figure out what happened. We are all on hyper alert now. Especially with the slings because a lot of the slings are old. We are now examining the slings every time we use one and the Hoyer lifts too. We're looking at the little metal disks now too to make sure they're not loose. We look at this each time now. In an observation and interview on 03/27/2026 at 3:50 PM, Staff D, CNA, demonstrated how she and a co-worker attached the Hoyer sling to the Hoyer lift prior to Resident 1's fall. Staff D said she remembered hearing the sling loops click into place, but she thinks one of the round metal disks might have been a little loose. Staff D said there has been a lot of training since the incident, and all new slings are being ordered. On 03/30/2026, at 1:56 PM, Staff G, Maintenance Director, said the mechanical lifts and slings were inspected monthly. He said there was a new policy in place where each resident will have their own slings. They will be labeled and dated for specific residents and new slings will be ordered each year. Record review of monthly maintenance logs for hoyer slings and lifts for January through December of 2025 and January, February, and March of 2026 showed no concerns noted with slings or lifts. On 03/30/2026, at 4:30 PM, Staff B, Director of Nursing Services, said the facility had expected a citation as Resident 1's fall from the Hoyer sling resulted in injury. While they don't know exactly how this occurred, they were doing everything they can to prevent recurrence and harm to other residents. Reference WAC 388-97-1060[3][g]

Based on observation and interview, the facility failed to store and label medications appropriately and failed to discard expired medications and expired medical supplies for 1 of 1 medication rooms, 1 of 1 emergency carts, 1 of 1 treatment carts, and 1 of 1 medication carts reviewed. These failures placed residents at risk of receiving expired or less effective medications, receiving treatment with outdated equipment, and residents having inappropriate access to medication. Findings included . Facility policy entitled, Medication Labeling and Storage, reviewed on 09/12/2024, documented, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. <Medication Storage Room> On 06/18/2025 at 2:44 PM, a concurrent observation with Staff C, Infection Control and Preventionist and Licensed Practical Nurse (LPN), showed many unopened bottles of expired over the counter medication (OTC, does not require a prescription) intended for resident use; a few examples of the many expired OTC medications included the following: -Four bottles of B Complex vitamins labeled with the expiration date of 02/2024. -Four bottles of B-12 vitamins labeled with the expiration date of 01/2025. -One bottle of liquid Iron, a supplement, labeled with the expiration date of 09/2024. -Three bottles of Folic Acid, a vitamin, labeled with the expiration date of 02/2025. -Three bottles of Vitamin C labeled with the expiration date of 02/2024. -Two bottles of Fish Oil, a supplement, labeled with the expiration date of 05/2025. <Emergency Cart> On 06/18/2025 at 2:09 PM, an observation of the facility Emergency Cart [a cart containing the medical equipment necessary for medical emergencies] showed six Suction, Catheter, and Glove Kits each labeled with the expiration date of 09/29/2024. < Flagship Medication Cart> On 06/18/2025 at 3:27 PM, a concurrent observation with Staff M, Charge Nurse/Registered Nurse (RN) of the medication cart, used in a section of the facility called Flagship, showed many opened bottles of medication with no date for when they were each opened for use, and no date for when they should be disposed of. On 06/18/2025 from 3:02 PM to 3:27 PM, the Flagship medication cart was in front of the nurses' station and was left unlocked and without a nurse nearby to ensure no one gained access. <Treatment Cart> On 06/18/2025 from 3:02 PM to 3:27 PM, a treatment cart was across the hall from the nurses' station and was left unlocked and without direct observation of a nurse to ensure no one gained unauthorized access. On 06/18/2025 at 3:27 PM, when this investigator alerted the charge nurse that the Flagship medication cart and a treatment cart were both unlocked; Staff M said, Oh those are mine [referring to the Flagship medication cart and the treatment cart], I should have locked them, I took them over at 3:00 for half an hour until [the floor nurse] gets here. On 06/19/2025 at 10:22 AM, when asked if anything was done when they need to walk away from the medication or treatment cart, Staff O, LPN, said, We have to lock it. On 06/19/2025 at 10:24 AM, when asked if anything was done when they need to walk away from the medication or treatment cart, Staff S, LPN, said, We have to lock it. On 06/19/2025 at 10:35 AM, when asked what the expectation was regarding locking medication carts and locking treatment carts, Staff B, Director of Nursing and Registered Nurse (RN) said, tThey need to lock them when they are not directly using them. On 06/15/2025 at 12:24 PM, Medication cart on Horseshoe Hall was observed to have a bottle with medication on the medication cart, placed in an open container on an ice pack. Staff O, Licensed Practical Nurse, who was at the cart, locked the cart and walked away leaving the medication on the cart. At 12:31 PM, the medication was still on the cart when Staff O returned. When asked what medication was on the cart and placed on an ice pack, Staff O said the medication was a bottle of probiotics and it needed to be placed on ice or refrigerated. Staff O said he was told to leave the medication on ice and stated, it should probably be locked in the cart, referring to the bottle of probiotics. At 12:33 PM, Staff U, RN, was observed standing at the Long Hall cart. Medication cart on Flagship Hall was observed to have a bottle with medication on the medication cart, placed in an open container on an ice pack. When asked what medication was on the cart and placed on an ice pack, Staff U said the medication was a bottle of probiotics and it needed to be placed on ice. When asked if medication should be left on the medication cart Staff U stated, we've always left them on the cart, referring to the bottle of probiotics. On 06/20/25 at 9:04 AM, Staff B said it was her expectation that medication would be locked and secured in the medication cart when not in use by the licensed nurses. Reference WAC 388-97-1300(2) .

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to timely administer 13 of 27 medications for 4 of 9 residents (35, 24, 201, and 25) observed during medication pass audit resulted in a medication error rate of 48.15%. The failure to administer medications on time placed residents at risk for side effects and/or altered medication effectiveness. Findings included . <RESIDENT 35> During a medication administration observation on 06/18/2025 at 10:38 AM, Staff S, LPN (Licensed Practical Nurse), prepared and administered to Resident 35: -Atropine Sulfate Ophthalmic Solution 1 % Give 2 drops sublingually (under the tongue) two times a day for EOL (End of Life) comfort rt (related to) excess secretions -Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for dry eyes. -Dexamethasone Oral Tablet 2 milligrams (MG) Give 1 tablet by mouth one time a day related to dysphagia. -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (milliliters) Give 3 ml by mouth two times a day for improved breathing. -Pred Forte Ophthalmic Suspension 1 % Instill 1 drop in both eyes one time a day for inflammation for 1 Week. -Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth two times a day for bowel management, constipation. -Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth one time a day for EOL anxiety/dyspnea Review of Resident 35's June 2025 MAR (Medication Administration Record) and physician's orders, showed these medications were scheduled to be given at 9:00 AM. <RESIDENT 24> During a medication administration observation on 06/19/2025 at 10:11 AM, Staff O, LPN, prepared and administered to Resident 24: - Carbidopa-levidopa 25-100MG Give 1 tablet by mouth three times a day related to Parkinsons. Review of Resident 24's June 2025 MAR and physician's orders, showed these medications were scheduled to be given at 6:00 AM. <RESIDENT 201> During a medication administration observation on 06/19/2025 at 10:15 AM, Staff O, LPN, prepared and administered to Resident 201: -Amlodipine 10MG Give 1 tablet by mouth one time a day for lowers blood pressure related to essential hypertension. Review of Resident 201's June 2025 MAR and physician's orders, showed these medications were scheduled to be given at 9:00 AM. <RESIDENT 25> During a medication administration observation on 06/20/2025 at 9:03 AM, Staff U, RN (Registered Nurse), prepared and administered to Resident 25: -Acetaminophen 500MG Give 2 tablet by mouth two times a day for chronic pain related to osteoarthritis. -Doxycycline 100MG Give one tablet by mouth two times a day relate to methicillin resistant staphylococcus aureus infection (antibiotic resistant infection). Review of Resident 25's June 2025 MAR and physician's orders, showed these medications were scheduled to be given at 8:00 AM. On 06/19/2025 at 10:35 AM, when asked what the expectation was regarding administration time of medication, Staff B, Director of Nursing and a Registered Nurse, said medications were expected to be administered within the parameters of one hour before the time listed on the MAR to one hour after the time listed on the MAR. Reference WAC 388-97-1060 (3)(k)(ii) .

Based on interview and record review the facility failed to report falls with significant injury, misappropriation, and an allegation of abuse/neglect for 5 of 5 residents (11, 21, 35, 41, and 252) reviewed for reporting. The facility's failure to report delayed appropriate oversight and investigation, placing residents at risk for harm and unidentified abuse and/or neglect. Findings included . <Resident 11> Review of the 06/08/2025 Quarterly Minimum Data Set assessment (MDS), showed Resident 11 admitted to the facility on [DATE] and had moderate cognitive impairment with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Review of the facility Grievance Log for May 2025, showed a grievance was filed on 05/17/2025 for Resident 11 regarding care issues. Review of the Grievance form for Resident 11, dated 05/17/2025, stated, Resident had a friend call in really upset regarding the care that [Resident 11] was receiving. [Friend] called stating she just got off the phone w/ [with] res [Resident 11] and resident told [friend] that the staff last night was yelling at her and being rude to her. Review of all Facility Reported Incidents in 2025 showed no reported allegations of abuse/neglect. <Resident 21> Review of the 02/15/2025 Quarterly MDS, showed Resident 21 admitted to the facility on [DATE] and was cognitively intact with diagnoses including hypertension (elevated blood pressure) and post-traumatic stress disorder (a mental health condition that can develop after experiencing prolonged or repeated trauma). Review of the facility Grievance Log for February 2025, showed a grievance was filed on 02/18/2025 for Resident 21 regarding missing money. Review of the Grievance form for Resident 21, dated 02/18/2025, stated, [Resident 21] received $100.00 2/3/2025 from [staff] in business office. [Resident 21] received 5 $20.00 bills. [Resident 21] took out $20.00 and gave it to activities to get her stuff at [store], then she fell asleep. When {Resident 21} woke up from her nap and the $20.00 was sitting on her end table with a note that the trip to [store] was canceled r/t [related to] no transportation. [Resident 21] states when she went to put the $20's in her purse, [Resident 21] realized the 4 $20.00 were gone .[Resident 21] unable to state exactly which day [the money went missing]. The grievance form did not have any further information, there were no results of the investigation nor resolution/follow up. On 06/19/2025 at 2:40 PM, when presented with the Grievance form and asked about the grievance of [Resident 21] from 02/18/2025, Staff A, Administrator, said. I don't recall this one, it looks like we never completed it. There was a period of time that we did not have a social worker and that grievance is from that time; it must have fallen through. Review of all Facility Reported Incidents in 2025 showed no reported misappropriation. <Resident 35> Review of the 05/10/2025 Quarterly MDS, showed Resident 35 admitted to the facility on [DATE] and had moderate cognitive impairment with diagnoses including supranuclear ophthalmoplegia (an inability to properly move the eyes). Review of the facility Incident Report Log for January through June 2025 showed Resident 35 had sixteen falls in the lookback, two of which had documented injuries to the residents' head. 1. Review of the facility Incident Report Log for January 2025 shows Resident 35 fell on [DATE] and sustained injuries including an abrasion and a bump and stated, Hotline-no documenting the facility did not report the fall to Residential Care Services (RCS). Review of the facility Initial Resident Investigation Report stated, Resident was trying to go to the bathroom, at the bathroom door he lost his balance and documents the type of injuries as, 1. Bump 6cm across, round 2. Scrape 4.5 cm long, 4cm wide. Review of the facility Witness Report stated, . (Resident 35) lying on the floor on his back-head resting on roommates' dresser .neuro checks started, small bump on crown of his head, 4cm long scrape on back of right shoulder. 2. Review of the facility Incident Report Log for February 2025 showed Resident 35 fell on [DATE] and sustained injuries including an abrasion and a goose egg and stated, Hotline-no documenting the facility did not report the fall to Residential Care Services (RCS). Review of Progress Notes for Resident 35 showed a note on 02/23/2025 at 1:27 AM which stated, CNA [Certified Nursing Assistant] found resident in his wheelchair in the TV room at 2330 [11:30 PM] with an abrasion on his face. When the CNA asked what happened the resident stated he had fallen and got back in his chair .neuro checks were started. Resident told RN that he had fallen in the TV room at 2250 [10:50 PM] and got a rug burn on his face from the carpet. Review of Progress Notes for Resident 35 showed a note on 02/23/2025 at 3:37 PM which stated, .fall follow-up, pupils unequal, notified charge nurse .bruising remains on right side of forehead with facial abrasions. Review of all Facility Reported Incidents in 2025 showed no reported falls with significant injury. <Resident 41> Review of the 05/20/2025 admission MDS, shows Resident 41 admitted to the facility on [DATE] and had moderate cognitive impairment with diagnoses including cholelithiasis (gallstones in the gallbladder) in the acute kidney failure (a sudden loss of the kidneys' ability to filter waste and excess fluid from the blood). Review of the facility Incident Report Log for January through June 2025 showed Resident 41 had a fall with injury resulting in a, hematoma on 05/25/2025 and states, Hotline-no documenting the facility did not report the fall to RCS. Review of the facility Initial Resident Investigation Report showed Resident 41 sustained a head injury and documented the type of injury as a, dark area .R [right] outer eyebrow. Review of the facility Witness Report, completed by Staff H, CNA on 05/25/2025 at 5:10 PM stated, [Resident 41 was] exiting the restroom and slipped. Review of a Progress Notes for Resident 41, documented by Staff B, Director of Nursing Services and a Registered Nurse on 05/25/2025 at 6:39 PM stated, .[Resident] denies hitting head. Called out after noise heard thus do not believe she lost consciousness. However, area to left eyebrow appears new .Ice applied to prevent or reduce swelling and bruising. Neuro checks started. Review of all Facility Reported Incidents in 2025 showed no reported falls with significant injury. <Resident 252> Review of the 01/07/2025 Quarterly MDS, shows Resident 252 admitted to the facility on [DATE] and had moderate cognitive impairment with diagnoses including malignant neoplasm (cancer) of the left lung and respiratory failure (failure of the lungs to properly exchange oxygen and carbon dioxide). Review of the facility Incident Report Log for January through June 2025 showed Resident 252 had a fall with injury resulting in a, deep laceration on 01/28/2025 and stated, Hotline-no documenting the facility did not report the fall to RCS. Review of the facility Initial Resident Investigation Report showed Resident 252 sustained a laceration to their LLE (left lower extremity), measuring 6 to 7 inches long and 2 inches wide and documented the nurse, heard [resident] yell for help .her right leg has a 7-8 inch laceration down her shin, about 1-1.5 inch wide, bleeding profusely .received ok to transport to hospital. Review of all Facility Reported Incidents in 2025 showed no reported falls with significant injury, no reported misappropriation, and no reported allegations of abuse/neglect. Reference WAC 388-97-0640(5)(a) .

Based on observation, interview, and record review, the facility failed to ensure hot beverages were served at a safe temperature at or below 150 degrees Fahrenheit for 1 of 6 sampled residents (1) reviewed for accident hazards related to hot beverage service. This failure caused harm to Resident 1 who sustained three first degree burns and one second degree burn after a cup of hot cocoa spilled in their lap. This failure placed residents at risk for serious or life threatening injury from burns and a diminished quality of life. An Immediate Jeopardy was called on 10/25/2023 at 4:15 PM after observation, interview, and record review identified beverages were being served and were available at an average temperature ranging from 170 to 180 degrees Fahrenheit with no controls in place to prevent injuries to residents. Exposures to hot beverage temperatures of 124 degrees for 3 minutes, or 127 degrees for one minute, can place residents at risk for 3rd degree burns. The immediacy was removed on 10/26/2023 at 10:50 AM, after the facility management team reviewed policies, made modifications, and initiated training on taking the temperatures of coffee and hot water prior to leaving the kitchen and then again before service of hot beverages is initiated, and would not be serving hot beverages above 150 degrees. Finding included . The facility's policy, updated 02/20/2023, entitled Safety of Hot Liquids, documented staff were to maintain a hot liquid serving temperature of not more than 150 degrees Fahrenheit and food service staff would monitor and maintain foods temperatures that comply with food safety requirements but not exceed temperatures to prevent scalding. Resident 1 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, a neurological disease affecting speech and causing tremors, rigid muscles, slow movement, and impaired balance. Record review of a document entitled Daily Food Temp Monitor, dated 10/01/2023 to 10/25/2023, showed hot coffee and hot water temperatures ranged from 170 to 180 degrees Fahrenheit. A progress note, dated 10/23/2023 at 9:13 AM, documented Resident 1 had spilled hot cocoa on their lap and had burns present. The right anterior burn started to peel right away and all other area burns were bright red with no open skin. A Skin Observation Tool, dated 10/24/2023 at 2:49 PM, documented the placement and measurement of the burns as follows: --Right anterior (front) inner thigh, 6 centimeters (cm) by 6 cm. --Left anterior inner thigh, 7 cm by 4 cm. --Right posterior (back) thigh, 15 cm by 1 cm. --Left posterior thigh, 14 cm by 7 cm. On 10/25/2023 at 10:58 AM, Staff C, Activity Director, said she and her department were responsible for serving the hot beverages. The beverage service times were 7:30 AM, 11:30 AM, and 4:00 PM. When asked who tested the temperatures of the coffee and hot water, Staff C said this was a dietary staff task. Staff C said she had not been trained to take temperatures of hot beverages. Staff C said the coffee cup for Resident 1 had a lid and straw in place. At 11:10 AM, Staff D, Dietary Manager, said the hot beverage service times were 7:30 AM, 11:30 AM and 4:00 PM. Staff D said the testing process was to take the temperature of the coffee or hot water after it was brewed directly into the coffee carafe. Staff D said the average temperature of the coffee was 170 degrees Fahrenheit. The kitchen line staff and a dietary aide present indicated the average temperature of the coffee was 170 degrees Fahrenheit. Staff D said the carafes usually sat 30 minutes to an hour prior to going out on the floor to be served. Staff D said the activities staff check the temperature of hot beverages again before serving. On 10/25/2023 at 11:15 AM, Staff E, Dietary Staff, said the person who came in at 5:00 AM was the one who brewed the coffee and the hot water. The brewing process was usually completed by 6:30 AM and the activities staff came to get the beverage cart by 7:30 AM. The carafes held the beverage temperature for two hours. Staff E said the facility had a constant brewing process. Once she started brewing coffee and hot water, she did not stop. The carafes went out and were emptied and returned to the kitchen to be filled up again. Staff E said she was the one who brewed the coffee and hot water the morning of 10/24/2023. The Hot Beverage Log, showed on 10/25/2023 at 11:15 AM, the coffee was 172 degrees Fahrenheit, and the hot water was 175 degrees Fahrenheit, after Resident 1's burns on 10/23/2023. On 10/25/2023 at 11:49 AM, Resident 1 was observed during wound care. Observation showed a second degree burn to Resident 1's right anterior thigh and three first degree burns to the right posterior thigh, left anterior thigh, and left posterior thigh. At 12:27 PM, the surveyor temped the hot water, after being brewed and directly into the carafe, at 176.4 degrees Fahrenheit. At 2:08 PM, Staff F, Nursing Assistant Registered, said she was the one who found Resident 1 with the coffee cup in their lap. Staff F said a lid and straw were in place. Staff F said she heard Resident 1 call out; and upon entering the room, found the cup had spilled and soaked through the blankets covering the resident's lap. Staff F said she called the nurse. The bedding was removed, and cold compresses were applied right away. At 3:15 PM, Staff D was observed testing the temperature for the evening hot beverage service. Temperatures for coffee and hot water were 150 degrees Fahrenheit. At 4:15 PM, Staff A, Administrator, said the staff had not followed the policy for hot beverages and residents had been served beverages with temperatures over 150 degrees Fahrenheit. Staff A said he and Staff B, Director of Nursing Services, already had a plan in place for the training of dietary staff and activities staff for temping the coffee and hot water prior to serving. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 5 of 8 sampled residents (#26, 53, 39, 36 & 37) reviewed for resident to resident altercations. This failure placed residents at risk for physical harm, pain, and a diminished quality of life. This failure caused harm to Resident #39 when she experience pain and swelling in her hand. Findings included . 1) Resident #39 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 07/09/19, showed the resident had severe cognitive impairment. An investigation report, dated 07/14/19, documented Resident #39 had her hand grabbed and finger bent backwards by Resident #26 as she was being pushed past Resident #26 in the hallway. The incident reporting log showed Resident #39 had pain and swelling from the incident on 07/14/19. A progress note, dated 07/14/19 at 7:53 AM, showed Resident #39 was medicated for right finger tenderness. A progress note, dated 07/14/19 at 8:27 AM, showed the physician was called regarding Resident #39's sore finger from an altercation with other resident that morning. A progress note, dated 07/14/19 at 10:46 AM, showed new orders were received to x-ray Resident #39's right hand and fingers. An x-ray report, dated 07/14/19, showed the reason for study was pain in right fingers. 2) Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], showed the resident had severe cognitive impairment and delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident #26's [MEDICAL CONDITION] medication care plan, dated 06/10/19, identified a target behavior of violence and aggression towards staff and others. A behavior care plan for physically aggressive behaviors, initiated 06/24/19 and revised 07/15/19, showed the resident punched residents and staff. Interventions to keep other residents safe included guide away from source of distress, engage calmly in conversation and if aggressive staff to walk away and approach later. The (MONTH) 2019 incident and accident log showed Resident #26 was involved in four resident to resident altercations where Resident #26 was physically abusive to other residents. The other residents involved were Resident #39, Resident #53, Resident #37, and Resident #22. 3) Resident #53 was admitted to the facility on [DATE]. The MDS, dated [DATE], showed the resident was cognitively intact and had no behaviors. An investigation report, dated 07/07/19, documented Resident #53 was hit on the arm by Resident #26 when Resident #53 tried to tell Resident #26 he should not be rummaging through the covered supply cart. 4) Resident #37 was admitted to the facility on [DATE]. The MDS, dated [DATE], showed the resident had severe cognitive impairment. An investigation report, dated 07/11/19, documented Resident #37 was sitting in the hallway when Resident #26 hit Resident #37 and stated Resident #37 hit him first. 5) Resident #36 was admitted to the facility on [DATE]. The MDS, dated [DATE], showed the resident had moderate cognitive impairment. An investigation report, dated 07/31/19, documented Resident #36 was hit in the back by Resident #26. Prior to hitting Resident #36, Resident #26 yelled at Resident #36 to get out of his chair. On 08/09/19 at 9:12 AM, Staff D, Licensed Practical Nurse, said Resident #26 was confused and thought he owned the facility. Staff D said Resident #26 would strike out if he thought he was being confronted. Staff D said Resident #26 was independent in mobility and staff tried to always be on guard for where he was to keep the other residents safe. At 9:49 AM, Staff G, Restorative Nursing Assistant, said Resident #26 had aggressive behaviors and would be fine one minute and mad the next. Staff G said staff were on alert to keep an eye on Resident #26; and if his behaviors were escalating, get other residents away from him. At 10:19 AM, Staff F, Nursing Assistant, said Resident #26 could be violent at times and would try to punch, hit or kick when people walked by. Staff F said staff tried to keep Resident #26 away from other residents by encouraging them to go a different way. At 10:50 AM, Staff C, Registered Nurse (RN) and Resident Care Manager, said Resident #26 was perpetually on the move and self-propelled throughout the facility in his wheel chair. Staff C said the longer the resident was at the facility the more behaviors he was having. Staff C said he initially was air boxing where he would punch in the air, and as time went on it became more deliberate where he would hit staff and residents. At 4:07 PM, Staff B, RN and Director of Nursing Services, said the resident to resident altercations involving Resident #26 came with no warning. Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to consult with a physician regarding ongoing deterioration in condition for 1 of 5 residents (#1, former/discharged ). This failure delayed an opportunity to adjust the resident's treatment, placed the resident at risk for clinical complications and caused harm for the resident who required hospitalization for dehydration [MEDICAL CONDITION] (infection throughout the body). Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 11/27/13, the Resident was alert with some memory problems and required extensive assistance with activities of daily living. The resident had an ostomy (collection bag for bowel care) and was incontinent of urine. Resident #1 was discharged to the hospital on [DATE] at the request of the family. On 11/14/13, an admission nursing note reflected "Res {resident} coherent and cognizant. Res in good spirits and able to laugh. Res follows instruction and is able to make needs known." On 11/16/13 at 01:40 p.m., nursing notes reflected "Resident very anxious and yelling. Requested medication for anxiety, stating 'It just keeps building. I feel like I'm going to climb the walls.' MD {physician} notified. Received order for [MEDICATION NAME] {a medication for anxiety}." On 11/17/13, the resident continued to yell and cry out, the medication was not effective, the physician was not consulted. On 11/22/13, chart notes reflected the family was concerned about the resident's continuing behavior and asked the staff to contact the physician. Staff spoke with the doctor about changing the medication from [MEDICATION NAME] to [MEDICATION NAME] (another type of anti-anxiety medication). For the next 4 days, the resident continued to have periods of "Calling out", "Stripping off clothing", "Thrashing in bed", "Delusional", and "Hollering". The resident was not responding to the medication change. The resident may have been having an adverse reaction to the new medication or may have had a recurrence of the urinary tract infection that had been treated prior to admission. The physician was not consulted. On 11/27/13, chart notes indicated the resident was experiencing "Agitated state, hitting out, hitting wall, hitting hand on bed rail, glass on bed, swung trapeze {an overbed device used to assist in repositioning} into glass picture on a wall, calling out, called MD, left a message." The physician did not respond. For the next 5 days, nursing notes recorded the resident's behavior: "Yells out, delusional", "Hollering out, unable to redirect", "Yells through the night", "Very confused", "Banging on wall with overhead trapeze, delusional and confused". There was no indication the physician was consulted regarding the resident's continuing distress. On 12/03/13 a physician responded to the earlier message with an order to "discontinue the trapeze." There was no evidence the physician was aware of the resident's continuing behaviors. On 12/05/13, chart notes indicated the resident "Broke hole in wall with remote control, MD {physician} notified." The physician gave orders to check a urine specimen, as an infection can sometimes cause [MEDICAL CONDITION]. The urine test showed the resident did have a urinary tract infection, and treatment was started. Despite receiving treatment for [REDACTED]. The physician was not consulted. On 12/16/13, chart notes indicated the resident "Continues to yell and pound the wall." A care conference was held with the family to discuss the resident's "anxiety." The family made an appointment with a physician they wished to have as the primary care provider. The family also requested [MEDICATION NAME] (another type of medication used for anxiety) as the resident had used it in past. The physician was contacted regarding the family's request for the [MEDICATION NAME] and for another type of pain medication. On 12/20/13, 12/21/13 and 12/22/13, the resident had periods of non-stop yelling for 2-3 hours at a time, unrelieved by the new medication. The physician was not consulted. On 12/23/13, chart notes reflected the resident was calmer, but "Delusional" in the morning, then yelling later in the afternoon. At 5:30 p.m., the family called the physician answering service to request medication or something to help the resident. An order was received for the medication to be changed to [MEDICATION NAME] ( a medication given for symptoms of [MEDICAL CONDITION]) and to repeat a urinalysis. On 12/24/13, chart notes reflected the family "Asks that MD office be contacted and resident to sent to ED {emergency department} for evaluation." At 2:10 p.m., the resident was sent to the hospital via ambulance. There was no indication the physician was consulted on a total of 25 different days for resident behaviors that were not present on admission. The behaviors included : continued anxiety, crying out, throwing items, yelling, agitation, hitting, [MEDICAL CONDITION], screaming, hollering and pounding. It appeared the physician was contacted when there was an incident, like the resident falling out of bed, or pounding a hole in the wall, and when the family wanted the resident discharged to the hospital. The physician was not consulted by the facility regarding the resident's on-going distress regarding the possible need to alter treatment, to commence a new treatment or to make a decision to transfer or discharge the resident from the facility. On 12/30/13 at 12:10 p.m., when asked whether the physician was consulted about the resident's on-going distress, Licensed Nurse (LN) A stated "The resident's wife was trying to brainstorm why the resident was changing so much. The family thought the resident had new behaviors but the facility thought the resident was so compromised in every way that it was hard for us to figure it out." When asked where the staff would record consultations with the physician, LN A replied, the information "probably did not get written down." Refer to F 309 .

Based on observation, interview and record review, the facility failed to ensure that each resident received optimal care when they failed to recognize and determine the cause of resident behaviors for 2 of 5 residents (#1, former/discharged , & #2). This failure caused harm for Resident #1 who required hospitalization for dehydration [MEDICAL CONDITION] (infection throughout the body) after 6 weeks of ineffective treatment with medications for anxiety, and caused Resident #2 to experience unnecessary anxiety and diminished levels of participation in social interactions. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 11/27/13, the Resident was alert with some memory problems and required extensive assistance with activities of daily living. The resident had an ostomy (collection bag for bowel care) and was incontinent of urine. The resident was admitted with a Stage IV (deep pressure sore, with bone involvement) pressure sore on the back and 2 unstageable (black) areas on the heels. Resident #1 was discharged to the hospital on [DATE] at the request of the family On 11/14/13, an admission nursing note reflected "Res {resident} coherent and cognizant. Res in good spirits and able to laugh. Res follows instruction and is able to make needs known." On 11/15/13, chart notes reflected the resident was seen by the family physician of long standing. On 11/16 at 1340, nursing notes reflected "Resident very anxious and yelling. Requested medication for anxiety, stating 'It just keeps building. I feel like I'm going to climb the walls.' MD {physician} notified. Received order for [MEDICATION NAME] {a medication for anxiety}." On 11/17/13, day shift chart notes indicated the resident was "Very anxious, pulling at own skin, crying out, threw teeth, keeps pulling linen off himself, crys out with care. Yelling at MD as if he were in the room." Evening shift charting at 10:00 p.m., nursing notes reflected "Very anxious, yelling out, pulling at covers of bed and call light cord." Interventions of repositioning, medications and food were not effective in reducing the resident's anxiety. On 11/18/13, the resident rolled onto the floor. The physician was notified and orders were obtained for an x-ray of the hip. No behavioral distress was documented. On 11/19/13, the facility received orders from the family physician to check the resident's blood sugars routinely because of the history of diabetes. At 2200, chart notes reflected "Started yelling loudly - stated 'I'm going to tear this room apart'. " The facility called the family and administered medication. On 11/22/13, chart notes reflected the staff talked with the physician about medication changes requested by the family. The family had requested a change from [MEDICATION NAME] to [MEDICATION NAME] (another type of anti-anxiety medication), based on prior successful management of the resident's previous episodes of anxiety. On 11/23/12, 11/24/12, 11/25/13 and 11/26/13, nursing notes reflected at various times the resident was experiencing high levels of anxiety with "Calling out", "Stripping off clothing", "Thrashing in bed", Delusional" and "Hollering". Although the resident was receiving [MEDICATION NAME] and pain medication, there was no indication the facility had attempted to ascertain why the behaviors were continuing. The staff failed to recognize the new onset of [MEDICAL CONDITION] could indicate an acute medical problem or an adverse reaction to a medication change. On 11/27/13, chart notes indicated the resident was in an "Agitated state, hitting out, hitting wall, hitting hand on bed rail, glass on bed, swung trapeze {an overbed device used to assist in repositioning} into glass of picture on wall, calling out, called MD, left a message." Although the incident was reported via message machine, by not communicating directly with the physician, the facility indicated a minimal concern for the continuing delirious behavior of the resident. On 11/28/13, 11/29/13, 11/30/13, 12/01/13, and 12/02/13, nursing notes recorded the resident "Yells out, delusional", "Hollering out, unable to redirect", "Yells through the night", "Very confused", "Banging on wall with overhead trapeze, delusional and confused." The resident continued to receive pain medication and [MEDICATION NAME] during this time, there was no indication the facility considered the resident to be having an adverse reaction to a new medication, or physical problems requiring medical attention. The physician was not consulted. On 12/03/13 a physician's orders [REDACTED]." No behaviors were noted, but the resident received [MEDICATION NAME] twice during the day. On 12/04/13 nursing notes for the day shift indicated the resident's medications were helpful for "Screaming [MEDICAL CONDITION]" and indicated the resident "Keeps calling out for the dog and to go to the podiatrist." The resident received medication with little effect. Further assessment was not completed. On 12/05/13, chart notes indicated the resident "Broke hole in wall with remote control, MD notified. Yelling, MD give orders for UA {urinalysis}." [MEDICATION NAME] continued to be administered. On 12/06/13, nursing notes recorded the resident was "Delusional, wants to go upstairs". Medications were administered, the physician was not consulted. A urine specimen was collected and sent to the laboratory. On 12/07/13, chart notes written at 3:45 a.m. reflected "Resident slept 4 hours after [MEDICATION NAME]. He has increased anxiety, yelling out, stating 'He is a police officer and he is going to arrest staff for dereliction of duty'. Poor re-directability." Medications were administered, the physician was not consulted. On 12/08/13 at 12:10 a.m., the night nurse recorded "Resident calling out from 9:00 p.m. until now {over 3 hours}. Resident calls out different names and commands that do not make any sense." Medications were administered, the physician was not consulted. On 12/09/13 and 12/10/13, chart notes indicated the resident was threatening to staff, restless, anxious, yelling out for help, yelling repeatedly, asking for the police to be called, banging on the wall and requesting to be helped. Medications were administered, the physician was not consulted. On 12/11/13, UA results were reported with a urinary tract infection being confirmed, physician orders [REDACTED]. The organism identified on the culture was E. coli, strains 1 and 2, a common cause of urinary tract infections. No behaviors were documented. On 12/12/13, 12/13/13, 12/14/13 and 12/15/13 the resident had "Increased confusion, "Hollering frequently for 'Help', "Hollering 'Help' for 2 and 1/2 hours", and "Pounding on walls." Despite being treated for [REDACTED]. The physician was not consulted. On 12/16/13, chart notes indicated the resident "Continues to yell and pound the wall." A care conference was held with the family to discuss the resident's anxiety. The family made an appointment with a physician they wished to have as the primary care provider. The family also requested [MEDICATION NAME] (another type of medication used for anxiety) as the resident had used it in past. The physician was contacted regarding the family's request for the [MEDICATION NAME] and for another type of pain medication. On 12/17/13, 12/18/13, 12/19/13 and 12/20/13 nursing notes reflected the resident received [MEDICATION NAME] with good results with decreased yelling and anxiety. On 12/20/13 the resident began experiencing suicidal ideation and was able to tell staff about how he would carry out the plan. Mental health and the crisis hot line were contacted. The resident refused to speak with the crisis hot line. Every 15 minute checks were initiated to monitor the resident's safety. The physician was not made aware. At 10:35 p.m., nursing notes indicated the resident was yelling for 3 hours because the staff was unable to give the [MEDICATION NAME] earlier than scheduled. No attempts to alter the treatment plan were made. The physician was not consulted. On 12/21/13, chart notes reflected the resident was begging to "Just let me go" and was hollering non-stop for 2 and 1/2 hours after receiving [MEDICATION NAME]. The family requested the facility contact the physician. There was no indication this was completed. On 12/22/13, the resident was "Hollering" and calling out "Help" for 2 and 1/2 hours, then for 2 additional hours, after receiving [MEDICATION NAME]. There was no indication the staff took action to determine why the resident continued to be in distress. The physician was not consulted. On 12/23/13, chart notes reflected the resident was calmer, but "Delusional" in the morning, then yelling later in the afternoon. At 5:30 p.m., the family called physician answering service to request medication or something to help the resident. An order was received for the medication to be changed to [MEDICATION NAME] (a medication for psychotic behavior) and to repeat a urinalysis. At 10:00 p.m., the [MEDICATION NAME] was administered and was effective for "Approximately 30 minutes of quiet, the resident began yelling again and it has not stopped." The physician was not consulted, additional interventions were not documented. On 12/24/13, chart notes reflected the family "Asks that MD office be contacted and resident to be sent to ED {emergency department} for evaluation." At 2:10 p.m., the resident was sent to the hospital via ambulance. The resident was treated with 4 different types of medications. The resident experienced a urinary tract infection and received treatment from 12/11/13 through 12/16/13. There was no indication the facility had an awareness the resident might be experiencing an acute medical condition, a reaction to medications or require a higher level of care. The physician was notified at the request of the family or when there was an incident. Documentation did not indicate the physician was made aware of the ongoing distress of the resident. On 12/30/13 at 12:35 p.m., the Social Services Director (SSD) stated "The resident was alert when he first came in. He told me he was in a lot of pain. Toward the end of his stay, he made statements of wishing for death. He was definitely giving up." At 4:35 p.m., the Director of Nursing stated "I have known {the Resident} for years because he worked as a medical professional in the area. We felt like we were still seeing the side effects of a stroke. He also had pain issues because of the pressure sores and had a history of [REDACTED]. We did not think it was necessary to send him to the hospital because we thought we were still seeing symptoms from his stroke. Also, we couldn't get the family all together at once and they all had a different opinion about what needed to be done." 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], the resident was alert and oriented and required extensive assistance with ADL's. The resident's score on the depression assessment was 16, indicating moderately severe depression. The Resident was taking no routine anti-depressant medications. On 12/30/13 at 09:00 a.m., Nursing Assistant (NA) D stated "I have never seen {Resident #2} hit, yell or throw things at staff. He can be a little grouchy sometimes, but there is usually a reason." At 09:30 a.m., NA F stated "{Resident #2} has always been real polite to me. The only time I have ever seen him upset was the day the Administrator and Director of Nursing talked with him. I don't know what that was all about." At 12:35, SSD stated "We issued an eviction notice to {Resident #2} because he threw a cup of coffee at one of the kitchen staff. The resident was upset that we would not take him shopping. But the facility van is only used for assisted living residents and there isn't any non- medical transportation in the community. The resident refused to take any medication for depression, yet he admits to being incredibly depressed. He is very unhappy. Mental health is involved, but the resident sometimes refuses to go." At 3:00 p.m., Resident #2 stated "I am supposed to be going to counseling, but I haven't gone for 3 weeks because appointment times keep getting messed up. I am depressed about being here. I would like to go shopping, but the facility won't take me out in the van because it is mostly used for the more independent residents. I need to find another place to live, but I don't feel the facility is being very helpful." .

Based on interview and record review, the facility failed to ensure that each resident's drug regime was free from unnecessary drugs when they failed to ensure adequate monitoring, failed to provide adequate indication for use and failed to ensure non-pharmacological approaches were utilized for 1 of 5 residents (#1, former/discharged ). This failure caused harm to Resident #1 when hospitalization for dehydration and infection was required following more than 6 weeks of ineffective treatment with psychoactive medications. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 11/27/13, the Resident was alert with some memory problems and required extensive assistance with activities of daily living. The resident had an ostomy (collection bag for bowel care) and was incontinent of urine. The resident was admitted with a Stage IV (deep pressure sore, with bone involvement) pressure sore on the back and 2 unstageable (black) areas on the heels. Resident #1 was discharged to the hospital on [DATE] at the request of the family. The resident was admitted to the facility on [DATE] and was alert, oriented and was able to make his needs known. On 11/16/13, the physician was contacted at the request of the family for medications to help with the resident's anxiety. The facility did not attempt to determine the source of the anxiety and obtained an order for [REDACTED]. (by mouth) every 6 hours as needed for anxiety." The medication was given several times with little effect. On 11/22/13, the family noted the resident was not responding to the [MEDICATION NAME] and requested the physician be called about changing the orders to [MEDICATION NAME] (another type of anti-anxiety medication). The physician was notified and orders were received to "Discontinue [MEDICATION NAME], give [MEDICATION NAME] 0.5 mg P.O. every 6 hours as needed for anxiety." The medication was given several times with the resident having increasing incidents of yelling, [MEDICAL CONDITION] and pounding on the walls. The facility did not determine the source of the anxiety or inform the physician of increasingly delusional behaviors. On 12/12/13 through 12/16/13, the resident received intra-muscular antibiotics for a urinary tract infection. On 12/16/13, the family noted the resident was getting worse and asked for the physician to be notified. The family recalled the resident had taken [MEDICATION NAME] (a type of anti-anxiety medication) in the past and requested for that to be tried. The physician was contacted and orders were received to "Discontinue [MEDICATION NAME], give [MEDICATION NAME] 5 mg P.O., 1-2 tablets every 8 hours as needed for anxiety/nerves." The medication was given several times with the resident's [MEDICAL CONDITION] becoming increasingly significant. Possible medical sources for the [MEDICAL CONDITION] were not evaluated. On 12/23/13, the family contacted the physician to request something to relieve the resident's constant screaming and yelling. The physician gave an order for [REDACTED]. On 12/24/13 the family requested the doctor be contact and the resident to be sent to the emergency department. The resident was admitted to the hospital with [REDACTED]. On 12/30/13 at 12:20 p.m., Licensed Nurse A stated "The family was bringing their concerns to us. Their biggest issue had to do with communication. The family thought this was new behavior. We were just trying to figure out what was going on with the resident." At 12:30, the Social Services Director stated "The resident was definitely giving up. Sometimes he had very lucid moments and sometimes he was very confused." At 4:30 p.m., the Director of Nursing stated "I have known {the resident} for years because of his work as a medical professional. His stroke had done a lot more damage than we thought. It was obvious he had pain issues, he also had a history of [REDACTED]. A urinary tract infection could cause the symptoms the resident was experiencing, but we did not think about that, we were focused on the stroke. And each family member had their opinion about what was going on with the resident and it took us a while to get everyone together as a group." Refer to F 157, F 250 and F 309 .

Based on observation, interview and record review, it was determined the facility failed to provide necessary dental services for identified dental problems for 2 of 3 current sample residents (#s 31 and 43) reviewed for dental services. This failure caused Resident #31 to experience ongoing tooth decay, tooth loss, problems with chewing and closing her jaw, and limited food choices. This failure caused Resident #43 to experience ongoing tooth decay, tooth loss, difficulty with chewing, and to remain nearly edentulous (having no teeth) without intervention for at least one full year after requesting a full set of dentures as recommended by his dentist. Findings include: RESIDENT #31 Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), an assessment tool, dated 12/13/12, indicated Resident #31 ambulated independently with use of a walker and required cuing with oral care. The Care Area Assessment, dated 12/14/12, reported the resident had "broken natural teeth with moderate gingivitis." Observation during an interview on 9/17/13 at 1:49 p.m. showed Resident #31 to have a full upper denture in her mouth but no lower denture. All of the resident's lower teeth appeared broken and decayed (black) at the gum line. Resident #31 denied mouth pain but stated it was difficult to chew "because of my teeth" and said that, as a result, she was "real fussy about food," limiting herself to items which were easier to chew. The resident also stated she could not close her mouth all the way, demonstrating for the surveyor that when she closed her jaw as far as she could, her lower gum was approximately one inch from the bottom of her upper denture. When asked, Resident #31 said yes, she would like to see a dentist about getting a lower denture. The resident further stated that no one at the facility had ever offered to assist her with making a dental appointment. Resident #31 stated she thought it was because she didn't have the money to see a dentist or pay for a denture. The Visual Oral Health Screening Form, dated 8/20/12, filled out by the dental hygienist, stated Resident #31 had moderate gingivitis and all lower teeth were broken except for #22. The resident was referred for dental services. The progress note, dated 9/26/12, signed by the Social Services Director (SSD), stated Resident #31 decided not to have her one remaining lower tooth pulled and not to get a lower denture. The Woodland Rehab Oral Health Screening Form, dated 2/11/13, indicated Resident #31 had decay in her one remaining lower tooth: #22. No information regarding condition of oral tissues was provided. The hygienist did not answer the question on the form as to whether additional dental services were recommended. The Woodland Rehab Oral Health Screening Form, dated 8/5/13, stated "All lower teeth broken, decayed at gum line"; tooth #22 was no longer present. The hygienist checked the box indicating that dental services were "not appropriate at this time" but did not explain why dental services were not appropriate for the resident's broken, decayed teeth. Further record review revealed documentation supporting Resident #31's statement that she was "real fussy about food" due to chewing problems, limiting herself to items which were easier to chew. The Quarterly Nutrition Reviews dated 3/11/13, 6/3/13 and 8/28/13, indicated Resident #31 was on a regular *liberalized diet (*not strictly adhering to usual diabetic prescriptions) with small portions and an evening snack. The resident's weight was stable even though her intake at meals was "poor ...25%." The nutrition note, dated 6/3/13, stated Resident #31 hoarded sugar and hot chocolate packets which she ate right out of the package. The nutrition note, dated 8/29/13, stated Resident #31 accepted ice cream, fruit salad, cottage cheese and yogurt. The nursing progress note, dated 9/8/13, stated that Resident #31 continued "to not eat meals" but, in the evening, "wants snacks" such as peanut butter and jelly sandwiches, yogurt and sugar packages. On 9/19/13 at 10:51 a.m., during an interview, the DNS stated Resident #31 had not told facility staff she had trouble with chewing and closing her jaw. The DNS said Resident #31 had not seen a dentist since she was admitted to the facility. The DNS was unable to provide documentation to verify that any staff had followed up with Resident #31, to inquire if the resident would like to see a dentist, since the SSD note, dated 9/26/12, stating the resident decided not to get a lower denture. When asked if gingivitis, tooth decay, or broken teeth would indicate the need for an appointment with a dentist, the DNS said yes, but when residents lacked financial resources to pay for dental services, appointments were made only when the resident reported pain or proactively requested an appointment. The facility failed to provide necessary dental services for Resident #31 when, despite identified dental problems, no staff offered to make a dental appointment for the resident. This failure caused Resident #31 to experience ongoing problems including tooth decay, broken teeth, problems with chewing and closing her jaw, and limited food choices. RESIDENT #43 Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS, dated [DATE], indicated Resident #43 was alert, oriented and usually able to express his needs. The resident was non-ambulatory and required assistance with all activities of daily living, including oral hygiene. The Care Area Assessment, dated 3/27/13, stated the resident had no natural upper teeth and had 5 remaining lower teeth and some tooth fragments. On 9/17/13 at 1:55 p.m., during an interview, Resident #43 was observed to have no upper teeth and only 5 lower teeth in front with one tooth broken at the gum line. All of the resident's teeth were yellow-brown. The resident denied having mouth pain. Record review revealed documentation indicating that Resident #43 requested a full set of dentures at least one year ago. On 9/5/12, the SSD documented a discussion with Resident #43's legal guardian about the resident's request for dentures. The guardian said "go ahead" with a dental appointment for dentures. The Visual Oral Health Screening Form, dated 9/10/12, indicated Resident #43 had extreme periodontal disease with inflammation, had only anterior lower teeth, all of which were decayed, and had inadequate oral hygiene. Dental services were recommended. The nursing note, dated 9/17/12, indicated that Resident #34 had an appointment with the dentist that day. On 9/24/12, the SSD documented that Resident #43's guardian said the resident did not have financial resources for dentures. On 1/2/13, the SSD documented that Resident #43 recently lost a tooth but the resident said it didn't bother him. The resident stated he knew his guardian was trying to save money for dentures and said, "I can wait." The Visual Oral Health Screening Form, dated 1/7/13, documented Resident #43 had moderate gingivitis, broken and decayed teeth, and inadequate oral hygiene. The space for indicating further dental services was left blank. On 8/2/13, the SSD documented she spoke with Resident #43's guardian and inquired about selling the resident's electric wheelchair to pay for dentures. The guardian stated that money from the sale of the wheelchair should be applied toward funeral expenses. The Quarterly Nutrition Reviews, dated 6/24/13 and 9/12/13, documented Resident #43 was on a regular diet, exceeded his ideal body weight, was taking 90 -100% at meals and had no apparent chewing difficulty. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident also received [MEDICATION NAME], 15 milliliters, "swish and spit," twice daily for gingivitis. On 9/18/13 at 12:10 p.m., during an interview, further observation showed the gum line surrounding Resident #43's few remaining lower teeth was red and inflamed. The resident stated it was "hard to eat with the only teeth I've got" and said he would like to have his remaining lower teeth removed and get a full set of dentures. During the interview, Resident #43 asked Licensed Nurse (LN) A to tell the SSD he would like to set up an appointment to get dentures. (LN A was present for the interview at Resident #43's request.) On 9/19/13 at 10:51 a.m., during an interview, the DNS stated Resident #43 did not have money for dentures and the facility could not afford to pay the cost of his dentures. On 9/20/13 at 10:32 a.m., during an interview, the SSD stated Resident #43's last dental appointment was 9/17/12 at River Dental. The SSD stated River Dental recommended removing Resident #43's remaining teeth and providing a full set of dentures. River Dental indicated Medicaid would not pay for dentures, so the SSD did not pursue a Medicaid benefit to provide dentures for the resident. The facility failed to provide necessary dental services for Resident #43 when, after the resident requested to have dentures made, as recommended by his dentist, facility staff did not pursue a Medicaid benefit to provide dentures for the resident. This failure caused Resident #43 to experience ongoing tooth decay in his few remaining teeth, further tooth loss, difficulty with chewing, and to remain nearly edentulous without intervention for at least one full year after requesting a full set of dentures. .

Based on observation, interview and record review, the facility failed to maintain a safe and accident free environment for 3 of 7 current sampled residents (#83, #30, #85) of 7 residents reviewed, to provide adequate supervision for 1 of 1 former resident (#71) with repeated elopements reviewed for accidents and supervision. The facility failed to keep hazardous chemicals locked. Failure to provide adequate supervision and implement safe interventions for residents placed them at risk for safety hazards and the potential for serious injury, harm, or impairment. These failures caused actual harm to Resident #83. Findings include: <Resident #83> Resident #83 was admitted to the facility on [DATE], with multiple medically disabling conditions requiring assessment and monitoring. The resident was on multiple medications making him prone to fragile skin conditions and bleeding. A care plan dated 6/28/12, documented the resident's skin was at risk. Care plan approaches included the resident was to wear geri-gloves at all times except when he was bathing. The resident's Minimum Data Set (MDS), an assessment tool, dated 7/07/12, documented the resident had poor safety awareness and was at risk for falls and injury. He required extensive assistance from staff to ambulate, transfer and perform activities of daily living. Staff was to check the resident frequently and anticipate his care needs. On 7/30/12 at 11:25 a.m., Resident #83 said he was trying to get through a doorway a few days before when he hit his hand causing a cut. The resident's left hand was extensively bruised along the outer and top part of the hand. The resident had steri-strips (bandages) covering a skin tear. An incident report dated 7/24/12, documented, "Resident reported to staff he was in the small dining room trying to get to the vending machine and grabbed a table with left hand and received a skin tear, 1x1x1 cm (centimeter). " On 7/24/12 at 12:45 p.m. Resident #83 was observed using his hands to self propel towards the doorway of the small dining room. An activity assistant started to assist the resident out of the room when his left hand scraped the vending machine that partially obstructed the doorway by one foot. Resident #83 was observed trying to maneuver between another resident in a wheelchair (blocking another 6 inches of the doorway) and the vending machine in an attempt to get through the doorway when the accident occurred. The activity assistant along with a nursing assistant immediately took the resident to a nurse. On 8/02/12 the doorway was measured at approximately 4.5 feet. The vending machine was noted to partially block the doorway reducing the doorway exit to 3.5 feet. The width of the resident's wheelchair was approximately 2.5 feet. There appeared to be very little space for the resident to maneuver between the other wheelchair and the vending machine that partially blocked the doorway. On 7/3/12 at 3:40 p.m., the Director of Nursing Service (DNS) stated the vending machine blocked the dining room doorway "somewhat" and thought it should be moved. On 8/02/12 the DNS reported she interviewed the resident the same afternoon as the incident. Resident #83 told the DNS he was trying to get through the partially blocked doorway when he sustained the skin tear. The DNS acknowledged the resident tore his skin on the vending machine. <Resident #71 > The former resident was admitted [DATE] from the hospital with [DIAGNOSES REDACTED]. The former Resident was discharged on [DATE], unavailable for interview and observations. The resident's MDS dated [DATE] identified the resident was severely impaired for daily decision making skills with disorganized thinking and inattention behaviors. The MDS documented the resident had daily wandering behavior without placing the resident at risk for exiting to the outside of the facility. The quarterly MDS dated [DATE], documented the resident exhibited wandering behaviors placing her at significant risk for getting to a potentially dangerous place. The resident's "Alteration in Cognition" care plan with a printed date of 3/22/12 included the resident exhibited behaviors of exit seeking and wandering. The goals were for the resident to accept and acknowledge helpful reminders and direction through the next evaluation date. The care plan did not contain specific goals to address the resident's exit seeking behaviors or wandering. The care plan interventions listed #1 as ability to exit building. Documented below this was "unable to exit or be alone outside." There were no specific interventions addressing the resident's wandering or exit seeking behaviors. A progress note dated 3/25/12 documented Resident #71 exited the facility and was found outside during the day shift and again at 4:00 p.m. A Social Service Director's (SSD) note dated 3/26/12 documented a new intervention of the family agreeing to move the resident's room closer to the nurse station. On 3/27/12, the facility placed the resident on location checks every 15 minutes. The progress note documented, "CP (care plan) revised." A record review showed none of the resident's care plans contained documentation of the 15-minute check intervention or the 2 incidents fo the resident exiting the facility on 3/25/12. Progress notes within a 17-day period, dated 4/18/12 at 8:12 p.m., 4/28/12 at 10:45 p.m. and 5/2/12 at 12:30 p.m., 5/4/12 at 12:30 p.m., documented the resident read and entered the correct egress codes on the keypad for all doors. The resident exited the facility and was found outside 5 times, unsupervised. No specific outside location was documented. After each incident of the resident's ability to exit the building, unsupervised, there were no new documented prevention measures on any of the care plans to mitigate the occurrence of additional incidents of the resident exiting the building, unsupervised. The facility provided documents titled Resident Location starting with 4/21/12. The facility was not able to locate the Resident Location documents for 3/25/12 to 4/20/12. The documentation for the continuous 15-minute location check contained blank spaces during the time the resident was able to exit the building unsupervised on 4/28/12, 5/2/12 and 5/4/12. Record review revealed after the resident eloped a total of 7 times, on 5/17/12, the SSD documented for the first time a discussion with the family regarding the best setting for the resident including placement in another facility. Twenty-eight days after the SSD's documentation of potentially placing the resident at another facility, the facility's investigative report dated 6/14/12 documented the resident climbed out of the window and went uptown. The documentation for the 15-minute location check contained blank spaces during the time the resident exited the facility from her room window, unsupervised. There were no new interventions documented in the resident's record to prevent the resident from climbing out of her room window or addressing her ability to enter the correct egress codes on the keypad for all doors and exit the facility, unsupervised. Physician notes dated 5/16/12 and 6/20/12 documented review for safety/elopement and behavior with interventions in place. The physician did not document new orders or recommendations to alleviate additional incidents of the resident exiting the facility, unsupervised. Between 6/17/12 and 7/8/12, record review revealed the resident continued to enter the correct egress codes on the keypad for all doors and exit the facility, unsupervised 7 more times. A progress note dated, 6/17/12 at 2:30 p.m., documented Resident #71 was found in the front parking lot at the beginning of the next block away from the facility. The documentation for the continuous 15-minute location check contained blank spaces during the time the resident was able to exit the building unsupervised. The resident was found in the front parking lot on 6/27, 6/28, on the patio on 6/30. The Resident Location document for 7/8/12 indicated the resident "made it all the way to the stop sign at the end of the road." The resident walked off of the facility's property reaching the main business road. The resident's record did not reflect prevention interventions to mitigate 15 documented incidences between 3/25/12 to 7/27/12 of the resident exiting the facility to the outside through a window or her ability to enter the correct egress codes on the keypad for all doors and exit the facility, unsupervised The physician's note dated 7/18/12 reviewed the resident's blood pressure, weight, and pain control. There was no documentation addressing the resident's additional 7 incidents of exiting the facility totaling 15 within 4 months. On 8/02/12 at 10:05 p.m., the DNS said the facility did not have a specific elopement care plan for former Resident #71. The DNS said the ongoing elopement issue was only addressed under the "Alteration in Cognition" care plan problem section. There was no other care plan section with specific guidance to staff to address multiple elopements over a 4 month period. Regarding supervision of residents, the Administrator said the facility was not equipped to manage residents who had "elopement behaviors." The Administrator said the facility was unaware of the resident's prior elopement history upon admssion. The Administrator acknowledged the facility retained the resident in the facility for 7 months when the resident had multiple incidents of leaving the facility unattended. The Administrator stated the facility had no clear plan except to discharge the resident as soon as the facility could find placement. <Resident #30> Record review found Resident #30 was admitted to the facility admit 9/23/06 with medically disabling conditions affecting mobility and cognition. Resident #30s Care Area Assessment (CAA) dated 6/4/12 and care plan dated 6/27/12 identified that the resident had limited mobility and uses a tilt wheelchair with footrests for mobility and safety. Observation on 8/1/12 at 10:50 a.m. noted Resident #30 seated in her tilt wheelchair in her room accompanied by a family member. The resident was awake and conversant but confused. Resident #30's family member stated that the tilt wheelchair had many issues, demonstrating these for the surveyor: The left foot rest was difficult to latch and maneuver; both calf rests had gouges in upper outer or inner corners, exposing padding; the left side tire was completely worn down; the right brake did not align with the wheel unless it was manually moved over; the metal plate footrests were worn at the edges. On interview Resident #30 ' s family member stated that the Director of Environmental Services (DES) knew about it and told him "that's a mess" but did nothing. According to the family member, Resident #30 has had the chair for 5 years and the lack of service and repair was a great concern "It is not just matter of comfort issue, it is safety." On interview 8/1/12, the Director of Nursing (DON) and Licensed Nurse (LN) #2 (who is also the rehabilitation coordinator) stated that the chair's condition was not acceptable. The LN stated that she had no idea how it happened that no one noticed that the chair was not in good repair. "No one mentioned it (family, Hospice, nursing assistants, maintenance staff or restorative aides). We replace worn equipment all the time." <Resident #85> Record review found that Resident #85 was admitted to the facility with medically disabling conditions including lung disease requiring continuous Oxygen therapy. Resident #85 ' s care plan dated 7/9/12 stated "resident is on oxygen, report concerns to nurse ie: tubing twisted or removed, oxygen turned off, equipment making noise or not functioning and follow respiratory protocol." Facility policy on Oxygen Therapy states that the nursing department will determine appropriate oxygen equipment to provide the resident with maximum independence and safety. Observation on 7/31/12 at 4:39 p.m. noted Resident #85 seated in his room with Oxygen delivered by a concentrator via nasal prongs. A portable e-cylinder containing Oxygen was observed lying unsecured across the handlebars of the resident's seated walker. On interview, Licensed Nurse (LN) #8 stated that facility staff had tried to talk Resident #85 into other means to carry O2 but the resident was set in his ways. The LN addressed Resident #85 " You are set in your ways aren't you." The resident agreed that he was set in his ways. Resident #85 then rose from his chair, changed his tubing to the e-cylinder, turned on the Oxygen and walked down the hallway with the e-cylinder balanced on the handlebars of his seated walker. Observation on 8/1/12 at 3:50 p.m. noted Resident #85 in his room with the e-cylinder again resting unsecured on the handle bars of seated walker. Nursing Assistant Certified (NAC) #8 stated " That is not safe, it would be better to have this tied down." Resident #85 said "That would be good, then I could sit on my walker, I can't sit there now". Licensed Nurse #2 came to Resident #85's room and identified that it was not safe to keep the unsecured Oxygen tank balanced on the handlebars of the seated walker because the tank could fall and cause injury to residents. <Unlocked Chemicals> Observation noted the following: 7/27/12 10:17 a.m. Horseshoe Hall tub room: One gallon heavy duty carpet prespray cleaning solution (label reads caution causes eye and skin irritation) unsecured on the floor next to tub and a 24 oz container of shampoo on back of tub (2 oz remaining). This was brought to Licensed Nurse #1 ' s attention, who promptly locked the shampoo and carpet cleaning solution. On interview 7/30/12, the ESD stated that the carpet prespray cleaning solution was left there from scrubbing floors 1-2 days before and should have been locked up. According to the ESD the shampoo should also have been locked up. 7/30/12 11:00 a.m. Flagship Hall large shower room: 1 gallon body wash pump was located in the in unlocked common shower room. The label included the warning: "Caution for external use only. "Avoid contact with eyes. In case of eye contact, flush eyes and call physician. There was a locked padlock on a storage cabinet but the padlock was not looped through both doors. The unsecured storage locker contained a full 15 oz Suave shampoo; 14 oz shaving cream, a partially full 23.7 oz dry scalp shampoo; ? full 16 oz hibicleans pump soap, 2 gallons (almost empty) of the body wash. 7/12/12 11:44 a.m. Horseshoe Hall shower room: One gallon body wash open and accessible, multiple containers of shampoo noted in unlocked cupboard. Bath Aide (BA) #1 stated that the shampoo not locked this a.m. when she showered a resident. According to BA #1 the rule is that the cupboard is supposed to be locked" as we have residents who like to wander. It needs to be locked so residents don't harm themselves." Bath Aide #1 then took a padlock key from a cup stored on the linen supply shelf, accessible to all. 7/30/12 12:05 p.m. Mid Flagship Hall shower room: Two unlocked cupboards contained common shampoo, razor and shaving cream. A gallon container of tearless body wash with pump was open and accessible. BA #2 asked, "Should this be locked up?" and then stated that the container would not fit in the storage cupboard (although the body wash was secured in an identical cupboard in the Horseshoe shower room). Bath Aide #2 showed the key to the soap cupboard was kept on a hook on the back of the door. According to BA #2, no one knew about the key for the large Flagship shower room as it was the shower room used by Occupational Therapy. "They tried the keys this morning and none worked." During the 8 days of survey 7/24, 7/25, 7/26, 7/27, 7/30, 7/31, 8/1, 8/2/12 Resident #56 (who had obvious cognitive impairment) was observed actively mobile throughout the facility. Facility staff identified two other mobile residents (Resident #21 and Resident #55) with cognitive impairment. Unsecured chemicals placed those residents at risk for accidental ingestion or burning from toxic substances. In addition to unsecured chemicals and hygiene supplies, topical medications were observed in the Horseshoe Hall Tub room treatment cart on 7/27/12. Refer to F-431 .