Every finding on record at Agility Health and Rehabilitation

Based on observation, interview and record review, the facility failed to timely assess, investigate and implement interventions for significant weight loss for 1 of 3 sampled residents (Resident 112) reviewed for nutrition services. Resident 112, a resident identified as at risk for weight loss, experienced harm when they had a significant weight loss of 20 percent total body weight in a month, mild-moderate wasting as observed in temples and orbitals and appeared thin. This failure placed them at risk for functional decline, impaired wound healing, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 112 admitted to the facility on [DATE] with diagnoses that included diabetes (uncontrolled blood sugar), weakness, and hemiplegia and hemiparesis affecting right side (partial loss of strength and near complete loss of voluntary movement) due to a stroke. Resident 112 was able to make needs known. On 06/04/2026 at 9:32 AM Resident 112 appeared gaunt and thin. Review of the EHR showed Resident 112 weighed 184 pounds on 03/14/2026, 150 pounds on 04/11/2026 and 146 pounds on 04/19/2026, a 20 percent loss in total body weight. Review of Resident 112's 02/10/2026 care plan showed staff were to monitor meal intake and offer meal replacement if Resident 112 ate less than 50 percent. Review of Resident 112's nutritional intake task documentation for March 2026 showed Resident 112 had less than 50 percent intake for one or more meals 26 out of 31 days. Review of Resident 112's nutritional intake task documentation for April 2026 showed Resident 112 had less than 50 percent intake for one or more meals 15 out of 30 days. Review of the nutritional intake task documentation from 05/14/2026 to 06/09/2026 showed Resident 112 had less than 50 percent intake for one or more meals for the 28 days. The EHR showed no documentation that staff offered Resident 112 meal replacement during March, April, May or June 2026. Review of the Kardex (Care Plan directive for staff) showed no intervention to offer Resident 112 a meal replacement. Review of a Dietary/Nutrition progress note dated 04/21/2026 showed, Resident is triggering for significant weight loss, will discuss feeding tube related to poor nutritional intake at 4/29/2026 care conference. Review of the quarterly Interdisciplinary Team care conference document dated 04/29/2026 showed Resident 112's dietary/nutrition status showed the following documentation, IDT reviewed with no concerns, changes, or questions at this time. Reivew did not show a feeding tube or other weigh loss strategies were implemented. Review of a Nutritional Assessment completed 05/07/2026 showed, Accounting for weight loss from 4/11/26 - 4/19/26 (not significant); suspect weight precision masked true weight loss as resident's clothes appeared to fit more loosely than on admit and mild-moderate wasting observed in temples and orbitals. Diagnosis- unintentional weight loss, swallowing difficulty and self-feeding difficulty. Continue regular diet; add fortified foods, large protein, evening snack and assistance with meals. During an interview on 06/05/2026 at 3:04 PM, Staff X, Regional Dietician, stated weight reports were pulled weekly and addressed by nursing staff and the Dietician on Tuesdays. Staff X stated based on Resident 112's documented weights in the EHR, the weight loss should have been addressed sooner than the 05/07/2026 progress note. Staff X stated the Certified Nursing Assistants (CNA) should have offered meal replacement and maybe they did but the facility did not have a place for the CNA to document if meal replacement was offered and accepted. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to ensure care plans were accurate to include all needed care and/or remove discontinued/resolved health issues for 5 of 22 sampled residents (Residents 7, 5, 27, 4, and 98) reviewed for accuracy of care plans. This failure placed residents at risk of lack of care, unmet needs, inaccurate medical records, and a diminished quality of life. Findings included.Resident 7 Review of the electronic health record (EHR) showed Resident 7 admitted to the facility on [DATE] with diagnosis of stroke with right side weakness and had a pressure injury to the bottom. The resident was able to make needs known. During an interview on 06/03/2026 at 10:05 AM, Resident 7 stated their bottom was real sore. The resident was lying flat on their back with their feet/heels on the mattress. Review of the EHR on 05/03/2026 showed no actual pressure injury care plan. Review of the weekly skin assessment dated [DATE] showed Resident 7 had a stage two (through the top layers of skin) pressure ulcer to their bottom. During an interview on 06/08/2026 at 10:20 AM, Staff N, Licensed Practical Nurse (LPN), stated Resident 7 should have had a care plan for pressure injury but did not. During an interview on 06/08/2026 at 10:24 AM, Staff B, Director of Nursing Services (DNS), stated Resident 7 should have had a care plan in place for pressure injury but did not. Resident 5 Review of the EHR showed Resident 5 re-admitted to the facility on [DATE] with diagnoses to include heart failure and diabetes (high blood sugar). Resident 5 was able to make needs known. Review of the focused care plan for skin integrity initiated on 03/04/2026 showed Resident 5 had a right lower leg chronic venous leg ulcer/wound upon admission and was ongoing. Review of Resident 5's EHR on 06/05/2026 showed no documentation of a current venous wound on the right lower leg. Review of Resident 5's annual minimum data set assessment (MDS) dated [DATE] showed Resident 5 had 0 (zero) venous ulcers/wounds. During an interview on 06/08/2026 at 1:36 PM, Staff C, LPN, stated Resident 27 used to have a venous ulcer; however, it had resolved and the care plan should have been updated. Resident 27 Review of the EHR showed Resident 27 re-admitted to the facility on [DATE] with diagnoses to include cancer, peripheral vascular disease (slow circulation problem where blood vessels restrict blood flow to parts of the body), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Resident 27 was sometimes able to make needs known. Review of the care plan initiated on 12/18/2025 showed Resident 27 was on anticoagulant therapy (AC, medication used to prevent blood clots from forming or getting larger). It further showed Resident 27 had a focused care plan for thrush (a fungal/yeast infection) initiated on 04/14/2026. Review of Resident 27's EHR on 06/04/2026 showed no documentation of current AC therapy or a thrush infection. During an interview on 06/08/2026 at 1:45 PM, Staff C, LPN, stated Resident 27 was not currently taking an AC medication, and the care plan should have been updated at the time the AC was discontinued in January 2026. Staff C stated Resident 27 no longer had thrush and the focused care plan for thrush should have been resolved and that did not happen. During an interview on 06/08/2026 at 2:01 PM, Staff B, DNS, stated residents' care plans should be updated with resolution of conditions and/or completion of treatments. Staff B stated the expectation was that care plans reflected a resident's current status. Resident 4 Review of the EHR showed Resident 4 admitted to the facility on [DATE] with diagnoses to include surgical amputation, osteomyelitis (a swelling of bone tissue caused by infection), and diabetes. Resident 4 was able to make needs known. Review of Resident 4's provider's orders showed Resident 4 received an AC medication. Review of the plan of care, initiated 06/01/2026, showed no focus area related to Resident 4's use of an AC. During an interview on 06/09/2026 at 10:36 AM, Staff N, LPN, stated staff were aware of a resident's use of an AC medication by placing it into the plan of care. Staff N stated Resident 4's AC use was not included in their plan of care, and it should have been. During an interview on 06/09/2026 at 10:39 AM, Staff B, DNS, stated a resident's use of AC medication use should be included in their plan of care so staff were aware of what side effects to monitor. Staff B stated Resident 4's plan of care not including their AC use did not meet expectations. Resident 98 Review of the EHR showed Resident 98 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (when blood flow to an area of the brain is blocked or significantly reduced), diabetes, and end stage renal disease (when kidneys function can no longer filter waste and excess fluid from body). Resident 98 was able to communicate needs. During interview on 06/04/2026 at 9:10 AM and 06/08/2026 at 1:32 PM, Resident 98 stated they were unable to see and use their glasses and needed to see the eye doctor. Resident 98 had glasses nearby on the table and was not using them. Review of the significant change minimum data set (MDS, a required assessment) dated 03/31/2026 showed Resident 98 had alteration in visual function related to impaired vision and visual function would be addressed in the care plan. Review of the care plan created on 03/01/2026 showed Resident 98 had no problem, goal or intervention about their visual deficit and use of glasses. During an interview on 06/08/2026 at 1:32 PM, Staff H, Registered Nurse, stated visual deficits should be addressed in the care plan. During an interview on 06/09/2026 at 9:43 AM, Staff B, DNS, stated the lack of visual deficit on the care plan for Resident 98 did not meet expectations. Reference WAC 388-97-1020(1)(2)(a)(b)

Based on observation and interview, the facility failed to ensure bathroom call light pull cords were accessible to residents from the floor on 2 of 4 sampled halls (100 and 300) reviewed for call light systems. This failure placed residents at risk for inability to summon help in the event of an emergency, increased risk of injury and unmet or delayed care needs. Findings included. Observations on 06/03/2026 at 2:27 PM and 06/09/2026 at 9:30 AM showed the bathroom emergency call light pull cords in resident rooms 106, 107, 121 and 311 hung above the handrail on the wall and were not readily accessible to a resident if they were on the floor after a medical emergency or fall. During an interview on 06/09/2026 at 10:39 AM, when asked to look at the emergency call light pull cords in rooms 106, 107, 121, and 311, Staff Q, Maintenance Director, asked how long the pull cord had to be and stated they were unaware of any regulation related to bathroom call light pull cords. During an interview on 06/09/2026 at 11:09 AM, Staff A, Administrator, stated the expectation was that resident bathroom pull cords should be accessible to call for help if the resident was on the floor. Reference WAC 388-97-2280 (1)(a)

Based on interview and record review, the facility failed to ensure the minimum data set (MDS, a required assessment tool) accurately reflected the status of 2 of 22 sampled residents (Residents 112 and 21) reviewed for accuracy of assessments. This failure placed the residents at risk for inappropriate care planning, unmet care needs, and a diminished quality of life. Findings included . Resident 112 Review of the electronic health record (EHR) showed Resident 112 admitted to the facility on [DATE] with diagnoses that included diabetes (uncontrolled blood sugar), weakness, and hemiplegia and hemiparesis affecting right side (partial loss of strength and near complete loss of voluntary movement). Resident 112 was able to make needs known. Review of the EHR showed Resident 112 weighed184 pounds on 03/14/2026, 150 pounds on 04/11/2026 and 146 pounds on 04/19/2026. Review of Section K (Swallowing/Nutritional status) on the 05/06/2026 quarterly MDS showed Loss of 5 percent or more in the last month or loss of 10 percent or more in last 6 months marked NO or UNKOWN. During an interview on 06/08/2026 at 9:41 AM, Staff G, MDS/Licensed Practical Nurse (MDS/LPN), stated the dietician completed that part of the MDS; however, it should have reflected significant weight loss and been marked YES During an interview on 06/06/2026 at 2:56 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that MDS assessments were coded accurately. Resident 21 Review of the EHR showed Resident 21 was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm (cancer) of lung, secondary malignant neoplasm of brain and adrenal gland (small gland that produces hormones). Review of admission MDS dated [DATE] showed Resident 21 was able to communicate needs and did not have cancer diagnoses in section I for active diagnoses. During an interview on 06/05/2026 at 12:01 PM, Staff G, MDS/LPN, stated the cancer diagnosis was missing from the MDS and it should have been coded. During an interview on 06/09/2026 at 9:41 AM, Staff B, DNS, stated the expectation was for active diagnoses to be on the MDS. Reference WAC 388-97-1000(1)(a)(b)(4)(a)

Based on observation, interview and record review, the facility failed to ensure the use of antipsychotic medications (medications affecting the mind) was appropriate by providing adequate monitoring or appropriate indications for its use for 1 of 5 sampled residents (Resident 50) reviewed for unnecessary medications. This failure placed the resident at risk for adverse side effects and a decreased quality of life. Findings included. Review of the facility policy titled Use of Psychotropic Medication, revised 04/23/2025, showed Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication and Pre-admission screening [PASRR, a mental health screening tool] and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility. Review of the electronic health record (EHR) showed Resident 50 admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that effects memory) with behaviors, and depression. The resident was sometimes able to make needs known. Review of the facility initiated PASRR form dated 03/27/2026 showed Resident 50 had a diagnosis of depression and anxiety. Review of an updated PASRR form dated 04/06/2026 showed Resident 50 had a diagnosis of severe depression. Review of the provider orders showed Resident 50 was prescribed Risperidone (an antipsychotic medication) daily at bedtime for dementia with behaviors with a start date of 03/31/2026. Review of the EHR showed no order to monitor target behaviors related to the antipsychotic medication. Review of the EHR on 06/05/2026 showed no documentation that Resident 50 was reviewed on admission for the use of an antipsychotic medication. During an interview on 06/05/2026 at 10:56 AM, Staff N, Licensed Practical Nurse, stated Resident 50's diagnosis of dementia with behaviors was not an appropriate diagnosis for an antipsychotic medication and the resident should have a monitor for target behaviors for the antipsychotic in place but did not. During an interview on 06/05/2026 at 11:01 AM, Staff P, Social Services Director, stated Resident 50 should have been reviewed in the monthly psychotropic meeting on admission. Staff P stated dementia with behaviors was not an appropriate diagnosis for the use or Risperidone and related behaviors should have been monitored. Staff P stated Resident 50 did not display aggressive or violent behaviors; they just wandered frequently. During an interview on 06/05/2026 at 11:56 AM, Staff B, Director of Nursing Services, stated it was their expectation that Resident 50 should have been reviewed in the monthly psychotropic meeting, had target behaviors monitored and an appropriate diagnosis for the use of an antipsychotic. Reference WAC 388-97-1060(3)(k)(i), -0620(1)(a)

Based on interview and record review, the facility failed to ensure incidents of potential abuse and/or neglect were identified and reported to the Administrator and/or the State Survey Agency for 2 of 7 sampled residents (Residents 27 and 7) reviewed for abuse and/or dignity. Failure to report allegations of abuse/neglect or verbal abuse placed residents at risk for additional abuse and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines titled, The Purple Book, dated October 2015, showed The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator of the facility and to other officials in accordance with State law .including to the State survey and certification agency.Resident 27 Review of the electronic health record (EHR) showed Resident 27 re-admitted to the facility on [DATE] with diagnoses to include cancer, peripheral vascular disease (slow circulation problem where blood vessels restrict blood flow to parts of the body), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Resident 27 was sometimes able to make needs known. During an interview on 06/03/2026 at 11:22 AM, Collateral Contact F, Family Member, stated a couple of days ago Resident 27 told them two nursing aids, one large and one smaller male nursing aids, had awaken them (Resident 27) in the middle of the night or early in the morning and started to rough handle them when trying to change them. Collateral Contact F stated they reported it to two nursing staff on Sunday (05/31/2026). Review of Resident 27's EHR on 06/04/2026 showed no documentation of an allegation of abuse. Review of the facility's June 2026 incident log from 06/01/2026 – 06/04/2026 showed no incident logged for Resident 27. During an interview on 06/05/2026 at 12:32 PM, Staff E, Certified Nursing Assistant, stated a few days ago Resident 27's family member had told them and a nurse that Resident 27 reported two nursing aids had been rough with them during care. Staff E stated the family member told them that Resident 27 stated that they had been left up all night in their wheelchair and had not eaten breakfast. Staff E stated they did not report the incident because they thought the nurse in the room would follow up. During an interview on 06/05/2026 at 12:54 PM, Staff A, Administrator, stated the nurse and/or Staff E should have reported Resident 27's allegation of abuse to the State, followed the facility's policy for abuse, and initiated an investigation. Staff A stated the way Resident 27's allegation was handled did not meet their expectations. Resident 7 Review of the EHR showed Resident 7 admitted to the facility on [DATE] with diagnoses of stroke with right side weakness and recent abdominal surgery. The resident was able to make needs known. During an interview on 06/03/2026 at 10:00 AM, Resident 7 was tearful and stated staff talk about them like they were not there and said they were fat. Resident 7 stated they had told the speech therapist about the concern about a week ago. During an interview on 06/04/2026 at 1:44 PM, Staff L, Speech Therapist, stated Resident 7 did mention the concern but Resident 7's husband was in the room and stated this happened at the last facility. Staff L stated they would report it if the resident said this happened here but that was not what they understood. During a joint interview on 06/04/2026 at 3:05 PM, Resident 7 stated the incident happened here at the facility. Collateral Contact AA stated Resident 7 had told them about the incident just prior to reporting it to the speech therapist. During a joint interview on 06/04/2026 at 3:15 PM, Staff A, Administrator (ADM), and Staff B, Director of Nursing Services (DNS), stated it was their expectation that this be reported and investigated and this did not meet their expectations. Reference WAC 388-97-0640(5)(a)

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 8 sampled residents (Resident 81) reviewed for bowel management and anticoagulant therapy. These failures placed the residents at risk for poor clinical outcomes, decreased comfort, and poor quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 81 admitted to the facility on [DATE] with diagnoses of a stage 4 (including bone and muscle) pressure injury to their bottom and sepsis (the body's response to severe infection). The resident was able to make needs known. <Bowel anagement> During an interview on 06/03/2026 at 10:35 AM, Resident 81 stated they had been having loose stools (bowel movement) for a couple weeks. Review of a provider note dated 06/02/2026 showed [Resident 81] stated has had 3 days of diarrhea with abdominal discomfort, Loperamide [medication to treat loose stools] was started as needed [PRN] for diarrhea management. If Loperamide did not aid in symptom relief, symptoms persist for more than 3 days to notify the provider. Review of the bowel monitor showed Resident 81 had two loose stools on 06/04/2026, three large loose stools on 06/05/2026 and two large loose stools on 06/06/2026, 06/07/2026 and 06/08/2026. During an interview on 06/05/2026 at 8:55 AM, Resident 81 stated it happens all the time. If they moved, they had wet stool. Resident 81 stated staff had not given them any medication for it. Review of the June 2026 medication administration record (MAR) showed no doses of Loperamide were documented as administered. Review of the EHR showed no documentation that the provider was notified of the three large loose stools on 06/05/2025. During an interview on 06/05/2026 at 8:54 AM, Staff M, Registered Nurse (RN), stated if a resident was having frequent loose stools they should report to the provider and give any PRN medications. During an interview on 06/05/2026 at 10:51 AM, Staff N, Licensed Practical Nurse (LPN), stated if a resident was having more than three loose stools in 24 hours the staff should have notified the provider and given any PRN medications and placed them on alert charting. During an interview on 06/05/2026 at 12:08 PM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that staff notify the provider, place the resident on alert, test for infection if indicated and give any PRN medications. This did not happen for Resident 81 and should have. <Anticoagulant> Review of the EHR showed Resident 81 was receiving anticoagulant (blood thinning) injections daily with a start date of 05/21/2026. During an interview and observation on 06/03/2026, Resident 81 laid in bed with an indwelling urinary catheter (a tube used to drain urine from the bladder). There was dark red urine noted in the tube/bag. Resident 81stated It's never been like that. It's scary. Review of the EHR on 06/05/2026 showed no monitoring for bleeding and bruising related to being on anticoagulant therapy. Review of the progress notes on 06/05/2026 showed no documentation related to the blood in the urine and no alert charting. During an interview on 06/05/2026 at 10:39 AM, Staff O, Certified Nursing Assistant (CNA), stated Resident 81 had the blood in their catheter for a couple days. During an interview on 06/05/2026 at 10:42 AM, Staff M, RN, stated if Resident 81 was on an anticoagulant they should be monitored for bleeding and bruising. During an interview on 06/05/2026 at 10:44 AM, Staff N, LPN, stated Resident 81 should have had a monitor for bleeding order but did not and should have been placed on alert for bleeding but was not. During an interview on 06/05/2026 at 11:58 AM, Staff B, DNS, stated Resident 81 should have had an anticoagulant side effect monitor in place and should have been placed on alert for bleeding and this did not happen. Reference WAC 388-97-1060(1)-(3)

Based on interview and record review, the facility failed to ensure residents with limited range of motion received the necessary services to maintain their level of functioning for 2 of 4 sampled residents (Residents 24 and 112) reviewed for limited range of motion (ROM). This failure placed residents at risk for further decline in range of motion, increased dependence, pain and a diminished quality of life. Findings included .Resident 24Review of the electronic health record (EHR) showed Resident 24 admitted to the facility on [DATE] with diagnoses that included ankylosis of left knee (stiffness and immobility of a joint), diabetes (uncontrolled blood sugar), and generalized muscle weakness. Resident 24 was able to make needs known. During an interview on 06/04/2026 at 9:20 AM, Resident 24 stated they were told they would be starting an exercise program after discharge from physical therapy. Resident 24 stated they had not been offered participation in a restorative program. Review of Resident 24's Physical Therapy Discharge summary dated [DATE] showed Discharge Recommendations: Restorative Range of Motion Program (bilateral lower extremity). Review of Resident 24's care plan initiated 12/25/2025 showed no Restorative program intervention. During an interview on 06/05/2026 at 12:48 PM, Staff D, Director of Rehabilitation (DOR), stated the facility failed to initiate and implement a restorative program for Resident 24 after discharge from physical therapy. Resident 112Review of EHR showed Resident 112 admitted to the facility on [DATE] with diagnoses that included diabetes, weakness, and hemiplegia and hemiparesis affecting right side (partial loss of strength and near complete loss of voluntary movement). Resident 112 was able to make needs known. Observations on 06/03/2026 at 1:25 PM and 06/04/2026 at 9:33 AM showed an elbow splint on a corner table in Resident 112's room. Review of the EHR showed an order to Apply right elbow extension splint on in AM for up to six hours per day, as tolerated three to six times per week. Review of a 06/04/2026 progress note showed, Discontinued restorative program and splinting per recommendations related to resident refusing. Updated care plan, tasks and restorative aid. Review of the restorative flow sheet from 05/14/2026 to 06/04/2026 showed Resident 112 refused splint assistance on three occasions. Documentation showed Resident 112 was re-approached by alternate staff and was agreeable to wear the splint. During an interview on 06/05/2026 at 11:16 AM, Staff Y, Restorative Aide, stated they did not have any experience with Resident 112 refusing splint assistance. Staff Y stated the best approach with Resident 112 was to explain that the splint would not be painful. During an interview on 06/05/2026 at 12:27 PM, Staff D, DOR, stated it was uncommon for three refusals in 30 days to warrant discontinuation of a restorative program. Staff D stated it did not meet expectations that the program was discontinued for three refusals. Reference WAC 388-97-1060(3)(d)

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for 2 of 5 sampled residents (Residents 27 and 50) reviewed for accidents. Failure to provide a properly fitting wheelchair for Resident 27 and failure to implement interventions after a fall for Resident 50 placed the residents at risk for accidents or injuries and a decreased quality of life. Findings included .Resident 27 Review of the electronic health record (EHR) showed Resident 27 re-admitted to the facility on [DATE] with diagnoses to include cancer, peripheral vascular disease (slow circulation problem where blood vessels restrict blood flow to parts of the body), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Resident 27 was sometimes able to make needs known. Observations on 06/03/2026 at 11:06 AM, 06/04/2026 at 2:11 PM, and 06/08/2026 at 9:17 AM showed Resident 27 in a slightly tilted back wheelchair with feet extended beyond the footrests and the back of Resident 27's lower legs above the ankle/heel area rested against the hard footrests. It showed a pillow either on the floor or behind the legs and not padding the actual footrests. Review of the focused care plan for skin integrity initiated on 04/27/2026 showed, padding to wheelchair footrests. During an interview on 06/08/2026 at 9:22 AM, Staff D, Director of Rehabilitation, stated Resident 27's feet extended past the wheelchair footrests. Staff D stated the footrests were too short and needed to be adjusted or replaced. Staff D stated staff should have notified therapy and that did not happen. Staff D stated Resident 27 needed to be assessed and wheelchair adjusted and/or modifications made to ensure a proper fit. During an interview on 06/08/2026 at 2:29 PM, Staff B, Director of Nursing Services (DNS), stated staff should have documented or put on the communication board for therapy to look at Resident 27's wheelchair for proper positioning, and looked at the care plan for better interventions related to the footrests. Staff B stated this did not meet their expectations. Resident 50 Review of the EHR showed Resident 50 admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that effects memory), history of falls, and urinary tract infection (UTI). The resident was sometimes able to make needs known. Review of the plan of care for Resident 50 showed an entry dated 03/30/2026 for at risk for falls. Review of the EHR showed a progress note dated 05/17/2026 which stated Resident 50 had an unwitnessed fall in the 300 hallway. Review of the incident investigation showed interventions were added to monitor orthostatic blood pressures (a drop in blood pressure when moving from sitting to standing) and to refer to physical therapy. Review of the medication administration record for the month of May showed an order for orthostatic blood pressure on 05/20/2026 that was not completed, and an order for orthostatic blood pressures for three days which showed the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026 and 05/24/2026. During an interview on 06/04/2026 at 2:59 PM, Staff D, Director of Rehabilitation, stated they had not received a post fall referral for Resident 50. During an interview on 06/05/2026 at 12:07 PM, Staff B, DNS, Stated Resident 50 was not referred to therapy but it was discussed in clinical meeting. Staff B stated Resident 50 should have had their orthostatic blood pressures taken accurately to rule out orthostatic hypotension. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of nine errors were made in thirty-one opportunities during a medication administration for 1 of 6 sampled residents (Resident 96) reviewed for medication administration. This placed the residents at risk for receiving medications that were not effective or less effective and a diminished quality of life. Findings included .Review of the provider's orders for June 2026 showed Resident 96 was prescribed nine oral medications with a specific time of administration to be given at 8:00 AM. Observation of medication administration on 06/08/2026 at 9:36 AM showed Staff J, Licensed Practical Nurse (LPN), prepared and administered these nine oral medications to Resident 96 (one hour and 36 minutes late). During an interview on 06/08/2026 at 10:13 AM, Staff J, LPN, stated the nurses had up to two hours to administer medications after the ordered time. During an interview on 06/08/2026 at 10:17 AM, Staff B, Director of Nursing Services, stated the medication administration time was one hour before and one hour after the specific time of the order, and the expectation was for nurses to follow orders including the correct time of administration and this did not meet expectations. Reference WAC 388-97-1060(3)(k)(ii)

Based on observation, interview and record review, the facility failed to initiate a grievance after a resident concern regarding staff customer service for 1 of 3 sampled residents (Resident 138) reviewed for abuse/grievances. This failure placed residents at risk of unmet needs, higher likelihood of neglect, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 138 admitted to the facility on [DATE] with diagnoses to include pneumonia (a lung infection causing inflammation), chronic kidney disease, and diabetes (too much sugar in the blood). Resident 138 was able to make needs known. Observation and interview on 06/05/2026 at 12:02 AM showed Resident 138 sat in their wheelchair just inside their room door with an upset expression. Resident 138 stated they had turned on their call light because they needed assistance to use the restroom. Resident 138 stated a staff had entered their room, turned off their call light, and stated they would return to assist Resident 138. Resident 138 stated they had been waiting for fifteen to twenty minutes for the staff to return, and they were pissed they had to wait to use the restroom. Observation on 06/05/2026 at 12:28 PM showed Resident 138's concern regarding staff turning off their call light without assisting them was reported to Staff S, Licensed Practical Nurse. During an interview on 06/09/2026 at 10:03 AM, Staff A, Administrator, stated if a resident made a report that staff had turned off their call light without providing care, a grievance should be completed for the concern. Staff A stated turning off the call light without providing care increased the likelihood of neglect occurring if the staff member forgot to return. Staff A stated no grievance or investigation was initiated in response to Resident 138's concern, and this did not meet expectations. Reference WAC 388-97-0460

Based on observation and interview, the facility failed to maintain a clean, sanitary and well-maintained resident environment for 2 of 22 sampled residents (Residents 112 and 67) reviewed for homelike environment. These failures placed residents at risk for reduced comfort, unsanitary conditions and a diminished quality of life. Findings included . Resident 112 Observation on 06/03/2026 at 10:16 AM and 06/06/2026 at 9:20 AM showed Resident 112's room had a single crack in the right windowpane extending the length of the window. During an interview on 06/09/2026 at 10:55 AM, Staff Q, Maintenance Director, stated the window had been broken for six months, they did not have the authority to purchase a replacement window, and facility administration was aware of the crack. During an interview on 06/09/2026 at 10:16 AM, Staff A, Administrator, stated they were unaware the window was cracked. Staff A stated the maintenance department conducted several monthly resident room audits and the window should have been noted and repaired. Staff A stated the cracked resident window did not reflect a homelike environment. Resident 67 Review of the electronic health record (EHR) showed Resident 67 admitted to the facility on [DATE] with a diagnosis of diabetes (when the body cannot process sugars) and the resident was able to make needs known. During an interview and observation on 06/03/2026 at 9:25 AM, Resident 67 stated Housekeeping does not sweep and mop, and they just finished cleaning their room but left the floors dirty. There was trash and a liquid spilled on the floor between the beds. During an interview and observation on 06/04/2026 at 11:31 AM, Resident 67 stated staff had still not swept or mopped, and the trash and spill was still observed on the floor between the beds. Review of the resident council notes for the month of March 2026 showed a resident request for housekeeping to ensure beds, nightstands and surrounding areas were cleaned thoroughly. Review of resident council notes for the month of April 2026 showed reported concerns for housekeeping not removing trash from under the bed for three days. During an interview on 06/09/2026 at 9:40 AM, Staff K, Housekeeping, stated the rooms should be swept and mopped every day. During an interview on 06/09/2026 at 9:59 AM, Staff A, Administrator, stated it was their expectation that the resident rooms be swept and mopped daily and as needed. Reference WAC 388-97-0880, -2040 .

Based on interview and record review, the facility failed to initiate a grievance for resident care concerns voiced at the resident council meeting for 1 of 4 resident council meetings minutes (May 2026) when reviewed. This failure placed residents at risk for unmet care needs, poor hygiene and a diminished quality of life. Findings included .During an interview on 06/08/2026 at 2:21 PM, Resident Council members stated the facility did not consistently provide resolutions to concerns discussed during resident council meetings. Review of the resident council minutes for May 2026 showed concerns voiced by members related to getting out of bed for meals and activities and a shortage on washcloths and towels. Review of the grievance logs for 02/2026 through 06/2026 showed no grievances that corresponded with concerns verbalized at the resident council meeting. During an interview on 06/08/2026 at 2:33 PM, Staff R, Activities Director, stated they did not initiate a grievance related to the residents' concerns but should have. During an interview on 06/09/2026 at 10:15 AM, Staff A, Administrator, stated it did not meet their expectations that specific concerns brought up in resident council had not been addressed and followed up on. Reference WAC 388-97-0920

Based on interview and record review, the facility failed to implement their abuse prohibition policy for 2 of 2 residents (Residents 2 & 3) reviewed for abuse and/or neglect. The facility failed to completely and thoroughly investigate Resident 2's unexpected death and failed to conduct through investigations to identify the root cause(s) and contributing factors related to Resident 2 & 3's falls. Failure to conduct a thorough investigation placed residents at risk for further injuries, potential abuse/neglect, and other negative health outcomes.Findings included .Review of the facility Abuse, Neglect and Exploitation Policy revised 05/01/2025, showed Neglect means the failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. According to the policy the facility would investigate suspicion and/or reports of abuse, neglect, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. In addition, all alleged violation would be reported as required.RESIDENT 2FALL INVESTIGATIONDuring an interview on 09/18/2025 at 3:20 PM a collateral contact stated Resident 2 fell on [DATE], hit their head, broke their arm and hip and had to have surgery the following day.According to 07/31/2025 5-day scheduled Minimum Data Set (MDS - an assessment tool) Resident 2 had a fall in the facility which resulted in a major injury.Review of the 07/31/2025 1:30 PM incident report and investigation showed that a student told Staff D, Resident Care Manager (RCM), that Resident 2 had fallen. Upon entering the room, the resident was found in a prone position (flat on their stomach) on the floor with their right arm extended to their side. Visible blood was observed on the floor and an open area to the resident's right wrist. Resident 2 complained of severe discomfort to their right shoulder and wrist. Right wrist observed with swelling and suspected hematoma (localized collection of blood in tissue), possible deviation or dislocation. The investigative root cause analysis was that Resident 2 stated they were attempting to self-transfer to the wheelchair to use the restroom. Call light was not on at the time of the fall. Resident was impulsive and non-compliant with asking for assistance. Resident recommended to not self-transfer. Abuse and Neglect was unsubstantiated as Resident stated they attempted to transfer to the bathroom without assistance, forgetting to lock their wheelchair and fell.Further review of the investigative documents showed Resident 2 was found on the floor at 1:00 PM with 02 running at 2 Liters per Minute (lpm). The resident was last attended at 11:45 AM, when their briefs were wet and they voided urine, they were last seen at 12:04 PM when a nurse administered as needed pain medication.The investigation did not address what may have occurred between 12:04 PM and 1:00 PM. For example, did the resident eat lunch, and did the nurse follow up to determine if the pain medication was effective.On 09/19/2025 at 1:48 PM the posted lunch meal time for Resident 2's hallway was 12:15 PM, with a note that times may vary up to 15 minutes before or after.In an interview on 09/19/2025 at 2:31 PM Staff C, Assistant Director of Nursing, stated they would expect the nurse to follow up regarding the pain medications in 30 minutes to one hour after administered. Staff C stated Resident 2 was toileted at 11:45 AM, came back from the bathroom, asked for pain medication, which was administered at 12:04 PM. Staff C stated Resident 2 was impulsive and would get up, but could not go to the bathroom by themselves.The investigation did not include statements from the staff who delivered the resident's lunch, picked up the resident's lunch tray, or the nursing assistant assigned to Resident 2's care or from the student who found the resident on the floor.In an interview on 09/19/2025 at 2:31 PM Staff C confirmed as part of the investigation they would expect to find out from staff what they were doing at that time.Review of the July Medication Administration Record (MAR) showed 07/28/2025 orders for Oxygen at 6 lpm per Nasal Cannula (NC) continuously, to maintain the SpO2 (blood oxygen saturation level) at 90% or greater. Therefore, the resident was not receiving oxygen at the physician ordered rate when they fell.The resident was sent to the emergency room and diagnosed with a right distal radius (wrist) and a right intertrochaneteric femur (hip) fracture.Review of July 2025 and August 2025 Abuse Reporting Logs showed the fall with significant injury was not reported. In an interview on 09/19/2025 at 2:44 PM, Staff B, Director of Nursing, confirmed the incident was not, but should have been reported on the log as a substantial injury reasonably related to the fall.DEATH INVESTIGATIONDuring an interview on 09/08/2025 at 12:04 PM Resident 4 stated the night before a resident next door to them had choked and died at the facility.During an interview on 09/08/2025 at 12:44 PM when asked, Staff C stated Resident 2 passed unexpectedly, after having been provided a lunch meal. When asked if the resident choked, Staff C stated, no.During an interview on 09/10/2025 at 12:22 PM Staff C stated they were waiting for the results of the Medical Examiner. Staff C stated again they were unaware of any choking. The facility was within the five-day investigation period, so Staff C was encouraged to investigate the possibility of the resident choking as there was food involved.Review of the 09/07/2025 1:00 PM facility incident investigation showed that at approximately 12:45 PM, a CNA delivered a lunch tray to Resident 2 in their room. Resident was responsive and answered appropriately. At 12:55 PM, the CNA returned to the room noted the resident was unresponsive and they called out for help. Staff J Licensed Practical Nurse (LPN), checked on the resident and Code Blue was announced. CPR was initiated, 911 was called and EMTs (Emergency Medical Technicians), pronounced the resident dead at 2:00 PM.Review of the investigation on 09/16/2025 showed staff did not consider the possibility of Resident 2 choking as a cause of death.Review of the 09/07/2025 police incident report showed the officer was dispatched to the facility around 1:56 PM. Upon arrival the officer spoke to the fire department and was told Resident 2 possibly choked on their food and was pronounced deceased at 1:50 PM. According to the report, the officer interviewed Staff M, Nursing Assistant, who stated they delivered Resident 2's tray, cut up the food when the resident requested and left to deliver more trays. Staff M said when they returned around 12:50 PM, Resident 2 was unresponsive, and the food tray was on Resident 2's stomach.During an interview on 09/24/2025 at 12:06 PM Staff J, stated when the nursing assistant called out, they went into the room. Resident 2 was on the bed, supine (laying on their back), with the head of bed elevated, leaning forward. When asked where the lunch tray was, Staff J stated it was on the bedside table, then recalled no, the aid said it was falling on the ground. Unsure, Staff J stated they did not pay much attention to the room as they were assessing the resident, noted no pulse, pale, chest not rising, so they proceeded with the calling the code. During an interview on 10/02/2025 at 2:46 PM, Resident 2's representative stated when they entered the room on 09/07/2025 there were items from the food tray all over the room, so clearly, the resident made a commotion. There was food, napkins, cups by the door, a meal tray on the opposite side of the room, with nothing on the tray. The medics tried to trach them, but something was blocking their airway, which they had since found out was food stuck in the trach.During an interview on 10/03/2025 at 10:56 AM Staff K, Housekeeping, stated they cleaned Resident 2's room later that day. Staff K stated they noted it had been hectic earlier, but they did not really understand what had happened. Staff K stated earlier the staff had to move the roommate and took the bed out of the room too. Staff K stated by the time they went to clean the room the meal tray, cups, dishes had already been picked up but there was blood, peas and carrots all over the floor. There was food on the ground.During an interview on 09/19/2025 at 11:07 AM Resident 4 stated (on 09/07/2025) they had gone outside on and found two people who were upset that their dad had just passed away, saying that he choked on lunch. Resident 4 stated the people asked them what was served for lunch, but Resident 4 did not know as they had not eaten it. Resident 4 stated they had not heard Resident 2 choke but heard banging around from the room.During an interview on 09/19/2025 at 11:07 AM Resident 5 said lunch had been roast beef, mashed potatoes, green beans or peas. Resident 5 stated the roast beef was tender and easy to chew.Review of the 09/07/2025 police incident report showed Resident 2's representative told the officer that Resident 2 had a choking hazard before they were at the facility.During an interview on 10/02/2025 at 2:46 PM, Resident 2's representative stated Resident 2 had been a choking hazard for years, was a very loud person, choked loudly, and could be heard outside the room. Resident 2's representative stated when they visited, they found Resident 2 laying down multiple times, even eating laying down. I asked them, and they said it was his choice. I asked how it was his choice, as it's a choking hazard.Review of 09/02/2025 11:09 AM Therapy Note showed Resident 2 did not report any dysphagia at that time. They had a raspy voice and was on 6 lpm of oxygen, required cues to sit upright for meals and taking rest breaks to coordinate breathing and swallowing.During an interview on 09/19/2025 Staff I, Director of Rehabilitation, stated Resident 2 was seen by Speech Therapy from 09/01-09/06/2025, but not for swallowing. The resident was readmitted three times and each time received another evaluation, and each time the resident remained on regular texture foods, with thin liquids. During an interview on 09/19/2025 at 1:50 PM, Resident 10 (Resident 2's roommate) recalled the incident. Resident 10 stated that Resident 2 ate meals in bed, usually sat up with the head of bed elevated. Resident 10 denied hearing Resident 2 cough that date but noted that Resident 2 frequently coughed because they had COPD and in the middle of the night the resident had a horrible, weird sounding cough.During an interview on 09/18/2025 at 3:20 PM a collateral contact stated Resident 2 was very loud, not quiet and would throw things around the room. The collateral contact stated Resident 2 choked on lunch since, according to the death certificate, the autopsy found a food bolus.Review of the certificate of death dated 09/12/2025 showed that autopsy findings were available to complete cause of death, which was choked on food bolus (meat).RESIDENT 3According to the 09/12/2025 Quarterly MDS Resident 3 had severely impaired vision, had one non injury fall since the prior MDS.Review of the 06/09/2025 Activities of Daily Living Care Plan (CP) showed Resident 3 required extensive assistance by two staff to turn and reposition in bed. Review of the 06/18/2025 Risk for Falls CP showed an intervention to Follow facility fall protocol.The CP also noted that Resident 3 had an unwitnessed fall on 09/06/2025.Review of the Incident report showed on 09/06/2025 at approximately 7:20 PM, Resident 3 was found on the floor, next to their bed, with their head nearest the foot of the bed. Resident 3 stated they did not know how they slid off the bed. According to the incident investigation the resident was last seen by staff at 5:00 PM. The investigation did not question why the resident was not seen from 5:00 to 7:20 PM.During an interview on 09/19/2025 at 1:38 PM Staff B stated Resident 3 ate between 75-100% of the dinner meal, which was scheduled for delivery on Resident 3's hall at 5:00 PM, and Staff C stated the resident required one on one staff to eat because they were blind. Review of the September 2025 MAR showed a 07/07/2025 order to encourage the resident to be up out of bed and in wheelchair for all meals: document acceptance vs refusal before meals. On 09/06/2025 5:30 PM staff documented refusal.During an interview on 09/19/2025 at 2:59 PM Staff H, LPN, stated Resident 3 was diagnosed with COVID-19, so they were in the room with the door closed, on a bariatric size (for plus sized residents) mattress. Staff H stated they had never seen Resident 3 kick their feet off the bed, or sit up on the edge of the bed, and they had no idea how the resident got out of bed.During an interview on 09/19/2025 at 1:38 PM, Staff B acknowledged the investigation was incomplete.REFER TO: WAC 388-97-640(2)(5)(6)

Based on observation, interview and record review the facility failed to ensure respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 4 of 5 residents (Resident 2, 7, 8 & 9) reviewed for respiratory services. This failure placed the residents at risk for respiratory complications, unmet needs and diminished quality of life.Findings included .Review of the facility Oxygen Administration policy revised 07/03/2024 showed oxygen was administered to residents who needed it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. According to the policy Oxygen would be administered under orders of a physician, staff shall change oxygen tubing and mask/cannula weekly and as needed, change humidifier bottle when empty, weekly or per facility policy, or as recommended by the manufacturer. Oxygen delivery by Nasal Cannula (NC) requires humidification at flow rates greater than 4 Liters per Minute (lpm).RESIDENT 2Review of the 06/15/2025 History and Physical showed Resident 2 had multiple diagnoses including chronic hypoxic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, used a Continuous Positive Airway Pressure (CPAP) at night, but the machine broke two weeks prior and the resident was unable to replace it. The resident was on 6 lpm NC at baseline. Resident arrived at the Emergency Department on 10 lpm delivered through a non-rebreather mask (delivers high concentrations of oxygen, using one-way valves to prevent rebreathing exhaled air).Resident 2 was discharged from the hospital to the facility on [DATE]. Review of the Post Acute & Transition of Care Orders showed Resident 2 needed to be on Bi-level Positive Airway Pressure (BiPAP) while sleeping, at nighttime and as needed for SOB. Review of 06/23/2025 hospital records showed the BiPAP needed to be set up prior to discharge.Review of the June 2025 Treatment Administration Record (TAR) showed 06/23/2025 order for oxygen at 6 lpm per NC continuously, which staff documented as done.A 06/24/2025 7:00 PM Nurses Note showed they titrated the oxygen (O2) down to 4 lpm. An 8:41 PM Nurse's Note showed the resident had shortness of breath (SOB) on exertion and when lies flat, gets easily SOB, SpO2 (blood oxygen saturation level) 94% at 4 lpm via NC continuous. A 06/25/2025 9:47 PM Nurse's Note showed Resident 2 was on 4 lpm via NC.Review of the 06/24/2025 Provider Admit Visit Encounter Note showed Resident 2 was admitted for acute respiratory failure related to not using CPAP for two weeks due to equipment malfunction. Baseline Supplemental 6lpm NC, with a goal of Sa02 88-92%, and instructions to staff to monitor and call Provider for evidence of acute exacerbation, wheezing, SOB, increased O2 requirement.A 06/28/2025 2:30 PM Nurse's Note showed Resident 2 had SOB on exertion, SOB when lied flat, mild SOB at rest and was on 02 at 4 lpm via NC.Review of the June 2025 TAR showed a 06/28/2025 order for oxygen at 2-4 lpm per NC continuously every shift. Staff initialed indicating the order was followed but did not note the oxygen rate delivered.A 06/29/2025 10:22 PM, Nurse's Note showed 02 at 6 lpm via NC was maintained. A 06/30/2025 10:09 PM, Nurse's Note showed Resident 2 was on 02 at 6 lpm via NC. Similarly, on 07/01/2025 at 9:32 PM, and 07/03/2025 at 9:32 PM.According to a 07/06/2025 7:56 PM Nurse's Note, when Resident 2's oxygen was decreased to 3 lpm, the resident insisted they needed oxygen at 6 lpm, stated, my doctor told me I need 6 Liters. When they were instructed about why they did not need 6 lpm the resident got upset, defensive, and accusatory.A 07/20/2025 2:47 PM Nurse's Note showed Resident 2 had labored breathing, complained of SOB, cough and chest pain. Resident 2 was sent out to the hospital for further evaluation.Review of the After Visit Summary showed Resident 2 was hospitalized from [DATE]-[DATE] with a primary diagnosis of COPD Exacerbation.Review of the facility census showed Resident 2 was readmitted to the facility on [DATE].A 07/23/2025 4:47 PM Infection Control note showed Resident 2 was unable to sustain a saturation of above 90% on 10 liters of oxygen. Notifications were completed and the resident was sent back to the hospital.Review of the 07/28/2028 hospital discharge records showed a discharge diagnosis of acute on chronic hypoxic hypercapnic respiratory failure (a condition in which the body fails to remove carbon dioxide CO2 from the blood) secondary to COPD and Interstitial Lung Disease - ILD exacerbation (lung damage with inflammation and scaring, making it difficult for lungs to exchange oxygen and CO2). The resident was discharged on baseline oxygen of 6 liters.Review of the July Medication Administration Record (MAR) showed 07/28/2025 orders for oxygen at 6 lpm per NC continuously - Maintain SpO2 90% or greater.Record review showed Resident 2 was hospitalized from [DATE] - 08/08/2025 following a fall with fractures.Review of 08/08/2025 hospital discharge orders showed orders for continuous oxygen at 4-6 liters via NC, with a target SaO2 of 88-92% and BIPAP at night.Review of the August 2025 MAR showed the 07/28/2025 oxygen orders of 6 lpm remained in place.A 08/09/2025 7:26 PM eMAR Administration Note showed the nurse increased the oxygen rate to 8 lpm via NC.The 08/08/2025 hospital discharge orders were started on 08/10/2025 at 6:00 AM, with an O2 flow rate of 4-6 lpm.Review of the August MAR showed a 08/14/2025 order for Oxygen at 6-8 lpm via mask continuously to maintain SpO2 at 88-92%. The order was clarified on 08/20/2025 to add May use NC during meals. If patient refused to use mask inform provider.Review of the census showed Resident 2 was sent to a higher level of care on 08/26/2025 and readmitted [DATE]. Review of the 09/01/2025 after visit summary showed the primary diagnosis was Acute Hypoxic on Chronic Hypercapnic Respiratory Failure. Review of the 09/01/2025 Nursing Home provider transfer orders showed that Resident 2 was switched from a BiPap to a CPAP.During an interview on 10/02/2025 at 2:46 PM, Resident 2's representative stated the resident was released from the hospital with instructions to be on a CPAP during naps and when sleeping, that their life depended on it and the facility did not have one for three days.Review of an 09/02/2025 9:54 PM EMAR Administration note showed the CPAP was not available yet.Review of the facility fax to the medical equipment supplier, showed the facility faxed the CPAP orders on 09/02/2025 at 10:37 PM and a face sheet at 11:49 PM. Review of supplier's documents showed the CPAP was delivered to the facility on [DATE] at 10:00 AM.RESIDENT 7According to the 07/07/2025 Quarterly MDS Resident 7's diagnosis included COPD, the resident used oxygen therapy, and experienced SOB when lying flat.Review of the COPD Care Plan (CP) revised 10/24/2023 showed the oxygen was to be delivered by nasal prongs/mask per MD (Medical Doctor) order. Review of the resident is on oxygen therapy care CP revised 07/07/2025 showed the oxygen was delivered by nasal prongs, and staff were directed to titrate to maintain Sp02 at 88% or greater.On 09/19/2025 at 11:45 AM Resident 7 was observed with oxygen running by NC at 2. 5 lpm. The oxygen concentrator had a humidifier and the oxygen tubing was dated 09/15/2025.In an interview at that time Resident 7 stated they were breathing okay and denied shortness of breath.Review of the September 2025 TAR showed an order dated 02/27/2023 for 02 at a rate of 0 to 4 liters, unless otherwise ordered. Titrate up to maintain and keep sats greater than 90% every shift. Staff initialed the order, indicating it was done, but did not document the oxygen flow rate or the corresponding Sa02.In an interview on 09/24/2025 at 3:37 PM, Staff E, Resident Care Manager, reviewed the TAR and stated the staff were not, but should be documenting the flow rate.Review of the September 2025 TAR showed an order dated 11/18/2022 to change the nasal canula weekly every night shift every Friday for oxygen management. Staff documented it was done 09/05/2025, and 09/12/2025. In addition, an order dated 03/06/2023 to change O2 tubing and clean filter every week and as needed, every night shift every Sunday. Staff documented it was done on 09/07/2025 and 09/14/2025.In an interview on 09/24/2025 at 3:37 PM, Staff E, stated only one of the orders was necessary to change the canula weekly.RESIDENT 8According to the 07/28/2025 Annual MDS Resident 8 was diagnosed with COPD, used oxygen therapy, experienced shortness of breath with exertion and when lying flat.Review of the 03/11/2025 COPD CP showed the resident was using O2 at 2 lpm via NC, had a CPAP at night, and increased nasal saline gel for dry nares related to O2 with humidifier.On 09/19/2025 at 11:45 AM Resident 8 was observed with O2 running at 2.5 lpm through a NC from an O2 concentrator. The tubing was dated 09/15/2025. The humidifier was dated 09/08/2025 and empty. In an interview at this time, Resident 8 stated that COPD was a new diagnosis for them, they were having trouble keeping the CPAP on at night, but when it was able to stay on, they woke up feeling great.Review of the September 2025 TAR showed 01/19/2025 orders to change O2 tubing, concentrator bottle (if needed) and clean filter every week every night shift every Sunday which was documented as done night shift of 09/07/2025 and 09/14/2025.Further review of the September 2025 TAR showed a 03/02/2025 order to change NC every 14 days every night shift every 14 days, which was documented as done the night of 09/14/2025.A 02/26/2025 physician's order directed staff to check Sp02 every shift in a range from 90-98%. Staff documented the sats measured every shift, but did not indicate if the resident's oxygen saturation level was measured with or without O2.During an interview on 09/24/2025 at 3:37 PM, Staff E reviewed the documentation and stated they were sure the nurses changed the tubing, and not the bottle. Staff F stated the tasks needed to be separated into different orders.RESIDENT 9According to the 08/11/2025 Quarterly MDS Resident 9 had a diagnosis of COPD, used oxygen therapy and experienced SOB when lying flat.Review of the 08/14/2025 COPD CP showed staff were directed to administer O2 as ordered.On 09/19/2025 at 12:29 PM Resident 9 was observed seated in a wheelchair looking out the window in their room, not wearing O2. On their wheelchair was a small 02 tank was with attached NC tubing. Next to their bed was a 02 concentrator running at 4 lpm, without a humidified bottle. The 02 tubing was dated 09/14/2025.On 09/24/2025 at 11:24 AM Resident 9 was observed seated in their wheelchair at bedside watching television. Resident 9 was observed wearing 02 at 4 lpm by NC with tubing dated 09/21/2025. There was no humidified bottle on the 02 concentrator.Review of the September 2025 TAR showed orders dated 02/10/2025 for oxygen at 2 lpm per NC routine; keep sats greater than 90% every shift. Staff documented the orders were followed.Review of the August and September 2025 TARs showed orders dated 02/11/2025 to change humidifier bottle every 28 days every day shift, which staff documented as done 08/26/2025.Review of the September 2025 TAR showed an order dated 02/11/2025 to change nasal canula every 14 days which was documented as done 09/09/2025.Further review of the September 2025 TAR showed a 02/16/2025 order to change oxygen tubing, concentrator bottle (if needed) and clean filter every week, every night shift, every Sunday, which was documented as done on 09/07/2025, 09/14/2025 and 09/21/2025.During an interview on 09/24/2025 at 11:38 PM, Staff B, Director of Nursing, stated they needed to change how the orders were written.During an interview on 09/24/2025 at 11:27 AM Staff G, Licensed Practical Nurse (LPN), observed Resident 9 and the 02 setting and stated they 02 was running at 4.5 lpm, and was supposed to be at 2 lpm.During an interview on 09/24/2025 at 11:31 AM, Staff F, Resident Care Manager, stated oxygen tubing and humidifiers should be changed weekly, and residents should receive oxygen at a rate ordered by the provider.REFER TO: WAC 388-97-1060(3)(j)(vi)

Based on interview and record review the facility failed to ensure medically-related social services were provided for 1 of 4 residents (Resident 2) reviewed for respiratory services. The failure to involve facility social workers for residents demonstrating behaviors of rejection of care placed residents at risk for unmet health needs and other negative health outcomes.Findings included .RESIDENT 2Review of Minimum Data Sets (MDS - an assessment tool), dated 07/31/2025, 08/14/2025 and 09/03/2025 showed Resident 2 was cognitively intact and did not reject care that was necessary to achieve the resident's goals for health and well-being.Review of a 07/07/2025 8:41 PM Nurse's Note showed Resident 2 continued removing oxygen tubing on and off, kept bed in flat position, when encouraged to have head of bed up to ease breathing, became upset. Resident 2 was resistant to care, declined shower offered, encouraged to have shower, kept refusing.Review of a 07/08/2025 11:39 AM note written by Staff D, Resident Care Manager, showed Resident 2 was non compliant with diet, aware of risks and benefits and risks for complications related to diabetes and other conditions. Daughter also aware of this and stated she will help with resident's non compliance with over all care and medical recommendations.Review of a 07/08/2025 6:00 PM Nurse's Note showed Resident 2 refused to have head of bed elevated, lied flat and got angry at staff when encouraged.During an interview on 10/03/2025 at 11:25 AM, Staff D, stated it was up to Resident 2 if they wanted to sit up in bed or not, and they were able to use the remote control.Review of a 07/28/2025 4:15 PM Nurse's Note documented by Staff D, showed that Resident 2's representative was notified Resident 2 was noncompliant with BIPAP, care and treatment. A 07/30/2025 Nurse's Note showed Resident 2 refused to use the PAP machine. Review of the August 2025 Medication Administration Record (MAR) showed 08/21/2025 orders for Oxygen (02) at 6-8 Liters Per Minute (lpm) via mask continuously to maintain SpO2 (blood oxygen saturation level) at 88-92%. May use NC (nasal cannula) during meals. If patient refuses to use mask inform provider.Review of an 08/20/2025 Nurse's Note showed Resident 2 breathed better with mask on, but kept removing mask. When encouraged to keep it on, yelled out no and requested to be put back on NC.During an interview on 10/03/2025 at 11:25 AM, Staff D stated Resident 2 had a lot of noncompliance. Staff D referred to a 08/24/2025 8:20 AM Administration Note that showed Resident 2 was on 7 lpm 02 and refused to have the mask on. Staff D stated they would encourage Resident 2 to keep it on and Resident 2 would keep removing it and request to be put back on NC. Staff D stated Resident 2 was non-compliant with fluid restrictions also.Review of Administration Notes showed Resident 2 refused to use the CPAP on 09/04/2025, and 09/06/2025. Review of a written notification to the provider (SBAR) dated 09/06/2025 at 9:00 PM showed the nurse documented the situation as Resident 2 continuously refusing CPAP, complained the setting was too strong for them and wanted to readjust the setting. The provider did not acknowledge the notification until 09/09/2025, after the resident passed away on 09/07/2025.During an interview on 10/02/2025 at 2:46 PM, Resident 2's representative stated they had been in the facility months prior (beginning of July 2025) and explained their concerns regarding Resident 2 refusing the Bi-level Positive Airway Pressure (BiPAP), laying in bed, and not being showered. Resident 2's representative said they told the six people in the room, if there were any problems to call them. Resident 2's representative stated the facility staff were going to communicate with them anytime Resident 2 refused Continuous Positive Airway Pressure (CPAP), BIPAP, and anytime he refused from that point forward they would call so they could go into the facility and talk to Resident 2. Resident 2's representative stated they did not receive a call from that point on.During an interview on 10/03/2025 at 11:25 AM, Staff D Resident Care Manager (RCM) stated when Resident 2's representative was in the facility they were talking about Resident 2 refusing showers, and they told Resident 2's representative that they would call if Resident 2 refused showers.Review of the 09/01/2025 Care Plan Report showed no behavior care planned interventions to address Resident 2's refusals of care.During an interview on 10/03/2025 at 12:02 PM, Staff N, Social Services Director, stated they were unaware of Resident 2's refusals. Staff N stated they would expect nursing to notify family, and for social services to be notified to explore potential reasons for the refusals, and if necessary to discuss refusals in care conferences, code the MDS and develop a plan of care.REFER TO: WAC 388-97-0960(1)

Based on observation, interview, and record review, the facility failed to ensure a provider's order for blood pressure parameters were consistently followed for 1 of 5 sampled residents (Resident 81) and initiated non-pharmacological interventions (NPI) prior to the administration of as needed (PRN) pain medication for 3 of 5 sampled residents (Residents 100, 79, and 18) when reviewed for unnecessary medications. These failures placed residents at risk for receiving unnecessary medications, a diminished quality of life, and unmet needs. Findings included . Review of a facility document titled, Medication Ordering and Receiving From Pharmacy Provider, Medication with Boxed Warning, dated 01/2025, showed all licensed nurses (LNs) must be familiar with medications used by residents that carry a boxed warning relevant to the resident. In addition, nursing staff shall refer to boxed warning monitoring guidelines and appropriate references for specific health risk and signs and symptoms for monitoring. Nursing staff shall include the appropriate monitoring parameters on the residents and monitor for adverse consequences (i.e. assessing vital signs may be indicated if a medication was known to affect blood pressure and pulse rate). Resident 81 Review of the quarterly minimum data set (MDS, a required assessment tool), dated 02/21/2025, showed Resident 81admitted on [DATE] with multiple diagnoses to include heart, lung and kidney disease, and hypertension (high blood pressure). The electronic health record (EHR) showed the resident was able to make needs known and required assistance with activities of daily living (ADLs). Review of Resident 81's provider's order for midodrine (a medication used to treat hypotension [low blood pressure]) dated 02/15/2025 was to be administered by the LNs twice a day for hypotension and to hold for a systolic blood pressure greater than 120 (top blood pressure reading). Review of Resident 81's medication administration record (MAR) dated February, March and April 2025, showed multiple dates where LNs had administered the medication midodrine when the resident's blood pressure was greater than 120 systolic. The February 2025 MAR showed the LNs had administered the medication 11 out of 27 times, March 9 out of 62 times, and April 2025 the LNs administered the medication 5 out of 15 times. During an interview on 04/10/2025 at 2:43 PM, Staff L, Licensed Practical Nurse (LPN), stated if there were (provider's orders) blood pressure parameters to hold them for any systolic blood pressure greater than 120 then the expectation would be for the LN to hold the medication as ordered. During an interview on 04/10/2025 at 3:05 PM, Staff B, Director of Nursing Services (DNS), stated it was their expectation was the LNs were to hold any blood pressure medication as per the provider's order if there were parameters to hold. 38344 Resident 100 Review of the EHR showed Resident 100 readmitted to the facility on [DATE] and was able to make needs known. The quarterly MDS dated [DATE] showed Resident 100 had diagnoses of depression, diabetes (too much sugar in the blood), and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of Resident 100's provider's orders showed an order dated 12/17/2024 for acetaminophen (a medication used to treat minor aches and pain) every six hours as needed for pain. Review of the MAR dated March 2025 and April 2025 from 04/01/2025 - 04/07/2025 showed the ordered as needed acetaminophen was provided three times in March and three times in April with no NPI documented as offered or provided. During an interview on 04/09/2025 at 1:27 PM. Staff F, Licensed Practical Nurse Supervisor, stated NPI should be offered/provided and documented in the MAR and/or progress notes prior to giving any as needed pain medication. Staff F stated Resident 100 had no NPI documented for as needed acetaminophen provided in March and April 2025. During an interview on 04/09/2025 at 1:34 PM, Staff B, DNS, stated Resident 100's documentation for NPI prior to being administered as needed acetaminophen three times in March and in April 2025 were not documented in the MAR or in a progress note and this did not meet expectations. 46067 Resident 79 Review of the EHR showed Resident 79 admitted to the facility on [DATE] with diagnoses of osteomyelitis (inflammation and infection of the bone), pressure ulcer and heart failure. Resident 79 required extensive assistance with most activities of daily living. Review of Resident 79's provider's orders showed an order dated 10/19/2024 for acetaminophen 650 milligrams every eight hours as needed for pain. Review of the MAR dated March 2025 showed the ordered as needed acetaminophen was provided seven times in March with no NPI documented as offered or provided. Review of the MAR dated April 2025 from 04/01/2025 - 04/08/2025 showed the ordered as needed acetaminophen was provided two times in April with no NPI documented as offered or provided. During an interview on 04/09/2025 at 1:27 PM, Staff F, Licensed Practical Nurse Supervisor, stated NPI should be offered/provided and documented in the MAR and/or progress notes prior to giving any as needed pain medication. During an interview on 04/09/2025 at 1:34 PM, Staff B, DNS, stated lack of NPI documentation did not meet expectations. 49926 Resident 18 Review of the EHR showed Resident 18 was admitted to the facility on [DATE] with diagnoses to include fractures of lumbar (low back) and thoracic (middle back), depression, and acute kidney failure. Resident 18 was able to communicate needs. During an interview on 04/08/2025 at 9:30 AM, Resident 18 stated their pain was all over the back, was worse with movement, and the pain prevented them from doing activities. Resident 18 stated the nurses were giving them pain medicine about two times a day, and there were no NPI used for their pain. Review of the MAR for March 2025 showed Resident 18 was receiving oxycodone (narcotic medication) on as needed basis 57 times without documentation of NPI that were tried prior to the medication. Reference WAC 388-97- 1060(3)(k)(j)

Based on observation, interview, and record review, the facility failed to ensure food items were dated and meals/beverages were served at the appropriate temperatures when reviewed for kitchen services. These failures placed residents at risk for foodborne illnesses and diminished quality life. Findings included . Observation during the brief initial tour on 04/07/2025 at 9:12 AM showed multiple flavored syrups and large containers of seasonings to include Parsley, Paprika, Taco, Ground Pepper, Thyme, Ginger, [NAME] undated. Observation of tray line on 04/10/2025 between 11:17 AM and 11:39 AM showed Staff O, Cook, put all entrees and side items for the lunch meal on the steam table. Observation on 04/10/2025 at 11:42 AM, showed Staff O preparing resident plates. There were no observations of temperatures taken prior to service. Review of the lunch meal temperature log on 04/10/2025 at 12:00 PM showed temperatures for all items to include cold beverages. During an interview on 04/11/2025 at 11:16 AM, Staff E, Dietary Manager, stated Staff O admitted to not taking the temperatures of beverages but stated they did take the temperature of the food out of view. Staff E stated the lack of temperatures did not meet their expectations. During an interview on 04/11/2025 at 11:32 AM, Staff A, Administrator, stated the expectation was for temperatures to be taken according to regulation and the lack of tmeperatures did not meet their expectations. Reference WAC 388-97-1100 (3), -2980

Based on interview and record review, the facility failed to follow up on concerns of the resident council related to resident care for 3 of 4 resident council meetings minutes (November and December 2024, and January 2025) when reviewed. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . During an interview on 04/09/2025 at 8:37 AM, Resident 14 stated management did not follow up with concerns discussed during the resident council meetings. Review of the resident council minutes, dated 11/25/2024, showed concerns voiced by members regarding evening shift staff chatting at the nurse's station and not promptly responding to call lights. Review of the resident council minutes, dated 12/30/2024, showed concerns voiced by members regarding night shift staff on their cell phones and long call light wait times. Review of the resident council minutes, dated 01/27/2025, showed concerns voiced by members to include night shift staff on their cell phones and continued long call wait times. Review of the grievance log dates 11/2024 through 03/2025 showed no grievances that corresponded with concerns verbalized at resident council meetings. During an interview on 04/10/2025 at 1:57 PM, Staff G, Activities Supervisor, stated they did not initiate grievances related to concerns expressed during resident council meetings. Staff G stated if residents had grievance concerns during resident council meetings they should follow up with the social services department for assistance. During an interview on 04/11/2025 at 10:51 AM, Staff A, Administrator, stated it did not meet their expectation that specific concerns brought up in resident council had not been addressed and followed up on. Reference WAC 388-97-0920

Based on interview and record review, the facility failed to have psychotropic medication (medications that affect a person's mental state) informed consent accurately completed prior to administering the medication for 1 of 5 sampled residents (Resident 100) when reviewed for unnecessary medication use. This failure placed the resident and/or their legal representative at risk for lack of knowledge to make an informed decision regarding the use of the medication, inaccurate data in the medical record, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 100 readmitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set (MDS, a required assessment tool) dated 03/03/2025 showed Resident 100 had diagnoses of depression and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of Resident 100's provider order dated 03/28/2025 showed the resident was prescribed olanzapine (an antipsychotic medication) two times a day for delirium (a mental state of confusion, disorientation, and not able to think or remember clearly) with agitation. Review of Resident 100's form titled, Informed Consent for Use of Psychotropic Medication, dated 03/28/2025, showed the diagnosed condition for which the medication was prescribed was for a psychotic disorder. Review of Resident 100's EHR on 04/09/2025 showed no diagnosis of psychotic disorder. During an interview on 04/09/2025 at 11:10 AM, Staff F, Licensed Practical Nurse Supervisor, stated Resident 100 was taking an antipsychotic medication. Staff F stated Resident 100's informed consent dated 03/28/2025 was not accurately filled out because the resident did not have a diagnosis of psychotic disorder, and this did not meet expectations. During an interview on 04/09/2025 at 11:27 AM, Staff B, Director of Nursing Services, stated Resident 100's informed consent for their prescribed psychotropic medication was not accurately completed because it showed Resident 100 had a diagnosis of psychotic disorder; however, the resident did not have that diagnosis. Staff B stated the expectation was for informed consents to be completed accurately. Reference WAC 388-97-0260

Based on interview and record review, the facility failed to provide the required assistance to prevent falls with associated injuries for one of two residents (Resident 1) reviewed for falls. The facility also failed to ensure staff followed safe practices and care plan for bed mobility while providing care. Facility staffs' failure to provide two-person assistance with bed mobility, as the resident was assessed to require, resulted in harm to Resident 1 who rolled out of bed during care and sustained injuries, swelling, and bruising to their forehead and right forearm. Findings included . Review of a revised February 2018 facility policy titled Fall Risk Assessment, showed the facility promoted resident safety and reduced falls by proactively identifying, care planning and monitoring the resident's fall indicators through a Fall Risk Assessment. This policy showed that the staff and attending physician will evaluate functional and psychological factors that may increase fall risks including activity of daily living (ADLs), capabilities and activity tolerance. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try minimizing the consequences of risk factors that are not modifiable. Review of a 01/31/2022 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], muscle weakness, and chronic kidney disease. This assessment showed that Resident 1 required two people extensive for bed mobility, and one-person extensive assistance for transfers and toilet use. Resident 1 was assessed with moderate cognitive impairment but was able to understand and be understood in conversation. Review of a revised 02/15/2022 Fall Care Plan (CP) showed that the resident was at risk of falls related to muscle weakness, balance deficit, unsteadiness on feet, knee buckle at times, poor trunk control and fatigue. The CP directed staff to provide two-person assistance with bed mobility. A 02/27/2022 Fall Risk Evaluation identified Resident 1 at risk for falls. A progress note dated 03/08/2022 showed Staff D, Certified Nursing Assistant, (CNA) reported during patient care, Resident rolled out of-bed and landed on his R [right] side with back to the wall. Injury fall @ 1130am witnessed, upon assessment noted R forehead and R wrist bump elevated, tender to touch, applied ice pack, skin intact, no new neurological deficiencies noted-see flowsheet, given Tylenol PRN [as needed] for pain to R forehead, 2/10, localized which was effective, third fall in approximately 2 weeks, second time rolling out of bed, needs anticipated, placed on alert monitor. In an observation and interview on 03/14/2020 at 12:32 PM, when asked about the fall that occurred on 03/08/2020, Resident 1 stated, I was in bed and staff was helping with change, rolled to my left side and fell on the floor. Resident 1 was observed with a healing greenish colored bruise and a bump to the right forehead and a swollen right arm with healing bruises. Resident 1 confirmed that only one staff was present during care, and that staff was standing next to the bed when, I rolled out of bed to the left side. In an interview 03/22/2022 at 3:13PM, Staff C stated the resident was assisted by one staff when the resident rolled out of bed. When asked about Resident 1's bed mobility, Staff C stated two people assist with bed mobility. When asked if the staff followed the resident's care plan. Staff C said No The above findings were shared with Staff B, Interim Director of Nursing, on 03/23/2022 at 2:10 PM. When asked if the facility followed the instructions to provide the resident two staff with bed mobility, Staff B stated, No. Resident 1 had a history of falls and out of bed since admission, The facility failed to ensure staff followed safe practices and care plan for bed mobility while providing care and addressed the resident's required staff support. These failures resulted in Resident 1 falling out bed sustaining right forehead pump, right arm swelling, and bruises. REFERENCE: WAC 388-97-1060 (3)(g) This is a recurring citation for 2567 Statement of Deficiency dated March 18, 2021 and November 16, 2021.

Based on observation, interview and record review, the facility failed to protect the resident from neglect by failing to ensure care plan interventions were followed as required for one of four residents (Resident #1) reviewed for abuse and neglect. This failure resulted in harm causing the resident to fall, sustain fractures to the right femur (thigh bone) and right rib, and end up being admitted in the hospital. Findings included . Review of the facility's policy and procedure titled, Protection of Residents: Reducing the Threat of Abuse &Neglect, dated 03/20/20, stated that it was the policy and practice of the organization to protect all residents from all types of abuse and neglect. The facility's policy and procedure defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Review of Resident #1's admission record dated April 2019, showed that the resident admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan updated 10/07/2019, showed that the resident had cognitive impairment, self-care deficit and was a risk for fall. Interventions required total dependence on two-person assistance with bed mobility, transfers and personal hygiene. The care plan also indicated that the resident had a stage 4 pressure ulcer (ulcer that extends into the deep tissues and as far down to the bone) and was on an air mattress bed that required two-person assistance during bed mobility and transfers. Review of Resident #1's Kardex (a care directive for the nursing assistants) undated, showed that the resident was totally dependent on two staff for repositioning and turning in bed. Review of a progress note dated 05/22/20 at 8:00 AM, showed that the licensed nurse (LN) was notified by a nursing assistant certified (NAC) that Resident # 1 was on the floor at around 5:00 AM. The NAC was in the room with the resident and witnessed the fall. A head to toe assessment found a bump to left side back of head of the resident with no bleeding noted. Bilateral lower extremities were checked, the resident complained of pain to right hip and shortening to the right leg was noted. Review of a progress note dated 05/22/20 at 1:52 PM, showed that Resident #1 admitted to the hospital with [REDACTED]. An observation on 05/26/20 at 3:20 PM, showed Staff D, NAC, and Staff E, NAC, provided care to a resident on an air mattress bed. During an interview on 05/26/20 at 3:25 PM, Staff D, NAC, stated that two-person assistance was required for a resident on an air mattress bed. According to Staff D, NAC, the resident's care plan and Kardex indicated the level of assistance required by the resident and if two-person assistance was needed, the staff would get another aide from her hall to help or ask the nurse for help. During an interview on 05/26/20 at 3:30 PM, Staff E, NAC, stated that the Kardex was checked every day for any changes in care. Staff E, NAC stated when two-person assistance was required for any type of care, then staff must get another aide to help or the nurse if the other aides were busy. During an interview on 05/26/20 at 3:50 PM, Staff F, LPN, (Licensed Practical Nurse) stated the nursing aides would come ask for help with moving or transferring a resident that needed two-person assistance. Staff F, LPN, stated that the nursing aides usually helped each other out but would come ask the nurse, if needed. During an interview on 05/26/20 at 4:10 PM, Staff G, NAC, stated it was easy to find the care needed for each resident in the Kardex which was found in the computer. Staff G, NAC, stated the Kardex would show how to transfer a resident or move them in bed. It would also show if the resident could move independently or required one or more staff to assist with care. Staff G, NAC, stated that if two-person assistance was indicated for repositioning in bed then to always get a second person to help. Staff G, NAC further stated that it would not be safe to do two-person care with one person. During an interview on 05/26/20 at 4:15 PM, Staff B, Director of Nursing Services (DNS) stated that on 05/22/20, Staff C, NAC, had pulled a drawsheet to turn the resident (Resident #1) onto her right side and the resident continued to roll out the right side of the bed onto the floor. Staff B, DNS, stated that Resident #1's care plan indicated the resident was to have two people to provide care, and Staff C, NAC, failed to follow the care plan. Review of the facility's investigation report dated 05/26/20, showed that on 05/22/20, Resident #1 sustained a fall with significant injury while Staff C,NAC, provided care. According to the investigation report, the DNS and Executive Director (ED) conducted a phone interview with Staff C, NAC and determined that the staff was aware Resident #1 required two-person assistance with bed mobility, transfers and personal hygiene and proceeded with resident care on her own. During an interview on 05/26/20 at 5:30 PM, Staff A, ED, stated that Resident #1's fall was preventable and that Staff C, NAC, failed to follow the care plan. Reference WAC 388-97-0640 (2)(a)(3)(c)

Based on observation, interview and record review the facility failed to have a system in place to verify and ensure that nursing staff had appropriate competencies, and skills to provide services to residents with acute medical conditions. This failure placed all nursing staff at actual risk of providing unsafe, substandard quality care and all residents at risk for harm. The lack of systematic approach to ensure competent nursing staff created a situation of Immediate Jeopardy. Findings included: RESIDENT #7 Resident #7 admitted to the facility on [DATE] after ankle surgery. Resident #7 remained without pain medication for 48 hours. Staff R, RN admitted Resident #7 on 12/19/19 according to the admit record. Staff R, RN did not have training on the admit process which lead to an omission error which contributed to resident harm. In an interview with Staff R, RN on 01/27/20 at 11:26 AM reported she did not know how to complete and admit and had no training on the admission process. Staff R, RN said she did not fax the prescription for a narcotic medication to the pharmacy on 12/19/19 because she assumed it was medical records responsibility, subsequently the resident remained in severe pain for 48 hours. Staff R, RN also reported that she did not have access to facility emergency medication supply including narcotics. Refer to F697 for details related to Resident #7 experiencing severe pain following surgical procedure and acute pain for 48 hours. RESIDENT#18 Resident #18 admitted to the facility on [DATE] following hospitalization for serious burns. The Resident #18 admitted to the facility with a right arm amputation surgical wound, burn site with a skin graft on the right chest wall extending under the arm, and a graft site to the thigh area. The resident also had a nephrostomy (a tube inserted in the back into the kidneys to drain the urine.) Record review showed there were no orders transcribed to the (MONTH) 2020 Treatment Administration Records (TAR) for the right thigh graft site and no orders for the amputation site. There was no documentation showing these areas were assessed at least daily. Further record review showed there was no treatment completed for nephrostomy tubes as evidenced by lack of documentation on the TAR. The treatment record for (MONTH) 2020 showed the nephrostomy tubes were not checked daily for thirteen days. Review of nursing progress notes did not find evidence of daily assessment of the medical devices. According to nursing notes on 01/20/20 the Resident #18 had increased confusion and was sent to the hospital. Hospital records showed the Resident #18 admitted to the emergency roiagnom on [DATE] with confusion, and was [DIAGNOSES REDACTED]. On 02/03/20 at 11:10 AM and on 02/04/20 at 12:39 PM during interview Staff P, VP of Clinical Services said that wound orders were missed at the time of admission and daily nephrostomy tube assessment/monitoring was not done. RESIDENT #7 Resident #7 admitted to the facility on [DATE] after having foot surgery as documented in the hospital records. Resident #7 had discharge instructions to take [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg (narcotic pain medication, for moderate to severe pain) 1-2 tablets every four hours as needed, according to hospital discharge documents. Resident #7 was neglected and suffered physical and psychological harm when nursing staff failed to complete a through physical assessment, identify and treat severe pain for 48 hours. At the time of admit the prescription for narcotic medications was not faxed to the pharmacy and facility nursing staff failed to follow through on obtaining narcotic medication for the resident. During observations and interview on 12/30/19 at 8:35 AM, Resident #7 explained she came to the facility for rehabilitation after a having surgery to treat a broken foot and a broken arm. Resident #7 described experiencing severe pain for two days. Resident #7 said she asked multiple nurses for pain medication but it was not available. The resident said her pain was (10/10). Staff R, RN (Registered Nurse), RCM (Resident Care Manager) on 01/27/20 at 11:26 AM said she admitted Resident #7 on 112/19/19. During the interview it was identified Staff RN, RCM had no training on how to complete a new admission. Staff R, RN RCM said she did not send the prescription for pain medication to the pharmacy because she assumed it was medical records responsibility. Staff R, RN RCM reported she had no access to Omni cell (emergency supply of medications including narcotics.) Interviews with other licensed nurses conducted on 01/27/20 revealed the facility did not have adequate orientation process and/or training was adequate in order to deliver safe care. The interviews identified there was lack of education and competencies related to completing admissions, access to the emergency narcotic supply, and knowledge about accessing the facility policy and procedures. Staff T, LPN on 01/27/20 at 11:40 AM reported she did not have access to Omni cell (emergency medication supply) and had no keys to the medication room. Staff T, LPN reported that during orientation there was no training on Omni cell access. Staff T, LPN reported she was not aware where facility policy and procedures were located. Staff T, LPN reported on any given day she was responsible to take care of 22 to 27 residents. Staff DD, LPN was interviewed on 01/27/20 11:43 AM about location of facility policy and procedures. Staff DD, LPN was not able to verbalize where she would find policies. Staff DD, LPN reported she was assigned anywhere from 24-27 residents. Staff EE, LPN on 01/27/20 at 11:49 AM reported she did not have access to Omni cell and did not have keys to the medication room. Staff EE, LPN was asked if during orientation she received training on where to find facility policy and procedures and reported she was not informed. Staff EE, LPN said she is assigned to care for up to 24-27 residents. Staff S, RN was interviewed on 01/27/20 at 11:50 AM and stated he worked at the facility at least three months. Staff S, RN stated he did not receive adequate orientation. Staff S, RN did not know where policy and procedures were located and said he did not have access to Omni cell. On 01/27/20 at 11:26 AM Staff R, RN RCM (Resident Care Manager) reported she did not have orientation on the RCM position or how to complete new resident admit. Staff R, RN RCM reported she did not want to put her license on the line because staffing was unsafe and she terminated her employment for that reason. In an interview on 02/05/20, at 2:10 PM, Staff N, RN, stated she the admission process takes four to five hours to complete in order to do it thoroughly. Staff N, RN, stated she works the floor and does not have time to complete admissions. In an interview on 02/05/20 at 2:10 PM, Staff O, RCM, stated the previous Director of Nursing, DNS, directed the staff who were doing the admissions to just do what you can do, then pass it to the floor nurse to complete. Staff O, RCM, was asked if the floor nurses have time to complete the admissions process in addition to passing medications, completing treatments, and responding to resident needs, Staff O, RCM, stated the floor nurses do not have enough time to complete an admission, but the charge nurse and the RCM also did not have enough time to complete admissions during their shift. In an interview on 02/05/20, at 3:30 PM, Staff O, Resident Care Manager, RCM, stated the facility has not had a specific staff member assigned to admitting new residents. When asked how they determine who is going to admit an incoming resident, Staff O, RCM, stated it depends on who did it last, and that the staff take turns, and rotate who will do the admission process. Staff O, RCM, stated the admission process was rotated between Resident Care Managers, Charge Nurses, and MDS (Minimum Data Set, an assessment tool) nurses. Staff O, RCM, stated there was no training or orientation of what tasks needed to completed, or how to complete them, related to the admission process. Staff O, RCM, stated there was not a checklist, or other type of tool, for staff to use to ensure all of the steps of the admission process were complete. In an interview on 02/05/20, at 3:30 PM, Staff O, RCM, was asked how staff know what needs to be done to complete an admission when there is not a training or check off list. Staff O, RCM, the biggest thing to do is get the physician's orders [REDACTED]. Staff O, RCM, stated the staff who work in the medical records department will review the orders and confirm them. Staff O, RCM, stated the nurse will then meet with the resident and call the doctor to make any needed adjustments or clarification of the orders. Staff O, RCM, stated once the medications are ordered, the admissions nurse should complete a head to toe assessment, obtain consent forms, get pictures and the remaining required documents. In an interview on 02/05/20, at 3:17 PM, Staff F, Medical Director, MD, stated there has been issues with staff obtaining orders from the hospital transferring residents to the facility. Staff F, MD, gave the example of staff will receive orders for medications, but there will not be orders for dressing changes or wound care. Staff F, MD, stated the facility staff cannot provide care without treatment orders. Staff F, MD, stated the facility does have staff completing admissions that do not have the skills to complete the admission process adequately. Review of employee records of clinical competencies on 02/5/20 at 3:18 PM for Staff O, RN, RCM, Staff U, LPN, Staff FF, RN showed there was no evaluation of skills related to admission process, nephrostomy tubes and process for obtaining controlled substances including narcotic medications. In an interview on 2/5/20 at 3:53 PM Staff P, VP of Clinical Services explained she was working on multiple Process Improvements but was unable to tackle this problem yet. Reference WAC 388-97-1080(1)

Based on the interview and record review, the facility failed to have a functioning governing body to oversee the management and operation of the facility. The governing body failed to act timely to protect the well-being of residents from potential negative outcomes of financial hardship and ensure bills were paid timely. Additonally, the governing body failed to ensure safe and effective clinical systems as evidenced by repeat harm level citations leading up to Immediate Jeopardies over a nine month period. These failure resulted in substandard care related to resident neglect. Findings included: Review of the facility Administrative Management policy dated 2011, showed that the governing board shall be responsible for the management and operation of the facility. The governing board is responsible for but is not limited to, conversion and use of the facility's funds. In an interview on 01/06/2020 at 11:30 AM, Staff E, VIP of Operations was asked about governing body members and respective dates of employment. The newly formed governing body consists of the following individuals: -Staff E, VIP of operations who started on 11/1/19. -Staff D, Operations started on 1/01/2020 -Staff K, Operations started on 1/01/2020 -Staff L, Financial Consultant- employed since 2019. -Staff J, Facility Owner since (YEAR) On 09/23/19 the facility was issued a citatiaon when the Administration failed to effectively, efficiently, and in accordance with acceptable standards of practice manage its resources to ensure continued services. Failure of the facility placed residents at risk of service disruptions. The facility alleged back in compliance date of 12/02/19. On (MONTH) 4, 2019, the State of Washington imposed a directed plan of corrections that The licensee must hire a qualified financial advisor/accountant at its own expense, to assist the facility in the development of an effective system in an ongoing effort to sustain financial stability of operations for the provision of care to all residents. The licensee and financial advisor/accountant must meet with the department to review the facility's financial assessment and plan to re-gain substantial compliance. The facility was found delinquent in payments with the following entities/vendors/contractors: DEPARTMENT OF REVENUE Records from the Department of Revenue (DOR), on 12/06/19, showed the facility was issued two tax warrants for nonpayment. The company entered into a payment agreement with DOR in (MONTH) 2019. The agreement was that the company pay its current monthly combined excise tax returns on time and remit $5,000 per month towards back taxes. The company defaulted upon the agreement immediately on the first due date of 09/25/19. The payment for (MONTH) 2019 taxes was declined by the bank for insufficient funds. No payment has been remitted for the (MONTH) 2019 taxes that was due (MONTH) 25, 2019. A review of records provided by the DOR showed that on 09/25/19 a warrant for unpaid taxes was filed in the County Superior Court. On 10/02/19 an additional warrant was filed for unpaid taxes. On 01/06/2020 at 11:30 AM, Staff E, VIP of Operations and Staff D, Operations/Consultant knew the arranged payment plan with the DOR, but they did not know the checks bounced and that facility has been issued tax warrants. SAFETY NET ASSESSMENT (SNA) According to DSHS records, on 12/06/19 the facility was notified that the SNA account was 60 days overdue and the account was turned over to the Office Of Financial Recovery (OFR). Review of state records dated 12/13/19 showed the facility has defaulted on (MONTH) 2019 SNA payment. US FOODS During an interview on 01/03/2020 at 2:41 PM, a representative from US Foods stated that the facility made a payment today, on day 17, a few days beyond their 14-day term. The current balance was $21,321.91. There is no probability of service interruption in the future. RT HOOD In an interview on 01/03/2020 at 12:43 PM, RT Hood representative stated that the facility has not made a payment for hood cleaning services provided in (MONTH) 2019, and owe the company $742.08. The company will seek reimbursement before providing future services and will reach out to the facility in (MONTH) 2020 when another cleaning is due. If the facility does not pay outstanding balance they will be taken off the schedule. CASCADE FIRE AND ALARM On 01/06/2020 at 2:48 PM interview with a representative from Cascade Fire and Alarm (company which evaluates quarterly and/or annually fire suppression system) reported the facility failed to pay a bill in the amount of $12,202.23, which was due for services in (MONTH) 2019 and (MONTH) 2020. The representative stated that it would be up to the supervisor's discretion to continue to provision of services with an outstanding balance. GENERATOR The facility uses Legacy Generator Services to complete yearly testing. In an interview on 01/08/2020 at 9:30 AM, Staff H was asked about a potential interruption in service for the generator. Staff H reported the generator testing was current at this time. Staff H was not sure if future services would be interrupted because the facility owes them money. Staff H said if he was to call the company to service the generator he does not know if they would come out due to outstanding balance. MEDICAL DIRECTOR During an interview on 01/03/2020 at 2:24 PM, Staff F, Medical Director reported she has not been paid for 15 months for services, and the facility owed her $72,000. Staff F, Medical Director said she was not sure what she was going to do about continuing providing services without payment. Staff F said she was likely to continue providing services. MEDICATION VENDOR Review of documents provided by Omnicare (pharmaceutical services and medications) representative on 01/03/2020, showed the facility was behind in payments and had failed to make the latest payment towards agreed-upon Promissory Note due 12/15/19. The facility owes $112,732.32. According to the Vendor Balance Summary dated 12/23/19 the facility owes Omnicare $170,205.28. Omnicare also indicated there was a probability of service interruption in the future as a result of non-payment. On 01/03/2020 Omnicare sent out a Notice of Termination letters to the facility, explaining that services would terminate on 01/27/20, however, the owner of the facility has been in contact with the pharmacy and is working on overdue payments. DENTAL SERVICES During an interview on 01/03/2020 at 1:06 PM, a representative from Smile Seattle Dentures stated that they service 10-15 residents a month, and each resident once a year for annual checkup. According to the representative, the facility was a year behind in payments and in (MONTH) 2019 a letter was sent to the facility that they needed to pay their outstanding bill, or arrange a payment agreement for service to continue into the new year. REPEAT DEFFICIENCIES AND HARM TO RESIDENTS NARCOTIC MANAGEMENT The facility failed to sustain a plan of corrections for previous citations related to narcotic management, and medications errors, issued on 09/23/19 with alleged back in compliance date of 12/02/10. The facility was issued another citation on 02/05/20 related to inadequate narcotic management. Refer to F755 for additional information. PAIN MANAGEMENT The facility failed to sustain a plan of corrections for a harm level citation issued on 09/23/19 for inadequate pain management. The facility alleged back in compliance date of 12/02/19. On 01/23/20 an Immediate Jeopardy situation was identified when Resident #7 did not receive pain medicaton for 48 hours for acute surgical pain. Refer to F697 for additional information related to Resident #7. MEDICATION ERRORS The facility failed to sustain a plan of corrections for previous harm level citation for significant medication errors issued on 10/21/19 with alleged back in compliance date of 12/02/19. The facility was found out of compliance again on 02/05/20 related to medication errors. Refer to F658 and F760 for additional information. FACILITY INVESTIGATIONS The facility was cited for failing to thoroughly investigate all reports of alleged abuse, neglect or quality of care concerns. The facility alleged compliance on 03/08/19. The facility was cited again for failing to conduct thorough investigations on 09/13/19 with an alleged compliance date of 12/02/19. On 2/05/20 the survey team identified a pattern of failure related to not investigating all allegations and identifying neglect and abuse that occurred in (MONTH) and (MONTH) of 2020. Refer to F610 for additional information QUALITY OF CARE On 10/21/19 the facility was issued four harm level citations related to inadequate management of post surgical wounds, assessment, preventing pressure injuries, falls, and high risk medications. The facility also received a citaiton related to nursing competencies. The facility alleged back in compliance date of 12/02/19. On 02/04/20 the facility was found in Immediate Jeopardy related to actual harm and neglect of a resident who required post surgical monitoring. On 02/05/20 the facility was found in Immediate Jeopardy related to lack of competent nursing staff. The repeat deficiency demonstrate lack of effective and/or strategic approach to managing finances and clinical services by the governing body. Reference WAC 388-97-1620(2)(c)

Based on observation, interview and record review the facility failed to ensure required structures, processes and systems were in place for managing pain, skin conditions, change of condition and indwelling medical devices. These failures resulted in harm related to neglect for Residents #'s (7, 18 &21). Combination of these failures created a situation of Immediate Jeopardy. Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Findings included: RESIDENT#18 Resident #18 was neglected when nursing staff failed to manage surgical wounds and nephrostomy tubes (tube placed through the lower back into the kidney to drain urine), the resident subsequently [MEDICAL CONDITION]. Resident #18 is no longer at the facility. Resident #18 admitted to the facility on [DATE] following hospitalization for serious burns. The Resident #18 admitted to the facility with a right arm amputation surgical wound, burn site with a skin graft on the right chest wall extending under the arm, and a graft site to the thigh area. On 01/6/20 Resident #18 was sent to the emergency room for a leaking nephrostomy tube and readmitted back to the facility after the tube was replaced. 1. Record review showed documentation on the Treatment Administration Record (TAR) for a daily wound care to the right [MEDICAL CONDITION] 01/08/20. The TAR showed documentation holes indicating the wound care was not complete between 01/07/20 and 01/20/20 for seven days. 2. There were no orders transcribed to the (MONTH) 2020 Treatment Administration Records (TAR) for the right thigh graft site and no orders for the amputation site. There was no documentation showing these areas were assessed at least daily. There was no evidence to support staff clarified or questioned the provider. 3. There was no treatment completed for nephrostomy tubes as evidenced by lack of documentation on the treatment record. The treatment record for (MONTH) 2020 showed the nephrostomy tubes were not checked daily for thirteen days. Review of nursing progress notes did not find evidence of daily assessment of the medical devices. According to nursing notes on 01/20/20 the Resident #18 had increased confusion and was sent to the hospital. Hospital records showed the Resident #18 admitted to the emergency roiagnom on [DATE] with confusion, and was [DIAGNOSES REDACTED]. On 02/03/20 at 11:10 AM and on 02/04/20 at 12:39 PM during interview Staff P, VP of Clinical Services said that wound orders were missed at the time of admission and daily nephrostomy tube assessment/monitoring was not done. Staff P, VP of Clinical Services verified that Resident #18 was not followed by a wound team, no measurements and/or wound assessment was done. Additionally, the prior Interim Director of Nursing instructed staff not to document weekly skin assessments as a wound team was supposed to document those. RESIDENT #7 Resident # 7 was neglected and suffered physical and psychological harm when nursing staff failed to complete a through physical assessment, identify and treat severe pain for 48 hours. Resident #7 admitted to the facility on [DATE] after having foot surgery as documented in the hospital records. Resident had discharge instructions to take [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg (narcotic pain medication, for moderate to severe pain) 1-2 tablets every four hours as needed, according to hospital discharge documents. During observations and interview on 12/30/19 at 8:35 AM, Resident #7 explained she came to the facility for rehabilitation after a having surgery to treat a broken foot and she had a broken arm. Resident #7 described experiencing severe pain for two days. Resident #7 said she asked multiple nurses for pain medication but it was not available. The resident said her pain was (10/10). The resident said she tried meditating and using a coloring book to distract her from pain. Nursing note dated 12/21/19 at 12:15 AM documented Resident #7 complained of pain level 10/10 and demonstrated frustration due to severe pain, but no medication available in the narcotic drawer. Interview with Staff R, RN (Registered Nurse), RCM (Resident Care Manager) on 01/27/20 at 11:26 AM revealed she had no training on how to complete a new admission. Staff R, RN RCM said she did not send the prescription to the pharmacy because she assumed it was medical records responsibility. Refer to F726 Staffing Competency for additional information. RESIDENT#21 Resident #21's wounds were neglected when nursing failed to complete thorough assessment and obtain wound measurements. Resident #21 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Podiatry Consult dated 12/23/19, showed Resident #21 had no open areas on the right foot. Observations and interview with Resident #21 was conducted on 01/28/20 at 1:32 PM. Resident #21 had a right immobilization cast to the right lower extremity. Resident #21 was unable to provide information about wound care. Resident #21 said she was not sure if she admitted with wounds. 1. Review of TAR for (MONTH) 2020 showed the Resident had a wound to the bottom of the right foot and there was an order for [REDACTED]. 2. Review of TAR for (MONTH) 2020 showed an order to complete head to toe skin checks weekly. On 01/15/20 the skin check was not signed off as complete. 3. Review of TAR for (MONTH) 2020 showed an order to apply medicated cream daily to the groin area, to the stump area twice daily, and ointment to the buttock folds three times a day. On the following days the orders were not carried out on 01/06/20, 01/09/20, 01/15/20, and 01/16/20 and on 01/19/20. Record review Resident showed on 01/25/20 Staff O, RN, RCM (Resident Care Manager) obtained physician orders [REDACTED]. Staff O, RN RCM on 01/28/20 at 1:34 PM was asked about how and when the resident developed wounds to the right foot. Staff O, RN RCM did not know if the resident admitted with wounds or developed them at the facility and said the wounds were not investigated to rule out abuse/neglect. Staff O, RN RCM was unable to provide weekly assessments and measurements for the wounds. Staff O, RN RCM was informed about multiple omissions of wound care on the (MONTH) 2020 TAR. The facility staff demonstrated serious disregard for consequences by not providing assessment and treatment to prevent actual and potential negative outcomes. Reference WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to adequately manage pain for 1of 3 Residents (#7). The facility failed to assess and recognize acute pain and immediately implement interventions. The lack of action demonstrated serious disregard for consequences and resulted in physical and psychological suffering. This failure resulted in an Immediate Jeopardy. Findings included: RESIDENT #7 Resident #7 was hospitalized [DATE] through 12/19/19 for displaced [MEDICAL CONDITION] bone and closed fracture of left forearm bone. Resident had ankle surgery on 12/13/19, according to the hospital records. Resident #7 admitted to the facility on [DATE]. Observation and interview with Resident #7 was completed on 12/30/19 at 08:35 AM. The resident reported she was in severe pain with spasms due to a broken foot for two days and asked multiple nurses for pain medication but it was not available. The resident said her pain was (10/10), but she could probably tolerate 5/10 pain level without medications. The resident said she tried meditating and using a coloring book to distract her from the pain. Hospital document titled After Visit Summary, showed Resident #7 discharged to the facility on [DATE] with instructions to take [MEDICATION NAME]-[MEDICATION NAME] (strong narcotic medication for moderate to severe pain) 1-2 tablets every four hours as needed. The same document showed the resident received this medication while hospitalized . Review of hospital discharge records on 01/24/19 at 2:31 PM showed a prescription dated 12/19/19 for [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg with instruction to take 1-2 tablets every four hours as needed for pain. Review of the facility admit orders and Medication Administration Record [REDACTED]. Further record review did not find evidence that licensed nursing staff assessed Resident #7 for subjective and objective signs of pain every shift for the first 48 hours. Additionally, the nurses failed to assess and document the resident's tolerable pain level in order to determine effective interventions. The comprehensive pain assessment was not complete until 12/27/19, eight days later. Interview and record review with Staff Q, LPN RCM on 01/24/20 at 1230 PM, showed the pain care plan was not initiated until 12/21/20. Staff Q, LPN RCM said that interim care plan should be initiated on the day of admit for acute pain. Nursing note dated 12/21/19 at 12:15 AM documented Resident #7 complained of pain level 10/10 and demonstrated frustration due to severe pain, but no medication available in the narcotic drawer. Review of facility incident investigation dated 12/21/19 showed Resident #7 did not receive [MEDICATION NAME] (narcotic pain medication) for 48 hours after being admitted to the facility, although there was an order and a prescription issued by the hospital. The incident investigation documented that on 12/21/19 in the afternoon, Resident #7 reported to the nurse she did not receive pain medications since the arrival to the facility (12/19/19). The resident said How could I not be in pain? I have a broken leg; and, a broken arm .I've asked everyone for pain medication; and, no one will help me. Further review of the incident investigation showed on 12/21/19 during the night shift a nurse witnessed Resident #7 moaning and groaning in pain. The resident tried repositioning her casted leg but it was ineffective. The nurse described the resident was tearful and said her pain level was 10/10. On 01/27/20 at 11:26 AM, Staff R, Registered Nurse reported she completed admit paperwork for Resident #7 on 12/19/20. Staff R, RN stated she did not receive training on admit process and she did not know that it was her responsibility to fax the prescriptions to the pharmacy. Additionally, Staff R, RN reported narcotics are available in facility emergency supply which can be given to any resident with a physician's orders [REDACTED]. Interviews conducted on 01/27/20 between 10:38 AM and 12:00 PM with four licensed nurses who were assigned to provide direct patient care. Three out of four nurses, Staff T, LPN, Staff S, RN and Staff EE, LPN reported they did not have access to omnicell (emergency supply of medication, including narcotics). On 12/30/19 at 8:28 AM, Staff A, Director of Nursing said the nurses should have contacted the physician and obtained a narcotic authorization code sooner. Refer to F 600 for additional information related to neglect involving Resident #7 and F610 for failure to conduct a thorough investigation of neglect. Reference WAC 388-97-1060

Based on observation, interview and record review, the facility failed to ensure each allegation was thoroughly investigated involving Residents #s (18, 7, 16, 26, 15, 11, 10&21) and failed to prevent ongoing abuse and neglect. Additionally, the facility failed to maintain state incident reporting log. Failure to thoroughly and timely investigate allegations of care concerns resulted in the facility determining the allegations were unsubstantiated, which led to neglect and harm to residents. Findings included: STATE REPORTING LOG In an interview on 01/24/20 at 1:30 PM, the surveyor requested a copy of the facility's state reporting log for the previous three months. Staff P, VP of Clinical Services (VPCS) said the log was missing. RESIDENT #18 Review of a facility grievance form dated 01/19/20 showed Resident #18's daughter had spoken to facility staff and reported she had the following concerns; *change in condition that was not being addressed *had received the wrong medications *weight loss *resident had been bullied *not receiving scheduled showers *dressing changes not being done *staff had been argumentative with family *mucus in chest had not been addressed *foaming at mouth - new change Additionally, the family requested that the identified staff who had been argumentative not be assigned to provide care for Resident #18. Review of the grievance summary dated 01/23/20 showed Abuse and Neglect have been ruled out. Review of Resident #18's (MONTH) 2020 Treatment Administration Record (TAR) showed a physician's orders [REDACTED].#18's chest and right torso daily. At the time of the review on 1/23/20, the dressing change had only been documented as being completed on six of 16 days, Further review of the (MONTH) 2020 TAR showed there was no order for the surgical incision on Resident #18's right thigh where he had recent surgery to remove skin for a skin graft, and no order to care for surgical incision where the resident's arm had recently been amputated. There was no documented evidence the surgical incisions were being monitored for healing and/or signs of infection. Staff P, VPCS, reviewed the chart and was not able to locate documentation of wound care or wound monitoring for the identified surgical sites Review of Resident #18's record showed a physician's orders [REDACTED]. Staff P, VPCS, stated she did not know why staff had not documented giving or offering showers daily. Review of Resident #18 weight record showed he had one weight documented in his chart, on 01/20/20, the day after his family alleged he had lost weight. Resident #18's family reported care concerns including weight loss, lack of showers, and lack of dressing changes, argumentative staff, and being bullied. In an interview on 01/28/20, at 12:23 PM, Staff BB, Interim Director of Nursing, IDNS, stated the concerns reported by Resident #18's family should have been entered on the state reporting log and should have been investigated as an allegation of neglect. Resident #18's record showed that staff had not taken his weight, and therefore were not monitoring him for weight loss, dressing changes and wound monitoring were not being completed by nursing staff, showers were not documented, and there was no documentation that the allegation of the wrong medication had been addressed. The summary indicated abuse and neglect had been ruled out, but the record clearly showed the reported concerns were correct. The facility failed to identify the reported concerns as alleged neglect and failed to identify neglect had occurred. Refer to F 600 for additional information related to neglect for Resident #18. RESIDENT #7 Review of the facility incident investigation dated 12/21/19 showed Resident #7 did not receive [MEDICATION NAME] (narcotic pain medication) for 48 hours after being admitted to the facility with acute pain following foot surgery, although there was an order and a prescription issued by the hospital. The incident investigation documented that on 12/21/19 in the afternoon, Resident #7 reported to the nurse she did not receive pain medications since the arrival to the facility (12/19/19). The resident said How could I not be in pain? I have a broken leg; and, a broken arm .I've asked everyone for pain medication; and, no-one will help me. The incident investigation summary did not substantiate neglect although staff demonstrated serious disregard for consequences and allowed the resident to suffer in pain. Refer to F600 and F697 for additional information related to Resident #7 DIVERSION Review of the facility investigation dated 01/20/20 there had been an allegation of staff diverting narcotics. RESIDENT #16 The investigation did identify Staff AA, Licensed Practical Nurse, LPN, was involved in missing narcotic medications,including 92 missing [MEDICATION NAME] tablets belonging to Resident #16. Review of Resident #16's MDS (Minimum Data Set - an assessment tool) dated 01/12/20, showed Resident #16 had discharged to the hospital with anticipated return. The investigation identified that Resident #16 was missing four cards of narcotic medications. All four cards of medications were missing from the drug cart. All four corresponding pages in the narcotic count book had documentation that staff transferred the medications to a different page in the book. However, upon review of the book, there were no other pages to account for the medication being used or ever being accounted for since the time of transfer. Further review of the facility investigation into the diverted narcotics showed a conclusion of unsubstantiated, misappropriation did not occur as the identified residents no longer reside in the facility. The facility did identify that Resident #16 was missing medications, and Staff AA, LPN, had singed them out of the narcotic book without a witness, therefore misappropriation did occur. The facility failed to identify misappropriation of resident property (medication), as form of abuse. Further review of narcotic book on 01/24/20 showed additional inconsistencies, not previously identified by the facility investigation involving Resident #26. RESIDENT #26 In an interview on 01/24/20, at 4:50 PM, Staff S, Registered Nurse, RN, reviewed the narcotic log book with the surveyor. Staff S, RN, reviewed page 21 of the book and confirmed the page indicated the medication cart should have 21.75 milliliters of [MEDICATION NAME] (a narcotic pain reliever). Staff S, RN, opened the medication cart and stated the medication was not in the cart. Staff S, RN, stated that although he had signed the narcotic book, indicating that all medications listed in the book were accounted for, he had not actually seen the [MEDICATION NAME], and could not remember ever seeing the [MEDICATION NAME]. Refer to F755 for additional investigative finding related to mismanagement of the narcotics involving multiple other residents. The facility failed to complete thorough review of all secured medications to determine the severity of the diversion. RESIDENT #15 Review of the facility incident investigation dated 01/21/20 indicated Resident #15 was missing $90 cash that had been in his pocket. The investigation included a statement from Resident #15, who stated he woke up to see a young male in his room going through his clothes, and then checked him to see if he had been incontinent. The investigation did not include statements from the resident's roommate related to seeing a male in the room matching the description provided and did not include staff statements related to seeing a male who matched the description in the facility. Additionally, there was no evidence to show the facility reviewed the assigned staffing schedule to identify if there was a staff who matched the description assigned to provide care for Resident #15. Review of Resident #15's records showed an assessment dated [DATE] which identified the resident was newly admitted to the facility, and having depression related to being placed in a skilled nursing facility. Further review of Resident #15's record showed he was not placed on alert monitoring for potential psycho-social harm related the missing money or for increased depression following the incident. In an interview on 1/27/20, at 3:00 PM, Staff D, Operations, was informed of the concerns identified when reviewing the investigations and confirmed the investigation was not thorough. RESIDENT #11 Review of the facility state reporting log showed an entry dated 01/21/20 that indicated there had been a resident to resident altercations in which Resident #11 was the victim. Review of facility incident investigation dated 01/21/20 which indicated Resident #11 was physically struck with a walker by another resident. Further review of the investigation showed no documentation that facility staff had notified law enforcement of a physical altercation. There was no evidence that Resident #11 was asked if she wanted law enforcement notified. In an interview on 01/27/20, at 3:00 PM, Staff D, Operations, was notified the investigation did not include contacting or offering to contact law enforcement. Staff D, Operations, was not able to provide any further details. RESIDENT #10 Review of the facility's state reporting log showed an entry dated 01/20/20 indicating there had been an allegation against staff related to the treatment of [REDACTED]. Review of the identified investigation showed that Resident #10 alleged Staff Z, CNA, had thrown a towel at him while providing care. The investigation included a statement from Staff Z, CNA, which described the incident and stated that Staff S, RN, had entered the room. The investigation did not include a statement from Staff S, RN, who was the only witness to the interactions between Resident #10 and Staff Z, CN[NAME] The allegations was unsubstantiated as the investigation only included descriptions of the interactions between Resident #10 and Staff Z, CNA, from the two involved, and did not include a statement from the only other person who entered Resident #10's room during the identified timeframe. In an interview on 01/27/20, at 3:00 PM, Staff D, Operations, was given the information related to the lack of witness statements included in the investigation. Staff D, Operations, was not able to provide any additional information. RESIDENT#21 Resident #21's wounds were neglected when the facility failed to complete thorough and consistent assessments and obtain wound measurements from 12/24/20 through 1/28/20. Resident #21 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations and interview with Resident #21 was conducted on 01/28/20 at 1:32 PM. Resident had a right immobilization cast to the right lower extremity. Resident was unable to provide information about wound care. Resident#21 said she was not sure if she admitted with wounds. Record review of Podiatry Consult dated 12/23/19, showed Resident #21 had no open areas on the right foot. 1. Review of TAR for (MONTH) 2020 showed Resident #21 had a wound to the bottom of the foot and was scheduled for a daily dressing change. The documentation on the TAR showed the dressing changes were not completed on 01/6/20, 01/9/20, 01/10/20, 01/15/20, and 01/19/20. 2. Review of the (MONTH) 2020 TAR showed an order to complete head to toe skin check weekly. On 01/15/20 the skin check was not signed off as complete. 3. Review of the (MONTH) 2020 TAR showed an order to apply medicated cream daily to the groin area, to the stump area twice daily, and apply ointment to the buttock folds three times a day. On the following days the orders were not carried out as evidenced by multiple holes in documentation on 01/6/20, 01/9/20, 01/15/20, and 01/16/20 and on 01/19/20. On 01/25/20 physician orders [REDACTED]. Staff O, RN Resident Care Manager (RCM) on 1/28/20 at 1:34 PM was asked about how Resident #21 developed wounds. Staff O, RN RCM did not know if Resident #21 admitted with these wounds or developed them at the facility. There was no investigation completed to rule out abuse/neglect. Staff O, RN RCM was unable to provide measurements for the wounds. Staff O, RN RCM was informed about multiple omissions of wound care on the (MONTH) 2020 TAR. Reference WAC 388-97-0640(1)

Based on observation, interview and record review the facility failed to assess and determine risk factors for elopement, and adequately supervise and monitor two of three residents (Residents #s 6 and 7) to ensure they remained safe and/or free from falls when they left the facility unattended. Harm occurred when Resident #6 walked outside the building at night and fell , resulting in facial laceration requiring transport to the hospital for treatment with stitches. Findings included . Facility Resident Elopement Guideline documented a resident who demonstrated behavior indicated risk for elopement would be assessed utilizing the Elopement Risk Evaluation, and added to the list of elopement risk residents and plan of care. Facility policy titled Wandering, Unsafe Resident documented the resident's care plan would identify interventions to try to maintain safety, such as a detailed monitoring plan. RESIDENT #6 Resident #6 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/12/19, physician orders [REDACTED]. An Admission Evaluation showed the resident had a history of [REDACTED]. A Minimum Data Set Assessment (MDS, required assessment) dated 08/19/19 and 09/02/19 both showed the resident had memory impairment. Resident #6 scored low (three and five) out of 15 on a Brief Interview for Memory Status assessment. A nursing note dated 08/13/19 showed Resident #6 independent with mobility and transfer. During observation on 10/17/19 at 4:55 PM, Resident #6 walked from the end of the bed and sat down without using a walker located on the opposite side of the bed. The resident had healing stitches approximately two inches long above the left eye. When asked what happened, the resident stated he fell outside and tripped on bushes at midnight. The resident stated he chased something and could not remember what he chased or why he went outside. Later observation and interview on 10/21/19 at 11:35 AM, Resident #6 stated that it didn't feel good going to the emergency room . The resident also stated he could not open his eye for for two to three days after he fell . The resident wore a wandergaard on the left wrist and stated that he didn't know what it was for. Resident #6 exhibited behavior of wanting to leave the facility and discharge on multiple occasions. A nursing note dated prior to the fall on 09/01/19, showed Resident #6 packed up belongings and sat down on the couch by the nursing station; appeared anxious and irritable and stated I am discharging today. I am ready to go. What's taking so long? Get me a taxi. Staff notified the resident's family and spoke with the resident and the resident returned to his room. The record did not contain evidence staff conducted an initial assessment to determine risks for wandering/elopement at the time of admission or after concerning actions and statements of wanting to leave. The resident's care plan and aide directive did not identify additional level of supervision needed to assure safety after informing staff he wanted to leave. On 09/17/19 and 09/29/19, social service notes documented the resident wanted to discharge home. Note written 09/17/19 showed Staff K, Social Services Assistant (SSA,) recommended the resident remain in the facility due to lack of safe discharge plan. Both notes showed Staff K, explained resident rights to the resident and was free to leave AM[NAME] Staff K's note written 09/29/19 showed Resident #6 agreed to wait to discuss discharge until care conference with family on 10/01/19. Resident #6 left the facility during the night the day after notifying staff he wanted to leave multiple times. Nursing note dated 09/30/19 written at 12:10 PM, showed Resident #6 exited the building at an unknown time, approximately 10:00 PM. A nursing note written at 12:15 AM showed staff found the resident seated under a covered area, upright in a chair, outside the kitchen door on the north side of the building. AccuWeather report showed low temperatures on 09/30/19 were 40 degrees Fahrenheit that night. Notes showed staff found the resident, provided first aid and sent the resident to the hospital. A facility investigation showed Resident #6 stated he went outside and fell four times, and each time I tried to get up I had a hard time; but I did it. Then I found my way here and tried to get inside but couldn't. During an interview on 10/17/19 at 3:45 PM, Staff G, Licensed Practical Nurse (LPN), stated that Resident #5 fell down the hill into bushes and did not always walk steady. Nursing note dated 09/30/19 at 6:53 AM showed Resident #6 returned to the facility with stitches for a laceration on the forehead and prescribed pain medication. A nursing note written 10/03/19 showed Resident #6 had eight intact sutures above the left eye and fading dark red bruising around the eye. On 10/07/19, the facility obtained informed consent for Resident #6 to wear a wander guard to alert staff if the resident exited the building again. The resident's record did not include an assessment for elopement risk or identify the level of supervision in the care plan following elopement, for staff to follow to assure resident safety. An elopement binder kept at the nursing station for staff to identify residents at risk for elopement, did not include information for Resident #6. During an interview on 10/21/19 at 8:55 AM, Staff D, Registered Nurse, Resident Care Manager (RN RCM), looked in the elopement binder and confirmed it did not include information regarding Resident #6. FORMER RESIDENT #7 Resident#7 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Facility assessment dated [DATE] resident had severe cognitive impairment. Nursing note dated 10/11/19 described Resident #7 was found outside off of the facility grounds by staff. The facility reported the incident to the state agency on 10/11/19. The resident was discharged to another facility on 10/15/19. Record review on 10/17/19 did not find evidence that wandering and/or elopement risk assessment was complete at the time of admission to the facility. On 10/17/19 at 4:17 PM Staff A, administrator said she expected residents to be evaluated at the time of admission for wandering/ elopement risk. The facility did not complete elopement incident investigation until 10/21/19, ten days later. WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to ensure three of five residents (Residents #8, 9 and 10) who were reviewed for medications were free of significant medication errors. Significant medication error resulted in harm for Resident #8 due to critical blood levels that occurred from failing to monitor effects of anticoagulant medication. Significant medication error means one which causes the resident discomfort or jeopardizes his or her health safety. Findings included: ANTICOAGULANTS RESIDENT #8 Resident #8 admitted to the facility on [DATE]. Resident's [DIAGNOSES REDACTED]. Hospital discharge records identified resident was prescribed [MEDICATION NAME] (anticoagulant, blood thinner.) with therapeutic goal levels between 2-3. This medication is from a category that requires the resident to be titrated to a specific blood level and has a narrow therapeutic index ( where therapeutic dose is close to toxic or harmful dose). According to the hospital discharge documentation dated 10/11/19, Resident # 8 had abnormally high INR (international normalized ratio, laboratory measurement of blood clotting time) levels on 10/4/19 and it was reversed with vitamin K. Given this history resident was a high risk for bleeding from [MEDICATION NAME] use. The same hospital discharge orders showed Resident #8 was prescribed [MEDICATION NAME] to be administered concurrently with three different antibiotics (Imipenem, [MEDICATION NAME]). It is known that [MEDICATION NAME] and antibiotics have drug to drug interaction and may increase blood levels of the anticoagulant, therefore increased monitoring is appropriate. The facility ANTICOAGULANT PROT[NAME]OL obtained on 10/17/19 stated that INR levels should be checked daily after admission until INR is in goal range and checked on Monday and Thursday while resident is on an antibiotic to maintain in goal range. Between 10/11/19 and 10/15/19 resident received [MEDICATION NAME] 3 mg four times concurrently with an antibiotic. On 10/14/19 Administration Record showed that INR levels should have been checked on 10/11/19 and on 11/14/19, but lab tests were missed. Resident's laboratory test obtained on 10/16/19 showed resident developed INR of 8.4, a critical level. The facility system for monitoring [MEDICATION NAME] and tracking blood levels involved filling out a [MEDICATION NAME] flow sheet. Review of facility [MEDICATION NAME] book on 10/14/19 located at the nurses station did not include a flow sheet for [MEDICATION NAME] tracking for Resident #8. On 1015/19 at 10:15 AM during an interview Staff E, LPN, RCM stated that nursing staff should be utilizing INR flow sheet to track blood levels and medication administration but were not using it. RESIDENT #9 Resident #9 admitted to the facility on [DATE]. Resident's [DIAGNOSES REDACTED]. Hospital discharge orders dated 08/24/19 showed resident was to receive 5 mg of [MEDICATION NAME] on Tuesday, Wednesday, Thursday, Friday and 4.5 mg of [MEDICATION NAME] on Monday. The INR goal was 2-3. The discharge notes from 08/21/19 showed that resident was to have INR levels checked weekly. Between 08/23/19 and 10/4/19 Resident #9 received 44 doses of [MEDICATION NAME] without INR levels checked. Records showed the resident was at risk for potential bleeding due to low hematocrit level of 29 on 08/20/19 and use of an anticoagulant. Review of facility records did not find evidence of bleeding monitoring as evidenced by lack of weekly skin assessments. Review of facility evidence of medication error investigation on 10/14/19 did not show that other residents were reviewed for similar problems. The investigation did not identified how and why the medication administration process failed. Additionally, the facility did not identify systematic intervention to decrease the likelihood of future unsafe medication administration practices. ANTIBIOTIC OMISSION. RESIDENT #8 Resident #8's dicharge hospital records dated 10/12/19 showed an order for [REDACTED]. Review of Medication administration order with Staff F, Registered Nurse (RN) on 10/17/19 at 12:31 PM identified [MEDICATION NAME] dose was not transcribed to the facility admission orders [REDACTED] Review of Medication administration orders with Staff F, RN on 10/17/19 at 12:31 PM identified the Resident missed five doses of iv antibiotics. INSULIN RESIDENT #10 Resident #10 readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview on 10/18/19 at 3:06 PM Resident #10 sat on the edge of the bed and stated she relied on nursing staff to give insulin injections twice a day. The resident also stated a nurse told her the physician ordered a new insulin that started Wednesday. On 10/04/19, the physician ordered nursing staff to administer by injection, 40 units of [MEDICATION NAME] 70/30 insulin at 7:30 AM and 20 units at 5:00 PM to Resident #10. (MONTH) 2019 Medication Administration Records (MAR) showed to start the medication on 10/05/19. There are many types of insulin available. Each has a specific amount of time when the medication begins to work, peak and length of duration. [MEDICATION NAME] 70/30 is a combination of regular and intermediate acting insulin. This insulin starts to work within 10 to 20 minutes after injection, peaks in two hours and keeps working for 24 hours. During an interview on 10/18/19 at 2:15 PM , Staff B, Resident Care Manager, Licensed Practical Nurse (RCM, LPN) stated that when she worked the medication cart on Sunday (10/13/19), Resident #10 did not have 70/30 insulin in the cart and the facility did not have back up or emergency supply of the medication. Staff B also stated the order for the pharmacy had not received or processed the medication order and did not have 70/30 insulin to administer to the resident. Staff B stated that four staff signed they administered [MEDICATION NAME] 70/30 and did not document in the record the medication was not available. Staff B also stated medication errors occurred during nine days and two different shifts and involved multiple staff. A pharmacy delivery receipt showed the pharmacy delivered 70/30 insulin on 10/14/19 at 1:18 PM. October 2019's MAR indicated [REDACTED]. Licensed staff documented they administered 70/30 insulin to Resident #10 at 5:00 PM three times on 10/09/19; 10/11/19 and 10/12/19. October 2019's MAR indicated [REDACTED]. On 10/12/19 at 7:30 AM and on 10/05/19, 10/06/19 and 10/07/19 and 10/08/19 at 5:00 PM, licensed staff coded the MAR indicated [REDACTED]. On 10/06/19 Resident #10's blood glucose level measured 82. The record did not show why staff held the insulin when the blood glucose measured above 70. During an interview on 10/18/19 at 3:25 PM, Staff M, Registered Nurse (RN) stated that if nursing staff did not find 70/30 insulin in the medication cart, she would contact the physician and obtain alternate insulin orders until the pharmacy delivered it. During an interview on 10/18/19 at 4:30 PM, Staff H, Registered Nurse (RN, stated that on 10/08/19, she administered [MEDICATION NAME] R insulin instead of 70/30 insulin, and thought the two types of insulin were the same. Staff H confirmed the MAR indicated [REDACTED]. During an interview on 10/18/19 at 5:05 PM, Staff M, looked at Resident #10's vial of 70/30 insulin, and confirmed it did not show the date staff first opened the vial, and could not confirm the date the facility received the insulin and opened it. WAC 388-97-1060(3)(k)(iii)

Based on observation, interview and record review the facility failed to maintain a system for management of pressure injuries that included implementation of all interventions for prevention; conduct initial assessments and ongoing monitoring of pressure injuries; follow physician orders [REDACTED].# 2, 3, 4, 5 and 9) reviewed who had pressure injuries. Resident #2 experienced harm due to development of two new stage 2 pressure injuries. Resident #4 experienced harm due to worsening of a pressure injury from stage 2 to stage 4. Resident #5 experienced harm when pressure injury increased from stage 2 to stage 3. Findings included . Facility Pressure Ulcers/Skin Breakdown - Clinical Protocol showed nursing staff would describe and document full assessment of pressure ulcers including location, stage, length, width and depth, presence of exudates or necrotic tissue. Documentation should include reporting of a resident's mobility status, current treatments including support surfaces and depth of wound. Protocol for wound care showed for staff to document in the record all assessment data (ie; wound bed color, size, drainage etc.) obtained when inspecting the wound; document if the resident refused treatment and reasons and notify the supervisor if refused. The National Pressure Ulcer Advisory Panel (NPUAP) describes a stage 2 pressure injury as partial thickness skin loss with exposed dermis; stage 3 as loss of full thickness of skin in which fat is exposed; and stage 4 as full thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. On 10/17/19 at 2:46 PM, Staff D, Registered Nurse, Resident Care Manager (RN, RCM) stated that the facility did not maintain their own wound tracking sheets on residents who had pressure injuries. Staff D looked in the computer for resident wound assessments emailed to staff by outside consultant United Wound, to obtain current information on progress of resident pressure injuries. During an interview on 10/17/19 at 2:06 PM, Staff G, Licensed Practical Nurse (LPN) stated that he provided treatments to all resident wounds today. Staff G stated he had to look at individual resident's treatment records to see what treatments needed to be done because the facility did not provide a list of residents who needed them. Staff G also stated if the treatment was not on the treatment record, he would not know it needed to be done. FORMER RESIDENT #2 Resident #2 admitted to the facility on [DATE] following hospitalization . [DIAGNOSES REDACTED]. A nursing Admission assessment dated [DATE] and a Minimum Data Set (required assessment) dated 09/18/19, both showed the resident did not admit with or currently have pressure ulcers. The MDS assessment showed Resident #2 required assistance from two staff to move and turn in bed, transfer, toilet and personal hygiene; frequently incontinent of urine and always incontinent of bowels; dependent on staff for locomotion and used a wheelchair. The MDS also showed the resident had impaired memory, disorganized thinking and difficulty concentrating. Nursing notes dated 09/11/19 showed the resident could not always verbalize needs. When the resident asked to use the bathroom, he forgot what he asked for when help arrived. Nursing note dated 09/21/19 showed Resident #2 wheelchair bound and unable to walk. Nursing Aide bedside Kardex (careplan) interventions initiated after admission on 09/12/19, included interventions for nursing aides to follow: 1. Use a draw sheet or lifting device to move resident. 2. Extensive two-person assistance by two staff to turn and reposition in bed 3. Extensive assistance by two staff for transferring. DECREASED ORAL INTAKE/UNRELIABLE WEIGHTS Weight loss and dehydration are risk factors for development of pressure injuries. Food records dated between 09/12/19 through 09/29/19 showed Resident #2 ate variable amounts, between 26 % to 75% of meals and consumed less than 1000 ml a day in fluids. A Dietary Evaluation dated 09/18/19 showed Resident #2 needed to eat 83% of the meal to maintain weight and drink 1650 ml of fluid daily. Staff did not monitor Resident #2's weight following admission. Weights recorded only one weight on admission and a second weight taken 09/26/19, 13 days later. Weights recorded for Resident #2 on 9/11/19, 9/24/19, and 9/26/19 all showed Resident #1 weighed the same, 176.2 lbs. On 9/30/19 and 10/1/19, Resident #1 weighed 148.6 lbs. A Dietary evaluation dated 09/30/19 showed Resident #1 lost 15.7% of body weight in four days or a loss of 27.4 lbs. During an interview on 10/15/19 at 1:09 PM, Staff [NAME] Licensed Practical Nurse, Resident Care Manager (LPN, RCM) stated that new admissions should be weighed daily for three consecutive days and then weekly thereafter if stable. Staff [NAME] stated that the first three weights were questionable, and likely not accurate, since each weight was the same and did not show how they were obtained, such as sitting, standing or in a wheelchair. Staff [NAME] also stated that she investigated the weight loss right away and determined the 148.6 lbs. (last weight) was accurate and did not know why previous weights were unreliable. Resident #2's record did not show staff evaluated if the resident consumed dietary recommendations for amount of fluids in 24 hours. Lack of timely weight monitoring prevented staff from determining the trend of weight loss and implement interventions sooner than 09/30/19. During an interview on 10/15/19 at 1:35 PM, Staff B, LPN, RCM, ADON, stated that no one reported Resident #2 did not drink enough. Staff B stated that nursing staff should be looking at residents every day for adequate intake of food and fluids. NEW ONSET PRESSURE INJURIES Eleven days after admission, a nursing note, dated 09/22/19, showed Resident #2 developed two Stage 2 pressure ulcers; one on the left buttock and one on the right buttock. The left buttock measured 5 cm x 5 cm and the right buttock measured 3 cm x 4.5 cm. A facility skin investigation, revised date 09/22/19, showed a family member informed nursing staff of the new skin issues. Weekly Skin Observation - V 2 form dated 09/22/19 showed the wounds required further assessment. Resident #2's record did not contain further assessment of the wounds. The investigation did not identify causative factors or analysis how or why two stage 2 pressure injuries developed, such as impact of care provided by staff that included positioning and incontinence, and determine if avoidable or unavoidable. During an interview on 10/15/19 at 12:49 PM, Staff B, Licensed Practical Nurse, Resident Care Manager, Assistant Director of Nursing, (LPN, RCM, ADON,) stated that the investigation should show causative factors involved in development of pressure injuries, why it happened and if preventable or not. The facility skin investigation documented the Resident Care Manager would obtain an order for [REDACTED]. NOT TURNED OR REPOSITIONED On 09/22/19, the physician ordered to reposition Resident #2 every two hours. Treatment records and nursing notes did not provide evidence staff provided repositioning every two hours to offload pressure points before the onset of pressure injuries or thereafter. Nursing aide care plan Kardex did not provide directions and frequency for positional needs and changes. On 09/24/19, the care plan added directions to follow facility policies/protocols for the prevention/treatment of [REDACTED]. During an interview on 10/15/19 at 1:35 PM, Staff E, LPN, RCM, stated that the facility did not have a policy and procedure that specifically addressed turning and repositioning residents and skin prevention. During an interview on 10/17/19 at 3:09 PM, Staff H, Registered Nurse (RN), stated that Resident #2 was already up in a wheelchair by 1:45 PM and stayed up until 7:00 PM or 8:00 PM. Staff H stated that staff lay the resident down when being changed. Nursing aide task documentation did not show or provide evidence how often staff changed Resident #2's position or frequency of incontinence checks. Fifteen out of thirty three times, between 09/12/19 and 09/22/19, staff documented they moved the resident in bed with one staff, not two as directed in the care plan. Two staff were needed to use a draw sheet when moving the resident in bed to prevent skin damage such as friction and shearing. During an interview on 10/15/19 at 12:49 PM, Staff B, LPN, RCM ADON, stated that the nurse on the floor should ensure residents were turned and repositioned every two hours and nursing aides should document how often they repositioned and changed residents. FAILURE TO MONITOR Resident #2's record did not contain evidence staff monitored the condition of both pressure injuries or conducted reassessment one week after discovery (09/27/19), to determine if changes to the treatment plan were needed. During an interview on 10/15/19 at 12:49 PM, Staff B RN, RCM, ADON stated that nursing staff should document the progress of pressure injuries in nursing progress notes .it could be daily, every three days or weekly. During an interview on 10/15/19 at 1:09 PM, Staff E, LPN, RCM stated she did not locate any monitoring of Resident #2's pressure injuries in the record. WHEELCHAIR/CUSHION NOT ASSESSED During an interview on 10/15/19 at 1:35 PM, Staff [NAME] LPN, RCM stated that Resident #2 spent a lot of time seated in a standard wheelchair and wheelchair cushion. When asked to describe the type of seat and cushion, Staff [NAME] did not know and suggested to ask therapy staff. During an interview on 10/15/19 at 4:40 PM, Staff S Therapy Director (TD) stated Resident #2 had a standard wheelchair and displayed a two-inch foam cushion Resident #2 had for his wheelchair. Staff S stated that nursing should refer residents with new pressure injuries to evaluate for possible modifications to wheelchairs and cushions to assist with offloading pressure on wounds. Staff S stated he did not locate a request from nursing staff for therapy to evaluate Resident #2's wheelchair and cushion and did not know the resident developed pressure injuries. Nursing note dated 10/02/19, showed the evening before (10/01/19) at 9:45 PM, staff sent Resident #2 to the hospital due to dehydration. Additional late entry notes showed the resident had not voided in eight hours and refused two meals during the day (date not identified). The resident's record did not include reassessment of Resident #2's pressure injuries before staff sent the resident to the hospital. During an interview on 10/18/19 at 4:45 PM, Staff A, Administrator stated that the facility did not have investigations why Resident #2 developed dehydration and pressure injuries. Resident #2's record did not contain evidence the facility provided consistent interventions to prevent pressure injuries and promote healing that included frequent repositioning; obtain consistent weights to identify weight loss trends timely; identify positioning needs while seated in a wheelchair; and conduct monitoring of wound following identification. RESIDENT #5 During observations and interview on 10/10/19 at 10:15 AM, Resident #5 had a wound isolation cart outside the room door that showed Contact Precautions. The resident sat up in bed greater than 30 degrees. The mattress did not have a pump connected to it and the resident stated it was a facility mattress. The resident also stated he had pressure ulcers on his bottom and heels which worsened. The resident stated he had his own wheelchair but it did not work and did not get out of bed. Entry Minimum Data Set record (MDS, required submissions to Centers for Medicaid and Medicare Services) showed Resident #5 admitted to the facility on [DATE] following hospitalization . A Nursing Admission Evaluation dated the next day, 10/04/19, showed the resident had a stage 2 pressure injury to the right buttock that measured 2.0 cm x 1.5 cm and unstageable pressure injuries on the right and left heels with eschar (dead tissue.) The assessment also showed the resident had [MEDICAL CONDITION], bladder dysfunction; an infection and major [MEDICAL CONDITION], and a pressure ulcer on the right buttocks and both heels. The record did not contain an assessment of the wounds on the date of admission, or further description of wounds, such as measurements of heel ulcers, depth of right buttock wound or condition of wound beds, surrounding skin, or presence of exudate on all wounds. A Braden Scale for Predicting Pressure Sore Risks dated 10/04/19 showed Resident #5 had risk factors due to very moist skin; confined to bed; very limited mobility and sensory perception, and a potential for skin to shear when moved. An Admission MDS, Minimum Data Set Assessment (MDS, required assessment tool) dated 10/10/19 showed Resident #5 admitted with the pressure injuries, required extensive assistance from two staff to move and turn in bed; toileting, hygiene and transfer activities; had frequent episodes of incontinence of urine and always incontinent of bowel. The MDS did not show staff implemented a turn and reposition program for the resident. TURN AND REPOSITION Resident #5's care plans for skin impairment dated 10/04/19, contained interventions for heel protector boots; use of a draw sheet to move the resident; caution during transfers; clean the peri area after incontinence episodes; and follow facility policies/protocols for prevention of skin breakdown. The care plan did not include individualized interventions for staff regarding frequency of turning or specific positioning to offload pressure on heels when in bed; or how to minimize pressure on buttocks and maximize circulation to buttock pressure injury. Following admission, during the first 63 hours between the first nursing note entry documented 10/03/19 at 6:43 PM until 10/06/19 at 10:12 AM, the record did not show how staff positioned or how frequently they repositioned Resident #5. Nursing notes written later showed repositioning occurred at two-hour intervals intermittently. The record did not contain evidence staff assessed the resident's skin response to positioning to determine if two hour intervals to reposition was adequate due to promote circulation due to bedfast status. During an interview on 10/10/19 at 11:00 AM Staff W, Certified Nursing Assistant (CNA), stated that staff try to turn residents every two hours. Staff W also stated there could be many residents who need two person care so staff have to wait and find another staff member to assist. During an interview on 10/18/19 at 1:30 PM, Staff X, Certified Nursing Assistant (CNA), stated that sometimes aides work short staffed or wait for extra aides to come in to help. Staff X CNA, stated that sometimes residents had to wait to be changed or turned every two hours if aides were busy covering two runs or during busy times after meals. INCREASED STAGING OF PRESSURE INJURY Four days after admission on 10/07/19, United Wound Healing (team centered wound care), assessed Resident #5's wounds and increased the right buttock pressure ulcer staging from stage 2 to stage 3 that measured 1.0 cm x 1.0 cm x 0.2 cm. with exposed adipose tissue. Wound assessment on 10/14/19 conducted by United Wound healing, showed Resident #5's stage 3 pressure injury measured 3.0 cm length x 6.0 cm width and 0.1 cm depth. An MDS assessment dated [DATE] showed Resident #5 had frequent episodes of urinary incontinence and had bowel incontinence. The resident's record did not show when, or if staff changed the dressing following episodes of incontinence. From 10/04/19 until Resident #5 discharged [DATE], the record did not show facility nursing staff documented assessment or description of heel or buttock pressure injuries at least weekly for all nursing staff to have access to information. MATTRESS The initial nursing assessment dated [DATE] showed Resident #5 owned a personal air mattress. A social service note dated 10/07/19 showed staff contacted the family to bring the mattress to the facility per resident request. The record did not contain further information such as type of mattress the resident had; if the family brought the mattress to the facility; assessed it for therapeutic value and discussed it with the physician. During interview on 10/15/19 at 12:48 PM Staff B, Licensed Practical Nurse, Resident Care Manager (LPN, RCM), stated a resident with a pressure injury that did not walk should have an air mattress as a preventive measure. The record did not contain evidence nursing staff followed up with Resident #5 regarding the resident's preference to use his own air mattress or discussed risks and benefits regarding not using one, as part of wound care treatment upon admission. Resident #5's buttock pressure injury progressed from stage 2 to stage 3 between 10/03/19 to 10/07/19. The facility did not have an investigation that identified causal factors or if and how decline was unavoidable. RESIDENT #4 Resident #4 readmitted to the facility on [DATE] following hospitalization . Initial Admission/Readmission Evaluation 01/02/19 identified Resident #4 had [DIAGNOSES REDACTED]. The assessment showed the resident did not eat or drink by mouth; received nutrition through tube feedings; had impaired speech and vision; and dependent on staff for repositioning and turning in bed. A skin risk assessment dated [DATE] showed Resident #4 had high risk factors for developing pressure ulcers that included being bedfast; immobile and had occasionally moist skin and risk to cause shear/friction of skin. Significant Change Minimum Data Set assessment, (MDS, required assessment tool) dated 01/02/19 showed the resident had frequent incontinence of urine and always incontinent of bowel; had functional limitation for range of motion to both upper and lower extremities, and required extensive assistance from two staff for bed mobility; transfer; toileting; personal hygiene and bathing. Initial admission assessment dated [DATE] showed the resident admitted with a pressure injury on the left buttock that measured 5.0 cm x 4.0 cm x 0.5 cm. The record did not include further information such as stage, condition of wound and surrounding tissue. MDS dated [DATE] identified Resident #4's pressure injury as stage 2 at the time of admission. On 01/02/19, the physician ordered a United Wound consult for Resident #4 and to turn and reposition the resident every two hours. Assessments showed the wound increased from stage 2 between 01/02/19 to stage 4 on 01/17/19, within fifteen days. Eight days after admission, on 01/10/19, Weekly Wound Log assessment showed the left buttock pressure injury was stage 3. Weekly Wound Log dated 01/17/19 assessment showed the wound was stage 4, that measured 3.0 cm x 2.4 cm x 1.5 cm. On 01/31/19, a Weekly Wound Log assessment downgraded Resident #4's left buttock pressure injury to stage 3 which measured 2.5 cm x 2.5 cm x 1.1 cm. Pressure injuries stages are not downgraded but remain the highest stage until healed. United Wound notes dated 10/14/19 contained a summary of wound progress. Resident #4's wound required debridement multiple times; use of a wound VAC; developed tunneling and multiple changes to treatment. A tunneled wound has a channel that extends from the wound into the muscle or subcutaneous tissue. On 10/21/19, United Wound showed the wound was stage 4; not healed; and decreased in size that measured 0.5 cm x 0.4 cm x 0.2 cm. During observation on 10/17/19 at 10:42 AM, Staff G, Licensed Practical Nurse (LPN), positioned Resident #4 on the right side to complete a dressing change. The resident had a small opening approximately one half inch in diameter visible above the coccyx. Staff G placed a Q-tip into the wound opening and stated the tunnel length was about 1.1 to 1.2 cm long. Staff G applied medicated ointment to the wound and a dressing. During observation on 10/17/19 at 10:55 AM, Staff X, Certified Nursing Assistant, turned Resident #4 to the left side of the bed and placed a draw sheet beneath the resident. Staff X then walked to the opposite side of the bed and pulled the edges of the draw sheet from beneath the resident to pull the sheet toward the opposite side of the bed. Staff X did not use the assistance of a second staff person to assist with repositioning in bed and placed the resident at risk for shearing/friction of skin. INCONSISTENT WOUND MONITORING Weekly Wound Log assessments contained areas to document size, amount of exudate; stage and condition of wound bed, edges and surrounding skin; pain and progress of pressure injuries. This information would allow staff to track monitoring the condition and progress of the pressure injury week to week to determine if interventions were effective or changes to treatment and care were required. This also enabled all licensed staff who cared for the resident to have access to the information. Resident #4's record were missing wound assessments during the following weeks: 1. for nine weeks beginning 05/23/19 until 07/25/19; 2. for three weeks beginning 08/08/19 until 08/26/19; 3. for eight weeks beginning 09/02/19 through 10/21/19. During an interview on 10/15/19 at 4:20 PM, Staff O, Staff Development Coordinator (SDC), stated that when United Wound sent their reports to the facility, if they weren't given to medical records they wouldn't get scanned into the record. Later at 4:27 PM, Staff O SDC, stated that nursing staff went on rounds with United Wound and should take notes on measurements and wounds. Staff O thought United Wound reports were sent to Staff C, Licensed Practical Nurse, Admissions (LPN, A), and Staff D, Registered Nurse, Resident Care Manager (RN, RCM). During an interview on 10/17/19 at 10:46 AM, Staff D, Registered Nurse, Resident Care Manager (RN, RCM) stated that the facility had only been receiving wound notes from United Wound for the past month to month and a half. When received they were emailed and had to be scanned into the record. Resident #4's record did not show staff conducted consistent head to toe weekly skin observations. Beginning 03/11/19, staff documented results of weekly skin monitoring on Weekly Skin Observation forms in the electronic record Weekly skin monitorings were missing for multiple periods during the following weeks: 1. Two weeks between 04/16/19 and 04/29/19; 05/06/19 and 05/20/19 and 10/07/19 and 10/19/19. 2. Three weeks between 05/20/19 and 06/10/19; and 09/16/19 and 10/07/19. 3. Four weeks between 06/10/19 until 07/08/19; 07/08/19 until 08/05/19; and 08/05/19 until 09/02/19 Between 06/10/19 and 09/02/19, the record showed staff conducted weekly skin observations once a month and not once a week. A Weekly Skin Observation report dated 03/28/19 identified a new skin issue of a left trochanter wound that measured 3.0 x 3.0 x 0. The record did not include further information regarding ongoing condition or outcome of that wound. During interview on 10/17/19 at 10:25 AM, Staff G, Licensed Practical Nurse (LPN) stated that weekly skin observations were to be completed every week. AIR MATTRESS On 10/15/19 at 9:16 AM, during observation of specialty mattress (Proactive 8000) on Resident #4's bed, mattress settings showed alternate pressure, cycling every 20 minutes and showed a weight bar set at 350.The air pump at the end of the bed did not indicate settings were locked. The record did not include a physician order [REDACTED]. During an interview on 10/17/19 at 9:48 AM, Staff R, Licensed Practical Nurse (LPN) stated that the order showed to monitor the air mattress to ensure it worked properly. Staff R LPN did not think the settings for the mattress were written down anywhere and nursing did not look at the settings, and looked only to see if the air mattress was too hard or too flat. During an interview on 10/21/19 at 12:00 PM, Staff B, Licensed Practical Nurse, Resident Care Manager, Assistant Director of Nursing, (LPN, RCM, ADON) stated that nursing set up mattress settings and monitored to ensure the mattress worked and not the specific settings. During an interview on 10/21/19 at 12:50 PM, Staff Q, Licensed Practical Nurse (LPN), stated that the admission nurse would order the air mattress and the orders for nursing showed to Monitor for function and did not specify the settings on the pump. Failure to ensure correct air mattress pump settings had the potential for mattresses to not be therapeutic for residents or worsen condition of skin concerns. The facility did not provide further evidence they investigated causative factors related to worsening of Resident #4's pressure injury following admission, when requested during a meeting on 10/21/19 at approximately 3:30 PM. RESIDENT #3 Resident #3 readmitted to the facility on [DATE] following hospitalization with [DIAGNOSES REDACTED]. An Admission Minimum Data Set Assessment (MDS, required assessment tool) dated 08/01/19 showed the resident had [DIAGNOSES REDACTED]. The MDS showed the resident required extensive assistance from two staff to position and turn in bed, transfer and toilet; had an indwelling urine catheter and frequent bowel incontinence. A Nutritional Care Plan initiated 07/25/19 showed Resident #3 had failure to thrive. PHYSICIan order for [REDACTED].>A physician Consultation Report dated 08/14/19 included orders for staff to follow that included needs specialty mattress like a citadel (height adjustable/adaptable bed therapy system) to help with healing. During observations on 10/17/19 at 10:02 AM, Resident #3's room had a cart outside the room door and a sign that showed to follow Contact Precautions when providing care. The resident sat upright in bed eating breakfast. The resident did not have a pump at the end of the bed connected to a specialty air mattress. A wheelchair in the room had a two-inch foam pad on it. The resident stated he did not know where the wheelchair came from or used it often. During an interview on 10/21/19 at 12:00 PM, Staff B, Licensed Practical Nurse, Resident Care Manager, Assistant Director of Nursing, (LPN, RCM, ADON) stated that nursing requested air mattresses from maintenance staff. When asked what type staff requested, Staff B stated whatever we have available. Observation on 10/21/19 at 12:44 PM, Staff P, Licensed Practical Nurse (LPN), looked at Resident #3's air mattress and confirmed it was an overlay air mattress and not a specialty mattress with a pump. Staff B also stated that whenever residents had an open wound they usually used an alternating pressure mattress with a pump. Staff B also stated that maintenance staff set up facility owned mattresses. The record did not show staff clarified with the physician the specific type of air mattress Resident #3 needed. NOT TURNED AND REPOSITIONED CONSISTENTLY EVERY TWO HOURS A physician Consultation Report dated 08/14/19 included orders for staff to follow that included to turn and reposition the resident every two hours and to continue IV antibiotics every six hours. A physician Consultation Report dated 10/09/19 showed the physician noted to turn and reposition every two hours as very important and had three stars drawn after the note. On 08/14/19, nursing staff added the order to turn and reposition Resident #3 every two hours onto Treatment Administration Records (TARS). TARS did not show staff turned and repositioned Resident #3 nine times during (MONTH) 2019 and five times during (MONTH) 2019 and twice-in (MONTH) 2019. Length of periods without repositioning extended from six to 14 consecutive hours at a time. During an interview on 10/15/19 at 12:48 PM, Staff B, LPN, RCM, ADON stated that prevention measures for residents who were non ambulatory and at risk for developing ulcers included use of an air mattress and turning and repositioning every two hours. Staff B stated it was the responsibility of the floor nurse to ensure residents were turned. WOUND VAC NOT CHANGED CONSISTENTLY A wound VAC is a pump that applies negative pressure over a wound to remove excess drainage and promote wound healing. On 08/16/19, the physician ordered a continuous wound VAC with black foam changed every Monday, Wednesday and Friday and as needed. During (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, staff did not document on treatment records they changed the wound VAC for one week on Monday 08/26/19 or Wednesday 08/28/19; on Monday 09/01/19 and Wednesday 09/18/19; and on Monday 10/07/19. During an interview on 10/21/19 at 12:12 PM, Staff D, Registered Nurse, Resident Care Manager (RN, RCM), confirmed (MONTH) Treatment Sheets showed unsigned entries for turning and did not know what happened. Staff D also stated that the resident could have been out of the facility when staff left treatment times unsigned and staff should have documented if the resident was out of the facility and the record did not show that. WOUND MONITORING DID NOT [NAME]CUR Resident #3's medical record did not contain evidence facility staff monitored and documented the condition of pressure injuries weekly, to include measurements, condition of the wound bed and surrounding tissue; amount of drainage and associated pain. During an interview on 10/21/19 at 9:00 AM, Staff D RN, RCM, stated that nursing did not track the progress of Resident #3's wounds since the physician saw the resident every two weeks. At 11:50 AM, Staff D, reviewed Resident #3's electronic records and stated that she could not locate any further assessments for this resident. During an interview on 10/21/19 at 12:04 PM, Staff D stated she did not know if nursing staff requested records from the physician regarding the condition of the wound. The investigator did not locate ongoing assessments and monitoring for Resident #3's pressure injury or receive any from nursing staff following requests, to determine if the resident's pressure injury improved, maintained or declined. RESIDENT #9 Resident #9 admitted to the facility on [DATE] after hospitalization for a [MEDICAL CONDITION], and had other [DIAGNOSES REDACTED]. According to the skilled nursing note dated 08/31/19, Resident #9 was incontinent of bowel and bladder and was totally dependent on staff with repositioning and movement. Review of MDS (Minimum Data Set, a comprehensive assessment tool) dated 08/28/19 identified the resident was at risk for developing pressure ulcer. The same assessment showed the resident did not have any pressure injuries. The Nursing Admission/Readmission Evaluation form dated 08/21/19 also did not show any pressure injury. Record review completed on 10/18/19 at 2:00 PM did not find documentation showing that the resident had full head to toe skin assessment done weekly. On 10/18/19 at 2:53 PM resident said he was in a wet brief for at least thirty minutes and that his brief was tight. Observations of resident's skin revealed a linear red mark along the inner right buttock area resembling an imprint from a brief. There were three round areas a

Based on observation, interview, and record review the facility failed to assess three of five residents (Residents #1, 6 and 8) reviewed for monitoring of post-surgical wounds; bruising or laceration. This failure resulted in harm for Resident #1 due to a delay in identifying wound complications and resulted in repeat surgery and re-hospitalization and placed other residents at risk to not have complications identified timely and treated. Findings included,,, RESIDENT # 1 Resident #1 admitted to the facility on [DATE], following vascular surgery. The documentation found in the Admission Evaluation form dated 9/18/19 described a 7 centimeters (cm) groin area and a 9 cm thigh area incisions. Page 25 of the hospital discharge orders dated 9/18/19, included instructions for wound care twice daily to right groin incision, and specified to wash the area with soap and water, then dry and cover with gauze. Review of Resident #1's orders for (MONTH) 2019 revealed surgical site care instructions were omitted. The hospital discharge wound care orders were not transcribed onto the facility orders at the time of admit. Review of nursing progress notes and Treatment Administration Record (TAR) documentation between 9/18/19 and 9/27/19 did not find evidence of daily surgical wound assessment. On 9/27/19, nine days later Resident #1 had a surgical follow-up appointment. According to the surgeon's report Resident #1 found to have a necrotic edge of the groin wound (dead or devitalized tissue), requiring surgical debridement. On 10/3/19 at 11:02 AM Resident #1 was observed and interviewed at the hospital. Resident #1 said she had to have surgery because the groin wound was infected. Resident said she was having a hard time adjusting to this setback. On 10/2/19 at 4:04 PM, during interview Staff C, LPN, (Licensed Practical Nurse) explained that surgical orders for the groin and thigh area incisions were not entered at the time of Resident #1's admission. The nurse was asked about the steps of the admission process and it was identified that there should have been two nurses verifying and signing off admit orders for accuracy, but in the case of Resident #1 that was not done. Record review with Staff C, LPN on 10/2/19 at 4:04 PM found that a weekly skin assessment was scheduled on 9/25/19, or seven days following the admission. The assessment tool dated 9/25/19 and titled Weekly Skin Observation was found blank. Facility evidence of investigation provided on 10/3/19 at 4:11 PM did not identify potential contributing factors that lead to the omission of treatment order and daily nursing assessment. There was no evidence the facility reviewed other residents and evaluated the skin system and the admission process to decrease likelihood of future errors. RESIDENT #8 SURGICAL SITE ASSESSMENT Resident #8 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/18/19 at 4:50 PM observation revealed Resident #8 had an undated and loose dressing on the spine exposing the surgical site. The dressing was not intact. The resident stated he had the hardware removed from his back at the hospital, and the surgeon pulled a drain during a doctor's appointment on 10/15/19. Review of nursing notes and treatment records between 10/11/19 and 10/18/19 did not find evidence that nursing staff visualized and/or assessed the resident's spinal surgical incision and/or dressing site at least daily. CENTRAL LINE CATHETER ASSESSMENT According to hospital discharge history and instructions dated 10/11/19, Resident #8 had a central line catheter (a thin soft tube inserted under the skin in the chest that is threaded into the vein leading into the heart) was placed on 10/10/19. The instructions stated that a sterile dressing change and caps should be done every seven days and the catheter should be flushed with sterile solution after every use. Observations on 10/17/19 at 4:50 PM identified a central line catheter in the right upper chest area. The gauze covering the insertion site was soiled with dry blood. Review of physician orders, TARs and nursing progress notes between 10/11/19 and 10/17/19 did not find evidence that the central line catheter was assessed at least daily. FISTULA ASSESSMENT Resident #8 admitted on [DATE] with a fistula to the left upper arm ( a vascular connection that allows access for [MEDICAL TREATMENT]). On 10/4/19 resident had a fistulogram (procedure where a clot was identified and removed). Observation on 10/18/19 at 3:23 PM revealed the resident with an undated dressing over the left upper arm. Review of TAR and nursing progress notes did not find evidence that the resident's fistula was assessed daily between 10/11/19 and 10/17/19. RESIDENT #6 During observation on 10/17/19 at 4:55 PM, Resident #6 walked from the end of the bed and sat down without using a walker located on the opposite side of the bed. The resident had healing stitches approximately two inches long above the left eye. When asked what happened, the resident stated he fell outside and tripped on bushes at midnight. The resident stated he chased something and could not remember what he chased or why he went outside. Later on 10/21/19 at 11:35 AM, Resident #6 stated that it didn't feel good going to the emergency room . The resident also stated he could not open his eye for for two to three days after he fell . Nursing notes dated 09/30/19 at 6:53 AM showed Resident #6 returned from the emergency room with stitches on the forehead. A note dated 10/01/19 showed the resident had bruising to the left eye and skin tear to the top of the right hand. A nursing note documented on 10/03/19 showed the resident had a fading dark red peri-orbital bruise. The record did not show staff initially assessed the extent of eye bruising, such as color, swelling, impact on vision, and measurements as possible or documented the condition of eye brusing/injury in order for staff to have a baseline for comparison. During an interview on 10/10/19 at 10:30 AM, Staff G Licensed Practical Nurse (LPN) stated that bruises did not need to be monitored daily. During an interview on 10/10/19 at 11:19 AM, Staff M, Registered Nurse (RN), stated that the floor nurse monitored bruising and residents were placed on alert charting. Reference: WAC 388-97-1060 (1) (2) (3) (ii)

Based on observation, interview, and record review the facility failed to ensure seven of 15 Residents (#s 3, 4, 5, 6, 7, 8 & 9) with swallowing disorders received therapeutic diet textures that were consistent with the texture the physician ordered, the texture the speech therapist assessed as safe, and the texture the kitchen menu was using. Additionally the facility policy did not correlate with the diets being used by the kitchen, ordered by the doctor, or recommended by the speech therapist. It was identified on the facility did not have a safe system in place for standardizing altered diet terminology and/or reconcile various diet terms used by different providers on 8/30/19. The combination of these failures created a situation of confusion among the facility staff members resulted in residents receiving incorrect food textures. This constituted an Immediate Jeopardy situation placing all residents at imminent risk of harm from choking, aspiration and potential risk of inadequate nutrition. On 08/30/19 at 7:52 PM the facility Administrator was informed of the Immediate Jeopardy (IJ) related to F-692 for Assisted Nutrition and Therapeutic Diets-Related to serving incorrect diet textures foods to residents with swallowing problems. The facility completed education and changed processes, the IJ was removed on 09/4/19 as evidenced by surveyor observations of kitchen tray line, meal service, and review of staff training records. Findings included . Facility Diet Manual titled HPSI Menu Service was provided on 8/30/19 at 5:15 PM. The manual read HPSI recommends that the Diet Manual be approved by consulting dietician, medical director, and nursing prior to starting the menu program. The manual included the following guidance: -Mechanical diet described foods as chopped or pureed, commonly called mechanical soft and for a resident with chewing problems. The dysphasia textures were specifically for residents with swallowing problems. -Dysphasia pureed describes food that has been put into a blender and blended. -Dysphasia Mechanical altered described moist soft textured and simple to chew foods: excludes dry bread and peanut butter. This diet is intended to provide a transition diet between a puree diet and a mechanical soft diet and used for residents at aspiration risk, and swallowing mechanical problems. -Dysphasia advanced diet was for residents with difficulty chewing and swallowing food. All foods in this category should be soft and bite-size pieces. Flaky bread and dry cereals are excluded unless moistened and not sticky or crunchy. Dry toast and dry bread should be avoided RESIDENT #3 Resident #3 admitted to the facility on [DATE]. The MDS (Minimum Data Set, a required comprehensive assessment) dated 6/21/19 showed the resident required supervision, cueing and set up assistance from staff with meals. The facility Nutritional Evaluation dated 6/18/19 showed resident had difficulty swallowing related to [DIAGNOSES REDACTED].) Physician orders [REDACTED]. On 8/27/19 at 2:02 PM Resident #3 was in his room, on his meal tray there was a large meat patty, chopped broccoli, rice, ice cream, chocolate milk. The observations of the food textures did not meet the definition of a mechanical soft diet. The meal ticket on the tray did not indicate that Resident #3 had a prescribed altered diet type. At 2:32 PM the contents of the meal tray were observed tray with Staff E, Kitchen Manager. Staff [NAME] said that the resident received the wrong diet. Observations on 8/29/19 at 8:09 AM found the Resident #3's meal tray had two pieces of dry toast. Between 8:10 AM and 8:21 AM, Staff Q, Registered Nurse, RN, and Staff S, RN, both looked at resident's tray and reported that toast is not part of the mechanical soft diet placing the resident at risk for aspiration or choking. On 8/30/19 at 5:00 PM, Resident # 3 was observed eating in his room unsupervised and without cueing. On the meal tray, there was a hoagie roll with ground meat. The meal ticket specified a mechanically altered diet which differed from the physician's orders [REDACTED]. On 8/30/19 at 8:33 PM, Staff P, Speech Therapist, ST, said it was not okay for a resident on a mechanical diet to have a hoagie roll. Staff P, ST, also stated that toast would only be acceptable if it was moistened with syrup or jelly On 9/7/19 at 8:30 AM Resident #3 was in his room sitting on the bed. Resident took a sip of water and started coughing without being able to catch his breath. There was box of pizza on the resident's bed. Resident said he hated facility food and sometimes gets pizza. Resident said if the pizza is hard I choke on it. RESIDENT#4 Review of Resident #4's record showed he admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further review of the record showed a physician's orders [REDACTED].#4 to have a mechanical soft diet. Observations on 8/29/19 at 8:45 AM, showed Resident #4 eating breakfast. The diet slip on the breakfast tray showed Resident #4 was on a mechanical soft diet with nectar thick liquids. The resident's meal tray had two pieces of dry toast, which was not consistent with a mechanical soft diet. RESIDENT #5 Record review on 8/30/19 showed Resident #5 admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/29/19 at 8:50 AM Resident #5 was observed eating breakfast. The diet slip showed the resident was on a mechanical soft diet with nectar thick liquids. The resident's meal tray had two pieces of dry toast, which was not consistent with a mechanical soft diet. RESIDENT #6 Record review on 8/30/19 showed Resident #6 had [DIAGNOSES REDACTED]. In an interview on 8/29/19 at 8:52 AM, Resident #6 said she ate a cheese, an egg dish and a toast for breakfast. The resident said the toast got caught in her throat so she did not eat the second piece. The resident denied choking. The resident's diet slip showed a dysphasia ground diet. Observation on 8/30/19 at 5:40 PM of Resident #6's meal tray identified a French dip sandwich prepared with a hoagie roll bread and grown beef. During an interview on 8/30/19 at 6:15 PM Staff P, Speech Therapist said it was not okay for residents on dysphagia ground to eat thick bread, such as the hoagie roll, or toast because of choking/aspiration risk. RESIDENT #7 Record review on 8/30/19 showed resident admitted on [DATE] had [DIAGNOSES REDACTED]. On 8/29/19 at 8:47 AM, resident was eating breakfast in the dining room. The diet slip order showed a dysphasia ground diet. The resident's plate contained two pieces of dry toast, not consistent with a dysphagia ground diet. RESIDENT #8 Record review on 8/30/19 showed Resident #8 admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/29/19 at 9:09 AM, Resident #8 was observed eating in bed in his room. The resident's meal tray had a diet slip indicating he received a dysphagia ground diet. The breakfast tray contained two pieces of dry toast, not consistent with a dysphagia ground diet. Additional observations on 8/29/19 at 9:09 AM, found a suction machine on Resident #8's nightstand and it was out of the resident's reach. The resident explained he used the suction machine because he had a hard time managing oral secretions. On the bedside table, there was a Ziploc bag full of bread crust and bread pieces. Resident #8 said he has been putting bread in the bag because he has been receiving sandwiches and bread on his trays but he couldn't eat bread because it was hard to swallow. RESIDENT#9 Record Review on 8/30/19 showed Resident #9 admitted on [DATE] with [DIAGNOSES REDACTED]. The orders showed the resident was prescribed a dysphasia ground texture diet. Observations on 8/30/19 at 6:04 PM, revealed the resident was in his room with a tray on the bedside table. The diet card on the tray read ground dysphasia. The dinner plate contained ground meat and ground vegetables. Next to the tray was an empty clear plastic sandwich in a bag read PBJ 8/30. Additionally, there was a second plastic bag with contained a whole sandwich. The bag read PBJ 8/30. Resident #9 pointed to the plate and said he was not eating that food and wants a different texture. The resident said staff brought him two peanut butter and jelly sandwiches, and he had already eaten one of them. In an interview on 8/30/19 at 6:15, PM Staff E, Kitchen Manager, KM, was asked if peanut butter and jelly were considered a ground dysphasia diet. Staff E, KM, said he would have to check the diet spreadsheet. At 6:30 PM, Staff P, Speech Therapist stated that the peanut butter and jelly sandwich is not consistent with a ground dysphasia diet, and that the amount of crust and peanut butter is a concern for choking. On 8/29/19 between 9:00 AM and 10:00 AM, Staff A, Administrator and Staff E, KM reported that they would downgrade residents' diets in question until speech therapy assesses residents who received incorrect diet textures, clarify their diets and train staff. On 8/30/19 at 6:10 PM, Staff U, Director of Rehab reported that he received information around 4:30 PM today that the Speech Therapist was not coming to the facility today to reconcile diets and screen the affected residents, although Staff U was aware of diet reconciliation problems during the morning meeting on 8/29/19 and 8/30/19, yet he failed to initiate corrective steps to ensure resident safety during dining. During an interview on 8/30/19 at 2:50 PM, Staff E, KM, said he identified conflicting verbage on the diet slips approximately two weeks ago. The confusion was partially related to menus and diet terms provided by Sysco (Food Company) which no longer has a contract with the facility and we are not their customers. Other issues had to do with a turnover with speech therapists who used different terms adding to the confusion. Staff [NAME] was asked if there was a system in place for regular audits or systems review to identify discrepancies. Staff [NAME] reported that up until approximately six months ago facility had a contract with a Dietitian Consulting company that completed audits and surveyed food services to make sure it met facility policies, regulations, and quality control. Staff [NAME] said he used to receive monthly reports for quality review but in the last six months there have not been any similar types of surveying and no reports issued besides weight loss reports by the new dietician. Refer to F837 Governing Body for additional information related to oversight and compliance of systems. WAC Reference 388-97-1060(3)(h)

Based on observation, interview and record review the facility failed to ensure resident environment remained as free of accident hazards as possible. The facility failed to apply Root Cause Analysis for Residents (#'s 4, 7, 21, & 23) reviewed for repeat falls. The facility also failed to ensure medication carts were secured, emergency supplies set up in ready to use condition and safe assistive devices were used for Residents (#'s 5, 16 & 7.) These failures resulted in harm to Resident #7, 4 & 23. Findings included . FALLS RESIDENT #7 Resident #7 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a comprehensive assessment dated [DATE] the resident required two person assistance for mobility. Review of incident reporting log and nursing notes showed between [DATE] and [DATE] Resident #7 fell five times. On [DATE] at 2:50 PM Resident #7 was observed in bed. Observations of resident's wheelchair with Staff I, Nursing Assistant Certified (NAC) identified both armrests were loose and heavily taped. 1. Review of Resident #7 nursing progress note dated [DATE] at 4:30 PM, documented Resident #7 used a walker to get the bathroom. The resident was found on the floor. Review of the facility's evidence of incident investigation for [DATE] fall showed Resident #7 needed one person extensive assistance from staff using a wheelchair for mobility. The investigation did not identify whether Resident #7 used appropriate device prior to the fall. Admitting physician's orders did not specify which mobility/assistive device should be used. 2. Nursing progress note dated [DATE] at 6:45 PM, described Resident #7 fell out of the wheelchair, and hit his head. Review of the facility evidence of investigation for the [DATE] fall did not include a wheelchair assessment. 3. Nursing progress notes dated [DATE] at 7:46 PM, documented Resident #7 fell out of the wheelchair again. The note described Resident #7 sustained skin injuries to the left elbow, right hand and right eye bruising. 4. Nursing progress note dated [DATE] at 7:32 AM, documented Resident #7 was found on the floor between the bed and a nightstand. 5. Nursing progress notes dated [DATE] at 10:11 PM, documented Resident #7 fell again by the bed. The note also stated that the bed was not in its lowest position because staff had difficulty bringing it all the way down. Review of facility evidence of investigation did not find the bed was assessed and was safe to use. On [DATE] during a record review and interview between 10:15 AM and 10:23 AM, Staff B, Director of Nursing (DNS) was asked about each fall for Resident #7. Staff B, DNS stated that Root Cause Analysis (RCA) is not being done at this time because she is working on improving many clinical systems at once. The facility did not have evidence of root cause analysis to identify potential contributing factors for each fall and implement relevant interventions based on root cause findings. Resident #7 fell repeatedly and sustained injuries. RESIDENT #4 Resident #4 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4 had fallen six times between [DATE] and [DATE]. The fall on [DATE] resulted in injury as documented in the clinical records. 1. On [DATE] at 6:13 AM, the nursing note stated that a roommate reported Resident #4 was on the floor at 4:50 AM. 2. On [DATE] at 13:37 PM, the nursing note stated Resident #4 was found on the floor mat. 3. On [DATE] at 10:48 AM Resident #4 was found lying on the floor, according to progress notes. 4. On [DATE] at 9:30 PM nursing notes showed Resident #4 was found on the floor at 3:00 PM. 5. On [DATE] at 3:00 PM Resident #4 rolled out of bed according to the nursing note. 6. On [DATE] at 3:17 PM, nursing note showed Resident #4 was found on the floor mat at 8:00 AM. Six hours later, at 2:00 PM, staff noticed 2x3 centimeter skin injury the forehead. Resident #4's post- fall assessment did not gather adequate information for root cause analysis including ruling out signs of [MEDICAL CONDITION]. On [DATE] during a record review and interview between 10:15 AM and 10:23 AM, Staff B, Director of Nursing (DNS) was unable to produce evidence of thorough investigation of each fall for Resident #4 and stated that Root Cause Analysis (RCA) is not being done at this time. RESIDENT #23 Resident #23 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #23 no longer resides at the facility. Review of the state reporting log and nursing notes showed Resident #23 fell six times between [DATE] and [DATE]. 1. On [DATE] at 1:11 PM, Resident #23 was found on a floor and had a skin tear per nursing notes. The same note described Resident #23 was given [MEDICATION NAME] (a medication used as a sedative) for agitation after the fall. The post fall assessment and/or investigation did not identify potential contributing factors to the fall and possible reasons for agitation. Documentation did not find root cause analysis. 2. A nursing progress note dated [DATE] at 5:10 PM, showed Resident #23 had another fall around 4:00 PM and sustained a laceration to the right arm. Record review did not find root cause analysis. 3. In a nursing progress note dated [DATE] at 11:31 PM, staff documented Resident #23 was found on the floor behind his bed laying on his back. The right arm skin tear from the previous fall was bleeding. Record review did not find root cause analysis. 4. A nursing progress note dated [DATE] at 9:48 AM, revealed Resident #23 rolled out of bed and was found on the floor next to the mattress. The noted indicated Resident #23 seemed restless and staff gave Resident #23 [MEDICATION NAME]. There was no evidence that nursing staff assessed potential contributing factors causing Resident #23 to be restlessness. Record review did not find root cause analysis. 5. A nursing progress note dated [DATE] at 2:41 PM, documented Resident #23 was found on the floor at 6:45 AM that morning. Record review did not find root cause analysis. 6. A nursing progress note dated [DATE] at 4:00 AM, documented Resident #23 was again found on the floor according to facility incident investigation. Review of facility incident report showed the investigative summary was not concluded until [DATE]. Record review did not find root cause analysis. On [DATE] during a record review and interview between 10:15 AM and 10:23 AM, Staff B, Director of Nursing (DNS) was unable to produce evidence of through investigation of each fall for Resident #23 and stated that Root Cause Analysis (RCA) is not being done at this time. Resident #23 fell repeatedly and sustained injuries from falls. RESIDENT#21 Resident #21 had [DIAGNOSES REDACTED]. Review of the facility investigation revealed Resident #21 fell on [DATE] and [DATE]. Documentation indicated Resident #21 fell out of the wheelchair both times. There was no information whether Resident #21 had been assessed for safe use of the wheelchair prior to or after the fall. EMERGENCY SUPPLIES In an interview on [DATE] at 6:49 AM, Staff S, RN, stated there is a crash cart in the Rehabilitation lounge located next to the nurse station and a crash cart located at the end of the hall in the dining room. Observations on [DATE] at 6:50 AM, of the cart located in the Rehabilitation Lounge next to the nurse station showed the cart had a supply check-off list to ensure the cart was stocked. Included on the list was an AMBU bag (a bag filled with air that has a mask to deliver breaths if CPR is needed). Continued observations showed the cart did not have an AMBU bag on it. In an interview on [DATE] at 6:52 AM, Staff S, RN, also reviewed the cart and stated she did not see the AMBU bag on the cart. This failure placed residents at potential risk of a delay in getting emergency breathing with oxygen in the event CPR would be needed. The cart located closest to resident rooms did not have all necessary equipment which would mean staff would need to go down the hall to the dining room and return with a different emergency cart, thus creating a delay. HAZARDS IN THE ENVIRONMENT 1. DEFECTIVE TRANSFER LIFT RESIDENT #5 Observations on [DATE] between 6:37 AM and 7:00 AM, identified an Invacare brand mechanical lift (Hoyer lift #3, a mechanical device that lifts a resident who is slitting in a sling in order to move them from the bed to wheelchair or wheelchair to bed) used to transfer Resident #5 by Staff AA, Nursing Assistant (NA) and Staff BB, Nursing Assistant Certified (NAC). Following the transfer from bed to the wheelchair Staff BB, NA removed the lift away from the resident's wheelchair when the lift's legs opened to a wider position spontaneously. Staff AA, NAC said it does that on and off and we put it out of order, it gets fixed and it does it again. Further observations on [DATE] at 7:00 AM, showed Staff AA, NAC, and was pushing the lift down the hallway to another resident's room when the legs spontaneously opened again. Continued observations on [DATE] with Staff AA, NAC, and Staff BB, NAC, showed staff demonstrating the use of the mechanical lift. It was identified that the base of the lift was not stable and was shaking creating the bar to swing. Staff AA, NAC, explained that they applied the pressure to the handle bars to stabilize the lift, which is not how the lift was designed to work. Additionally, if a resident was suspended in the lift and the legs spontaneously changed position, the lift would become unstable and would be at risk for tipping and falling over injuring staff and/or the resident. At this time, Staff AA, NAC, removed the lift from service. At 7:11 AM on [DATE], Staff A, Administrator, ADM, was made aware of surveyors observations. 2. UNSAFE ASSISTIVE DEVICES RESIDENT #16 Resident #16 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's record showed a Minimum Data Set (MDS, an assessment tool) dated [DATE], which showed Resident #16 required extensive assistance from staff with bed mobility. Observations on [DATE] at 1:08 PM, showed Resident #16 on her back in bed, laying on a low air loss mattress which has a slippery surface. Staff BB, NAC was guiding the resident to move onto her left side. Resident #16 reached over and grabbed an unlocked front-wheel walker positioned on the right side of the bed. Resident #16 said she had fear of falling and liked to grab onto the walker when she turned side to side. Staff BB, NAC was informed at the time that was a potential risk for a fall. Repeat observations on [DATE] at 3:00 PM, [DATE] at 12:05 PM, [DATE] at 8:08 AM, [DATE] at 5:07 PM, and on [DATE] at 5:37 AM, Resident #16 continued to have the same unlocked front wheel-walker on the right side of the bed, which remained unlocked and in the same position RESIDENT #7 Review of Resident #7's record showed on [DATE] a physician ordered an evaluation for tilt in space wheelchair (a wheelchair that reclines back) for Resident #7. The record showed a physician's order dated [DATE] for a tilt in space wheelchair for better positioning for Resident #7. Observations on [DATE] at 2:50 PM, showed Resident #7 lying in bed. Observations of resident's wheelchair with Staff I, Nursing Assistant Certified (NAC) identified both armrests were loose and taped. Staff I, NA said she didn't know why the armrests were taped. Follow up observations on [DATE] at 1:09 PM, found Resident #7 sat in the same wheelchair with loose and taped armrests. Staff DD, NAC, felt the armrest and said they are not supposed to be loose. 3. UNL[NAME]KED MEDICATION CARTS Observations on [DATE] at 7:30 AM, showed Staff Y, LPN, left the keys to medication storage cart and narcotics hanging in the narcotic drawer and walked away from the medication cart. Continued observations on [DATE] at 7:42 AM, Staff Y, LPN, left medication unlocked and unsupervised, and walked away. Observations on [DATE] at 4:55 AM, showed the medication cart for the 400 sitting near the nurse station unlocked. The nurse assigned to work the cart, Staff X, Registered Nurse, RN, was sitting at the nurse station with her eyes closed. As the surveyor spoke to the other nurse, Staff S, RN, observations showed Staff X, RN, remained sitting, not moving with her head tilted to the right and her eyes closed. On the desk in front of Staff X, RN, was multiple cards containing medications that had been delivered from the pharmacy. Although the medications and cart were in line of sight of the assigned nurse, her eyes were not opened. Observations [DATE] at 9:40 AM, showed the nurse assigned to the 100 hall medication, Staff HH, LPN, cart preparing medications to administer by putting pills in a medication cup. Staff HH, LPN, then walked down the hall to administer medications to a resident sitting in her wheelchair, leaving her cart unlocked with the medication cup of pills sitting on top of the cart. WAC Reference [DATE](3) (g)

Based on observation, interview and record review, the facility failed to provide effective treatment for [REDACTED]. Additionally, the facility failed to develop comprehensive person-centered care plans and resident's goals, for three of three Residents (#s 1, 24 & 27) who required such services. Failure to develop and implement a plan to treat pain placed Resident #27 & #1 at risk of decreased quality of life and resulted in actual harm to Resident #24. Findings include . RESIDENT #24 Resident #24 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 9/8/19 at 3:22 PM, showed Resident #24's pain care plan was initiated on 12/6/19, and had target date of 3/14/19. The care plan described Resident #24 had pain as a result of back surgery. The interventions listed in the care plan read, Resident will verbalize adequate relief of pain and ability to cope with incomplete pain relieve. The care plan stated to evaluate the effectiveness of pain, anticipate the need for pain relief and respond to any complaint of pain immediately, monitor and document probable cause of each pain episode. Review of nursing progress notes showed repeat documentation on 8/18/19, 8/20/19, 8/21/19, 8/22/19, & 8/23/19 describing Resident #24 had pain related to excoriated buttocks. Nurses described the resident scratched her buttocks constantly then cried because it burned. The documented assessment of ongoing pain and suffering did not result in comprehensive pain assessment until 9/7/19. Observations on 9/7/19 at 7:44 AM, Resident #24 was heard out in the hallway from her room crying out help me, help me, it hurts so bad I can't take it anymore. This continued until 7:47 AM, meanwhile, Staff CC, Licensed Practical Nurse, LPN, was standing at the medication cart across from Resident #24's room. At 7:47 AM Staff CC, LPN was asked about why Resident #24 was crying out in pain. Staff CC, LPN's response was that the Resident always complained about pain and she is resistant to care because she does not want to get out of the bed. Staff CC, LPN reported she just gave resident Tylenol. Interview and observation on 9/7/19 between 7:48 AM and 7:50 AM revealed Resident #24 lying in bed. The resident was teary-eyed and pleaded please help me, I am in so much pain . it's all over. When Resident #24 was asked which part of her body hurt the most, the resident pointed to her back and explained it was itching and hurting. At this time observations of resident's back revealed reddened and excoriated buttocks with multiple scabs. On 9/7/19 approximately at 7:50 AM, Staff CC, LPN was asked to look at resident's buttocks. Staff CC, LPN was asked if she had completed a physical assessment of Resident #24's skin prior to giving resident Tylenol. Staff CC, LPN said she did not have to do an assessment because the Resident was given scheduled Tylenol. Staff CC, LPN added she did not have to look at resident skin because the Nurse Practitioner was going to see the resident. Staff, CC, LPN dismissed Resident#24's pain and did not complete a physical assessment as required by professional standards. RESIDENT #27 During observation and interview on 8/28/19 at 11:44 AM, Resident #27 reported to the surveyor she was in severe pain (8 on a scale of 1 to 10). Staff X, Registered Nurse (RN) was informed of Resident #27's pain at 11:46 am. Staff X, RN entered resident's room and asked the resident about [MEDICATION NAME] (a medication used numb/lessen pain) patch. Observations of the interactions between Staff X, RN and Resident #27 identified lack of a thorough pain assessment. The nurse failed to ask the Resident #27 about the type of pain, location of the pain, aggravating factors, relieving factors and did not inquire if the pain radiated to another part of the body. Staff X, RN also did not do a physical assessment. Staff X, RN was asked about her assessment of resident's pain. Staff X, RN stated that she should have asked more questions and should have completed a more thorough assessment. Staff X, RN, said she will reassess the resident right now. Without a thorough pain assessment, critical symptoms such as cardiac pain could be missed creating a potential delay in treatment. RESIDENT #1 Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's records showed he was receiving end-of-life care. Review of Resident #1's pain medication administration records showed between 6/1/19 and 6/25/19 there were 40 occasions when his pain was rated between level 7 and 8 (severe pain.) Comparison of narcotic ledger and administration record showed multiple discrepancies. The documentation on the ledger showed that a narcotic medication was removed but it was not documented as given on the Medication Administration Record [REDACTED] Refer to F756 for additional information related to management of controlled substances. Reference WAC 388-97-1060(1).

Based on record review and interview, the facility failed to ensure one of three residents (discharged Resident #1) reviewed for [MEDICAL TREATMENT] (process of cleaning toxins from the blood when the kidneys no longer function properly) consistently received [MEDICAL TREATMENT] as ordered. The facility failed to ensure the resident's initial [MEDICAL TREATMENT] was scheduled and failed to consistently notify the physician of missed [MEDICAL TREATMENT] treatments, provide timely care prior to appointments and ensure a communication system between nursing units and transportation coordinator. The above failures resulted in Resident #1 missing two of three [MEDICAL TREATMENT] treatments over a six-day period. Resident #1 sustained harm related to developing [MEDICAL CONDITION], which required emergency room treatment, emergent [MEDICAL TREATMENT] and hospitalization . Findings included: Record review showed Resident #1 admitted to the facility with medical [DIAGNOSES REDACTED]. Review of physician admission orders [REDACTED]. During interview on 06/04/2019 at 10:20 AM, Staff C, Admission Nurse, stated that the hospital case worker told her Resident #1's first appointment and transportation were set up for 05/22/2019; however, there was no documentation of an appointment or transportation. Staff C stated that she did not confirm that a [MEDICAL TREATMENT] appointment and arrangements for transportation were made. During interview on 06/04/2019 at 1:10 PM, Staff A, Administrator, stated that a resident's first [MEDICAL TREATMENT] appointment was usually made by the hospital. The hospital scheduled both the appointment and transportation. It was the responsibility of the Admission Nurse to ensure it was done. During interview on 06/04/2019 at 10:05 AM, Staff E, Receptionist/Transportation Coordinator stated on 05/22/2019, she tried to schedule an appointment for [MEDICAL TREATMENT] that day, however; it was too late. She scheduled an appointment for [MEDICAL TREATMENT] and transportation for the following day, 05/23/2019. Review of nursing progress notes showed there was no evidence the physician was notified that Resident #1 missed [MEDICAL TREATMENT]. Without this information, the physician did not have an opportunity to provide direction for the resident's care. During interview on 06/04/2019 at 10:30 AM, Staff D, Resident Care Manager (RCM) stated that Resident #1 missed [MEDICAL TREATMENT] on 05/23/2019 due to a shuttle service error in scheduling. The resident was rescheduled for 05/24/2019. There was no evidence the physician was notified Resident #1 missed [MEDICAL TREATMENT] for a second time. Review of nursing progress notes dated 05/24/2019 showed Resident #1 went to [MEDICAL TREATMENT] as scheduled. Review of the appointment calendar with Staff E, Receptionist/Transportation Coordinator on 06/04/2019 at 10:05 AM confirmed Resident #1 was scheduled for the next routine [MEDICAL TREATMENT] on 05/27/19. On 06/07/2019, Staff B, DNS, provided the investigator an investigative summary of events, which showed Resident #1 missed the [MEDICAL TREATMENT] appointment on 05/27/2019. During interview on 06/17/2019 at 2:25 PM, Staff A, Administrator stated Resident #1 missed the appointment on 05/27/2019 because the resident was not ready on time. Staff A stated that a care directive to get the resident ready for [MEDICAL TREATMENT] should have directed the care to night shift instead of day shift because the resident's pick up time was so early. Review of the above investigative summary showed on 05/27/2019, [MEDICAL TREATMENT] staff notified the facility of Resident #1's rescheduled appointment for 05/28/2019 at 5:49 AM. According to the above investigative summary, Resident #1 missed the [MEDICAL TREATMENT] appointment on 05/28/2019 because transportation was not set up. During interview on 06/04/2019 at 10:30 AM, Staff D, RCM, stated that Resident #1 had a change of condition at approximately 4:00 PM on 05/28/2019. The resident experienced shortness of breath. The physician was notified and gave an order to transport the resident to the hospital for [MEDICAL TREATMENT]. Review of the hospital record History and Physical dated 05/28/2019 showed admission [DIAGNOSES REDACTED]. Review of the hospital record Discharge Summary showed Resident #1 was admitted to the hospital from the emergency room and had immediate [MEDICAL TREATMENT]. During exit conference on 06/17/2019 at 2:15 PM, Staff A, Administrator, acknowledged the identified areas of failed practice related to Resident #1's missed [MEDICAL TREATMENT] appointments which included the admission nurse not confirming the resident's initial [MEDICAL TREATMENT] appointment and transportation, lack of coordination for provision of timely morning care resulting in one missed [MEDICAL TREATMENT] appointment, inconsistent communication between nursing staff and transportation coordinator and staff not notifying the physician when the resident missed [MEDICAL TREATMENT]. WAC Reference: 388-97-1060 (1)

Based on interview and record review the facility failed to ensure adequate, continuous supervision to prevent falls for one of three residents (Resident #1 ) reviewed for accidents. Staff failed to maintain continuity of one to one supervision for Resident #1 between night shift and day shift. Resident #1 was harmed due to a fall that resulted in a knee fracture when left unattended. Findings included . Refer to F610 for failure to thoroughly investigate fall for Resident #1. Resident #1 admitted to the facility on [DATE] following hospitalization . Admission records showed the resident had [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS, an assessment tool) dated 11/05/18 showed Resident #1 required extensive assistance from two staff to move in bed, transfer and toilet, and to meet personal care needs. The MDS also showed the resident had diminished functional use of one upper extremity and both lower extremities and used a wheelchair. A facility fall evaluation dated 12/03/18 showed Resident #1 had risk factors for falling that included decreased muscle coordination and specific medications that increased risks for falls. Resident #1 had three falls between 12/22/18 and 01/03/19. A facility investigation showed on 12/22/18 staff found the resident uninjured on the floor of the room. A care plan titled Actual Fall dated 12/22/18 showed staff added interventions of a mat on the floor on the right side of the bed and placed one side of the bed against a wall. On 12/24/18, a nursing note showed staff spoke with the provider regarding Resident #1's increased episodes of confusion that were worse when the resident remained alone. The provider ordered medical tests. On 12/25/18, a nursing note written 10:44 PM showed the resident had confusion and attempted to get out of bed multiple times and colored own face with markers. Staff assessed the resident and notified the physician. The next day on 12/26/18, nursing notes showed the resident received an antibiotic to treat an infection. Three days later, a nursing note dated 12/28/18 written at 6:27 PM, showed that during day shift, staff reported Resident #1 was found on the mat on the floor of the room. The resident stated that she placed herself on the floor to get belongings from the nightstand across the room, and then placed the items on the bed. No evidence was found staff changed the care plan to prevent a similar occurrence, such as placing items the resident wanted within safer access. On 12/29/18, a nursing note showed the provider advised nursing to start Resident #1 on a different antibiotic for seven days to treat a urinary infection. On 01/02/19, a nursing note written at 6:56 AM, showed Resident #1 remained awake during the night and made several attempts to self-transfer from bed to wheelchair. The note showed staff checked on the resident frequently. Resident #1's record did not contain evidence staff assessed or continued to monitor the resident during day or evening shift on 01/02/19. A nursing note written 01/03/19 at 4:39 AM, showed Resident #1 continued with antibiotic treatment for [REDACTED]. At 6:00 AM, nursing staff wrote they kept the resident on one to one supervision during the night and reported to the oncoming floor nurse to notify the physician. A facility investigation dated 01/03/19 showed at 7:00 AM, (one hour after shift change,) staff responded to a loud scream from Resident #1's room. Staff found Resident #1 on the floor with left leg folded under her bottom and right leg stretched out in front with wheelchair on the resident's right side. Resident #1 stated that she tried to transfer self from bed to the wheelchair and fell . The investigation showed the resident had pain from the back and leg at level ten out of ten (ten being the worst pain) and began to cry. The facility investigation dated 01/03/19 showed Resident #1 had an oxygen level of 89% following the fall and the provider ordered oxygen and directed staff to call 911 and transport the resident to an emergency room . Hospital records dated 01/03/19 showed the resident had acute [MEDICAL CONDITION] and a fractured left knee due to a mechanical fall. During an interview on 02/03/19 at 1:35 PM, Staff E, Regional Nurse Consultant (RNC) did not know what happened during the change of shift and why one to one supervision did not continue. During an interview on 02/08/19 at 1:40 PM, Staff D, Resident Care Manager (RCM) stated that ideally when nursing gave report between shifts, they would look at staff schedules and find an aide to replace the night shift aide assigned one to one. Staff D also stated that nursing staff did not inform her Resident #1 was on one to one (supervision) during the night and should have. Staff D stated that the information was not on the communication board and if known, would have notified Staff B, Director of Nursing (DON), and the staffing coordinator to find coverage to continue the one to one until nursing had an opportunity to reassess the resident and notify the physician. The investigator asked if notes were available from an interdisciplinary fall committee meetings that discussed Resident #1's falls. Staff D stated during this interview notes were not available and discussions with IDT (IDT, multiple disciplines) occurred in morning and afternoon meetings. Staff D also stated that the facility just recently started having Fall Interdisciplinary Team meetings. The facility did not maintain continuity of one to one supervision provided during night shift on 01/03/19 until nursing staff could reassess Resident #1's condition and determine what interventions were needed to maintain resident safety. Shortly following change of shift, when left unattended, the resident fell and fractured her knee. Reference WAC 388-97-1060(3)(g)

Based on interview and record review the facility failed to conduct ongoing monitoring for anticipated pain, and promptly intervene to obtain and administer pain medication. The facility also failed to assess location, characteristics of pain and implement non pharmacological interventions for pain management or consistently monitor for effectiveness after administration of medication to assure adequate pain management for one of three residents (Resident #1) reviewed for pain. During the first night following admission to the facility, Resident #1 waited over four hours before receiving requested narcotic pain medication, resulting in harm and increased anxiety from unrelieved pain due to recent back surgery. Findings included: Facility Clinical Services Policy and Guidelines for pain management showed pain evaluations may include history of pain and treatment; characteristics of pain such as intensity, pattern, location, frequency and duration; additional symptoms associated with pain such as nausea and anxiety; and resident goals for pain management. The policy showed to monitor the resident for presence of pain whenever exacerbation of pain is suspected. Former Resident #1 admitted to the facility on [DATE] following hospitalization and left the faciity on [DATE]. A hospital discharge summary showed the resident had back surgery involving multiple vertebrae, which included fusion and an implanted device to stabilize the spine. Physician orders [REDACTED].) Additional physician orders [REDACTED]. The order identified multiple non pharmacological interventions that could be attempted such as position changes. Nursing notes dated 09/03/18 showed Resident #1 had a surgical incision from the middle to the lower back and had increased anxiety related to the transfer from the hospital and ambulance ride. The note showed the resident was alert and oriented and could communicate needs to staff. A Nursing Pain Evaluation dated 09/03/18 showed Resident #1 had pain in the middle to lower back from a surgical incision and history of chronic pain. The assessment did not describe the characteristics of the pain, such as sharp, stabbing; duration or frequency, such as intermittent or continuous. The assessment showed the resident could verbalize pain; had pain during the previous five days; movement made the pain worse and took [MEDICATION NAME] 5 to 15 mg every three hours as needed and Tylenol to alleviate pain. Care Plan pain interventions noted in the evaluation showed for staff to anticipate the resident's need for pain relief and to respond immediately to any complaint of pain. A nursing note dated 09/03/18 written at 7:06 PM, showed staff obtained authorization to obtain [MEDICATION NAME] from facility pharmacy stock and administered 15 mg to the resident and [MEDICATION NAME] for increased anxiety. Medication records and nursing notes did not identify the exact time staff administered either medication. The record did not show staff monitored the effectiveness of either medication. Resident #1's (MONTH) (YEAR) electronic Medication Administration Record [REDACTED]. A nursing note written 09/03/18 at 10:04 PM, showed staff documented the resident's pain level later decreased to level 2. Resident #1's medical record did not contain evidence staff assessed and described the location and characteristics of pain the resident received prior to administration of both administrations of [MEDICATION NAME]. The record did not show if staff offered non pharmacological interventions before administration of [MEDICATION NAME] and results. EMAR records showed nursing did not administer a third dose of [MEDICATION NAME] until the following day, 09/04/18 until 4:20 AM, almost seven hours after the last dose pain medication was given. The record did not show staff followed up a short while later to determine if [MEDICATION NAME] given at 4:20 AM was effective. Resident #1's record did not show staff specifically assessed the resident for anticipated breakthrough pain. Physician orders [REDACTED]. Staff did not document they administered [MEDICATION NAME] again until 4:20 AM, and noted the resident's pain level at 8. Monitoring records showed staff recorded the number of hours the resident slept during the night was 0. A nursing note written 09/04/18 at 3:35 AM, documented the resident rested well during the night. These notes were not consistent and conflicted with the following resident interview. During telephone interview on 10/15/18 at 10:16 AM, Resident #1 stated she just had a seven hour back surgery on 08/28/18, with screws, and did not receive pain medication when needed. The resident stated right after midnight (09/04/18) her pain level reached a 10, informed the nurse and was told the pharmacy delivery for her pain medication was late and she did not get it until around 4:30 AM (more than four hours later.) The resident also stated she missed two doses of pain medication, and when she didn't get it on it time, the pain just got worse, and she shut down and wept because of the pain. During telephone interview on 11/01/18 at 11:20 AM, Resident #1 stated that she asked for pain medication several times after midnight. The resident also stated that no one asked her the location of the pain or what it felt like or even offered her Tylenol. The resident stated my acute pain was not taken care of and it caused me to spiral and increased anxiety. The resident stated she left the facility the next day (against medical advice), and went home and called the hospital to obtain a prescription for pain medication. The resident stated that she felt she would do better to manage pain at home. Resident #1's medical record did not identify actions nursing staff made to assess, monitor and provide pain management throughout the night. Interviews with staff were not consistent with the medical record. During an interview on 10/16/18 at 9:29 AM, Consultant B, Pharmacist, stated that the pharmacy tried to anticipate needs of residents and provided authorization for nurses to remove narcotic medication from emergency supplies in the facility, based on physician orders [REDACTED]. Consultant B also stated that if medication delivery was delayed, the nurse could call the pharmacy and request additional authorization to give Oxymoron from facility supply. During an interview on 10/30/18 at approximately 2:45 PM, Staff C, Licensed Practical Nurse (LPN), stated between 12:00 AM to 1:00 AM, when Resident #1's pain medication started to wear off, she didn't have any medication to give and had to tell the resident the pharmacy was coming. Staff C also stated she called the pharmacy and they couldn't provide authorization for more [MEDICATION NAME] from facility supplies. Staff C stated that the resident's pain level was high and the resident cried a lot because she did not want to be there and was uncomfortable. Staff C also stated the resident had a high anxiety level and had tried other interventions such as repositioning and offered Tylenol and the resident refused. Staff C stated that Resident #1 waited about three hours for delivery of her pain medication. Resident #1's medical record did not show what non pharmacological interventions staff attempted or when, and if they were effective. The record did not show staff offered the resident Tylenol during the night. During an interview on 10/30/18 at 3:33 PM, Consultant B Pharmacist, stated that the pharmacy did not have a record of further requests for additional authorization for more [MEDICATION NAME] for Resident #1 during the night. During this interview, Staff A, Director of Nursing (DON), stated that staff could have called the physician and requested authorization for more pain medication and explained the system in place for staff to do this. During an interview on 10/30/18 at 4:20 PM, with Staff D, Licensed Practical Nurse (LP) and Staff E, Licensed Practical Nurse (LPN), both stated that staff could call the physician or the Medical Director for an order for [REDACTED]. During an interview on 10/30/18 at 4:35 PM, Staff A, Director of Nursing (DON), stated that she expected nursing staff to check on residents who had pain every one to two hours and ensure they managed the pain. During interview on 11/01/18 at 2:40 PM, Staff F, Licensed Practical Nurse (LPN), stated that if a resident had a lot of pain, she would ask the resident the location of the pain, to describe it, check the incision, take vital signs, and continue to monitor them every forty five minutes to an hour and document in progress notes. Resident #1's record did not show if or when staff assessed and monitored the resident throughout the night shift for pain, when the effects of the dose of pain medication administered 09/03/18 at 9:29 PM may have worn off. The record did not show steps nursing staff took to attempt to obtain additional [MEDICATION NAME] until the pharmacy delivery arrived, to provide uninterrupted pain management, and prevent harm from experiencing continued pain while waiting for more pain medication to be delivered. WAC 388-97-1060(1)

Based on observation, interview and record review the facility failed to ensure residents were free from accidents and hazards: Failure to ensure 21 out 54 rooms (#'s 106, 107, 115, 120, 121, 204, 205, 206, 207, 209, 211, 402, 404, 406, 407, 410, 412, 414, 417 & 418) had objects placed away from baseboard heaters per manufactures guidelines, placed residents in immediate jeopardy related to potential fire hazard and/or resident injury for burns. Also the facility failed to ensure that the resident's environment was free of accidents hazards, identified potential risks, and provide adequate supervision when serving hot beverages (coffee or hot water) for four residents (#17, # 47, #62, and #319) out of twenty. Residents #17, #47, #62, and #319 all have physical disabilities and are wheelchair dependent. This failure had the potential to cause injury. Findings include . Residents' rooms were heat regulated with the use of individual self-adjusted thermostat, on the wall, inside of each resident's room. 100 Hall An observation on 12/04/17 at 09:45 AM, showed room [ROOM NUMBER] had a baseboard heater under the window, near a bed. A bedside table was approximately less than five inches from the front of the heater. There were two stacks of loose paper material on the top of that bedside table, one was approximately one foot high and other is approximately five inches high. An observation on 12/04/17 at 09:55 AM, showed room [ROOM NUMBER] had a night stand approximately less than four inches away from the front of the heater, and an electrical cord was hanging in front of the heater. An observation on 12/04/17 at 09:45 AM, showed room [ROOM NUMBER] had a chair, a night stand, and a plastic laundry basket was less than six inches from the front of the baseboard heater. An observation on 12/04/17 at 10:05 AM, showed room [ROOM NUMBER] had a bedside table and a wooden chair; room [ROOM NUMBER] had a fabric laundry bag and a small cabinet pushed against the baseboard heater. 200 Hall An observation on 12/04/17 at 11:49 AM, the heater in room [ROOM NUMBER] was hot to touch, and the temperature tested at 149 degrees Fahrenheit (F). Socks and a plastic bag of disposable briefs were one inch away from the heater, a wheelchair cushion was about two inches away, and a wheelchair was four inches away. An observation on 12/04/17 at 10:21 AM, room [ROOM NUMBER] showed the curtain touched the heater and a garbage can was pushed up against the curtain. The heater was hot to the touch. A wooden chair was about two inches away from the front of the heater. The bedside table was approximately five inches away from the front of the heater, and there was a box of soft tissue and a container of water on top of the table. An observation on 12/04/17 at 11:37 AM, in room [ROOM NUMBER]-B showed the base board heater was hot to touch and the temperature tested at 144 F. There was a blue recliner cloth chair approximately four inches away from the front of the heater, a wooden chair and a night stand about three inches away. There were multiple objects on top of the night stand: a box of tissues, a plant, two framed pictures, a phone, and a mug filled with pens, pencils, and a nail file. The curtain was about three inches away from the side of the base board heater. The dial on the wall thermostat was turned to the line between 50 and 60. An observation on 12/04/17 at 11:25 AM, in room [ROOM NUMBER], a bedside table, a pair of shoes and a night stand with a TV on the top was within six inches away from the front of the baseboard heater. An observation on 12/04/17 at 11:27 AM, in room [ROOM NUMBER], a decorated Christmas tree with a fabric blanket at the bottom of the tree was less than five inches away from the front of the baseboard heater. An observation on 12/04/17 at 11:30 AM, in room [ROOM NUMBER], a resident sat less than one foot away from the heater with only socks on both feet. During an interview on 12/04/17 at 12:36 PM, Staff M, Nursing Assistant Certified (NAC), stated that nothing was supposed to be around the heater that could catch fire and was told to keep things at least eighteen inches away. During an interview on 12/04/17 at 12:42 PM, Staff O, Licensed Practical Nurse (LPN), stated that the temperature in the room was adjusted according to resident's preference, and it was regulated by staff and family members, and even the residents if they could reach the thermostat. She also stated that the staff should keep things away from being directly up against the heaters. She stated she tried to keep objects twelve inches from the heater. When questioned about a policy related to the baseboard heater, she stated I honestly don't have an answer for you but I can find out. Staff O, LPN, stated that Resident #8 self-propels in her wheelchair throughout the facility and is considered at risk for wandering with [DIAGNOSES REDACTED]. She described Resident #46 as able to self-propel around the facility and was also confused with a [DIAGNOSES REDACTED].#46 received oxygen via nasal cannula and sometimes took his oxygen off leaving the resident even more confused. Resident #66 self-propeled up and down the halls and is confused as well. During an interview on 12/04/17 at 12:54 PM, Staff I, LPN, stated that usually the residents or the family members can regulate the temperature if they want or they can ask staff to do it. Staff I, LPN, stated that they were told to keep everything about eighteen inches away from the heater. She also described Resident #8 as being confused with sundow[DIAGNOSES REDACTED] symptoms almost every evening. 400 Hall An observation on 12/04/17 at 09:48 AM, multiple rooms (410,414,412,406, 402, 407) had furniture close to baseboard heaters. room [ROOM NUMBER] had a baseboard heater turned on, hot to touch. A wooden chair was placed approximately four inches away from the front of the heater. The resident stated that no one had told her to keep things away from the heater. Surface temperature of the baseboard heater measured at 149 F. An observation on 12/04/17 at 09:55 AM, room [ROOM NUMBER] had a nightstand placed against the front of the baseboard heater. There was a fiber doll on top of the night stand. The bottom of the curtain touched the front of the baseboard heater. The surface temperature of the baseboard heater measured at 149 F. An observation on 12/04/17 at 10:10 AM, room [ROOM NUMBER] had a wooden chair pushed against the baseboard heater. The surface temperature of the baseboard heater measured at 153 F. Resident was sitting next to the heater with bare feet. Her right foot was less than two inches away from the front of the heater, and she had an open wound at the bottom. Resident stated that she knew that objects were supposed to be placed at least twelve inches away from the baseboard heater. An observation on 12/04/17 at 10:20 AM, room [ROOM NUMBER] had a wooden chair pushed against the front of the baseboard heater. The Heater was hot to touch, temperature tested at 149 F. An observation on 12/04/17 at 10:40 AM, room [ROOM NUMBER] baseboard heater with the coils exposed. Hot to touch, temperature tested at 173 F. Resident stated that the coils been like this for long time. She told the NAC to leave the window half way open to prevent the room become too warm. An observation on 12/04/17 at 10:45 AM, room [ROOM NUMBER], 414, and 418 had chairs pushed against the baseboard heater. room [ROOM NUMBER] has a plastic cabinet and an electrical cord handing in front of the front of the baseboard heater. room [ROOM NUMBER] had a table with a table cloth draped less than six inches from the front of the baseboard heater. During an interview on 12/04/17 at 12:30 PM, regarding safety precautions of the base board heaters, staff F, LPN, Charge Nurse, stated that objects should be kept a least six inches away from the heater, and there was one confused resident (Resident #32) on the 400 hall but that resident is on one on one observation and is never left unattended. During an interview on 12/04/17 at 12:47 PM, M, staff N, NAC, Restorative Aide, stated that resident can adjust the temperature, and that everything should be kept three feet away, maybe like a foot away from the heater. When questioned about the policy concerning baseboard heaters, he answered I don't know. He also stated that he has not been received any training regarding the baseboard heater recently, and there were resident with wondering risk living in this hall. During an interview on 12/04/17 at 2:53 PM, Staff A, Administrator, stated that they did not have a written policy regarding the distance items should be away from the baseboard heaters. Staff A, also stated that she did not believe there was any recent staff trained on safe operations of the baseboard heater. Residents Self Serving Hot Liquids Review of Resident #17's care plan dated 09/26/17 reflected Resident had limited physical mobility, was totally dependent on staff for repositioning and turning in bed, required limited assistance with transfers and required use of wheelchair for locomotion on and off unit. Resident required set up assistance for meals. Review of Resident #47's care plan dated 09/26/17 reflected Resident had limited physical mobility, required limited assistance to turn and reposition in bed, required extensive assistance with transfers, was non weight bearing and was wheelchair dependent for locomotion on and off unit. Resident required set up assistance for meals. Review of Resident #62's care plan dated 12/05/17 reflected Resident has limited physical mobility, required limited extensive assistance to turn and reposition in bed, required limited assistance for transfers, was wheelchair dependent for locomotion on and off unit and required extensive assistance from staff. Resident required set-up assistance for meals. Review of Resident #319 care plan dated 11/27/17 reflected Resident has limited physical mobility, required extensive assistance to turn and reposition in bed, required extensive assistance with transfers, was wheelchair dependent for locomotion on and off unit and required limited assistance. Resident required set-up-assistance with meals. Record review revealed Resdient #17, #47, #62, and #319 had evaluations identifing risks to consume hot beverages and those risk had been discussed with the residents. However all four residents were also care planned for set up of meals and had physical disabilities that made them wheel chair dependent for locomotion. None of the evaluations and care plans reflected assessment to self-serving hot liquids or transport hot liquids while in a wheelchair. Observation on 12/04/17 at 11:38 AM, Resident #47 self-propelled out of room, approached unattended coffee cart in hall. Resident #47 then removed a coffee cup from the tray of cups on the second shelf of the coffee cart. Resident #47 then filled the cup with hot coffee from thermos with pump lever on top. Resident #47 wheeled back to room using left hand to wheel the wheelchair while carrying the hot coffee in the other hand. The coffee had no cover on it even though covers were available on the coffee cart. On 12/05/17 at 7:37 AM, Resident #319 self-propelled toward unattended coffee cart. Resident removed a cup from the second shelf of coffee cart, placed the cup under the spout and pumped the lever on top until the coffee cup was filled full with hot coffee. Without any assistance or supervision from staff, Resident #319 self-propelled the wheelchair approximately 15-20 feet back to room. The Resident moved the coffee from hand to hand wheeled with left hand with coffee in right hand, then transferred hot beverage to left hand and wheeled wheelchair with right hand, then switched hot coffee without lid or covering back to the right hand and again wheeled wheelchair with the left hand. Resident #319 did this motion back and forth until reaching bedside. During an observation and interview on 12/05/17 at 7:39 AM, Resident #62 self-propelled from room at the end of the hall to the unattended coffee cart. Resident #62 took a clean cup from the tray of cups and poured hot water from a thermos into the cup. Without assistance from the staff Resident #62 wheeled over half the distance of the hall. Steam was seen coming off the hot liquid without a lid. The resident wheeled the wheelchair with one hand, transferring coffee then wheeled wheelchair with the other hand. Resident #62 repeated this process over and over transferring the hot beverage from right hand to left hand so as to wheel wheelchair with opposite hand until reaching room at end of hall and placing beverage on over the bed table. Resident #62 stated that it was normal to get hot beverages independently and wheel back to room carrying it without cover. Observation on 12/05/17 at 7:45 AM, showed coffee temperature from the thermos was 160 degrees Fahrenheit. Observation on 12/05/17 at 11:28 AM, coffee cart arrive on 400 hall for lunch time meal service. Staff N, Nursing Assistant Certified (NAC), Restorative Aide, poured hot coffee into a cup and assisted this surveyor to obtain the temperature reading at 155 degrees Fahrenheit. Staff N, NAC, Restorative Aide, poured hot water in a cup and obtained the temperature reading of 157 degrees Fahrenheit. During an interview on 12/05/17 at 11:30 AM Staff N, NAC, Restorative Aide, stated that some Residents did get their coffee by them self but if he see them attempting to serve themselves, he offers to help them. Observation on 12/05/17 at 11:28 AM, Resident #17 sell-propelled out of room up to an unattended coffee cart. Resident #17 got a cup and attempted to pump lever for coffee when Staff N, NAC, approached the Resident and asked if he could assist. Staff N, NAC, then prepared the coffee as Resident #17 instructed and carried it into the Resident's room and placed it on the over the bed table. Observation on 12/06/17 at 12:12 PM, all three coffee carts for hall 100, hall 200 and hall 400 were parked inside the nurses station enclosure. Observation on 12/13/17 at 11:32 AM, all three beverage carts arrive and were placed in the nurses station enclosure. Observation on 12/13/17 11 at 11:34 AM, Resident #62 traveled down the hall to her room with hot beverage in hand. Steam was observed coming off the cup of hot water. The resident wheeled the wheelchair with one hand, transferring coffee then wheeled wheelchair with the other hand. Resident repeated this process over and over transferring the hot beverage from right hand to left hand so as to wheel the wheelchair with opposite hand until she was over half way down the hall. There was no lid on the cup. Resident was dressed in a facility gown. During an interview, Resident #62 stated I always get my own hot water for tea this time of day everyone is so busy. I like it really hot. When Resident #62 was asked where s/he obtained the hot water. Resident #62 describes heating the hot water up in a microwave in the therapy gym. Review of facilities policy and procedure titled Safety of Hot Liquids revised October 2014 reflects: Residents will be evaluated for safety concerns and potential for injury from hot liquids, upon admission, readmission and change of condition. Appropriate precautions will be implemented to maximize choice of beverage while minimizing the potential for injury. The policy directs that potential [MEDICAL CONDITION] hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition and nerve or musculoskeletal conditions. The policy further directs that once risk factors for injury from hot liquids are identified appropriate interventions will be implemented. Some interventions described were Serving hot beverage in cup with lid; Encouraging Resident to sit at a table while drinking or eating hot liquids; Providing protective lap covering or clothing to protect skin from accidental spills; and staff supervision or assistance with hot beverages. Professional reference titled State Operations Manual Chapter 7-Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities dated 6/12/14, showed that: Table 1. Time and Temperature Relationship to [MEDICAL CONDITION] Water Temperatures Time Required for a 3rd Degree Burn to Occur 155 degrees Fahrenheit 1 seconds 148 degrees Fahrenheit 2 seconds 140 degrees Fahrenheit 5 seconds 133 degrees Fahrenheit 15 seconds 127 degrees Fahrenheit 1 minute 124 degrees Fahrenheit 3 minutes 120 degrees Fahrenheit 5 minutes 100 degrees Fahrenheit safe temperatures During an interview on 12/13/17 at 11:44 AM, Staff U, Dietary Manager, stated that we do not take temperatures on hot beverages before they leave the kitchen. During an interview on 12/13/17 at 11:51 AM with Staff B, Director of Nursing Services (DNS), stated I was unaware that residents were serving themselves coffee or hot water. Staff B, DNS agreed the policy and current assessment for hot liquids was developed for Residents eating and drinking hot liquids. Staff B, DNS, stated I don't want the Residents serving themselves hot liquids and I definitely don't want residents transporting hot liquids while trying to self-propel in a wheel chair. During an interview on 12/13/17 at 12:08 PM, Staff B, DNS, stated I removed the microwave from the therapy gym so residents could no longer use it without supervision.

Based on observation, interview and record review, the facility failed to ensure the Main Dining room utilized for meals and as a multi-purpose room was a safe environment as free from accident hazards as possible, for 5 of five residents (#52, #43, #110, #30, #122)with increased risks for accidents and incidents related to cognitive imairment and wandering. Failure to ensure the stove (oven and stovetop) was secured and not accessible to unsupervised, vulnerable residents placed them at likelihood for injury, pertaining to burns, and resulted in an immediate jeopardy situation. Findings include: Observation on 1/3/17 at 10:30 a.m., revealed the main dining room was located down the hall from a nurses' station, therapy room, and visitor bathrooms. The kitchen was located across the hall from the dining room. In order to see inside the entire dining room, one needed to enter. An activity cart including magazines, books and games was located just outside the main dining room, so that residents could either take resources back to their rooms or enter the dining room for sufficient space to enjoy leisure time independently. Observation on 1/3/17 at 12:30 p.m., revealed an older-appearing stove was located in the main dining room next to the sink on the left side of the dining room upon entrance. The stove was placed along the wall and situated so that it was aligned with the counter tops. A small stack of two green lap covers sat on the counter on the left side of the stove, with a corner of the fabric touching the burner on the front left. The knobs to the stovetop were removed, however, the metal insert to the knobs, with one flat side, remained. The metal inserts required pushing in and turning in one motion, resulting in the light to the associated burner to come on. During the observation, a burner warmed up immediately, as evidenced by the color of the burner and was warm to touch. Two other burners were attempted with the same results. The plastic knobs to the oven were in place. When one knob was turned to oven, and the other to the desired temperature, the oven came on, as evidenced by the color of the burners and warm to touch. The oven door did not close all the way, leaving approximately an inch of gap for an opening. In interview on 1/3/17 at 1:33 p.m., Staff D stated his/her department had not used the stove with the residents since Staff D had started employment, approx. 2 years prior. Staff D was aware the stove was turned off by a breaker located just inside the kitchen, across the hall. In interview on 1/3/17 at 1:37 p.m., Staff L stated a lot of times residents would hang out in the dining room independently. I will try to pop in every once in a while to check on them. In interview on 1/3/17 at 1:38 p.m., Staff N stated some residents gathered in the dining room to play cards. Staff will sometimes be with them, but it is their right to be in there by themselves. In interview on 1/3/17 at 1:40 p.m., Staff O stated residents can be in the dining room at any time without staff. In interview on 1/3/17 at 1:40 p.m., Staff P Ocupational Therapy used the oven for cooking assessments related to discharge planning. The pots and pans were locked in a cabinet located above the stove. The therapy department had a key to secure the pans and knobs when not in use. In addition, the breaker in the kitchen was turned off to disable the stove when not in use. The last time the therapy department used the stove for resident use, was approximately 6 weeks to 2 months prior, according to Staff P. In interview on 1/3/17 at 1:38 p.m., Staff A stated the stove in the dining room was used for cooking groups with the activity department. A Christmas party was held for staff and someone wanted to warm some food. Someone monitored the stove the whole time it was being used, until staff were done with it. The stove was on a separate breaker located in the kitchen, and the breaker was expected to be in the off position when the stove was not in use. The nobs were also removed to keep residents from using it. According to Staff A, the breaker should not be on. Observation at 1:41 p.m., revealed Staff A entered the kitchen. Just inside the door, the breaker box was located and marked with a post it note, Activities stove. When the breaker door was opened, an orange sticker labeled, activities stove placed next to the breaker switch was found in the on position. At that time, Staff A switched it off. Staff A went to the stove and turned the oven nobs. This surveyor demonstrated the ability to turn the metal prongs to the burners, without the nobs. When asked how the facility planned to ensure the safety of the residents from a potential burn with a plan request, Staff A stated s/he knew the stove was a bad idea and was to remove it immediately. In interview on 1/3/17 at 1:50 p.m., Staff F stated s/he was not aware the stove worked and had thought it was for display. There was no maintenance schedule for the appliance. Additionally, Staff F stated the Christmas party was held Thursday, December 22. Record review of Staff A statement written 1/3/17 in response to the stove, Staff A wrote it was not certain how long the stove breaker was left in the on position other than 12/22/16, and unable to locate a policy relate to the use of the stove. Observation on 1/3/17 @ 2:50 p.m., revealed three residents were observed in the dining room unsupervised. Observation on 1/4/17 2:30 p.m. and 1/5/17 at 10:15 a.m., Resident #30 propelled him/herself in his/her wheelchair down the 200 hall. In interview on 1/10/17 2:40 p.m., when asked the resident if s/he felt sad, down or depressed, Resident #30 was not able to hear the questions asked adequately due to being hard of hearing. When the question was put in writing, the resident answered s/he did not know. In addition, the resident was not aware of the current month or year. In interview on 1/10/17 at 2:59 p.m., Staff HH stated Resident #30 exhibited behaviors to include wandering, confusion, or will want to go home. Sometimes the behaviors were not redirectable and sometimes giving him/her an activity would work. Observation on 1/4/17 at 4:10 p.m., revealed Resident #43 was observed in the dining room propelling him/herself independently, unsupervised. Observation on 1/5/17 at 2:05 p.m., revealed Resident #110 propelled him/herself down the 400 hall asking what s/he was supposed to being doing at that time. A staff member who said hello and told the resident s/he saw him/her almost daily, the resident responded s/he did not recognize the staff. Observation on 1/6/17 at 3:10 p.m., revealed Resident #43 was observed in the dining room with two other residents unattended. Resident #43 sat at a table looking at something across the room. Another resident seated at a table to the right side was reading a magazine. The resident that sat in his/her wheelchair at the front table, appeared to be sleeping. Observation on 1/9/17 @ 4:41 p.m., revealed Resident #52 entered the 300 hall, which was closed to residents. The resident propelled him/herself, while holding on to a railing on the wall, and looked into the empty resident rooms as s/he went by. Observation on 1/11/17 @ 1:30 p.m., revealed Resident #43 sat in his/her wheelchair at the nurses' station, and flipped pages in a binder located on the counter. The binder contained staffing flow sheets, including skin checks on residents during showers. Observation on 1/11/17 at 6:30 p.m., Resident #43 propelled him/herself down the 300 hall independently. Staff were not observed in the immediate area or in view. Record review of 11/8/16 Quarterly Minimum Data Set (MDS), a required assessment tool, revealed Resident #122 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented with short term memory loss, with impaired decision making skills, requiring cues/supervision for safety. The resident was able to self-propel in his/her wheelchair for mobility.

Based on observation, interview, and record review, the facility failed to assess and monitor skin conditions for 2 of 2 residents (#'s 40 & 168) reviewed for non-pressure related skin conditions, and failed to ensure pain management was provided for 1 of 2 residents (#40) reviewed for pain. These failures resulted in harm for R #40 when the facility did not address underlying causes of pain in a time consistent with the resident's pain management needs, and subsequently the resident remained with high levels of pain for an extended amount of time. In addition, the failures to assess and monitor skin conditions, placed residents at a potential risk of avoidable, worsening skin conditions. Findings include: RESIDENT #40-PAIN Resident #40 admitted to the facility on [DATE] with a [MEDICAL CONDITION] femur and a full leg cast in place from the mid to upper thigh down to the foot and with a wound to the left arm, caused when the resident fell and fractured her femur. An assessment of cognitive status, The BIMS score which was 15 out of 15, (Brief Interview for Mental Status), indicated the resident was cognitively intact. Review of the Admission MDS (Minimum Data Set- a required assessment tool) Admission assessment dated [DATE],revealed Resident #40 frequently had pain that limited day to day activities. The pain score on a scale of 1-10, with 10 the worst pain, was 8. Record review of the Order Summary Report dated 10/6/16, the day of admission listed [MEDICATION NAME] Sodium Tablet, 1 every 12 hours, to be given as needed for [MEDICAL CONDITION] arthritis and Tylenol tablet 325 mg, give 650 mg (2) as needed for mild pain (1-3) every 4-6 hours. Resident #40's care plan focus dated initiated 10/26/16 was Acute pain r/t GLF (general loss of function) with closed reduction to right femur fracture. Interventions listed included to anticipate need for pain relief and respond immediately to any complaint of pain, monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Notify provider if intervention are unsuccessful. This was not consistently acted upon to address pain needs of the resident. Review of Nursing Progress Notes record Resident #40 complaint of pain in right leg on admit to the facility and daily, several times a day. On 10/7/16 at 11:00 p.m., after numerous complaints of pain and three doses of Tylenol without relief, the provider was notified and an order for [REDACTED]. None of the treatments ordered were effective to relieve/reduce the resident's level of documented pain. The resident continued to complain of pain with movement of leg with pain medication given thereafter. The complaints of pain continued through 10/21/16 when according to the Nursing Progress Notes (NPN) dated 10/21/16, the resident's family questioned staff regarding ongoing complaints of discomfort related to the cast and pain in the right leg. This prompted a visit to the emergency room (ER) that evening for cast readjustment. The Discharge Summary report of the ER visit recorded x-rays of the leg revealed increased medial displacement of the fracture compared to the 10/13/16 study. Displacement now measures 12 mm previously 4 mm. The fracture appears more impacted. The cast was removed from the right leg and an immobilizer (brace) was placed on the extremity. Also recorded in the note was a report of pain in the left lower arm wound. Review of a provider note dated 10/15/16 recorded the resident with increased pain and minimal control with the Tylenol given as needed. The note identified Resident #40 with moderate pain in the left arm wound and displacement of the right leg fracture. The note reported Right leg definite change in length about 1-2 cm compared to left. Despite the start of [MEDICATION NAME] table 5/325 on 10/8/16 to be given as needed, and another order dated 10/26/16 to give as needed prior to dressing change to left arm, It was not until 11/27/16, with the start of Xeljanz 5 mg two times a day for arthritis and [MEDICATION NAME] (changed to) two times a day, scheduled, not as needed, that the resident began to report continued pain relief. The resident's pain was not comprehensively assessed until 11/22/16 with treatment interventions not revised until over seven (7) weeks after admission to the facility. A review of Physician Visit form dated 10/21/16, 11/25/16, 12/16/16 and 1/7/17 collectively describe the resident to have chronic pain, anxious, tearful, depressed, and complaining of pain. The resident was documented in the NPN of periods of forgetfulness with an order dated 11/18/16 for a mental health evaluation for cognition and short term memory loss. The resident was also noted to have started antibiotic therapy when loss began. Review of the Mental Health Evaluation dated 11/30/16 reported there was no indication for [MEDICAL CONDITION] medication for the resident and follow up only as needed. Resident #40 was identified on admission to the facility to have difficulty with pain. On admit the resident's typical pain score was 8 of 10. On admit the resident only had an order for [REDACTED]. RESIDENT #40-Skin Review of the Skin Condition Sheet dated 10/6/16 documented, the resident was admitted with a skin tear to the left upper extremity (LUE) measuring 7 cm x 5 cm (centimeters) with a scabbed area. The Skin Condition Sheet dated 10/20/16 of the LUE recorded the wound measured 9.5 cm x 6 cm, an increase in the size from the previous measurement, was open with abrasions, scabs, had a red wound bed, heavy serosanguinous (composed of serum and blood) drainage and no odor. Nursing note for that date stated the dressing change was performed by the wound team. Review of the Wound Assessment Progress Report dated 10/29/16 through 12/15/16. The initial wound assessment documented on 10/29/16 was recorded with the description of the wound on 10/20/16. The wound on 11/19/16, almost 20 days later was documented to measure 13 x 5 cm, brown in color with copious amounts of drainage, no odor and painful. Protein shakes/prostat was listed as a nutritional intervention. Despite worsening of the wound, culture of the wound was not done to rule out possible infection as a contributor to healing challenges. With progressive worsening of the wound, a provider order dated 10/25/16 written for, Ok for United Wound Healing eval (evaluation) and tx (treatment) for wounds. A nursing progress note dated 11/10/16, 20 days later, documented a wound assessment by the wound team. Although the need for intervention was identified and an order given to care for the wound, a delay in initiating care prolonged the start of intervention measures and further worsening of the wound. The wound assessment dated [DATE] documented wound measured 10.5 x 4/5 cm brown in color with scant drainage and no odor. Observation of the wound dressing change on 1/11/217 at 1:52 p.m., revealed the wound to be in a continued state of healing with some unhealed areas noted by the resident when touched during wound care. Although the resident was identified to be predisposed to wound healing challenges, the wound almost doubled in size before measures were started to effectively address wound care needs.

Based on observation, interview and record review, the facility failed to ensure nursing staff followed accepted professional standards of practice to transcribe complete physician orders [REDACTED].#s 1, 2, 3, & 4) reviewed who required anticoagulant medications. Licensed staff failed to transcribe physician orders [REDACTED].#1 during 21 days following admission. Licensed staff failed to follow physician orders [REDACTED]. This resulted in harm for Resident #1 when the physician discovered the resident developed a blood clot in the leg. Failure to consistently follow physician orders [REDACTED].#1; Resident #2; Resident #3 and Resident #4. Findings include: The Washington State Nurse Practice Act, WAC 246-840-710 (2) in part indicates nurses violate standards by: (c) Willfully or repeatedly failing to make entries .pertaining to the giving of medication, treatments, or other nursing care . (d) Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards . (i) Failure to protect clients from unsafe practices or conditions . and (8) The nurse shall have knowledge of the statutes and rules governing nursing practice . According to Nursing 2012 Drug Handbook; Lippincott Williams & Wilkins, 2012, Philadelphia, PA; Medication administration includes the 8 Rights: Right patient; Right medication; Right dose; Right route; Right time (double-check that you are giving the ordered dose at the correct time and confirm when the last dose was given; Right documentation AFTER giving the ordered medication, site of injections, vital signs checked before giving the drug; Right reason and Right response. According to Smith, Duell and Martin, Clinical Nursing Skills, Sixth Edition, pages 518-521, nurses are to administer medications as ordered by the physician. Additionally, nurses are to document the time of administration, route, dosage, and assess and document the resident's response to the medication. Nurses are to review the Medication Administration Records daily to validate all medications are in accordance with the physician's orders [REDACTED].>Refer to F 333 for observations, medical history, physician orders [REDACTED].#1; Resident #2; Resident #3 and Resident #4. Refer to F 157 and F 309 for observations, interviews and record review details regarding failure to monitor [MEDICAL CONDITION] for Resident #1 and notify the physician. Physician medication orders not implemented or consistently followed, included anticoagulant (blood thinning medications) [MEDICATION NAME] and [MEDICATION NAME] by injection, and oral [MEDICATION NAME]. NEW ADMISSION PHYSICIAN ORDERS [REDACTED]. RESIDENT #1 Resident #1 admitted on Saturday 7/2/16. Not all medication orders were discovered and transcribed by the admission nurse at the time of admission. Hospital discharge instructions dated 7/2/16 included directions for nursing home staff to please monitor for swelling, warmth, or pain behind the knee or within lower leg and if noted please contact your primary care provider of clinic urgently, as this can be a sign of a blood clot. Licensed staff failed to comprehensively assess Resident #1's [MEDICAL CONDITION] noted in progress notes beginning 7/11/16 and monitor for signs of a blood clot and notify the physician. A facility Medication Error Report dated 8/2/16 identified at the time Resident #1 admitted to the facility (7/2/16), licensed staff did not identify [MEDICATION NAME] was ordered on admission hospital transfer documents and transcribe them onto admission orders [REDACTED]. The error report also identified staff did not transcribe a [MEDICATION NAME] order on 7/29/16 in detail and the resident missed three days of this oral medication. As a result, licensed staff failed to administer 41 doses of [MEDICATION NAME] during 21 days, between 7/2/16 and 7/22/16. Staff did not identify orders for [MEDICATION NAME] were not provided until after the resident developed a blood clot in the leg. Corrective action noted on the Medication Error Report identified to prevent reoccurrence included to have two nurses recap (double check) medication orders at the time of admission. On 8/8/16 at 2:05 p.m., when asked how the facility ensured new admission orders [REDACTED]. Staff A did not know if there was a designated licensed nurse to conduct a second review on admission orders [REDACTED] On 8/8/16 at 2:12 p.m., Staff C reported resident records did not identify two nurses signed they reviewed new admission orders [REDACTED]. On 8/8/16 at 5:10 p.m., Staff G stated the charge nurse on the weekend reviewed all new admission orders [REDACTED]. Staff G reported if a resident admitted with a pelvic or [MEDICAL CONDITION] and admitted to the facility with anticoagulant orders, he/she would have contacted the physician and clarify if orders for anticoagulant medication were needed. On 8/9/16 beginning 1:20 p.m., Staff C reported the facility did not have a system in place for two nurses to sign they reviewed new admission orders [REDACTED].) Staff C stated at this time, licensed staff did not initial new admission orders [REDACTED] ADDITIONAL FAILURES TO FOLLOW PHYSICIAN ORDERS Medication Records contained blank spaces where licensed staff should have initialed to indicate they administered ordered anticoagulant medications. The following records did not contain evidence staff followed physician orders [REDACTED]. RESIDENT #1 1. [MEDICATION NAME] on 7/29/16; 7/30/16 and 7/31/16. 2. [MEDICATION NAME] at 8:00 a.m. on 8/4/16 and 8/5/16. Facility records did not contain evidence licensed staff reported and fully investigated [MEDICATION NAME] omission medication errors on 8/4/16 and 8/5/16. During an interview on 8/16/16 at 1:50 p.m., Staff C reported the medication error on 8/4/16 and 8/5/16 had not been reported to administration. RESIDENT #2 Medication Records for July 2016 and August 2016 did not contain initials of licensed staff to indicate they administered [MEDICATION NAME] to Resident #2 as ordered at 10:00 p.m. on 7/30/16; 6:00 a.m. on 7/31/16 and 6:00 a.m.; and on 8/1/16 as scheduled. RESIDENT #3 Resident #3's July 2016 MAR identified on Friday, 7/29/16, staff did not document they administered 4 mg of [MEDICATION NAME] as ordered by the physician. RESIDENT #4 1. Admission physician orders [REDACTED]. The July 2016 MAR contained blank spaces and did not provide evidence staff administered [MEDICATION NAME] in the morning on 7/18/16 and 7/19/16. 2. An INR (International normalized Ratio) blood test is used to monitor the effects of administration of blood thinning medication [MEDICATION NAME]. Physicians identify INR level needed to maintain to maximize therapeutic effect of this medication to prevent the development of blood clots. INR level blood tests are ordered by physicians to determine medication dosing. On 7/17 /16, the physician ordered for staff to check INR levels daily for the first three days following admission beginning 7/18/16 for Resident #4. The resident's record did not contain evidence staff checked the INR as ordered on [DATE]. 3. A physician order [REDACTED]. Licensed staff documented they administered [MEDICATION NAME] on 7/20/16, 7/21/16 and 7/22/16 when the INR measured greater than 2.0 and did not hold the medication as ordered. 4. Licensed staff did not document on the July 2016 MAR they administered 3 mg of [MEDICATION NAME] as ordered on [DATE] or on 7/30/16. On 8/8/16 at 5:10 p.m., Staff G reported if nurses observed blanks on the MAR (to indicate a medication was not given) they reported it to Staff B. Staff G stated Staff B would then call the nurse at home and leave them a note to sign the MAR. Staff G stated if the nurse did not give the medication they should write a note on the reverse side of the MAR. During an interview on 8/11/16 beginning 12:35 p.m., Staff E reported if a floor nurse discovered a medication error they should complete a medication error report. Staff E stated, the Resident Care Manager (RCM), would obtain a statement from the nurse who made the error. On 8/11/16 at 2:20 p.m., Staff B reported if a blank space on the MAR was found, staff should touch base with the nurse on that shift. If staff determined the medication was not given, they should fill out a medication error report. Staff B also stated, I want to be notified about errors. The facility did not provide evidence blank spaces denoting possible medication errors on MARS were reported or investigated to determine why licensed staff did not follow physician orders. INCORRECTLY DISCONTINUED PHYSICIAN ORDERS [REDACTED].>RESIDENT #4 1. On 7/17/16, the physician wrote an order for [REDACTED]. Staff transcribed the order onto the MAR as INR qd (daily) x 3 days. Staff did not identify the original date of the order on the MAR. On 7/22/16, the physician ordered for staff to check the INR on 7/23/16. Staff did not discontinue the first order or rewrite the new order on a separate line of the MAR. Staff drew lines to mark and box out the date on 7/23/16 they were supposed to recheck the INR on the same line as the first, discontinued order. On 7/25/16, the physician ordered for staff to recheck the INR on 7/26/16. Staff did not discontinue the first INR order and rewrite a new order for the next INR due. Licensed staff crossed a line through x 3 days on the first order and added the date 7/26/16 beneath the previous order. The date on the first order was noted as 7/26/16 and not the date of the original order. Licensed staff did not discontinue previous INR orders on the July 2016 MAR when the physician wrote new orders for INR tests on 7/23/16 and 7/26/16 as according to professional standards. Not all physician orders [REDACTED]. 2. Resident #3's July 2016's MAR contained two [MEDICATION NAME] orders incorrectly discontinued on 7/28/16. Both of the original physician orders [REDACTED]. A Medication Error Summary Report dated 8/3/16 identified discontinued medications will be highlighted in yellow and a note written to identify the order was discontinued. During an interview on 8/15/16 at 3:35 p.m., Staff M reported nurses should highlight orders on the MAR in yellow to discontinue them.

Based on observation, interview and record review, the facility failed to ensure staff thoroughly assessed and consistently monitored [MEDICAL CONDITION] timely and thoroughly assessed a bruise for 3 of 5 Sampled Residents (#s 1, 2 & 3) reviewed for use of anticoagulant medications. For Resident #1, failure to thoroughly assess and monitor leg [MEDICAL CONDITION], prevented staff from timely identifying symptoms of a blood clot in the leg; delayed more timely discovery staff failed to administer ordered anticoagulant medication upon admission; and delayed physician intervention. This resulted in harm for Resident #1 who developed a blood clot in the leg ([MEDICAL CONDITION]-[MEDICAL CONDITION]. For Resident #2, failure to thoroughly assess and monitor leg [MEDICAL CONDITION] had the potential for staff to not timely identify if the resident developed medical complications [REDACTED]. For Resident #3, failure to timely and thoroughly assess a facial bruise, had the potential for staff to not obtain all information necessary to rule out abuse and obtain baseline information to observe and monitor for change in condition. Findings include: RESIDENT #1 During observation on 8/9/16 at 10:55 a.m., Resident #1 sat in a wheelchair in his room and stated, about two weeks after admitting to the facility, he had pain behind the knee to the middle of the calf and swelling in the calf down to the foot. Resident #1 admitted to the facility on [DATE]. The hospital Discharge Summary printed 7/2/16 indicated the resident received treatment for [REDACTED]. The Admission Record identified additional [DIAGNOSES REDACTED]. A Hospital Discharge Summary dated 7/2/16 included orders for medication to treat high blood pressure combined with a diuretic; and to administer [MEDICATION NAME], an anticoagulant (blood thinning medication) for six weeks twice a day to help prevent blood clots. Hospital discharge instructions included directions for nursing home staff to please monitor for swelling, warmth, or pain behind the knee or within lower leg and if noted please contact your primary care provider of clinic urgently, as this can be a sign of a blood clot. Resident #1's plan of care related to high blood pressure and [DIAGNOSES REDACTED], initiated 7/5/16, contained an intervention to monitor pedal pulses and report abnormalities to the physician. Interventions also identified for staff to monitor/document/report as needed any changes in lung sounds on auscultation, [MEDICAL CONDITION] and changes in weight. A Resident Occurrence Report dated 8/2/16 revealed, the facility identified hospital orders for [MEDICATION NAME], an anticoagulant, were not transferred to Resident #1's physician orders [REDACTED]. Medication records identified staff did not administer the anticoagulant between 7/2/16 through 7/22/16. The initial skin assessment conducted by staff on 7/2/16 did not identify Resident #1 had [MEDICAL CONDITION] to the legs or feet upon admission. Nursing notes dated 7/3/16 and 7/4/16 documented the resident did not exhibit any [MEDICAL CONDITION]. On 7/11/16, nursing staff documented at 6:50 p.m., Resident #1 had 2+ [MEDICAL CONDITION] present to both lower extremities and staff encouraged the resident to elevate them. One method to determine extent of [MEDICAL CONDITION] was use of a scale from 1+ to 4+. If [MEDICAL CONDITION] or swelling was observed, a finger was pressed over the tibia and the depth of depression was determined and length of time it took for the depression to recover. The greater the extent of [MEDICAL CONDITION] the higher the number. Further nursing notes regarding Resident #1's [MEDICAL CONDITION] documented the following: 7/13/16: [MEDICAL CONDITION] to both legs. 7/18/16: [MEDICAL CONDITION] to the left foot 7/19/16: non-[MEDICAL CONDITION] to the right leg Resident #1's medical record did not contain further assessment regarding [MEDICAL CONDITION] such as details of what areas of the leg had [MEDICAL CONDITION]; the extent of [MEDICAL CONDITION] using measurements and/or pitting scale; correlation to weight or other symptoms, color; temperature; pulses; altered sensation or associated pain or discomfort. Medication Administration Records (MAR) for July 2016 identified staff administered a narcotic medication for pain in the right leg once on 7/10/16; once on 7/14/16 and twice on 7/19/16. The record identified staff administered pain medication 7/3/16 through 7/9/16 for mid or lower back pain and right side pain. A nursing note documented 7/22/16 at 9:30 p.m., revealed the physician arrived to see Resident #1 and ordered an ultrasound test to the right leg to rule out a [MEDICAL CONDITION]. According to the Merck Manual in an article titled [MEDICAL CONDITION] written by James D. Douketis, MD, [MEDICAL CONDITIONS] is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. [MEDICAL CONDITION] is the primary cause of [MEDICAL CONDITION] embolism. [MEDICAL CONDITION] results from conditions that impair venous return, lead to endothelial injury or dysfunction, or cause hypercoagulability. [MEDICAL CONDITION] may be asymptomatic or cause pain and swelling in an extremity; [MEDICAL CONDITION] embolism is an immediate complication. Resident #1's ultrasound report dated 7/23/16 identified the resident had an occluding [MEDICAL CONDITION] in one of the veins in the right leg. On 7/23/16, the physician ordered two medications to treat the condition; [MEDICATION NAME] and [MEDICATION NAME]. Resident #1's medical record did not contain a comprehensive nursing assessment related to the onset of [MEDICAL CONDITION] first noted on 7/11/16; 7/13/16 and 7/19/16 and leg pain noted 7/10/16 to determine if it corresponded with signs of a blood clot. The record did not contain an assessment of the resident's symptoms for a [MEDICAL CONDITION] after the physician identified it on 7/22/16 during a routine visit, later confirmed by ultrasound. During an interview on 8/8/16 at 5:00 p.m., Staff H reported if nursing discovered a new onset [MEDICAL CONDITION], they should assess and document if it is one sided or bilateral, note the facts, circulation, and review the weights, trends, obtain measurements and sometimes notify the physician. RESIDENT #2 On 8/9/16 at 1:10 p.m., Resident #2 sat in bed in his/her room and reported he/she had surgery to the left hip and had an incision. The resident stated, while trying to get into bed on own he/she fell on the floor. The resident stated he/she didn't think there was leg swelling and did not wear support hose. Resident #2 admitted to the facility on [DATE] following hospitalization . A hospital Operative Note dated 7/16/16 identified the resident had surgical repair of a left fractured neck of the femur. [DIAGNOSES REDACTED].) The resident did not experience [MEDICATION NAME] effects from the [MEDICAL CONDITION]. A facility [DIAGNOSES REDACTED]. This heart condition can increase the risk of developing a blood clot within the heart that could travel and cause complications such as a stroke. A hospital Imaging Result report dated 7/14/16 identified Resident #2 had a specialized filter placed in a major blood vessel to prevent life-threatening blood clots from traveling to critical areas of the body, such as heart and lungs. A physician order [REDACTED]. A facility care plan for Hypertension and IVC Filter Placement initiated 7/22/16 contained an intervention to monitor for and document any [MEDICAL CONDITION] and to notify the physician. The care plan did not provide further details such as how often and how staff were to monitor for [MEDICAL CONDITION] or how and where to document findings. Review of nursing notes documented the following: 7/20/16: Resident #2 had [MEDICAL CONDITION] in the left lower leg from mid-thigh to the foot with 2+ [MEDICAL CONDITION] noted around the ankle and top of foot. Pedal pulses were present bilaterally. 7/21/16: bilateral lower extremity generalized [MEDICAL CONDITION]. 7/27/16: bilateral 1+ [MEDICAL CONDITION]. The note did not identify the location of [MEDICAL CONDITION]. 7/28/16: [MEDICAL CONDITION] on bilateral ankle extremity. The record did not contain evidence of a complete assessment of [MEDICAL CONDITION] on admission or reassessments, such as approximate onset date of [MEDICAL CONDITION]; if associated with injury and surgery or if it was a chronic condition; correlation with weights, color, pulses or measurements. Resident #2's medical record did not contain Medicare nursing notes to indicate staff assessed the resident's general condition on 7/22/16 or 7/23/16, the third and fourth day following admission. On 8/9/16 at 12:05 p.m. when asked how staff were expected to monitor resident's [MEDICAL CONDITION], Staff C provided a copy of an [MEDICAL CONDITION] Measurement form and stated staff should document [MEDICAL CONDITION] assessments. Staff C provided a copy of the form which contained an area to document the leg measurements of ankles; insteps and mid-calf and to identify the extent of [MEDICAL CONDITION] using a 0 to 4+ scale. Staff C also stated he/she hoped the forms were in resident records and staff completed them weekly. On 8/9/16 at 2:03 p.m., Staff G reported the facility used to have a form to measure and document [MEDICAL CONDITION] but it faded away a month or two ago. During an interview on 8/11/16 at 12:35 p.m. Staff M reviewed Resident #2's record and reported I would have assessed extent of [MEDICAL CONDITION] using + (plus) method and monitor it daily for the first 72 hours. Staff M also stated staff should call the physician to see if the resident needed TED stockings (special hose worn to reduce [MEDICAL CONDITION] in legs.) Staff M also reported nursing should assess residents who admit every shift for the first 72 hours following admission then daily after that. Staff M reviewed the resident's record and stated there should be assessment notes written for 7/22/16 and 7/23/16. Resident #1 and Resident #2's records did not contain completed assessments for lower extremity [MEDICAL CONDITION]. During an earlier interview on 8/9/16 at 12:05 p.m., Staff C could not locate a written policy and procedure that described the system to assess and monitor [MEDICAL CONDITION], when, by whom, how often or where to document findings. following a request to see the facility policy and procedure for assessment and monitoring [MEDICAL CONDITION] during an interview on 8/10/16 beginning 10:30 a.m., the facility did not provide one. RESIDENT #3 On 8/11/16 at 3:33 p.m., Resident #3 lay in bed under covers. The resident had eyes closed and did not respond to simple questions. An Admission Record identified Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. June 2016 Physician order [REDACTED]. A quarterly assessment dated [DATE] identified the resident had impaired memory and difficulty with recall or words spoken and did not correctly identify the year, month or day of the week. On 7/16/16 the physician prescribed an antibiotic given for three days to treat a urinary infection. Antibiotics and [MEDICATION NAME] can interact to increase risk of bleeding. Staff documented in a nursing note dated 7/18/16 written at 12:30 p.m., the resident had a purple bruise on the left corner of the mouth with no swelling around the area. The note did not contain further description or assessment of the bruise at the time of discovery such as the size, color, shape, presence of discomfort or if injury involved the inside of the mouth. Resident #3's record did not contain further assessment regarding the bruise until nursing documented the size and color the following late evening on 7/19/16 at 11:50 p.m., almost 36 hours later. Additional details regarding the bruise were documented on an investigation report dated 7/20/16. The investigation report described the bruise as purple/blue in color. The bruise, located near the left mouth crease measured 4.5 cm x 0.5 cm. The bruise on the right side of the mouth crease measured 4.3 cm x 0.4 cm. On 8/9/16 at 1:45 p.m., Staff H reported nursing should assess bruising when found and write the location and measurements of size on the treatment record. Staff H reported staff should place the resident on alert charting and monitor for the first 72 hours and then weekly until resolved. On 8/9/16 at 5:30 p.m., Staff L reported, nursing should monitor a bruise right away and note the color, size and shape and write the information on the treatment record for staff to refer to for monitoring daily until resolved.

Based on observation, interview and record review, the facility failed to ensure 4 of 5 Sampled Residents (#1, 2, 3 & 4), reviewed who received anticoagulation medications (blood thinning medication), were free of significant medication errors. Staff failed to either initiate prescribed medication given to prevent development of blood clots or administer them consistently in accordance with physician orders. Staff failed to administer ordered anticoagulant medication to Resident #1 for 21 days between 7/2/16 and 7/22/16. Omission of medication became a contributing factor that led to the resident's development of a [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot in the leg) which constituted harm for this resident. Failure to consistently administer anticoagulant medications to Resident #2, Resident #3 and Resident #4 placed them at risk for inadequate or fluctuating responses to blood thinning medications and not obtaining their full therapeutic effect. Findings include: [MEDICAL CONDITIONS] occurs when a blood clot forms in one or more of the deep veins in the body, usually in your legs. [MEDICAL CONDITION] can cause leg pain or swelling, but may occur without any symptoms. [MEDICAL CONDITION] is a serious condition because blood clots in veins can break loose, travel through your bloodstream and lodge in lungs and block blood flow (pulmonary embolism). A blood test, INR (International Normalized Ratio) is used by physicians to determine resident response to anticoagulant medication and determine dosing levels. RESIDENT #1 During observation on 8/9/16 at 10:55 a.m., Resident #1 sat in a wheelchair in his room and stated he received injections in the hospital in my belly to prevent blood clots. The resident stated a day or two after admitting to the facility, I asked staff why I wasn't getting them? The resident also stated staff told him, according to the doctor I didn't need them. The resident reported about two weeks later, he had pain behind the knee to the middle of the calf and swelling in the calf down to the foot and started getting injections and blood tests again. The resident stated when he found out he had a blood clot in the leg, he wondered why he hadn't been getting injections all along. Resident #1 admitted to the facility on [DATE]. The hospital Discharge Summary printed 7/2/16 indicated the resident received treatment for [REDACTED]. The Admission Record identified additional [DIAGNOSES REDACTED]. A care plan for Activities of Daily Living initiated 7/5/16, identified Resident #1 used a front wheel walker with assistance from one staff to transfer and complete toileting activities. The hospital discharge summary identified recommended precautions included to bear weight on the left lower extremity as tolerated and to place the weight of the right leg on a flat foot and to continue therapy. Therapy notes identified the resident received consistent therapy during stay in the facility. Hospital transfer documents noted the resident received medication for prevention of blood clots during hospitalization . Hospital transfer records did not contain results of Resident #1's INR level prior to leaving the hospital before admission to the facility. The Discharge Summary included physician orders [REDACTED]. On 8/8/216, during review of Resident #1's admission orders [REDACTED]. Medication Error #1 Records revealed staff did not transcribe hospital discharge physician orders [REDACTED]. Medication records did not contain evidence staff administered [MEDICATION NAME] from 7/2/16 through 7/22/16, and the resident did not receive a total of 41 doses of medication that were ordered. On 8/8/16 at 1:20 p.m., Staff C reported, during initial review of Resident #1's medical record a week ago, he/she knew the resident required anticoagulation medication due to the resident's diagnosis, and found the orders in the hospital records in the discharge medication list right away. Staff C stated the nurse who did the admission did not see the order. A Physician Visit Form dated 7/22/16 identified the physician noted Resident #1 had right lower extremity swelling with calf pain and ordered an ultrasound test to the right leg. An ultrasound report dated 7/23/16 identified Resident #1 had a [MEDICAL CONDITION] to the right popliteal vein (leg vein.) On 7/23/16, the physician ordered for staff to administer 60 mg of [MEDICATION NAME] (twice the dose initially ordered at the time of admission to the facility) subcutaneous every 12 hours. Orders also included administration of an oral anticoagulant ([MEDICATION NAME]) beginning 7/24/16 and to recheck the INR level on 7/26/16. On 7/26/16, after receiving six doses of [MEDICATION NAME], Resident #1's INR measured 1.1. The physician ordered for staff to continue administration of both [MEDICATION NAME] and [MEDICATION NAME]. During an interview on 8/15/16 beginning 5:25 p.m., Provider D reported a therapeutic INR level for blood clot prevention was 1.5. Provider D also stated risks for developing a blood clot increased if the INR was below 1.5 for greater than 24 to 48 hours. When asked if the [MEDICAL CONDITION] was caused by the lack of anticoagulant medication, Provider D stated if the resident was not on a [MEDICATION NAME] goal for the medication it may have been a contributing factor. Medication Error #2 On 7/29/16, the facility [MEDICATION NAME] Flow Sheet for Resident #1 identified the resident's INR level was 2.2. On 7/29/16, the physician ordered to discontinue [MEDICATION NAME] injections and reduced the dose of [MEDICATION NAME]. Resident #1's [MEDICATION NAME] Flow Sheet identified the resident's INR level decreased from 2.2 on 7/29/16 to 1.4 on 8/1/16. The July 2016 Medication Record for Resident #1 did not contain evidence staff administered [MEDICATION NAME] on 7/29/16; 7/30/16 or 7/31/16 as ordered. On 8/1/16, the physician ordered an increase in the dose of [MEDICATION NAME] from 4.5 mg to 5.5 mg daily. Medication Error #3 On 8/3/16, Resident #1's INR level measured 1.3. On 8/3/16 the physician ordered for staff to continue [MEDICATION NAME] and to restart injections of [MEDICATION NAME] every 12 hours until the INR level rose to greater than 2.0. The resident's August 2016 Medication Record noted for staff to administer [MEDICATION NAME] twice a day at 8:00 a.m. and 8:00 p.m. The record did not contain evidence staff administered the 8:00 a.m. dose for two consecutive days on 8/4/16 and 8/5/16. Staff did not begin administration of the 8:00 a.m. dose of [MEDICATION NAME] until 8/6/16. During an interview on 8/16/16 at 1:50 p.m., Staff C confirmed staff did not administer the morning dose of [MEDICATION NAME] on both days. On 8/8/16 when Resident #1's INR level rose above 2.0, the physician discontinued injections of the anticoagulant [MEDICATION NAME] and continued the [MEDICATION NAME]. A facility Medication Error Report dated 8/2/16 confirmed staff failed to transcribe orders for [MEDICATION NAME] for Resident #1 on 7/2/16, and staff did not administer the medication. The report also confirmed staff failed to administer [MEDICATION NAME] for three days beginning 7/29/16. During a meeting on 8/15/16 beginning 4:12 p.m., Staff E reported Resident #1 would need to continue [MEDICATION NAME] for six months due to the [MEDICAL CONDITION]. RESIDENT #2 Resident #2 admitted to the facility on [DATE] following hospitalization . A hospital Operative Note dated 7/16/16 identified the resident had surgical repair of a left fractured neck of the femur. The facility Admission Record identified the resident had [DIAGNOSES REDACTED].) The resident did not experience [MEDICATION NAME] effects from the TIA or infarction. A facility [DIAGNOSES REDACTED]. This heart condition can increase the risk of developing a blood clot within the heart that could travel and cause complications such as a stroke. A hospital Imaging Result report dated 7/14/16, identified Resident #2 had a specialized filter placed in a major blood vessel to prevent life-threatening blood clots from traveling to the heart and lungs. A nursing progress note dated 7/20/16, documented the resident used a walker and bore partial weight on the left leg and had an incision on the left hip. A physician order [REDACTED]. Medication Administration Records (MAR) for July 2016 and August 2016 did not contain initials of staff on three occasions to indicate they administered [MEDICATION NAME] consistently. Medication records identified staff did not document they administered [MEDICATION NAME] at 10:00 p.m. on 7/30/16; 6:00 a.m. on 7/31/16 and 6:00 a.m.; and on 8/1/16 at 6:00 a.m., as scheduled. During an interview on 8/15/16 at 3:10 p.m., Staff G reviewed the medication record and stated the nurse who arrived on the next shift should check the reason the previous nurse did not give the [MEDICATION NAME]. Staff G did not know why staff did not administer it to Resident #2 three times between 7/30/16 and 8/1/16. RESIDENT #4 Resident #4 admitted to the facility on [DATE] following hospitalization . A hospital Physician Assessment and Plan dated 7/15/16 identified the resident's transfer [DIAGNOSES REDACTED]. Medication Error #1 Hospital Transfer Physician order [REDACTED]. Orders also directed staff to administer [MEDICATION NAME] injections twice a day and [MEDICATION NAME] 3 mg once a day and to adjust the dose based on the INR level. Licensed staff noted on the July 2016 MAR to administer [MEDICATION NAME] in the morning and at bedtime. The MAR did not contain evidence staff administered [MEDICATION NAME] the morning of 7/18/16 and 7/19/16. Medication Error #2 A facility physician order [REDACTED]. The facility [MEDICATION NAME] Flow Sheet identified on 7/20/16, Resident #4's INR measured 2.1 and on 7/22/16 the INR measured 2.8. The July 2016 MAR documented staff administered [MEDICATION NAME] once on 7/20/16 and once on 7/22/16 when the INR level measured greater than 2.0 and staff did not discontinue [MEDICATION NAME] as directed. Initials documented by staff on 7/21/16 were difficult to determine if staff administered the medication or if initials were circled indicating staff held it. The reverse side of the MAR did not contain a note that staff held the medication. Medication Error #3 A physician order [REDACTED]. The July 2016 MAR did not identify staff administered 3 mg of [MEDICATION NAME] as ordered on [DATE] or an explanation why it was not given. On 7/26/16 the physician adjusted the dose of [MEDICATION NAME] and ordered staff to administer 3.5 mg alternating with 3 mg every other day. Staff did not document on the July 2016 MAR they administered 3 mg of [MEDICATION NAME] as ordered on [DATE] or why it was not given. During an interview on 8/10/16 at 3:09 p.m. Staff E reviewed the MAR and reported there should not be any blank spaces and the back of the MAR did not know if it meant the medication was not given or what? Staff E also stated the physician ordered for staff to administer [MEDICATION NAME] 3 mg at bedtime on 7/23/16 and did not know why staff did not document they administered it. RESIDENT #3 An Admission Record identified Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. July 2016 Physician order [REDACTED]. On 7/16/16 the physician prescribed an antibiotic given for three days to treat a urinary infection. Antibiotics and [MEDICATION NAME] can interact to increase the risk of bleeding. On 7/19/16, Resident #3 had an elevated INR of 3.4 (meaning increased risk for bleeding). Physician orders [REDACTED]. The physician ordered [MEDICATION NAME] restarted on 7/21/16. Orders dated 7/21/16 and 7/28/16 identified specific doses of [MEDICATION NAME] given on specific days of the week. During record review on 8/11/6, Resident #3's July 2016 Medication Record identified on Friday, 7/29/16, staff did not document they administered 4 mg of [MEDICATION NAME] as scheduled. During an interview on 8/15/16 at 3:35 p.m., Staff M reported he/she did not know why Resident #2's MAR did not show they received [MEDICATION NAME] on 7/29/16. Staff M reported staff should notify the Resident Care Manager when medications were not given and the RCM was not notified nursing did not document [MEDICATION NAME] was given on 7/29/16.

Based on observation, interview and record review the facility failed to initially conduct a comprehensive safety assessment for use of a tilt in space wheelchair and attached device and identify for staff how to implement its use to ensure resident safety. The facility also failed to timely monitor and report changes in blood pressures during position changes to ensure all fall prevention measures were taken for 2 of 3 Sampled Residents (#1 & 2) reviewed for falls. The facility also failed to identify the root cause of a fall from a tilt wheelchair and timely implement further preventive measures for Resident #1 to prevent further falls. Failure to ensure safe positioning and adequate supervision while seated in a tilt wheelchair, resulted in harm, when Resident #1 fell from the wheelchair a second time, and sustained a head laceration that required transport to the emergency room and six sutures to the forehead. Failure to timely obtain and report sudden drops in blood pressure for Resident #2 prior to falling, prevented the physician from the opportunity to make changes in medications that had the potential to contribute to falls. Findings include: RESIDENT #1 Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Fall Risk Evaluation dated 8/19/16, identified staff assigned a score of 20 to Resident #1. A score of 10 meant a high risk for falls. Risk factors included a change in cognitive status, required assistance with elimination, and could not balance while standing, sitting or during transitions without physical help. A provider note dated 9/23/16 identified Resident #1 developed multiple ulcers on the left leg and foot due to peripheral vascular disease (decreased circulation in the leg.) An arterial study conducted on 9/20/16 indicated the resident had abnormal hardening of the arterial vessel. On 10/18/16 at 12:40 p.m. and later that day at 2:50 p.m. and 3:40 p.m., Resident #1 lay in bed asleep and did not respond when spoken to. The bed positioned low to the floor had a fall mat on the left side and the right side of the bed was positioned against a wall. On 10/19/16 at 10:42 p.m., Staff O and Staff P transferred Resident #1 from the bed to a tilt in space wheelchair. Later, during observations between 12:34 p.m. to 12:40 p.m., Resident #1 sat in the tilt wheelchair with a bed pillow placed beneath the resident ' s head and shoulders. The resident ' s upper body leaned to the left, and did not remain in an upright seated position, while seated in the wheelchair. The resident did not respond when spoken to and made breathing sounds of light snoring. The wheelchair was placed outside the resident's room door in the hall and no staff were present. The wheelchair mechanism to indicate degree of tilt (recline from upright positon) indicated 14 degrees. The wheelchair did not have an additional device, such as a half lap tray or arm trough attached, or extensive lateral support to assist with positioning needs. The resident had a visible scab on the left side of the forehead. Later, during observation on 10/21/16 at 11:45 a.m., Resident #1 sat in room in a tilt wheelchair with a family member present. A partial lap tray was positioned on the left side of the wheelchair arm and the resident rested his/her left arm on top of the firm surface of the lap tray. The wheelchair mechanism identified a degree of recline of 5 degrees. THERAPY ENCOUNTERS Occupational Encounter Notes dated between 8/19/16 and 9/23/16, identified Resident #1 had been hospitalized and received multiple fractures from a fall in June 2016, and later suffered a stroke. Additional therapy notes documented the resident had impaired sitting balance and postural control and leaned/pushed self heavily to the left toward the weaker (non-dominant) side of the body. A Physical Therapy Evaluation and Plan of Treatment Form for certification period 8/19/16 through 9/17/16, identified Resident #1 currently used a tilt in space wheelchair, tilted for trunk support. The note indicated the resident may need arm trough, device attached to the arm of the wheelchair to provide arm support. The neuromuscular assessment identified the resident had fair ability to sit for short periods and started to lean to the left. Notes identified, without therapeutic intervention, the resident was at risk for falls. A Physical Therapy Discharge Summary signed 10/1/16 documented, therapy assessed Resident #1's wheelchair for proper fit and functional and made the appropriate adjusted to aid the patient in attaining an upright sitting posture to limit pressure sore and muscle contracture development. Therapy notes did not contain specific directions or guidance for nursing staff to follow regarding degree/s or ranges of recline of the resident's tilt wheelchair, or if they recommended an arm trough or half lap tray for positioning. During an interview on 10/19/16 at 4:03 p.m., Staff E stated, therapy worked with the resident to improve and maintain the ability to maintain an upright position while seated. Later at 4:30 p.m., Staff E reviewed Resident #1's therapy notes and stated the record did not contain any information specific to use a half lap tray on the tilt wheelchair. Staff E also reported I have seen it (lap tray) used. SAFETY ASSESSMENT AND CARE PLAN Resident #1's medical record did not contain evidence nursing staff conducted ongoing observations and assessment of the resident while seated in the tilt wheelchair, to ensure the resident maintained safe positioning throughout the day and ensure all safety considerations were evaluated and benefits of the device outweighed the risks for use. The record did not identify how much supervision staff needed to provide to ensure the resident remained safe while in the wheelchair. The initial plan of care did not indicate Resident #1 used a tilt wheelchair. Resident #1's nursing aide directives inside the resident's closet, reviewed on 10/17/16 and 10/19/16, did not identify a range or degree/s of tilt (recline) necessary to ensure the resident maintained upper body control and did not lean to the side while seated in the wheelchair. The directive did not identify the need to attach a half lap tray to the wheelchair. An undated facility policy and procedure titled Soundcare Clinical Guidelines for Tilt in Space Wheelchairs, stated the degree of tilt will be administered and care planned as follows; · Resident will be as upright as resident tolerates during meals and for one half hour following meals. · At other times when up in the wheelchair the positon should be varied at least every two hours in order to distribute the pressure over the resident ' s back or bottom. This position should be determined by resident comfort. · At no time should a tilt in space be used for a restraint. If the resident is attempting to get up out of a chair staff will need to address their needs. · The resident will be attended to with at minimum line of sight supervision while in the upright positon. If the caregiver must leave the resident to attend another's care, the resident will be tilted for comfort and to prevent possible forward pitching out of the chair. Nursing will incorporate the appropriate information into the resident care plan and provide instruction to caregivers. During an interview on 10/18/16 at 3:46 p.m., when asked how therapy communicated to nursing regarding use of Resident #1's tilt wheelchair, Therapy Staff N reported, nursing staff were informed during stand up meetings, attended by the rehab manager, regarding the resident's therapy progress. Staff N stated a care plan was written and placed in the resident's closet and medical chart. RESIDENT FALLS Fall #1 A facility investigation dated 9/23/16, identified on 9/20/16, Resident #1 sat in his/her wheelchair in the room near the sink brushing teeth. The report indicated the resident leaned forward too far and could not stop momentum out of the chair. Staff stood nearby and could not stop the fall. The resident sustained [REDACTED]. During an interview on 10/21/16 at 11:45 a.m., when asked what staff identified as the root cause that led to the fall, Staff M stated there was no root cause analysis and did not recall a discussion of the incident between the Interdisciplinary Team (IDT) and nursing. Staff M stated he/she could not locate the IDT form usually attached to the incident report to indicate IDT discussion. Fall #2 A facility investigation dated 10/9/16, identified on 10/6/16, Resident #1 was found on floor in room. The investigation stated staff last saw the resident seated in a tilt wheelchair with a half lap tray in place. The investigation identified the resident leaned forward while seated in the wheelchair and fell to the floor and sustained a laceration to the left forehead and left elbow. The investigation also stated staff were not able to measure the head laceration due to pressure being applied until medics arrives. During interviews on 10/19/16 at 10:42 a.m., Staff P and Staff O stated when they arrived to the scene after Resident #1 fell , the wheelchair did not have a lap tray attached to it. Staff O stated he/she did not see a lap tray on the resident's wheelchair any time during the month. The investigation also stated, skilled therapy notified to assess need for half lap tray or full lap tray. A nursing note dated 10/13/16 identified nursing referred Resident #1 for an evaluation of changing from left ½ lap tray on W/C (wheelchair) to full lap tray. A Rehabilitation Screening Form completed 10/13/16 by Therapy Staff K, documented Resident #1 currently used a half lap tray to help with upper extremity positioning and to allow for shoulder and elbow extension. Therapy did not recommend use of a full lap tray due to safety concerns. Nursing staff did not conduct a Safety /Device Assessment for use of the tilt wheelchair until 10/9/16, after the resident fell the second time from the wheelchair, and required a trip to the emergency room . The Safety/Device assessment dated [DATE], identified Resident #1 had impaired decision making; unaware of safety needs; did not use a call light; was impulsive; and had risks for skin impairment/fragile skin. The assessment identified staff implemented the tilt wheelchair to improve sitting balance and did not indicate how or if the degree of wheelchair recline affected the resident ' s ability to remain in an upright position. The assessment did not identify how staff determined the tilt wheelchair safe for use based on data collected from responses to yes/no questions answered on the form. During an interview on 10/17/16 at 4:00 p.m., when asked how nursing staff knew how to use the tilt wheelchair for Resident #1, Staff F reported, not sure I feel it is self-explanatory. When asked if nursing staff knew the resident had trouble sitting, Staff F stated, because of his posture anyone would know that, and information was documented in therapy notes. Staff did not provide clear responses to how far to recline Resident #1 in the tilt wheelchair and provided conflicting information regarding use of a half lap tray attached to it. During an interview on 10/18/16 at 3:46 p.m., Staff F reported the resident had difficulty with balance while sitting and leaned to the left and could not self-correct. Staff F reported the resident did use a tilt in space wheelchair and therapy provided an arm trough to help with positioning. Staff F also stated the resident did not use a half lap tray. During interviews on 10/18/16 at 4:05 p.m., with Staff G, Staff H and Staff J, Staff G reported staff got Resident #1 up out of bed into a tilt in space wheelchair when the resident wanted to. When asked how far aide staff reclined the resident, Staff H stated, they tilted the resident so he/she didn't fall out of the chair. Staff H also stated the wheelchair had an arm bracket on it. Neither of the staff were aware of specific degrees of tilt the resident required to stay upright. Staff J stated sometimes the degrees of tilt was identified on the resident ' s care plan. Staff J also stated ' it would be beneficial for the care plan to identify the degrees to tilt (recline) a resident in a wheelchair. Staff followed the investigator into the resident ' s room and confirmed the aide directive in Resident#1 ' s closet did not indicate the degree/s to recline the wheelchair or to use a lap tray. During an interview on 10/21/16 at 10:00 a.m., Staff L did not identify specific degrees of tilt required and reported nursing should obtain a physician's orders [REDACTED]. The wheelchair should be tilted far back enough so Resident #1 would not fall out and not too far back to prevent the residents from doing anything. Failure to ensure staff comprehensively assessed Resident #1 was safe to remain unattended in a tilt in space wheelchair, identify how much visual supervision the resident required if left alone in the wheelchair, and identify what degrees of tilt were required to ensure the resident remained upright, resulted in two falls with injury to a leg that had impaired circulation, and a head injury that required emergency treatment, where the resident received 6 stitches. RESIDENT #2 Orthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a systolic blood pressure (upper number) decrease of at least 20 mm Hg or a diastolic blood pressure (lower number) decrease of at least 10 mm Hg within three minutes of standing.Orthostatic hypotension can cause dizziness or lightheadedness, and may result in fainting. During observations on 10/18/16 at 1:40 p.m., Resident #2 sat in a wheelchair in the therapy room. Therapy staff obtained Resident #2's blood pressure. The resident turned the wheels of the wheelchair independently and turned the direction and moved the wheelchair. Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. October 2016 Physician order [REDACTED]. Metoprolol was ordered to administer two times a day and Nifedipine 60 mg. extended release was ordered given once a day. The physician also ordered Coumadin, a blood thinner, and lab tests to monitor the results of the medication at the time of admission. A facility Fall Risk assessment dated [DATE], identified the resident as a high risk for falling that included; previous history of falls in the last 90 days; required assistance with toileting; unsteady and could not stabilize without assistance while standing, sitting and during transitions of positions; and health conditions. An undated In-Room Care Directive in Resident #2's closet, directed staff to provide extensive assistance from one person to assist with transfers. A facility investigation dated 10/6/16 identified at 4:00 p.m., noted staff heard the resident call for help and found the resident on the floor of the bathroom next to the wheelchair. The investigation noted staff obtained orthostatic blood pressures while sitting: 130/58 and while standing 84/53. These orthostatic blood pressures correlated with blood pressure readings staff documented on Resident #2's October 2016's Medication Record, obtained the day after the fall on 10/7/16, and not at the time of the fall. The fall investigation for 10/6/16 documented Resident #2's fall was reasonably related to orthostatic changes in positioning. During an interview on 10/18/16 at 3:50 p.m., Resident #2 sat in a wheelchair in the room and stated, the day of the fall, he/she just keeled over and fell . October 2016 ' s Medication Record contained a hand written directive dated 10/4/16, for staff to obtain orthostatic blood pressures every morning for three days and report to the physician. Staff blocked off the dates to obtain the orthostatic blood pressure readings on 10/5/16, 10/6/16 and 10/7/16. The record did not contain evidence staff obtained Resident #2's orthostatic blood pressures on 10/5/16, the morning before the fall. The morning of the fall on 10/6/16, staff documented orthostatic blood pressure readings as follows: sitting 118/62 and standing 92/50. This indicated a systolic drop of 26 mm Hg and a diastolic drop of 12, both indicative of orthostatic hypotension. Staff administered both blood pressure medications to the resident the mornings of 10/6/16 and 10/7/16. The facility investigation documented licensed staff did not inform Resident #2's physician when the resident fell in the bathroom on 10/6/16, until 10/7/16 at 5:20 p.m., approximately 25 hours after the resident fell . On 10/7/16, the physician ordered to reduce the amount of Nifedipine from 60 mg to 30 mg a day. During an interview on 10/21/16 at 1:08 p.m., Staff B reviewed Resident #2's medical record and did not know staff did not obtain orthostatic blood pressures as indicated to do so on the Medication Record and stated staff should have informed the provider sooner of blood pressure changes. Failure to timely obtain Resident #2's orthostatic hypotension blood pressures on 10/5/16, and notify the physician of the resident's drop in blood pressures the morning of 10/6/16, prevented staff from obtaining physician orders [REDACTED]. .

Based on observation, interview and record review the facility failed to timely inform and consult with the physician following onset of leg pain that occurred with an associated popping sound during transfer for 1 of 4 Sampled Residents (#1) reviewed for accident prevention. This resulted in harm for this resident due to delay in physician intervention to determine the resident experienced a [MEDICAL CONDITION] right leg and delayed transport to the hospital for treatment and surgical intervention. Findings include: Refer to F 323 for resident observation, medical history and additional information related to incident involving transfer resulting in leg fractures. On 2/29/16 at 4:50 p.m. Staff B transferred Resident #1 from the bed to a wheelchair, without a gait belt, using a stand and pivot technique. Resident #1's nursing aide directive dated 10/5/15 directed for two staff to transfer the resident with a gait belt and not one staff. Resident #1 experienced pain when his/her right foot got caught behind the wheel of the wheelchair. Staff heard a popping noise they thought was from the resident's knee when the resident sat down. A nursing note written 3/1/16 identified Resident #1 described the pain level of gently palpating the right knee at a level 10 on a one to ten pain scale. A level ten described the highest pain level. Staff D administered pain medication to the resident at 5:00 p.m. for tooth pain. The note identified later at approximately 6:00 p.m. to 6:30 p.m., Resident #1 complained of leg pain again. The 2/29/16 facility investigation identified the resident then slept approximately one and a half hours after being put to bed. Upon awakening, after complaint of continued pain, Staff D administered Tylenol for the pain. The investigation identified Staff D did not contact Resident #1's provider until 10:15 p.m., approximately six hours after the initial injury. The provider ordered a stat x-ray. A nursing note dated 3/1/16 documented x-ray arrived at approximately 10:45 p.m. Resident #1's x-ray of the right leg dated 3/1/16 read at 2:19 a.m. showed displaced, spiral fractures of both bones in the lower leg and thinning of the bones due to disuse. The x-ray report indicated staff notified the provider of the results at 3:00 a.m. A nursing note dated 3/1/16 documented Resident #1 went to the hospital by ambulance at 3:30 a.m., more than nine and a half hours after the injury occurred. Delay in notifying the provider pertaining to the resident experiencing pain associated with improper transfer and attempted assessment, delayed orders for an x-ray that revealed fractures requiring immediate medical intervention, and continued pain, placed the resident at increased risk for further complications and decline.

Based on observation, interview and record review, the facility failed to supervise care to ensure staff implemented planned interventions for safe transfer technique, for 1 of 4 Sampled Residents (#1) reviewed for accident prevention. This failure resulted in harm when Resident #1 fractured a leg that required hospitalization and surgical intervention, after one staff transferred the resident instead of two staff as care planned. Findings include: On 3/9/16 at 3:48 p.m. Resident #1 lay in bed with the head of bed elevated and a fall mat on the left side of the bed. Eyes were closed and the resident did not respond when spoken to and remained asleep. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's care plan revised 2/11/16, identified the resident had episodes of yelling. Staff interventions included non-threatening approaches, and to reassure the resident he/she was safe. The facility revised a care plan on 1/20/16 for lack of ability to self-perform activities of daily living due to lack of coordination and generalized weakness. The care plan and In Room Care Directive dated 10/5/15 located in the resident's room both identified Resident #1 required extensive assistance from two staff to stand, pivot and transfer with use of a gait belt. A facility investigation identified on 2/29/16 at 4:50 p.m. noted Staff B transferred Resident #1 from the bed to a wheelchair while Staff C stood behind the bed. The facility investigation revealed Staff B did not use a gait belt. Staff B described he/she straddled the resident's leg, reached around the waist and held onto the back of the resident's pants. While pivoting the resident from the bed towards the wheelchair the resident's right foot slid under the wheelchair and caught behind the front wheel of the wheelchair. When Staff B sat the resident down he/she heard popping and the resident became upset and yelled OW! Resident #1 continued to be upset and yelled OW! while the aide moved the resident's legs to place them onto wheelchair foot rests. The investigation noted Staff C, who stood behind the bed during the transfer, informed Licensed Staff D of the popping sound to the right knee when staff pushed the resident into the hallway. The resident screamed ouch and described the level of pain as 10 on a one to ten pain scale (with 10 at highest pain level), while Staff D gently palpated the right knee. The resident would not allow the nurse to complete a full assessment of the lower leg. A nursing note dated 2/29/16 noted at 5:00 p.m., staff administered 25 mg of Tramadol for tooth pain. Staff took the resident to the dining room and later put the resident back to bed. After sleeping for an hour and a half the resident yelled out help me and told Staff D it hurt to touch the right thigh and slightly move the leg. Ambulance records and nursing progress note dated 3/1/16 identified staff sent the resident to the hospital via ambulance the following morning at 3:30 a.m. A hospital discharge summary dated 3/4/16 identified the resident had acute fracture of the lower right leg requiring surgery and placement of a rod in a leg bone. Staff G, also stated at this time, a fundamental practice for nursing aides would include looking at placement of a resident's feet during the transfer. On 3/9/16 at 2:37 p.m., Staff E reported staff should always use a gait belt and place hands on either side of the belt during transfers. In addition Staff E stated, during a stand and pivot transfer I would look and make sure feet are in the right spot before I turn the body. According to Staff E, if the resident said they were hurt I would get the nurse to check them out right away. Facility policy and procedure titled Lift Transfers and Gait Belt Training identified all nursing assistants are to have a gait belt on their person at all times and to use them on every resident that required physical assistance with transfers and ambulation. The facility investigation concluded Resident #1's injury occurred during transfer and Staff B did not follow the care directive or facility protocol to use a gait belt. Licensed staff failed to supervise nursing aide staff as they transferred Resident #1 to ensure they used safe technique to prevent the resident's foot from getting caught behind the wheel of the wheelchair while pivoting and sitting to attempt to prevent injury.

Based on observation, interview and record review it was determined that the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 Sampled Residents (#1) reviewed for falls. This failure contributed to Resident #1 falling while attempting to ambulate to the bathroom. Resident #1 sustained a fracture as a result of the fall thus causing her harm. Findings include: Resident #1 was admitted to the facility 5/30/14. Resident #1 had recent surgery on her right leg. During an interview on 8/13/14 at 2:55 p.m. Staff B reported Resident #1 had not been cleared by therapy to ambulate with her walker by any staff other than staff from the therapy department. During an interview on 8/13/14 at 1:50 p.m. Therapy Staff D reported Resident #1 had recently started working on walking while using a walker with the facility's therapist. Therapy Staff D reported Resident #1 had only walked with therapy staff and she had not been cleared by the therapy to walk with the nursing assistants. Therapy Staff D reported Resident #1 should have been transferred by 1 staff member to her wheelchair, and then used the wheelchair for locomotion. Review of Resident #1's care plan indicated she had been recently upgraded from needing assistance from 2 staff and a mechanical lift for transfers to only needing 1 staff member to assist her to transfer. Resident #1 had been changed to 1 person transfer on 7/15/14. During an interview on 8/13/14 at 2:10 p.m. Staff C reported all of the residents have a care directive in their rooms. Staff C confirmed the directive is to direct staff how to care for the resident. Review of Resident #1's care directive revealed she was to have 2 staff members transfer her and she was to use a wheelchair for locomotion (the in room directive indicate Resident #1 should have had a 2 person transfer status, although therapy documentation indicated Resident #1 only needed 1 person to transfer her). Review of a facility investigation dated 7/18/14 indicated at 4:25 p.m. Resident #1 had fallen while ambulating to the bathroom with Staff C's assistance. Further review of the investigation revealed a written statement from Staff C which reported on 7/18/14 Resident #1 requested to use the bathroom and asked for her walker. Staff C reported she asked Resident #1 "wouldn't you rather use your wheelchair?". Resident #1 declined the use of the wheelchair so Staff C took the resident's walker to her bedside. Staff C's written statement indicated Resident #1 ambulated using her walker to the bathroom with nursing assistant. The statement indicated once Resident #1 reached the bathroom she fell . During an interview on 8/13/14 at 3:00 p.m. Therapy Staff D reported she did not think Resident #1 would have gotten out of bed to use her walker on her own. Staff D reported Resident #1 would not have ambulated with the walker if staff had not given it to her. During an interview on 8/13/14 at 2:30 p.m. Staff C confirmed she had not ever assisted Resident #1 with ambulating. Staff C confirmed there was a care directive in Resident #1's room that indicated how many staff should assist the resident and that Resident #1 needed a wheelchair for locomotion. Staff C reported she thought she needed a second staff member for assistance but had not actually looked at the care directive. Staff C's written statement described Resident #1's gait as being off balance making it hard for her to hold the gait belt for added support. The statement indicated Resident #1 fell on ce she was inside the bathroom. Review of Resident #1's hospital records revealed she was diagnosed with [REDACTED]. The hospital records indicated Resident #1 underwent surgical repair of the fracture and remained in the hospital for 5 days. Staff C allowed Resident #1 to choose if she wanted to use the wheelchair instead of the walker. Staff C did not educate Resident #1 of the risks, including injury, associated with not using the wheelchair as directed in her plan of care. Staff C failed to check Resident #1's in room care directive prior to assisting her up. Staff C retrieved the walker and placed it in front of the resident at the bedside for her use. Failure to use the assistive devices directed in Resident #1's plan of care contributed to her fall. The resident should have been transferred to a wheelchair and the transported to the bathroom in the chair as indicated in the plan of care. Resident #1's fall and fractured leg may have been avoided had she been supervised with the correct equipment.

Based on interview and record review the facility failed to timely consult with the physician about change in condition for 1 of 6 Sample Residents (#1) reviewed for accidents with injury that potentially required physician intervention. Following an unwitnessed fall Resident #1 suddenly stoped participating in physical therapy, and complained of increased and persistent moderate to severe hip/leg pain that lasted over a twelve day period. Resident's physician was not timely consulted about changes following the fall. This failure resulted in delayed [DIAGNOSES REDACTED]. Findings include: Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was unavailable for observation and interview. Record review revealed on 7/01/11 around 9:00 p.m. Resident #1 was found on the floor laying on the right side. Nursing noted resident bled from the cut on her head. The fall was not witnessed. Resident reported to the staff she was trying to go to the bathroom when she fell . Nursing medicated Resident around 9:15 p.m. after the fall for pain level of 6/10 (number scale used to describe pain severity the number values correspond to pain levels as follows: 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain.) Staff C on 7/20/11 at 2:50 p.m. reported the day after Resident #1 fell (07/02/11), she complained of right shoulder pain, right hip pain and a sore leg. Slight bruising was observed on the right hip. The resident was able to sit up in bed but refused to go to dining room. After Resident #1 fell on [DATE] she refused all physical therapy sessions which was a change from therapy participation in June 2011. Resident #1 had physical therapy four times from 06/09/11 to 06/15/11; three times 06/16/11 to 06/24/11, four times from 06/25/11 to 07/01/11. After 7/1/11 resident refused all therapy. Physical therapy staff indicated Resident #1 repeatedly refused physical therapy exercises. PT indicated on 7/6/11, 7/7/11, 7/8/11 and 7/11/11 Resident #1 did not want to do physical therapy despite extensive encouragement. Resident was discharged from therapy on 7/12/11. There was no information whether physical therapy staff considered 7/1/11 fall as a potential contributing factor for resident's refusal of PT services. Resident #1 demonstrated increase in pain frequency and severity after the fall. Resident required significantly more pain medicine in July as evidenced by comparing June 2011 and July 2011 pain medication administration documentation. The records showed Resident received 11 doses of PRN (as needed) pain medications from 6/10/11 to 6/30/11. From 7/1/11 to 7/13/11 Resident received 21 PRN pain medications. Between 7/1/11 and 7/13/11 Resident #1 had ongoing severe pain. During this period of time Resident had fifteen pain episodes on at least 8 days where pain levels were consistently at 7/10, 8/10, and 9/10. Increase in pain frequency, increase in pain medication use, continuous severe pain hip/leg, and refusal to do physical exercises with PT after a fall indicates a condition change and maybe a sing of significant injury. These changes require consulting the physician for further evaluation and diagnosis. The physician was not timely consulted about Resident #1's right hip pain until 7/12/11 when facility staff sent a fax to the doctor to report right hip pain. X-ray was ordered at that time. Resident #1's hospital notes showed on 7/13/11 a right femoral neck fracture ([MEDICAL CONDITION]) was identified. The note indicated the fracture was new compared with 05/28/11 study. On 07/20/11 at 9:25 a.m. in an interview Resident #1's family member reported Resident fell while in the facility and complained of hip pain. However; the facility did not x-ray the resident's hip for two weeks and then a fracture was discovered. The family member also reported he telephonically attended a care conference and felt the facility implied the resident was lazy and did not want to participate in therapy. .

Based on observation, interview and record review the facility failed to ensure 6 of 16 Sample Residents (#1,2,6,7,8, & 10) who entered the facility without pressure ulcers did not develop pressure ulcers unless they were unavoidable or those with pressure ulcers did not increase in size. The facility failed to demonstrate effective system was in place for pressure ulcer prevention. The facility failed to accurately identify pressure ulcer development risk, accurately assess skin, accurately and timely identify pressure ulcer development, continuously monitor residents' skin, develop individualized interventions for pressure reduction, consistently implement interventions, and periodically reevaluate pressure ulcer risk and the effectiveness of the intervention Of the 6 Sample Residents identified as having impaired skin integrity 5 Residents #'s 1,2,7, 8 &10 developed pressure ulcers and/or existing ulcers increased in size within the facility and sustained tissue damage constituting actual harm. Findings Include: The National Pressure Ulcer Advisory Panel (NPUAP) a recognized clinical resource identify pressue ulcer staging descriptions. -Stage I is defined as area of persistent redness that does not disappear when pressure is relieved. -Stage II involves a partial thickness skin loss involving the topmost layer of the skin. -Stage III is a full thickness tissue loss that extends through the second layer of the skin into the fat tissue. -Stage IV is a full thickness tissue loss with extensive destruction, tissue death or damage to muscle or bone. -Deep Tissue Injury is an area of localized discoloration of intact skin due to damage of underlying soft tissue from pressure and/or shear force. RESIDENT #1 Resident #1 was out of the facility during the onsite visits on 7/5/11 through 7/7/11. Closed record review was completed and included facility and hospital medical records including photographs taken on 6/30/11 at 12:06 p.m. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident required extensive assistance with transfers and was immobile. Resident was dependent on facility staff for assistance with activities of daily living including skin care. The facility assessments identified Resident #1 had no skin breakdown to the coccyx area or pressure ulcers at the time of admission. MDS (Minimum Data Set) assessment dated [DATE], 4/8/11 and 6/7/11 identified Resident #1 was at risk for developing pressure ulcers based on clinical assessment, and did not identify existing pressure ulcers. Review of skin of skin of Resident #1 by investigator on 05/31/11 at 1:15 p.m. revealed the only skin issue was small scabs on the right lower leg, shin area. The skin on the buttocks and lower back was clear without any indication of skin breakdown. Review of Care Plan revised 6/21/11 did not identify individualized interventions to decrease Resident #10's risk of pressure ulcer development. The nursing assistant care directive revised 6/21/11 specified resident used tilt-in-space wheelchair and to "reposition frequently" for comfort. There was no specific guidance on how to provide pressure redistribution to prevent risk of tissue damage. Facility TR (treatment record) specified to complete weekly skin assessment and to document "+" if skin was intact or "-" if not. If "-" was documented staff was to record in progress notes and appropriate skin sheet. TR for April, 2011 did not have documentation indicating Resident #1's skin was assessed from 4/14/11 to 4/26/11. TR for May 2011 showed From 5/1/11 to 5/10/11 and from 5/19/11 to 5/31/11 Resident # 1 did not have diabetic food care and assessment to identify swelling, and breaks in skin. From 5/12/11 to 5/24/11 the TR did not have documentation indicating that weekly skin assessment was completed. TR documentation for 5/25/11, 6/15/11 and 6/22/11 on the days when weekly skin assessment were due revealed staff initials without documented "-" or "+" sign to indicate whether skin problems existed. Staff E on 7/7/11 at 1:45 p.m. reported when weekly skin assessments were completed the staff was to document findings in the TR. Staff was to document "+" or "-" the check mark or blanks were unacceptable. Staff E reported if the skin was found nonblanchable then measurements should be obtained. Skin assessment completed by the nursing assistant and acknowledged by a licensed nurse on 6/22/11 identified Resident #1 had developed redness to the coccyx area that was blanchable, the assessment did not include thorough description of characteristics of the reddened area such as size and whether it was warm or cold. The description on condition of the surrounding tissue was absent. The care plan was not updated. On 6/22/11 barrier treatment cream was initiated however documentation showed the cream was applied a day later. The last skin assessment was completed on 6/25/11 by nursing assistant and acknowledged by a licensed nurse. The assessment documentation stated "no new skin problems." From 6/22/11 to 6/29/11 there was no evidence of ongoing skin assessment and monitoring. Record review found no documentation describing skin appearance and condition based on comprehensive nursing assessment and in accordance with professional standards. On 6/29/11 at 9:55 p.m. Resident #1 experienced change in condition and was transported to the emergency room . emergency room records dated 6/29/11 indicate Resident #1 was at the hospital at 10:22 p.m. and was receiving treatment. Observation of hospital photographs taken on 6/30/11 at 12:06 p.m. and wound therapy nurse's documentation revealed Resident #1 developed unsteageable pressure ulcer. The resident was found to have large non blanchable [DIAGNOSES REDACTED] over the coccyx extending to bilateral buttocks. Also black areas of necrotic tissue developing on each buttock. Suspected deep tissue injury was unstageable at the time secondary to unknown depth of the tissue damage. On 7/7/11 at 3:20 p.m. during a meeting with facility's administration Staff A and Staff B were informed of the findings related to Resident #1's tissue damage. Staff B reported she was not aware that Resident #1 had tissue damage. During an interview with a collateral contact on 7/8/11, it was reported facility staff did not reposition Resident #1 and he spent most of his time on his back while in bed or in a wheelchair. The facility failed to identify development of pressure related tissue damage for Resident #1 until it was found in the emergency room . This failure constitutes actual harm. RESIDENT #7 Resident #7 had [DIAGNOSES REDACTED]. Resident was bed bound. Resident was at high risk for developing pressure ulcers. resident had a history of [REDACTED]. On 6/27/11 Resident #7's Braden scale (used to predict pressure sore risk) was an 11. Per the facility's skin assessment form, any score below 16 indicates potential skin problems. On 7/4/11 the facility notified the physician Resident #7 had a "spotty red rash to coccyx inner buttocks" as indicated on the fax form. The assessment available at the time of record review did not indicate open skin present on buttocks or sacral region. The assessment did not include whether the red area was blanchable (when pressing on the skin it turns a lighter color momentarily then returns to normal or usual color). On 07/07/11 at 9:15 a.m., Resident #7 was observed lying on her back. Staff L provided resident with peri-care. During observation, Resident #7 was noted with redness to the sacral area (lower back). Resident had two open areas that were round and were approximately 1 x 1 cm in diameter on the sacral region resembling stage II pressure ulcers. The open areas did not have a dressing on. These areas of broken skin were not noted in resident's chart prior to this observation. Staff L was unable to identify if Resident #7's skin condition was new or improving. Follow up observations revealed on 7/7/11 at 9:15 a.m., 12:27 p.m., 1:20 p.m. and 2:00 p.m. Resident #7 was observed lying on her back. No pillows observed below resident legs to float heels. Physician orders [REDACTED]. The treatment record had physician orders [REDACTED]. Resident #7's "In-Room Directive" indicated Resident #7 required one person to assist with turning, resident is to have heels floated when in bed, and to turn resident every two hours when in bed. There was a turn schedule posted on the wall next to Resident #7's bed, which indicated the direction the resident should be facing and at what time of day. Per facility protocol, residents that are bed bound are to be repositioned every two hours. On 07/07/11 at 11:34 a.m., Staff L was asked how often residents were turned and how does the facility keep track of the turning schedule. Staff L stated that, "Residents at risk for developing pressure sores or already have them should be turned every two hours. There is no particular place where we can write down which direction or what time we turned the resident, like left side or right side. That would make a lot of sense though." On 07/07/11 at 11:37 a.m., Staff O stated residents that required every two hour turns and the staff just needs to do spot checks; and there was no place where they can write that. On 07/07/11 at 12:52 p.m., Staff P was asked about how frequently she was able to round or "spot check" residents that required turns every two hours. Staff P responded, "I try to round on residents to see if they got turned every two hours, but it doesn't always happen, I depend on the CNAs to do that." RESIDENT #8 Resident #8 admitted to the facility with history of stroke, and diabetes. The resident was chair bound and required assistance with repositioning. Record review revealed that as of July 4, 2011, there was no evidence to indicate whether or not resident had active bleeding from skin on left buttocks or open areas to the right buttock. Resident #8's "Plan of Care" dated 4/11/11 identified "Alteration in skin integrity" as a problem area. Goals were identified, but the facility failed to list interventions. Unable to locate resident's care directive as of 07/07/11 at 11:02 a.m. Based on record review, resident was not on a turn schedule or reposition schedule. On 07/07/11 at 10:16 a.m., Resident #8 was observed lying on her back. Staff L prepared the resident for a bed bath and turned the resident to remove her depends. Bright red blood was noted on the left edge of depends (where depends touches left buttock). During skin observation, Resident #8 had skin discoloration to the left buttock, left inner thigh, right inner thigh, and left upper thigh (front). Skin discolorations were noted on pervious nursing assessments dated 04/11/11. During the same observations the left side of the buttock was noted with shearing and the right buttock had a round open area approximately 1 x1 cm, with adipose(fat) tissue exposed. These areas of broken skin were not documented in the chart prior to this observation. Staff L was unable to identify if Resident #8's skin condition was new or improving. On 07/07/11 at 11:12 a.m., and 12:28 p.m., Resident #8 was observed sitting upright in her wheelchair. Resident was not interviewable. RESIDENT #10 On 6/13/11 Resident #10's skin was denuded (loss of epidermis or top skin layer). The area measured 2 x 2.5 cm as identified in the progress notes. On 6/17/11, four days later a Hospice nurse reported the resident had a stage II pressure sore on his sacrum; no measurement was noted based on the record review. On 07/07/11 at 10:07 a.m. observations of personal care revealed Resident #10 had an open area on the sacrum. The open area was not covered with a dressing leaving blood on the resident's brief. The open area measured approximately 6 cm x 6 cm. During same observation Staff I reported the resident did not have the open area two weeks ago when he last worked with the resident. From 6/13/11 to 7/711 Resident #10's pressure ulcer increased in size. Interview with Staff H on 07/07/11 at 10:30 a.m. revealed one week ago she noticed an open area on Resident #10's sacrum. Staff said she reported her finding to the nurse on duty. Two days later she noticed the open area was larger and the resident complained of pain to the site. Staff H said the resident never refused showers but complained that his buttocks hurt so bad he did not want to get up and be showered. Staff H said the resident did not have a dressing on his buttocks at that time and Staff H notified the nurse of the resident's pain. Interview with Staff G on 7/7/11 at 1:45 p.m. revealed no follow-up measurements were completed because the resident admitted with denuded skin. Resident #10's Admission assessment dated 03/10/11 indicated resident had macerated (Over-hydrated, whitish colored) tissue on the sacrum measuring 12 x 6.7 cm. An open area was not indicated. Another admission assessment dated [DATE] indicated the resident had "shiny pink scar tissue" measuring 1.4 x 4 cm; no indication of denuded tissue on sacrum noted at that time. Record review revealed only one skin assessment was completed during the month of April, no skin assessment was conducted during the months of May, June and as of yet in July. Staff J on 7/7/11 at 12:30 p.m. stated Resident #10 was a priority lay down due to his compromised skin. Priority lay-down meant the resident was out of bed for meals only. The MAR (Medication Administration Record) for June 2011 and July 2011 instructed staff to turn Resident #10 "frequently" while he was in bed. On 7/7/11 at 1:50 p.m. interview with Staff J and Staff K were unable to explain what "turn frequently" meant. Staff G on 7/7/11 at 2:00 p.m. during an interview stated that "turn frequently" did not dictate a specific time. When asked staff if frequency meant every 15 minutes or 5 hours Staff G agreed emphasizing no specific time. Resident #10 was found to have an open area on his sacrum that has increased in size from 6/13/11 to 7/7/11. The facility did not implement measures to ensure a dressing remained on the wound and did not measure the wound to track the progress. In addition the facility did not conduct scheduled skin checks for greater than three months and provided ambiguous guidance to the staff for turning and repositioning the resident. There was no evidence the facility determined the pressure ulcers that developed and increased in size were avoidable or unavoidable. RESIDENT #2 Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident was at risk for developing pressure ulcers related to steroid use, diabetes, immobility, weakness and loose stools. Admission assessment dated [DATE] revealed Resident #2 had macerated, and excoriated skin on the buttocks areas. The assessment did not identify presence of pressure ulcers. Nursing progress notes revealed on 6/29/11 Resident #2 complained of discomfort to " open area to buttocks " , however no detailed description was available such as size and appearance and condition of the surrounding skin. The care plan was not updated and revised after identified open area. Nursing assistant directive dated 6/24/11 indicated " turn frequently " and identified resident had " fragile, macerated, dry flaky skin. " Observations on 7/7/11 at 12:50 p.m. with Staff D revealed Resident #2 had three open areas on the buttocks measuring 0.5 x 0.5 cm (on the coccyx area), 0.5x3 cm and 2.5 x 2 cm. (gluteal areas). The the top skin layer was missing on the identified areas. The wound bed looked red and moist. Staff D identified the open areas as Stage II pressure ulcers. Treatment record reviewed with Staff D following the observations did not find documentation including prior measurements of open areas as identified on 6/29/11. The assessment did not include information such as skin appearance, condition of the surrounding skin tissue and whether it was blanchable. There was no evidence the facility determined whether the pressure ulcers that developed were avoidable or unavoidable. Observations on 7/7/11 at 9:02 a.m. revealed Resident #2 sat in a wheel chair on the left side of the bed. Resident asked the surveyor to turn on the call light to receive assistance. Resident said she wanted to get back into bed as she was instructed not to remain in her wheel chair past 9:00 a.m. Resident ' s call light was approximately two feet away from the resident located on the opposite side of the bed where resident sat. She was unable to reach the call light. Resident reported she was unable to reposition her self while in bed. Follow up observations at 9:30 a.m. on 7/7/11 found Resident #2 was in a wheel chair and asked the surveyor to turn on the call light again. The call light was observed in the same location. The resident was unable to reach the call light. Resident #2 stated that she should not sit in a wheelchair longer than two hours because she had a pressure sore before. Resident said " my butt hurts. " Observations on 7/7/11 at 11:32 a.m., 12:07 p.m., 12:45 p.m., 1:15 p.m., 1:30 p.m., and 2:00 p.m. revealed Resident #2 was in bed with head of the bed elevated and was on her back in the same position. Interview with a collateral contact on 7/7/11 at 1:30 p.m. it was reported that Resident #2 remained on her back most of the day and was repositioned on the side during perineal care. After personal care provided the resident was positioned onto her back. RESIDENT #6 Resident #6 readmitted to the facility in May 2011. Resident's [DIAGNOSES REDACTED]. Admission assessment in May 2011 indicated Resident #6 had a scab over a bony prominence on the right inner ankle area. Nursing progress note dated 6/30/11 identified a red area on Residents #6 right inner ankle. The area measured 1.9 cm x 1.9 cm. The pressure was related to resident's shoes being "too tight." In the same notes the staff documented the family and the physician was going to be notified in the morning of area "not pressure related." Observations on 7/6/11 at 10:02 a.m. revealed Resident #6 had a dressing on the right inner ankle over a bony prominence. The dressing was dated 6/30/11. Staff O removed the dressing exposing a 1 x 1 cm round area of partial thickness skin loss without obvious drainage and appeared to be a Stage II pressure ulcer. During observations the resident reported she wore a pair of shoes that were too tight and rubbed on the inner ankle causing her discomfort, and stated that since she got new shoes she has no more pain. After observations Staff O said the facility policy was to complete pressure ulcer risk assessment using the Braden scale, quarterly or as needed when there is a change. Record review with Staff O on 7/6/11 at 10:20 a.m. revealed the facility did not reevaluate resident's pressure ulcer risk after she developed Stage II pressure ulcer. Resident #6's open area was inaccurately identified as non pressure related when it was due to a tight fitting shoe causing pressure on the tissue. During status meeting with the facility on 7/7/11 Staff B confirmed stating that in this case the open skin was due to pressure. Facility's policy on Pressure Ulcer prevention provided guidance that included: - Daily inspect skin of residents who are unable to perform activity of daily living independently. - A licensed nurse was expected to complete weekly visual skin inspection. -Residents who were bed bound were to be repositioned every two hours. Use pillows/wedges to prevent bony prominence contract. use pressure reducing device for areas that are at risk. - Residents who are chair bound are to be repositioned every 1-1 hours. Assess postural alignment and use support devices as appropriate. .