Every finding on record at Alaska Gardens Health and Rehabilitation

Based on interview and record review, the facility failed to coordinate care and implement wound care orders from an outside provider for 1 of 3 residents (Resident 1) reviewed for wound care. Failure of the facility to update dressing change orders placed residents at risk of wound complications and delayed wound healing.Findings included .<RESIDENT 1>Review of the admission Minimum Data Set (MDS - an assessment tool), dated 04/15/2026, showed Resident 1 had a major surgical procedure during the prior inpatient hospital stay, involving the gastrointestinal tract, that required active care during the Skilled Nursing Facility stay. Resident 1 was assessed with a surgical wound, which required surgical wound care. Review of the Care Plan, initiated 04/10/2026, showed the resident had impaired skin integrity of the abdomen related to a surgical wound. Interventions directed staff to monitor/document location, size and treatment of skin issue weekly and report abnormalities to the physician.Review of a hospital surgery progress note, dated 04/09/2026, showed the abdominal surgical incision was assessed with a small area of skin dehiscence (splitting or opening of a surgical wound) along the lower portion of the incision. The directives were to continue dressing changes twice a day.Review of hospital discharge wound care orders, dated 04/10/2026, directed staff to keep incision clean and dry, and follow up in the surgery clinic in two weeks.Review of the 04/10/20206, Nursing Home admission Orders showed directions to cleanse midline abdominal surgical incision with wound cleanse solution or normal saline, apply skin prep to peri wound (peri wound skin prep protects the fragile tissue surrounding a wound from damage, moisture, and adhesive stripping) area letting it dry, apply dry dressing. Change daily and as needed.Review of the Treatment Administration Records for April 2026 and May 2026 showed staff documented performing the treatment as ordered until it was discontinued on 05/27/2026.During an interview on 06/04/2026 at 1:41 PM, Staff D, Wound Treatment, Licensed Practical Nurse (LPN), stated they saw Resident 1 weekly, and measured the wound, cleaned it with normal saline, patted dry and then applied a dry dressing. Staff D stated there were no orders for a special dressing.Review of a 04/28/2026 surgical clinic After Visit Summary (AVS) showed orders to change dressing every 2 days with hydrofera blue (a foam dressing that absorbs excess fluid and protect against infections). Cut long thin strip, moisten and place into wound. Cover with gauze dressing. Follow up in surgery clinic in 2 weeks.During an interview on 06/05/2026 at 1:41 PM, Staff G, LPN, admission Nurse, looked at the appointment calendar for Resident 1, and verified Resident 1 had an appointment on 04/28/2026 at the surgical clinic. Staff G searched in the resident's medical record and stated that it did not look like they received any paperwork after the appointment.During an interview on 06/05/2026 at 1:16 PM, Staff C, Registered Nurse (RN), Assistant Director of Nursing (ADON), reviewed Resident 1's record, confirmed there were no progress notes and no AVS for the 04/28/2026 clinic visit. Staff C stated if a resident returned from an appointment without an AVS the facility staff should call and request one.During an interview on 06/05/2026 at 1:53 PM, Staff B, Director of Nursing, stated that if no AVS was returned, the staff usually called the clinic and asked if they have any new orders for that visit.Review of a 05/12/2026 surgical clinic AVS in Resident 1's record, showed orders to change surgical dressing every other day, remove old hydrofera dressing, place new hydrofera in wound, and cover with gauze dressing. The AVS was noted on 05/12/2026 by Staff E, LPN, Care Coordinator.Review of Nursing Progress note written by Staff E, dated 05/12/2026 at 5:02 PM, showed Resident 1 returned from a Post Op appointment, no new orders received or noted. Resident with follow up appointment on 05/26/2026, copy given to scheduler/transportation.During an interview on 06/05/2026 at 1:49 PM, Staff E stated they missed the wound care orders. Review of a surgical clinic note dated 05/26/2026 showed the previously healed proximal wound had opened, the distal wound was unchanged. At the clinic the wounds were lightly packed with umbilical tape and covered with gauze dressing. New orders were written for the facility to repack wounds daily. Follow up in 2 weeks.Review of the 05/26/2026 surgical clinic AVS in Resident 1's record showed orders to change wound packing DAILY, pack both wounds lightly with umbilical tape and cover with gauze dressing and secure with tape. The AVS was noted by Staff E on 05/27/2026.During an interview on 06/05/2026 at 2:16 PM, Staff F, RN, stated when Resident 1 was discharging they were providing them with the orders in the computer and were told that there were wound care orders that Staff F had not previously seen. Staff F said they asked the wound nurse, Staff D, who also did not know. They told Staff E who returned with the new orders. Staff D stated the dressing was changed prior to discharge on [DATE], but there was no packing as they did not have the supplies.During an interview on 06/05/2026 at 11:23 AM, Resident 1's Representative (R1R) stated after every surgical care follow up, there were orders written and Resident 1 gave the facility staff the orders. R1R stated at the 04/28/2026 visit orders were written to pack the wound with hydrofera blue. R1R stated they asked Resident 1 who stated the staff were not packing the wound. R1R stated the facility staff was not following the doctor's orders.During an interview on 06/05/2026 at 3:00 PM, Staff B acknowledged Resident 1's wound care was not completed as ordered.Reference WAC 388-97--1620(2)(b)(i)(ii)(6)(b)(i).

Based on interview and record review, the facility failed to protect the resident's right to be free from abuse for 3 of 5 residents (Resident 1, 2 & 3) reviewed for abuse/neglect. Resident 1 experienced sexual abuse when Resident 2 touched their breast without consent. Resident 2 experienced physical abuse when they were hit by Resident 1. Resident 3 experienced mental/verbal and physical abuse when Resident 4 yelled at them and kicked their bed while they were sleeping. This failure placed the residents at risk of experiencing fear, intimidation, mental anguish, and emotional distress.Findings included.Review of the facility Freedom from Abuse Policy, dated March 2025, showed that each resident had the right to be free from abuse. Abuse is the willful inflection of intimidation, with resulting mental anguish, willful means the individual acted deliberately, Mental/Verbal abuse includes verbal assaults including yelling, and/or threatening and sexual abuse is non-consensual sexual contact of any type with a resident, including unwanted intimate touching of any kind, especially of breasts or perineal area.<RESIDENT 1>Review of the 03/11/2026 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 1 had diagnoses including dementia, was sometimes understood, able to communicate concrete requests and was independent in wheelchair mobility.Review of Resident 1's Care Plan (CP), dated 04/14/2026, showed Resident 1 experienced impaired psychosocial well-being, including but not limited to a Resident-to-Resident altercation of inappropriate touching/physical altercation on 04/30/2026.Review of the facility investigation, dated 04/30/2026, showed Resident 1 stated Resident 2 grabbed their breasts unprovoked. Resident 1 stated they screamed and pushed Resident 2 away. Resident 1 denied hitting Resident 2.During an interview on 05/14/2026 at 10:47 AM, Resident 1 stated, He touched my breast. When asked how that made them feel, Resident 1 stated, I didn't like it. When asked what they did in response, Resident 1 stated, hit him.<RESIDENT 2>Review of the 04/09/2026 Annual MDS showed Resident 2 had diagnoses including dementia, had clear speech, was able to understand and be understood, and was independent in wheelchair mobility.Review of Resident 2's CP, dated 04/10/2025, showed Resident 2 experienced impaired psychosocial well-being as evidenced by behaviors requiring intervention, including but not limited to inappropriate touching of another resident on 04/30/2026.During an interview on 05/14/2026 at 10:53 AM, Resident 2 stated, I grabbed one of her ti**ies and she didn't like it. When asked what happened next, Resident 2 stated that Resident 1 slapped them. Resident 2 stated they had been instructed to avoid Resident 1.During an interview on 05/14/2026 at 10:58 AM, Staff C, Licensed Practical Nurse (LPN), stated Resident 2 told them about grabbing Resident 1's breast. Staff C stated neither Resident 1 nor Resident 2 had any memory of when it happened, and both stated they did not report the incident at the time it happened.During an interview on 05/15/2026 at 12:20 PM, Staff A, Administrator, stated neither Resident 1 or Resident 2 remembered when or where the incident allegedly occurred. <RESIDENT 3>Review of the 05/06/2026 admission MDS, showed Resident 3 was assessed as alert and oriented and dependent on staff for bed mobility and transfers.Review of Resident 3's CP, revised 05/12/2026, showed Resident 3 had impaired psychosocial well-being as evidenced by behaviors requiring intervention, including but not limited to a 05/08/2026 resident to resident potential altercation.Review of the facility investigation, dated 05/08/2026, showed Resident 3 was sleeping in their bed when their roommate (Resident 4) started kicking Resident 3's bed. Further review showed the facility concluded that there was no physical contact, injury or psychosocial harm identified, the allegation of abuse and neglect were unsubstantiated.During an interview on 05/14/2026 at 11:34 AM, Staff D, Registered Nurse (RN), stated they entered the room and saw Resident 4 kicking Resident 3's bed. Staff D noted that Resident 4's legs weren't long enough to kick Resident 3. Staff D secured the resident, called for help, and Resident 4 was transferred into a wheelchair and removed from the room.During an interview on 05/14/2026 at 10:06 AM, Resident 3 stated that Resident 4 wouldn't quit yelling, I woke up to her kicking my bed, not too far from my body. Resident 3 stated Resident 4 was almost completely on the edge of their bed, kicking Resident 3's bed. Resident 3 stated it made them feel unsafe and commented if Resident 4 had gotten much closer, I would have had to fight her off! Resident 3 stated they felt very unsafe with Resident 4 in their room. When asked if they felt Resident 4's behavior constituted abuse,Resident 3 stated, Yes, I was waiting for the next episode where (Resident 4) would get angry with me and take a swing at me.<RESIDENT 4>Review of Resident 4's CP, dated 05/07/2026, showed Resident 4 had a diagnosis of Alzheimer's Dementia, with behaviors of agitation, calling out despite needs being met and yelling.On 05/14/2026 at 10:03 AM, Resident 4 was observed in a private room. In an interview at that time, Resident 4 did not recall the incident, and did not recall having previously had a roommate. Resident 4 denied having problems with any other residents and stated they felt safe in the facility.During an interview on 05/14/2026 at 11:46 AM, Staff E, RN, stated Resident 4 exhibited behaviors of yelling out and cussing at staff.During an interview on 05/14/2026 at 12:16 PM, Resident 4's Power of Attorney (POA) stated Resident 4 didn't last a couple of hours in the first room before they were moved to another room. Resident 4's POA stated that Resident 4 yells and swears a lot, but they were not aware of them being violent towards others.During an interview on 05/15/2026 at 12:20 PM, Staff A stated Resident 4 did not make physical contact with Resident 3. REFER TO WAC: 388-97-0640(1)

Based on interview and record review, the facility failed to ensure residents were screened for additional mental health supports through the Pre-admission and Resident Review (PASARR, a mental health screening tool) process for 2 of 5 sampled residents (Residents 97 and 6) reviewed for PASARR. This failure placed residents at risk of unidentified mental health needs, avoidable decline in mental health, unintended increase in negative behaviors, and a diminished quality of life. Findings included.Resident 97 Review of the electronic health record (EHR) showed Resident 97 admitted to the facility on [DATE] with diagnoses to include vascular dementia (a decline in mental abilities caused by reduced blood flow to the brain), depression, and adjustment disorder (stress-related mental health condition triggered by a significant life change or traumatic event). Resident 97 was able to make needs known. Review of the PASARR level one, dated 04/10/2026, showed Resident 97 had no mental health diagnoses and did not require a PASARR level two. During an interview on 05/07/2026 at 12:17 PM, Staff G, Regional Social Services, stated Resident 97's PASARR was inaccurate, needed modifications, and did not meet expectations. During an interview on 05/07/2026 at 12:27 PM, Staff A, Administrator, stated PASARR level one was completed by the admitting hospital, should be corrected if inaccurate, and Resident 97's inaccurate PASARR did not meet expectations. Resident 6 Review of the EHR showed Resident 6 admitted to the facility on [DATE] with diagnoses to include heart failure, respiratory failure, and post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event). Resident 6 was able to make needs known. Review of Resident 6's PASARR level one, dated 03/30/2026, showed no serious mental illness indicators marked on the form and showed no PASARR level two indicated. Review of Resident 6's EHR showed no other documented PASARR level one or PASARR level two. During an interview on 05/05/2026 at 11:55 AM, Staff D, Social Services Director (SSD), stated PASARR documentation was obtained from the hospital during the admission process, was reviewed for accuracy, and, if inaccurate, another PASARR level one would be completed. Staff D stated Resident 6's PASARR level one did not include their diagnosis of PTSD, and they should have had another PASARR level one completed to include PTSD. During an interview on 05/05/2026 at 12:15 PM, Staff A, Administrator, stated Resident 6's PASARR level one was not accurate and another PASARR level one needed to be conducted. Staff A stated they were unable to locate another PASARR level one or level two in Resident 6's EHR and this did not meet their expectations. Reference WAC 388-97-1915(1)(2)(a)-(c)

Based on observation and interview, the facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts (Hallways 400 and 500) reviewed for medication storage and labeling. This failure placed residents at risk of receiving expired medications, ineffective treatment, and a diminished quality of life. Findings included.Findings included. Observation of a medication cart on 500 hall on 05/05/2026 at 1:37 PM with Staff S, Licensed Practical Nurse (LPN), showed an open vial of insulin (a medication used to lower sugar in the blood) with no date. Observation showed an open bottle of eye drops with no date. During an interview on 05/05/2026 at 1:37 PM, Staff S, LPN, stated upon opening a vial of insulin or a bottle of eye drops, they should be dated immediately. Staff S stated both the vial of insulin and bottle of eye drops should have been dated immediately upon opening them. Staff S stated they would dispose of the undated vial and bottle. Observation of a medication cart on 400 hall on 05/06/2026 at 9:53 AM with Staff T, Registered Nurse (RN), showed two open bottles of eye drops with no dates on them. During an interview on 05/06/2026 at 9:52 AM, Staff T, RN, stated both bottles of eye drops should have been dated as soon as they were opened. Staff T stated they would get new eye drops and dispose of the undated bottles. During an interview on 05/07/2026 at 10:30 AM, Staff B, Director of Nursing/Registered Nurse (DNS/RN), stated if an eye drop was opened it should have been dated immediately. Staff B stated if an open multidose vial or bottle was found without a date on it, it should be discarded immediately. Reference WAC 388-97-1300(2)

Based on observation, interview, and record review, the facility failed to ensure the call light system was functioning for 1 of 3 call light panels (500 hall) when reviewed for call lights. This failure placed residents at risk of inability to receive timely assistance, possible neglect, and a diminished quality of life. Findings included.Observation on 05/03/2026 at 11:04 AM showed the call light panel in the 500 hall with room [ROOM NUMBER] lit, but the call light above room [ROOM NUMBER] was not lit. Observation on 05/04/2026 at 1:13 PM showed the call light panel in the 500 hall with room [ROOM NUMBER] lit, but the call light above room [ROOM NUMBER] was not lit. Observation on 05/07/2026 at 12:37 PM showed the call light panel in the 500 hall with room [ROOM NUMBER] lit, but the call light above room [ROOM NUMBER] was not lit. Observation on 05/07/2026 at 1:17 PM showed the call light panel in the 500 hall with room [ROOM NUMBER] continued to be lit, but the call light above room [ROOM NUMBER] was not lit. Review of the maintenance log for the 500 hall showed entries for call light not turning off on 03/03/2026, 03/06/2026, 04/10/2026, and 05/03/2026. Observation on 05/07/2026 at 1:20 PM showed the call light for room [ROOM NUMBER] bed B did not light above the door or at the call panel. During an interview on 05/07/2026 at 2:29 PM, Staff N, Maintenance Director, stated they ensured the call light system was functioning correctly by performing periodic audits and reviewing the maintenance binder at each nurses' station when nursing staff would log needed call light repairs. Staff N stated they had just repaired room [ROOM NUMBER] bed B's call light cord as it was not functioning. Staff N stated the call light system in the 500 hall would sometimes have lights lit on the panel but the call lights at the door would not be on. Staff N stated they resent the system when this occurred to clear the error. During an interview on 05/07/2026 at 3:42 PM, Staff A, Administrator, stated the facility ensured the call light system was functioning correctly by performing periodic audits and reviewing the maintenance binder at each nurses' station. Staff A stated the light on the call light panel should turn off when the light at the door was turned off, and observations of them not turning off did not meet expectations. Staff A stated resetting the panel each time the error occurred was a sustained repair of the system. Reference WAC 388-97-2280(1)(a)

Based on observation, interview, and record review, the facility failed to accurately document the amount of food eaten for 1 of 3 sampled residents (Resident 13) reviewed for nutrition. This failure placed residents at risk of inaccurate assessments, lack of timely interventions, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 13 admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (too much sugar in the blood), dysphagia (difficulty swallowing), and protein-calorie malnutrition (lack of nutrients in the body). The quarterly minimum data set (MDS, an assessment tool), dated 02/12/2026, showed Resident 13 was moderately cognitively impaired. Observation on 05/05/2026 at 12:09 PM showed a meal tray was delivered to Resident 13 in their room. Observation showed the meal tray was set up on a bedside table next to Resident 13's bed. Observation showed Resident 13 was eating slowly. Observation showed Resident 13 ate less than 25% of their meal and laid back in the bed and closed their eyes. Observation showed staff entered the room and removed the meal tray. Review of the Point of Care (POC) documentation for lunch on 05/05/2026 showed Resident 13 ate 76-100% of their meal. During an interview on 05/06/2026 at 1:20 PM, Staff R, Certified Nursing Assistant (CNA), stated Resident 13 typically would eat between 25-50% of their meals and never ate all of their food. Staff R stated if they did not pick up a tray, they would ask their coworker what the resident ate to document it in POC. Staff R stated Resident 13 ate well on 05/05/2026. Staff R stated they were told Resident 13 ate 75-100% of their lunch, so that is what they documented. During an interview on 05/07/2026 at 8:30 AM, Staff F, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated staff should document the amount eaten in POC under meal intake. Staff F said POC would show them the options and staff would use the correct space to document. Staff F stated if documentation was not accurate, it would affect the dietician's ability to have accurate information about caloric intake and the nutritional needs of Resident 13. During an interview on 05/07/2026 at 10:30 AM, Staff B, Registered Nurse/Director of Nursing Services (RN/DNS), stated it is their expectation for all staff to document meal intake accurately. Reference WAC 388-97-1720(1)(a)(i)-(iv)(b)

Based on observation, interview, and record review, the facility failed to ensure residents received needed dental care for 1 of 3 sampled residents (Resident 112) reviewed for dental. This failure placed the residents at risk of dental pain, decreased nutritional intake, unintended weight loss, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 112 admitted to the facility on [DATE] with diagnoses to include leg fracture, dementia (a decline in mental ability severe enough to interfere with daily life), and hearing loss in both ears. Observation on 05/03/2026 at 1:43 PM showed Resident 112 had missing lower teeth. Review of the admission minimum data set assessment (MDS), dated [DATE], showed Resident 112 had obvious or likely cavities or broken natural teeth. Review of the care plan, dated 02/24/2026, showed Resident 112 had oral/dental health problems related to likely cavities/broken teeth with an intervention to coordinate dental care and provide transportation. During an interview on 05/06/2026 at 1:54 PM, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and they were not referred for dental services. During an interview on 05/07/2026 at 10:53 AM, Staff M, Social Services Director, stated the facility identified dental needs on admission through the MDS, and resident needing dental services should be referred to social services to be scheduled for assessment by a dental care practitioner. Staff M stated Resident 112 should have been referred to dental services after the 02/24/2026 MDS assessment, and the lack of referral did not meet expectations. During an interview on 05/07/2026 at 11:35 AM, Staff B, Director of Nursing Services, stated residents with identified dental needs should be referred for follow-up with a dentist. Staff B stated Resident 112 should have been referred to the in-house dental provider, and the lack of referral did not meet expectations. Reference WAC 388-97-1060(3)(j)(vii)

Based on observation, interview, and record review, the facility failed to ensure residents' care plans were revised and accurately reflected the resident's status and care needs for 2 out of 21 sampled residents (Residents 6 and 71) reviewed for care planning and revision of care plans. Failure to address Resident 6's generalized anxiety disorder with target behaviors and interventions and Resident 71's dentures placed the residents at risk for unmet care needs, medical complications, inaccurate care plan documentation, and a diminished quality of life. Findings included.Resident 6Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with diagnoses to include heart failure, respiratory failure, and post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event). Resident 6 was able to make needs known. Review of the EHR showed the Resident 6 had a diagnosis of generalized anxiety disorder and was prescribed and administered a psychotropic medication (medication to manage mental health conditions). Review of the current care plan on 05/05/2026 showed Resident 6 had documentation to monitor side effects for antipsychotic medication (to manage psychosis/difficult to distinguish what is real from what is not), anticonvulsant medication (used to treat epilepsy/seizures, temporary changes in movement, behavior, consciousness, or feelings); however, Resident 6 was not prescribed these medications. The care plan showed Resident 6 had PTSD; however, it did not show the diagnosis of generalized anxiety disorder nor what behaviors to monitor for and interventions to implement related to the diagnoses of PTSD or anxiety disorder. During an interview on 05/06/2026 at 11:49 AM, Staff F, Licensed Practical Nurse/Care Coordinator (LPN/CC), stated Resident 6 was not taking and had not been prescribed antipsychotic or anticonvulsant medications; however, they were taking a psychotropic medication for their anxiety disorder. Staff F stated Resident 6's care plan did not meet expectations because it did not accurately reflect Resident 6's current status related to prescribed medications, did not include the diagnosis of anxiety disorder, and did not have target behaviors to monitor for anxiety disorder or PTSD listed. During an interview on 05/06/2026 at 1:37 PM, after reviewing Resident 6's care plan, Staff B, Director of Nursing Services (DNS), stated it did not meet their expectations related to psychotropic medications, target behaviors to watch for with interventions, and addressing the resident's diagnosis of generalized anxiety disorder. Resident 71Review of the EHR showed Resident 71 admitted to the facility on [DATE] with diagnoses to include PTSD, high blood pressure, and depression. Resident 71 was able to make needs known. Observation on 05/06/2026 at 11:30 AM showed a denture cup by the sink with Resident 71's name handwritten on the lid and new dentures, upper and lower with a date of 01/12/26. During an interview on 05/06/2026 at 11:30 AM, Resident 71 stated they had gotten new dentures; however, the bottom dentures did not fit well, and they were told to use a denture adhesive. Resident 71 stated they were provided with the adhesive to use on the lower dentures, but they still did not fit right but had not told staff yet. Review of Resident 71's current focused care plan for oral/dental health problems, initiated on 06/23/2026, showed the resident was edentulous (no natural teeth/toothless) and had difficulty chewing. It did not show Resident 71 had dentures or any interventions related to denture use or maintenance. During an interview on 05/06/2026 at 12:26 PM, Staff E, Certified Nursing Assistant (CNA), stated they had not seen Resident 71 wear dentures and were not aware they had new dentures that did not fit. During an interview on 05/06/2026 at 12:41 PM, Staff C, LPN/CC, stated they had recalled passing out new dentures to Resident 71 sometime in January 2026; however, they were not aware that they did not fit Resident 71. Staff C stated Resident 71's care plan did not show they got new dentures and should have been updated with interventions put into place when the dentures were obtained. During an interview on 05/06/2026 at 1:06 PM, Staff B, DNS, stated Resident 71's care plan should have reflected that they received dentures with interventions put into place. Staff B stated this did not meet expectations. Reference WAC 388-97-1020(2)(c)(d)

Based on observation, interview, and record review, the facility failed to provide individualized activities for 1 of 3 sampled residents (Residents 5) reviewed for activities. This failure placed residents at risk of boredom, isolation, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 5 admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depression, and weakness. The admission minimum data set (MDS, an assessment tool), dated 01/14/2026, showed Resident 5 was cognitively intact. During an interview on 05/03/2026 at 11:09 AM, Resident 5 stated they were unable to attend in person activities because of their legs. Resident 5 stated there were no activities offered to them in their room and they would like to have more activities to occupy them. Observation on 05/03/2026 at 11:09 AM showed Resident 5 laid in bed with the TV on. During an interview on 05/06/2026 at 11:23 AM, Resident 5 stated they did not remember the last time activities staff visited them to offer activities. Resident 5 stated they would mostly lay in their bed and watch TV. Resident 5 stated the activities staff would need to offer something they were able to do because they had difficulty doing some activities. Review of the activities care plan dated 12/26/2026 showed Resident 5 had a goal to participate in activities two to three times per week. Review of the progress notes showed activity staff visited Resident 5 on 12/22/2026 at 10:45 AM to provide a welcome packet and encouraged Resident 5 to participate in daily activities. Review of the progress notes showed no further documentation of activities. During an interview on 05/06/2026 at 11:00 AM, Staff H, Activities Aide, stated they remembered visiting Resident 5 once or twice in the past. Staff H stated if a resident was unable to come to activities, they would offer room visits at which time they would offer puzzles, arts and crafts, visiting, and chatting. Staff H stated documentation of all activities was placed in the tasks. Review of the task showed no documentation of activities for the past 30 days. During an interview on 05/06/2026 at 11:57 AM, Staff J, Activities Director, stated they had paper documentation of room visits with Resident 5. Staff J stated Resident 5 was on a list for room visits every Monday and Wednesday. Review of the room visit documentation showed activity staff visited Resident 5 four times on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026. During an interview on 05/06/2026 at 11:35 AM, Staff A, Administrator, stated offering of activities would depend on what the care plan said. Staff A stated if a resident was offered activities, it should be documented. Reference WAC 388-97-0940(1)(2)

Based on observation, interview, and record review, the facility failed to consistently implement pressure reducing strategies for 1 of 3 sampled residents (Resident 90) reviewed for pressure injuries. This failure placed residents at increased risk for pressure injuries, poor clinical outcomes, and a decreased quality of life.Findings included.According to NIH.gov, a diabetic foot ulcer (DFU) is an open sore or wound on the foot of a person with diabetes, and it is most commonly located on the plantar surface, or bottom of the foot. Pressure offloading serves as one of the primary treatments of DFU in ulcers accompanied by neuropathy (inability to feel).Review of the electronic health record showed Resident 90 was admitted to the facility on [DATE] with diagnoses of left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia (a group of symptoms that affect memory). The resident was not able to make needs known. The resident was dependent on facility staff for mobility.Observation on 05/03/2026 at 12:47 PM showed Resident 90 seated in a reclined position in their wheelchair, and their left foot/heel was rested on a footrest strap. There was a bandage in place to the resident's left heel and no pressure relieving boots were observed on the resident's feet.Review of the baseline care plan, dated 12/06/2025, showed an intervention for skin at risk: elevate heels and heel float boots as resident allows.Review of the admission skin assessment, dated 12/06/2025, showed Resident 90 had no wound on their left heel.Review of a care plan goal, dated 12/29/2025, showed The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. With an intervention for Elevate/float heels when in bed to offload pressure as resident allows.Review of the initial wound notes from the wound care provider, dated 01/05/2026, showed a recommendation to heel float with pillows or wedge, sage/moon boots.Review of the weekly skin assessment, dated 02/16/2026, showed Resident 90's left heel wound had resolved.<Re-opening of Wound>Review of the weekly skin assessment dated [DATE] showed Resident 90 had a new/reopened wound that was very painful to touch.Review of contracted wound care provider notes, dated 04/27/2026, documented, DFU to the left heel is reopened even after epithelial tissue has closed over wound bed, wound bed is in final stage of remodeling. wounds are elevated risk for reopening. Prior to debridement (removal of unhealthy tissue) procedure, wound described as full thickness - wound base: no epithelial (final skin layer that closes the wound), 1-10% granulation (healthy/new tissue), 76-100% slough (by product of the inflammatory phase of wound healing), no eschar (dead tissue) with the following measurements: 0.8 centimeters (cm) x 0.9 x 0.2.During an interview on 05/04/2026 at 1:15 PM, Collateral Contact 1 (wound care provider) stated Resident 90's heel wound was a DFU and had resolved but reopened a few weeks ago and they had recommended Resident 90 to wear the pressure relieving boots at all times.Review of the current care plan, reviewed 05/05/2026, showed no new interventions were added to Resident 90's plan of care following the 04/22/2026 wound identification.Observations on 05/05/2026 between 8:33 AM and 10:30 AM showed Resident 90 laid in bed with their heels directly on the mattress (not floated and no boots on).Observation on 05/05/2026 at 10:42 AM showed Resident 90 reclined in their wheelchair, and their left foot/heel was resting on the footrest strap. There was a bandage in place and no boots on the resident's feet.During an interview on 05/05/2026 at 2:23 PM, Staff Q, Certified Nursing Assistant, stated Resident 90 had never refused to wear the boots or float their heels and if they had the boots on, they left them on.During an interview on 05/05/2026 at 10:33 AM, Staff C, Licensed Practical Nurse/Care Coordinator (LPN/CC), stated if a resident had a heel wound, they would speak with the wound care provider and follow their recommendations such as floating heels or boots. Staff C stated Resident 90 should have had their plan of care updated with a new intervention when the wound to their left heel reopened on 04/22/2026.During an interview on 05/05/2026 at 10:48 AM, Staff B, Director of Nursing Services, stated it was their expectation that Resident 90 was assessed and the plan of care updated when their left heel wound reopened on 04/22/2026. Staff B stated Resident 90's heels should have been floated and boots applied per the care plan.Reference WAC 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to address residents' hearing and vision needs for 1 of 2 sampled residents (Resident 112) reviewed for communication-sensory. This failure placed the residents at risk of not being able to participate in activities, difficulty communicating, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 112 admitted to the facility on [DATE] with diagnoses to include leg fracture, dementia (a decline in mental ability severe enough to interfere with daily life), and hearing loss in both ears. Resident 112 was able to make needs known. During an interview and observation, Resident 112 stated they lost their glasses and were given readers but did not wear them because they were worried wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in Resident 112's room. Observation showed Resident 112 was hard of hearing, required an elevated voice to hear, and required questions to be repeated to understand. Resident 112 stated they did not use a hearing aid. Review of the admission minimum data set assessment (MDS), dated [DATE], showed Resident 112 had adequate hearing with hearing aid and adequate vision with corrective lenses. Review of the significant change MDS, dated [DATE], showed Resident 112 had moderate difficulty hearing and did not use a hearing aid and impaired vision and did not use corrective lenses. Review of the care plan, initiated 02/24/2026, showed Resident 112 had impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind Resident 112 to wear their glasses. Review did not show a focus area or interventions related to Resident 112's hearing loss or use of hearing aids. Review of a Resident Clothing List, undated, showed Resident 112 admitted to the facility with one pair of eyeglasses and one Super Ear headset personal sound amplifier. Observation and interview on 05/06/2026 at 1:55 PM showed Resident 112 in bed without eyeglasses or hearing device. Observation showed a personal sound amplifier in the top drawer of Resident 112's bedside table. Resident 112 stated they did not know where their glasses were. During an interview on 05/07/2026 at 11:20 AM, Staff K, Certified Nursing Assistant (CNA), stated they worked with Resident 112. Staff K stated Resident 112's hearing was strained and they did not use a hearing device or glasses. During an interview on 05/07/2026 at 11:24 AM, Staff L, Registered Nurse/Resident Care Manager (RN/RCM), stated the facility ensured residents with hearing or vision difficulties would receive services for these issues by being assessed at admission, referred to a provider as needed to obtained hearing aids or glasses, and be included in the plan of care. Staff L stated Resident 112 had hearing loss as a diagnosis and used a personal amplified device. Staff L stated Resident 112's use of hearing device should have been included in the plan of care to inform staff of the device. Staff L stated Resident 112 should have been referred to an eye care practitioner to be assessed for corrective lenses, and CNA should be aware of Resident 112's use of glasses to assist them in using them. During an interview on 05/07/2026 at 11:43 PM, Staff B, Director of Nursing Services, stated Resident 112's services to improve or maintain hearing and vision did not meet expectations, and the facility should of referred Resident 112 to eye and ear care practitioners to address these areas. Reference WAC 388-97-1060(3)(a)

Based on interview and record review, the facility failed to ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs, and what information was conveyed to the receiving provider for 1 of 4 sampled residents (Resident 14) reviewed for hospitalization. This failure placed residents at risk of potential delays in emergent hospital treatment and potential medical complications. Findings included.Review of the electronic health record (EHR) showed Resident 14 readmitted to the facility on [DATE] with diagnoses of respiratory failure, high blood pressure, and anxiety disorder. Resident 14 was able to make needs known. Review of the progress note dated 04/28/2026 showed Resident 14 complained of not being able to breathe, was diaphoretic (excessive sweating without heat or physical exertion), and a breathing treatment was provided. The provider agreed to send Resident 14 out for further evaluation and emergency transportation took Resident 14 to the hospital. Review of the EHR showed Resident 14 was discharged from the facility on 04/28/2026 and readmitted to the facility on [DATE]. No documentation was found to show what information was provided or communicated to the receiving facility, as required. During an interview on 05/07/2026 at 1:11 PM, Staff C, Licensed Practical Nurse/Care Coordinator (LPN/CC), stated documentation that should be sent to the hospital for a transfer included a Skilled Nursing/Nursing Facility (SNF/NF) to Hospital Transfer form, the resident's face sheet (profile/admissions record, with resident information), and the medication and treatment administration records. Staff C stated they were unable to locate what transfer documentation was provided to the hospital for Resident 14's transfer on 04/28/2026. Staff C stated they were unable to locate a SNF/NF to Hospital Transfer form completed for Resident 14's transfer to the hospital on [DATE] and there should have been. During an interview on 05/07/2026 at 1:21 PM, Staff B, Director of Nursing Services, stated they were unable to locate a SNF/NF to Hospital Transfer form completed for Resident 14's transfer to the hospital on [DATE] and this did not meet their expectations. Reference WAC 399-97-0120(1)(2)(a), -(d)(3)(a)(4)(b)(5), -0080, -0140(1)(a)-(c)(i)-(iii)

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 4 sampled residents (Residents 53 and 14) reviewed for respiratory care. Failure to transcribe/obtain and follow physician orders for oxygen (O2) therapy with indication for use, consistently monitor O2 saturation (Sats, measuring the percentage amount of O2 in the blood), and/or ensure O2 tubing was regularly changed and maintained, placed the residents at risk for unmet needs and potential negative outcomes. Findings included .Resident 53Review of the electronic health record (EHR) showed Resident 53 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, lung disease that causes restricted airflow and breathing problems) and chronic (long lasting/ongoing) respiratory failure with hypoxia (low levels of O2 in the blood). Resident 53 was able to make needs known. Observation on 05/03/2026 at 11:45 AM, 05/04/2026 at 1:14 PM, and 05/06/2026 at 10:29 AM showed Resident 53 laid in bed receiving O2 set to 2 liters (L, the flow of O2 being delivered per minute) via nasal canula (NC, devise to deliver O2 through a tube into the nose). Review of an order, dated 02/15/2026, showed Resident 53 was prescribed O2 at 1 to 4 L per minute, continuously, via a NC. This order did not show indication for use or acceptable O2 sats parameters to maintain to know what liter flow to use for the O2 therapy. Review of the April and May 2026 medication administration records (MAR) showed no documented order for the use of O2 therapy for Resident 53. Review of the April and May 2026 treatment administration records (TAR) showed Resident 53 had orders, dated 12/31/2025, to change O2 tubing if damaged or visibly soiled as needed; however, there was no order for O2 therapy. Review of Resident 53's EHR showed O2 sats were inconsistently being documented daily from 04/01/2026 - 05/04/2026. During an interview on 05/06/2026 at 2:16 PM, Staff C, Licensed Practical Nurse/Care Coordinator (LPN/CC), stated Resident 53's order for O2, dated 02/15/2026, was missing an indication for use, O2 sats parameters, and needed to be clarified with the provider. Staff C stated Resident 53's April and May 2026 MAR and TAR did not show documentation of O2 therapy being provided per provider's order. Staff C stated Resident 53's O2 sats were not being documented daily and/or every shift consistently in the EHR, and this did not meet expectations. During an interview on 05/07/2026 at 10:20 AM, after reviewing Resident 53's EHR, Staff B, Director of Nursing Services (DNS), stated Resident 53's order for O2 therapy was missing indication for use and O2 sats parameters. Staff B stated Resident 53's April and May 2026 MAR and TAR did not show documentation of being provided O2 and there should have been. Staff B stated Resident 53's O2 therapy care, services, and documentation did not meet their expectations. Resident 14Review of the EHR showed Resident 14 readmitted to the facility on [DATE] with diagnoses of respiratory failure, high blood pressure, and anxiety disorder. Resident 14 was able to make needs known. Observations on 05/03/2026 at 1:39 PM, 05/04/2026 at 1:33 PM, 05/05/2026 at 11:48 AM and 05/06/2026 at 10:36 AM showed Resident 14 in their room receiving O2 at 6 L via NC. During an interview on 05/05/2026 at 11:48 AM, Resident 14 stated they needed O2 therapy to breathe. Review of Resident 14's focused care plan for altered respiratory status/difficulty breathing, initiated on 11/26/2025, showed the resident was dependent on O2 use and was to be provided O2 per provider's orders. Review of Resident 14's provider orders on 05/04/2026 showed no orders for O2 therapy or for changing O2 tubing. During an interview on 05/07/2026 at 10:05 AM, Staff C, LPN/CC, stated Resident 14 was on O2 therapy continuously via NC; however, they were unable to locate O2 therapy orders to include changing of O2 tubing in Resident 14's EHR and there should have been. Staff C stated Resident 14's orders for O2 therapy and changing of O2 tubing were discontinued on 04/29/2026 after they were discharged to the hospital and did not get added back to the MAR or TAR when they readmitted to the facility on [DATE]. During an interview on 05/07/2026 at 11:06 AM, Staff B, DNS, stated Resident 14 should have had O2 therapy orders in place and this did not meet their expectations. Reference WAC 388-97-1060(3)(j)(iv)-(vi)

Based on observation, interview, and record review, the facility failed to post the daily nurse staffing data in a prominent place to include name of facility and total number and actual hours worked for 5 of 5 observed days during the survey period (05/03/2026 -05/07/2026) reviewed for nurse staff posting. This failed practice prevented residents, family members and visitors from knowing the facility's actual number of available nursing staff. Findings included.Observations on 05/03/2026 at 9:00 AM showed the front entrance, receptionist desk, and lobby areas with no daily nurse staffing data posted. Observations on 05/04/2026 at 11:00 AM, 05/05/2026 at 6:16 AM, 05/06/2026 at 8:55 AM, and 03/07/2026 at 8:51 AM showed the daily nurse staff data postings without the facility's name and with no actual total number or actual nursing staff hours documented (the form showed Actual Scheduled Staff and Actual Scheduled Hours), located in a glass covered bulletin board to the left of a wall picture and grandfather clock, after walking through the front entrance and when taking a left towards the 100/200 halls. If a person were to take a right towards the 300 hall, they may not have been able to view the daily nurse staff data. Observation of the daily staff data posting on 05/05/2026 at 6:16 AM showed postings for the previous day (05/04/2026). Observation on 05/05/2026 at 8:03 AM showed posting for the correct date of 05/05/2026. During an interview on 05/07/2026 at 1:33 PM, Staff O, Staffing Coordinator, stated people could miss seeing the nursing staff daily postings if they were to take a right after going through the lobby because the bulletin board was the only location for postings. Staff O stated they did not know why the nursing staff daily posting form did not have the facility's name on it and the form had been that way since they started working in February 2026. Staff O stated they filled out the form and posted the actual scheduled staff and actual scheduled hours on the form in the morning when they came in around 8:00 AM; however, actuals, were not posted. During an interview on 05/07/2026 at 1:56 PM Staff A, Administrator, stated nurse staff daily postings were posted the day before for the next day and on Friday they were posted for days through the weekend. Staff A stated typically the postings were updated/revised the next day within 24 hours as needed. Staff A stated they were unable to explain why the form did not have the facility's name on it and that actuals were not posted just scheduled. Reference WAC 388-97-1620(2)(b)(i)

Based on observation, interview, and record review, the facility failed to have a system in place that ensured basic life support was initiated immediately, as directed in the facility policy, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) when 1 of 1 resident (Residents 1) was reviewed for unexpected death in the facility. The facility failed to maintain the required unexpired supplies & equipment on the crash carts ready for immediate use and failed to maintain accurate Physician Orders for Life-Sustaining Treatment (POLST) data for immediate accessibility. This failed practice placed 70 additional residents (Residents 3, 4, 5, 6, 7, 8, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76 & 77), who had current POLST to receive CPR, at serious risk for adverse outcome including death and constituted an Immediate Jeopardy (IJ). On [DATE] at 5:03 PM, the facility was notified of an IJ. The facility removed the immediacy on [DATE] after they audited the records of all residents, audited the POLST binders, audited and stocked the crash carts, updated the facility CPR policy, educated staff on the facility's CPR Policy and Code Blue Emergency process during CPR, audited and ensured licensed staff had current CPR training and implemented a plan of correction to sustain ongoing compliance. Findings included . Facility PolicyThe facility policy titled Cardiopulmonary Resuscitation (CPR), updated [DATE], showed the facility would provide CPR to residents as requested. CPR is initiated for those residents who: Have requested, through advanced directive or POLST/POST/Other state approved methods, to have CPR initiated when cardiac or respiratory arrest occurs, have not formulated an advanced directive nor have a valid POLST (per state guidelines) in their medical record. Review of the facility policy did not show the procedure, process, documentation expectations or staff expectations during a cardiac or respiratory arrest event. During an interview on [DATE] at 2:51 PM, Staff J, Registered Nurse (RN), Regional Director of Clinical Operations, stated the facility did not have a policy that specified the expected necessary protocols for calling a Code Blue or initiation of CPR. Staff J stated their expectation of staff who found a resident non-responsive, not breathing, and/or without a pulse, was to immediately notify a nurse, and immediately initiate CPR if they were a full code, by any CPR certified staff. Staff J stated the licensed staff were responsible for verifying the code status prior to initiation of CPR. Staff J stated the facility did not have a policy or protocol in writing of their expectations for how staff were expected to handle a Code Blue emergency.RESIDENT 1Review of Resident 1's POLST showed it was signed by the Resident on [DATE] and signed by the Nurse Practitioner on [DATE]. The form showed Resident 1 wanted CPR if they were not breathing and had no pulse. The form showed Resident 1 wanted full treatment to prolong life by all medically effective means including transfer to the hospital and intensive care (Full Code). Review of Resident 1's Advanced Directive Care Plan (CP), initiated [DATE], showed Resident 1 was their own healthcare decision maker and had been informed of their advanced care planning options. Interventions listed were Honor my wishes for healthcare decisions and Check my chart for code status.Review of a [DATE] Nursing Progress Note showed Licensed Nurse (LN) was called by NAC (Nursing Assistant Certified) assigned to the resident. LN assessed Resident 1 to have no pulse and was unresponsive, transferred resident onto the floor flat, started CPR, called 911, and came in announced fetal pulse present and continue CPR and full treatment to the resident. At 10:55 PM Emergency Medical Technician (EMT) announced Resident 1 did not make it and had passed. Review of the facility's unexpected death investigation, dated [DATE] showed no documented code event minutes, no documented timeline of events and the staff investigation statements were contradictory with each other regarding the chain of events. Review of the staff statements showed at 9:40 PM, Staff F, NAC, found Resident 1 unresponsive. Staff D, NAC stated at 9:55 PM Resident 1 was still not responding; Staff D could not tell if they were breathing. Staff D did not check for a pulse and did not go tell the nurse. In their statement Staff H, NAC, stated that Staff D came out of Resident 1's room, said they were unresponsive, and that they thought they were dead as they approached the nursing station. Further review of the investigative staff statements showed Staff C, Registered Nurse (RN), stated she called a code blue, whereas Staff G, NAC, statement that in fact they called the cold blue over the page system which was collaborated in others statements. Staff C indicated they checked Resident 1's code status, but Staff K, NAC, indicated they did. Staff C indicated they grabbed the crash cart and on re-interview noted the crash cart was in the room when they arrived. Staff K stated they retrieved the crash cart. During an interview on [DATE] at 2:32 PM, Staff K stated the incident occurred during shift change, it was the end of their shift and they were getting ready to leave. Staff K stated Staff C asked Staff D to go check on Resident 1 and when they did not get up from the nurses station to do so, staff K stated they went to check on Resident 1. Staff K found Resident 1 unresponsive, they felt for a pulse, found no pulse, called Staff C into the room. Staff C told Staff K to check the resident's code status. Staff K said they checked the binder, found the POLST form that indicated Resident 1 was a full code. Staff K said they transferred Resident 1 to the floor. Staff K stated they told the NAC next to the phone, Staff D, three times to pick up the phone and page a code blue, as they did not do as directed. Staff K said they told Staff G to call code blue, which they did. Staff G then called 911. Staff K stated around 10:10 PM, they then took the crash cart to the resident's room where Staff C was performing chest compressions. Review of the Emergency Services,911, records showed the facility's initial call was at 10:15 PM. During an interview on [DATE] at 11:23 AM, Staff L, Licensed Practical Nurse (LPN), Resident Care Manager (RCM), stated a nursing assistant did not have to wait for a nurse, they could initiate CPR if they knew the code status of the resident and if they were CPR certified. Review of staff records on [DATE] at 12:42 PM, showed Staff D's CPR certification expired [DATE]. Review showed Staff F held a current CPR certification.During an interview on [DATE] at 10:33 AM, Staff A, Administrator, stated all Licensed Nurses were CPR certified so they had ample oversight. Staff A stated that NACs were not required to be CPR certified, but the facility appreciated that a lot of them were. CRASH CART- CODE EVENT MINUTE FORMObservation on [DATE] at 11:08 AM of the crash cart at the 100 unit nurses station showed a clipboard with a Code Event Minutes form, revised [DATE]. The form directed staff to note the date of event, location, resident name, response teams names, first responder name and tile, time found, status of resident when found, time code response called/initiated, vital signs, Advance Directives confirmed and correctly observed, CPR provided, if oxygen (O2) was administered with rate and route, when Emergency Medical Services were called and when they responded, that the physician was notified, responsible party notified and crash cart re-stocked. On [DATE] at 11:26 AM, review of the Dining Room crash cart did not show a Code Event Minutes (CEM) form on a clipboard. At 11:33 AM observation of the 300 unit nurses station crash cart did not show a CEM form on a clipboard. At 11:40 AM observation of the 500 unit nurses station crash cart showed a clipboard but no CEM form. During an interview on [DATE] at 11:13 AM, Staff L, LPN, Resident Care Manager, stated the Code Event Minutes form was supposed to be filled out after the code and given to the Director of Nursing. When asked if they did not expect staff to fill it out as the code was going, Staff L stated it depended on how many staff were around to document. Staff L said checking the crash cart was a night shift staff assigned duty.CRASH CART- NIGHT SHIFT AUDITReview of NOC [night] Shift Duties staff guidance sheet, undated, directed staff to check crash cart complete checksheet.On [DATE] at 12:26 PM, review of the 300-400 unit crash cart showed a Crash Cart Checklist was being utilized for [DATE] and did not show a Crash Cart Checklist was initiated for [DATE], missing checks on [DATE] through [DATE]. At 11:20 AM, review of the Dining Room crash cart showed a Crash Cart Daily Log Sheet (CCDLS) was being utilized and showed staff did not document a check for [DATE], and [DATE] through [DATE]. At 11:25 AM, review of the 100 unit crash cart showed CCDLS were being utilized and showed staff did not document a check for [DATE], and [DATE] through [DATE]. In an interview at that time, Staff L confirmed they were unable to find log sheets for [DATE]. During an interview on [DATE] at 11:51 PM, Staff BB, LPN, stated the NOC shift audited the crash carts every night and the RCMs should follow up to ensure it was done. CRASH CART- EQUIPMENT DESCREPANCYOn [DATE], review of log sheets posted on the facility crash carts (100/200, 300/400, 500 unit and Dining Room) showed two different forms (Crash Cart Checklist and CCDLS) being utilized by staff to ensure the carts were stocked with nonexpired supplies and equipment that were ready for use. Items that should be on the crash cart included, from both lists: Ambu bag (a handheld medical device that provides temporary positive pressure ventilation to patients unable to breathe adequately on their own), oxygen and a suction machine.When the log sheets were compared, they had conflicting listed items. The Crash Cart Checklist directed staff to ensure Suction Machine assembled and ready to use, whereas the CCDL directed staff to check that a suction catheter kit, suction connector, Yankauer suction tip (a suction tip with a large opening), and suction machine were present, not assembled. Review of the 100 unit crash cart, at 11:08 AM, showed there were suction machine tubes present in bags, but not connected to the suction machine.During an interview on [DATE] at 11:13 AM, Staff L said they thought the suction machine should be set up in case they needed to use it and did not have the time to put it together.The Crash Cart Checklist directed staff to verify that Glucostrips (blood glucose test strips) were on the cart, whereas the CCDLS did not. Review of the 100 unit crash cart on [DATE] at 11:47 AM, showed blood glucose test strips which expired [DATE]. Similarly, at 11:33 AM observation of the 300 unit nurses station crash cart showed expired supplies (blood glucose test strips) which expired [DATE] and at 11:40 AM observation of the 500 unit nurses station crash cart showed expired supplies (blood glucose test strips) which expired [DATE]. On [DATE] at 11:26 AM, Review of the Dining Room crash cart showed no blood pressure cuff which was required per the CCDLS form.Review of the CCDLS showed staff were to verify a Full O2 tank with a valve, whereas the Crash Cart Checklist directed staff to ensure Oxygen ready to use with regulator. On [DATE] at 11:33 AM observation of the 300 unit nurses station crash cart showed the oxygen tank was only 25 percent full, not full per the requirement. On [DATE] at 11:40 AM observation of the 500 unit nurses station crash cart showed the Lifesaving CPR Backboard was under a mop, on top of a blue plastic tub labeled emergency box. The cart did not have a bag of Normal Saline. Review of the CCDLS showed staff checked and initialed on [DATE] that Normal Saline was present.Further review of the 100 unit crash cart, on [DATE] at 11:08 AM, showed the oral airway kit box was short one oral airway and there were no non-rebreather masks. Similar findings were noted on [DATE] at 11:26 AM when the Dining Room crash cart was observed without a non-rebreather mask and on [DATE] at 11:33 AM observation of the 300 unit nurses station crash cart showed no non-rebreather masks. During an interview on [DATE] at 12:35 PM, when asked what equipment they used for respiratory arrest/rescue breathing, Staff O, RN, replied, a non-rebreather mask. Staff O stated the non-rebreather masks were available on the crash carts. Similarly, during an interview on [DATE] at 1:00 PM, Staff Y, LPN, replied a non-rebreather, Ambu bag and oxygen. During an interview on [DATE] at 1:10 PM, Staff AA, Central Supply, stated they were provided with the Crash Cart Checkoff Sheet revised [DATE] on [DATE] just prior to 1:10 PM, and directed by their supervisor to check the contents of the crash carts. Staff AA stated the facility was ordering an AED Defibrillator, but they did not know where it was.Review of the Crash Cart Checkoff sheet provided by Staff AA showed the cart should have oxygen tank with O2 (confirm full tank), Non-Rebreather Oxygen mask (delivers high concentrations of oxygen, using one-way valves to prevent rebreathing exhaled air), and an Automated External Defibrillator (AED - a lightweight, portable device that delivers an electric shock through the chest to the heart when it detects an abnormal rhythm and changes the rhythm back to normal) (if Applicable).During an interview on [DATE] at 11:51 PM Staff BB, LPN, stated the facility had an AED, but the facility had not used it as it needed to be hung up in a central location. During an interview on [DATE] at 12:45 PM Staff V, LPN, stated they thought the AED was located on the Medicare unit. On [DATE] an AED was observed in a box, in the Director of Nursing's office. During staff interviews on [DATE] staff were asked where resident's code status were located: at 12:15, Staff N, LPN, stated in PCC (resident's electronic medical record) and one of the binders at the nurses station; at 12:45 PM, Staff V, LPN, stated in the physician orders and POLST were located in the binders at the nurse station and were also scanned into the electronic record; at 1:00 PM, Staff Y, LPN, stated on a list at the nurses station on the 500-unit, in the electronic Medication Administration Record, and the original POLST in the binder; at 1:10 PM, Staff Z, NAC, stated in the care plan and/or ask the nurse.During an interview on [DATE] at 1:14 PM, Staff W, Medical Records, stated the facility no longer entered residents' code status into the physician orders. In the computer program under Code Status is written, For Advanced Directives and Code Status and/or POLST, see Disaster Recovery binder at nurses station. The process was changed on or around [DATE].During a review of the resident list and POLST binders at each nurse station on [DATE] at 1:21 PM showed:-Resident 11 was readmitted to the facility on [DATE] and was in room [ROOM NUMBER] A but no POLST was in the binder.-Resident 8 was admitted on [DATE] and was in room [ROOM NUMBER]A, but the POLST in the binder was for Resident 9.-Resident 9 moved to room [ROOM NUMBER] on [DATE]. Review of the binder on the 300-unit showed no POLST form for Resident 9.-Resident 12 census showed they were in room [ROOM NUMBER]B but moved to room [ROOM NUMBER]B on [DATE]. Resident 12's POLST was not found in the POLST binder under 107B but was located under room [ROOM NUMBER]B and was not moved when the resident moved.-The resident residing in 214A's POLST was under room [ROOM NUMBER]B and the resident residing in 214B's POLST was under room [ROOM NUMBER]A.-Resident 10's POLST was in the binder, but they were not listed on the census. Record review showed Resident 10 was discharged on [DATE].An observation of the 500-unit nurse station on [DATE] at 1:21 PM showed a list dated [DATE] was posted that contained 32 residents under the care of a Named healthcare group and the resident's current code status. Review of the posted list, in comparison with the POLSTs in the binders, showed Resident 78's POLST, dated [DATE], showed the resident opted for comfort-focused treatment and Do Not Attempt Resuscitation (DNAR). According to the posted list Resident 78 was DNR/DNI (Do Not Intubate, use of selective treatment) rather than DNR/Comfort.A review of resident code status and POLSTs on [DATE] showed 70 residents (Residents 3, 4, 5, 6, 7, 8, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76 & 77) had current POLSTs to receive CPR according to the facility policy. These 70 residents all resided in the facility on [DATE].REFERENCE: WAC 388-97-1060(1).

Based on observation, interview, and record review, the facility failed to ensure 2 of 5 staff (Staff N & O) reviewed had the appropriate knowledge, competencies, and skill sets to provide nursing and related services, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air), to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments, individual plans of care, and facility policy. Failure of the nursing staff to demonstrate a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics needed to successfully perform work roles or occupational functions resulted in deficiencies related to the competency of nursing staff and placed residents at risk for unmet care needs including not receiving CPR if/when needed, a diminished quality of life, and adverse outcomes including death.Findings included .<Facility Policy>The facility Cardiopulmonary Resuscitation (CPR) Policy, updated [DATE] showed Licensed nurses (LN) employed by the center have current CPR certification. CPR certification is reviewed routinely by the center to validate current certification is maintained for LN personnel. STAFF NDuring an interview on [DATE] at 12:15 PM, when asked what equipment they wound use in the event of respiratory arrest, Staff N, Licensed Practical Nurse (LPN), did not know. When asked what equipment was needed to perform CPR, Staff N replied, hands and was unable to name other equipment that may be needed. Review of Staff N's CPR certification showed it expired [DATE]. STAFF ODuring an interview on [DATE] at 12:35 PM Staff O, Registered Nurse (RN), stated they had received CPR training and had a current certification. Review of Staff O's CPR certification showed it expired [DATE].In an interview on [DATE] at 12:42 PM, Staff M, AP-Payroll, stated they were told the nurses had to have CPR and it was recommended for Nursing Assistants to have CPR, but not mandatory. Staff M stated they were trying to get another CPR class scheduled. Refer to F678 - Cardiopulmonary Resuscitation.REFERENCE: WAC 388-97-1080(1)

Based on interview and record review, the facility failed to ensure 1 of 8 out of state licensed nurses (Staff C) reviewed had a multistate license authorizing practice in the state the facility was located. This failure placed residents at risk of receiving care from an unlicensed and unqualified individual.Findings included . On [DATE] Resident 1 experienced a change in condition, and coded. CPR (Cardiopulmonary Resuscitation) was started, 911 notified, medics continued CPR and pronounced Resident 1 deceased . The assigned nurse, Staff C, Registered Nurse (RN),was suspended pending investigation. On [DATE] at 6:55 PM, Staff A, Administrator documented the facility investigation substantiated that Staff C did not meet the standard of care when responding to a reported change in condition. Staff C was terminated and license reported. Record review showed Staff C, was hired [DATE], and had a California State RN license with an expiration date of [DATE]. Review of the license verification report showed Staff C was only authorized to practice in California. During an interview on [DATE] at 12:42 PM, Staff M, AP-Payroll, stated Staff C, had an out of state license and was one of the facility's first compact nurse license (a compact nursing license/multi-state license, allows a nurse to practice in participating states without having to get a separate license in each state). Staff M stated they verify licensure online. Staff M stated (prior to termination) Staff C worked at the facility full time. Staff M was unable to explain how Staff C worked at the facility without authorization to practice in the state. Refer to F678 - Cardiopulmonary Resuscitation.Reference WAC 388-08-1660(1)(a)

Based on observation, interview and record review, the facility failed to provide ensure care and services were provided in a manner that maintained and promoted dignity and respect for 8 of 9 current residents (Residents 3, 4, 5, 6, 7, 10, 12 and 13) interviewed. Failure of the facility to respond to resident's requests in a timely, respectful and professional manner, placed residents at risk for diminished self-worth, frustration, and a decreased quality of life. Findings included . <Resident 3>During an interview on 07/16/2025 at 10:98 AM, Resident 3 shared an interaction with Staff D, Nursing Assistant Certified (NAC) that occurred during care. Resident 3 stated that Staff D was incredibly negative, talking under their breath the entire time and when the resident said sorry to inconvenience you, Staff D said, would you like another aide? , Resident 3 said that would be lovely, and right in the place Staff D stood and screamed down the hall for another aide and left Resident 3 entirely exposed and stomped out of the room.On 07/16/2025 at 11:33 AM, Staff D was observed in the doorway of a resident's room, to yell down the hall to another staff that they needed to change a resident by name, and that they would be there in a minute, before they turned and closed the resident's room door. <Resident 4>During an interview on 07/16/2025 at 11:08 AM, Resident 4 stated that Staff D was always disrespectful. Resident 4 shared a photo of Staff D dated 06/27/2025 at 1:23 PM, with Staff D wearing a T-Shirt with an image of the Rugrat [NAME], who according to Resident 4 was the Mean and bossy one. The caption on the shift was You Stupid Babies. Resident 4 stated, I found it offensive, like she considered us babies. Resident 4 stated it was demeaning to be in a nursing home anyways with a loss of freedom, but to have someone come into your room like that is a nail in the [NAME]. Resident 4 felt Staff D was belittling and came across like they were more important that the residents.During an interview on 07/16/2025 at 11:08 AM, Resident 4 said when they asked the nurses what pills they were giving them, the nurses respond that they don't know and say just take them. <Resident 6>Similar findings were noted with Resident 6 who during an interview on 07/16/2025 at 11:35 AM, stated when they nurses bring their medication, They don't tell you what you're taking. <Resident 5>During an interview on 07/16/2025 at 10:30 AM, Resident 5 stated that the call light response time had been up to two hours, it frequently took a while to get someone to their room in the back of the hall, It's frustrating.<Resident 7>During an interview on 07/16/2025 at 11:42 AM, Resident 7 stated their wait time was 30 minutes to an hour.During an interview on 07/16/2025 at 11:42 AM, Resident 7 stated they had orders for as needed pain medications, but when they asked for them, the nurses just shrug their shoulders and go on, They don't want to be bothered. <Resident 10>During an interview on 07/18/2025 at 9:01 AM, Resident 10 stated that when staff answer the call light some say, You'll have to wait. sometimes they had to wait 45 minutes, Like I'm another nobody in this place. <Resident 12>During an interview on 07/18/2025 at 12:41 PM, Resident 12 stated it sometimes took a half hour or longer for staff to respond to their call light and then they don't give you what you asked for. When asked how that made them feel, Resident 12 said, I don't know. if I can get my own stuff I will. <Resident 13>During an interview on 07/18/2025 at 1:02 PM, Resident 13 stated the staff don't respond to the call lights half the time so they must use the phone and call the front desk. Resident 13 stated when the staff did not answer the call light they felt disappointed and sad. On 07/24/2025 at 2:46 PM, the above was discussed and acknowledged by Staff A, Administrator and Staff B, Director of Nursing Services. REFERENCE: WAC 388-97-0180(1-4).

Based on interview and record review, the facility failed to convey the refunds of 2 of 3 residents (Resident 8 & 14) to the resident or to the individual or jurisdiction administering the resident's estate, or the Office of Financial Recovery within thirty days of the discharge, transfer or death. This failure placed resident family and/or representatives at risk for financial hardship.Findings included . Review of the facility admission Agreement last updated [DATE], showed the center would issue any refunds to the Resident Group or, in the even of the Resident's death, to the Resident's estate, or applicable state agency within the time required by law. <Resident 8>Resident 8 discharged from the facility on [DATE]. On [DATE] at 8:40 AM Collateral Contact 1 stated the facility overbilled Resident 8 and were withholding payment, stating the funds were already spent, but were unable to articulate if the funds were spent on the resident while they were a resident in the facility. During an interview on [DATE] at 12:26 PM, Staff C, Business Office Manager, stated Resident 8 had a refund due of $489.72. Staff C stated they sent the refund to the Office of Financial Recovery (OFR) on [DATE] (four months after discharge). OFR sent it back [DATE] as they only accept funds for deceased residents. Staff C stated they then resubmitted the check payable to Resident 8 on [DATE]. The facility changed billing accounting services in the end of January, beginning of February 2025. In February, Resident 8's representative stated they had not yet received the check, so it was reissued [DATE] and sent to a different address. Staff C stated on [DATE] they were notified of concerns that the resident did not receive the refund. Staff C stated they contacted the billing office that day, and found out on [DATE] that the check was not cashed. Staff C stated they needed to resubmit a request to have the check reissued. Staff C planned to have it sent to the facility and have Resident 8's representative pick it up there. During an interview on [DATE] at 4:02 PM, Resident 8's representative stated the facility fist told them the funds had been dispersed. Then they had been told the check was mailed, sent to the wrong addressed, cancelled and resent. Resident 8's representative stated they finally got the check as Staff C left it at the facility front desk and they picked it up Thursday ([DATE]). <Resident 14>Resident 14 was a long term care resident who passed away in the facility on [DATE]. During an interview on [DATE] at 10:55 AM, Staff C stated Resident 14 had a trust fund balance of $530.58. Staff C stated they were waiting to hear from the resident representative if they wanted the funds for funeral services and they said no. During an interview on [DATE] at 3:20 PM, Staff C stated Resident 14's account was closed, the refund check printed and they would send the check to OFR. On [DATE] at 2:46 PM, the above was discussed and acknowledged by Staff A, Administrator.REFERENCE: WAC 388-97-0340(5).

Based on interview and record review, the facility failed to identify and investigate allegations of abuse/neglect for 4 of 7 sampled residents (Residents 85, 32, 38 and 68) when reviewed for abuse/neglect. These failures placed the residents at risk of continued abuse/neglect, diminished quality of life and unmet needs. Review of a facility policy titled, Abuse Neglect and Misappropriation of Resident Property Prohibition, dated March 2025, showed each resident had the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, misappropriation of resident property, exploitation, and any physical or chemical restraint not required to treat the resident's medical condition. The Center implements policies and processes so that residents were not subject to abuse by staff, other residents, volunteers, consultants, facility members, and others who may have unsupervised access to residents. These policies addressed screening, training, prevention, identification, investigation, protection and reporting/response. <Pain Medication> Resident 85 Review of the electronic health record (EHR) showed Resident 85 admitted to the facility on [DATE] with diagnoses to include peritoneal abscess (a localized collection of pus within the peritoneal cavity, the space between the abdominal organs and the abdominal wall), malignant neoplasm of ovary (a cancerous tumor that develops in the ovaries, [female reproductive glands where eggs are produced]), muscle weakness, anxiety and depression. Resident 85 was able to communicate needs. During an interview on 05/19/2025 at 1:12 PM, when asked whether Resident 85 had any pain or discomfort that was not addressed timely while at the facility. Resident 85 stated, yes, they had experienced pain and their request for their as needed (PRN) pain medication was either delayed or was not administered at all whenever Staff G, Licensed Practical Nurse, (LPN) was assigned to them. Resident 85 stated they had requested a couple days ago, during a day shift, they had told several Certified Nursing Assistants (CNAs), they needed their pain medication. The CNAs told them they had informed Staff G on multiple occasions, but they (Resident 85) did not get their pain medication until 2.5 hours later or had to wait until the night nurse came in that evening. Resident 85 stated they had told a male licensed nurse supervisor, Staff F, Licensed Practical Nurse/Care Coordinator (LPN/CC), who stated the residents lack of pain control issue would be addressed. Review of Resident 85's provider's orders for pain medication, dated 04/16/2025, showed the provider had ordered multiple pain medications to include both scheduled and as necessary pain (PRN) medication to include oxycodone (a narcotic pain medication used to treat moderate to severe pain) 5 milligrams (mgs) every four hours PRN for severe pain and Tylenol 500 mg extra strength every eight hours PRN for pain. Review of Resident 85's medication administration record (MAR) for May 2025 showed Resident 85 had regularly received PRN pain medication whenever they had requested them throughout the month of May 2025; however, during the day shifts on 05/16/2025 to 05/18/2025, when Staff G was assigned to them, their pain medication was administered only once on 05/18/2025 at 6:23 PM. During an interview 05/21/2025 at 11:26 AM, Staff F, LPN/CC, stated they did not remember Resident 85 telling them or commenting they did not receive their PRN pain medication timely or not at all, but would now report it to the Director of Nursing Services (DNS). During an interview on 05/21/2025 at 2:04 PM, Staff B, Director of Nursing Services (DNS) stated it was their expectation if a resident was not getting their PRN pain medication or if they were getting them late and the CNAs and licensed nurses (LNs) knew about it then it should have been reported and an investigation taken place. 38344 <Resident to Resident> Resident 32 Review of the EHR showed Resident 32 admitted to the facility on [DATE] with diagnoses to include bipolar disorder (disorder associated with mood swings ranging from depressive low to manic highs), heart failure, and borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships). Resident 32 was able to communicate needs. During an interview on 05/19/2025 at 10:34 AM, Collateral Contact E, Visitor, stated Resident 32 had not been participating in activities ever since another resident touched a tattoo on Resident 32's arm, less than two weeks ago. Collateral Contact E, stated after the resident-to-resident altercation Resident 32 appeared upset and left the activity room and had not been to an activity since. During an interview on 05/19/2025 at 1:57 PM, Resident 32 stated a situation happened the other day during activities when another resident touched the tattoo on their arm, and it bothered them. Resident 32 stated they had told the resident not to touch them and then told the activity person about it. During a follow up interview on 05/21/2025 at 9:27 AM Resident 32 stated they had reported the resident-to-resident altercation incident, that happened in activities, to Staff D, Activity Director (AD). Resident 32 stated they told Staff D to tell that resident that touched them not to touch them again and to keep that resident away from them. Review of the facility's grievance log from April 2025 through 05/19/2025 showed no grievance logged for Resident 32. Review of the facility's incident reporting log from April 2025 through 05/16/2025 showed no resident-to-resident altercation logged for Resident 32. Review of Resident 32's EHR did not show documentation of a resident-to-resident altercation. During an interview on 05/21/2025 at 9:51 AM, Staff D, AD, stated Resident 32 had told them that Resident 90 had touched their tattoo and they (Resident 32) did not like being touched and wanted Resident 90 to be told not to touch them. Staff D stated they talked to Resident 90 and told them not to touch Resident 32; however, they did not document the interaction and should have. Staff D stated they thought the resident-to-resident altercation happened around 05/13/2025 or so and did not report the incident to the abuse hotline. During an interview on 05/21/2025 at 12:56 PM Staff B, DNS, stated Staff D, AD, should have reported details of Resident 32's feelings of being upset regarding being touched by Resident 90, and of wanting Staff D to talk to Resident 90, to inform Resident 90 not to touch Resident 32. Staff B stated an incident report investigation should have been initiated for Resident 32's resident-to-resident alteration. Staff B stated this issue should have been reported prior to now and this did not meet expectations. 46067 <Administrator> Resident 38 Review of the EHR showed Resident 38 admitted to the facility on [DATE] with diagnoses that included adjustment disorder with mixed disturbances (strong emotional or behavioral reaction to stress or trauma) and anxiety (emotion with worried thoughts). Resident 38 was able to make needs known. Review of a complaint intake, dated 04/28/2025, showed Resident 38 reported to an anonymous individual they were afraid of the administrator who was very rude. The report stated Resident 38 was afraid to come out of their room until after the administrator left as they were fearful of their well-being. Resident 38 stated they were afraid the administrator was going to kick them out of the facility. During an interview on 05/19/2025 at 1:30 PM, Resident 38 stated they felt Staff A, Administrator, retaliated against them for filing a grievance most recently related to a reported allegation of neglect of a former roommate. Resident 38 stated Staff A stated, You do not like the staff, you do not like the food, you do not need this level of care, why are you here? Resident 38 stated everyone is afraid of Staff A and described her as rude and stated, I just stay in my room when she's around to avoid her. Resident 68 Review of EHR showed Resident 68 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, a condition that prevents airflow to the lungs causing breathing issues), depression, generalized muscle weakness and was able to make needs known. During an interview on 05/21/2025 at 12:46 PM, Resident 68 stated, Staff A is not intimidating or abusive she's just rude, I avoid her as much as possible their energy just brings people down. During an interview on 05/23/2025 at 10:52 AM, Staff B, DNS, stated multiple residents brought up concerns about Staff A, but they did not rise to the level of abuse or neglect. Staff B stated one resident stated, I do not want her around me, I do not want her in my care conference, I just don't like her. Staff B stated another resident was told by Staff A, in a passive aggressive tone after an incident You don't seem to be happy here let's find you alternate placement. Staff B stated no allegation was identified by the facility; however, concerns about Staff A were reported to the regional management team. During an interview on 05/23/2025 at 11:45 AM, Staff A, stated a resident isolating in their room due to a resident or staff member could be a form of psychological harm and should be identified as an allegation of abuse. Staff A stated allegations of abuse should be logged, reported, investigated and the resident should be assessed for safety and put on alert for psychological harm. WAC Reference: 388-97-0640 (5)(a)

Based on interviews and record review, the facility failed to provid the supervision of two staff for bed mobility assistance per the plan of care for 1 of 5 sampled residents (Resident 1) reviewed for falls with injury. Resident 1 experienced harm when they received bed mobility assistance from one staff member, fell out of the bed and broke their arm. Findings included . Review of the electronic health records showed Resident 1 admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidney disease) and diabetes and was receiving dialysis (when waste in the blood is filtered through a machine). The resident was able to make needs known. Review of the care plan showed an intervention dated 11/20/2024 that Resident 1 required two-person extensive assistance for repositioning and turning in bed. Review of the progress notes showed that on 04/12/2025 at around 8:00 PM the resident fell out of bed while being changed and complained of right shoulder pain and inability to move their right arm. Resident 1 was sent to the emergency department and treated for a fractured right humerus bone (broken arm). Review of the facility incident investigation, dated 04/12/2025, showed Staff C, Certified Nursing Assistant (CNA), stated Resident 1 had slid from the bed while they were providing care and fell on their side to the floor. The facility had determined Staff C performed bed mobility with one staff instead of two staff per the care plan. During an interview on 04/29/2025 at 3:40 PM, Staff D, CNA, stated staff should review the Kardex (care plan delivery instructions) to see how many staff were required for bed mobility/positioning. Staff D stated if a resident required two people for a task they must follow it. During an interview on 04/29/2025 at 3:46 PM, Staff B, Director of Nursing Services, stated it was their expectation that staff followed the plan of care and Staff C should not have provided bed mobility/positioning alone. During an interview on 04/29/2025 at 4:00 PM, Staff A, Administrator, stated it was their expectation Resident 1 received two-person care during bed mobility/positioning according to their plan of care/Kardex. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review the facility failed to ensure residents received care and services to maintain acceptable parameters of nutritional status and there was a safe and accurate system to prevent complications from enteral (feedings administered through a tube) feedings for 12 of 12 residents (Residents 8, 19, 20, 22, 33, 21, 18, 26, 24, 14, 31 & 40) reviewed for nutrition and hydration. The failure to: accurately assess (and re-assess as needed) residents nutritional status and develop/revise/implement person-centered care plans (CP) for residents at risk; reconcile, accurately transcribe, and implement nutrition related physician orders and/or Registered Dietician (RD) recommendations; ensure timely RD evaluations; ensure residents were weighed according to policy/physician orders and monitored routinely; and ensure residents who required downgraded texture diets received the diet they were ordered and speech evaluations (Residents 14 & 24); and ensure residents who required fluid restrictions were monitored/documented accurately (Resident 31). These failures placed residents at risk for weight loss, electrolyte imbalances, dehydration, aspiration, pneumonia, and hospitalization and constituted an Immediate Jeopardy (IJ). Resident 20 experienced harm when they required urgent transfer to the hospital on 02/10/2025 and was admitted with a diagnoses with aspiration pneumonia, sepsis, severe dehydration, severe malnutrition, and acute kidney injury after the facility failed to: accurately assess and develop/revise a CP to ensure aspiration precautions were followed to help prevent aspiration pneumonia; monitor, document, and evaluate their nutritional status and intake to insure they received the nutrition/fluids they required to meet their daily needs to prevent avoidable dehydration and severe malnutrition; ensure licensed staff routinely provided physician ordered oral care to help prevent infection in the event of aspiration. Resident 22 experienced harm when they required repeated transfers to the emergency room and hospitalized for dehydration and uncontrolled blood sugars after the facility failed to: accurately assess their feeding tube status and develop CP interventions to prevent dehydration and fluid volume loss; were not provided the nutrition they were ordered to receive, and delayed implementation of physician orders for interventions to correct their electrolyte imbalance. Resident 40 experienced harm when they had an unplanned significant weight loss of 20 pounds in two weeks. The facility failed to develop and implement a person-centered nutrition CP that addressed their identified risks and care needs, consistently monitor weights, or evaluate oral intake for a resident identified at risk for altered nutrition. An Immediate Jeopardy (IJ) was called on 02/26/2025 at 2:45 PM in CFR 483.25(g)(1)-(3) when the facility failed to have a safe and accurate system in place for residents receiving nutrition enterally to maintain acceptable parameters of nutritional and hydration status. This failure caused harm to three residents and placed residents at risk for severe weight loss, significant dehydration, aspiration, and death. The immediacy was removed on 02/27/2025 after onsite verification by the investigator reviewed the facility's nutrition related documentation, nutrition assessments, staff education, facility audits, and accurate implementation of provider orders. Findings included . <POLICY> Review of the facility's Enteral Nutrition policy, revised November 2018, showed staff would provide adequate nutritional support via tube feeding as ordered by the physician. The nurse would confirm the tube feeding orders were complete including: the correct formula, the specific enteral access device (gastric tube or jejunostomy tube, etc.), the administration method (continuous, bolus, or intermittent), the volume/rate/time of administration, the volume/rate goals with advancement recommendations, and flushing (solution, volume, frequently, timing, and 24-hour volume). The provider would consider need for lab orders, head of bed elevation, oral care, and checks for gastric residual volume. Risk of aspiration (which was affected by was affected by moderate to severe swallowing difficulties, improper positioning of the resident during feeding, and failure to confirm placement prior to initiating feeding) would be assessed by the nurse and provider and addressed in the residents' care plan. The nursing staff and the provider would monitor the resident for signs or symptoms of inadequate nutrition, altered hydration, high or low blood sugars, altered electrolytes (such as sodium and potassium levels in the blood), and for worsening conditions that placed the resident at risk for nutrition/hydration complications. <RESIDENT 20> Review of the 02/16/2025 Quarterly MDS showed Resident 20 admitted to the facility on [DATE], had severe problems with cognition, and diagnoses included pneumonia, dysphagia, chronic obstructive pulmonary disease (restrictive airway), presence of a feeding tube, and was at risk for malnutrition. Resident 20's weight measured 127 pounds and was not assessed to have significant weight changes. Review of Resident 20's speech evaluation, dated 11/20/2024, showed Resident 20 had severe dysphagia and history of aspiration pneumonia. Resident 20 had asthma and a very weak cough that was not effective to clear aspirated materials when they were cued to cough. They were determined to require nothing passed orally (NPO) status with long-term assisted nutrition (tube feeding) as their new established baseline. The speech pathologist documented they were not able to treat further and placed a sign in their room regarding STRICT NPO status and recommended frequent oral care. Review of Resident 20's Nutrition Hydration risk CP, revised 01/08/2025, showed the CP interventions were not person-centered and did not include timeframes and parameters for monitoring to achieve desired nutritional goals including how often they should be weighed. Review of Resident 20's Feeding Tube CP, initiated 01/08/2025, directed staff to ensure their HOB was elevated at least 30-45 degrees during tube feeding and for 30 minutes after, NPO, and provide good oral care (with no frequency directives or how it was supposed to be provided). The task was assigned to both the NACs and Nurses. Review of Resident 20's February 2025 MAR/TARs showed: -A physician order dated 01/28/2025 for tube feeding formula at 70 ml/hr for 20 hours (total volume 1400 ml/day), on at 2:00 PM and off at 10:00 AM. Based on the order, the facility should have provided 560 ml on the Day shift and 840 ml on the night shift. The documentation showed 24-hour total volumes administered were: 02/01/2025 (560ml), 02/02/2025 (560 ml), 02/03/2025 (560 ml), 02/04/2025 (1120 ml), 1680 ml each day 02/05/2025, 02/06/2025, 02/07/2025, 02/08/2025, and 02/09/2025. -A physician order dated 01/09/2025 for tube feeding water hydration water flush of 49ml/hour x 20 hours while the tube feeding formula was running (to total 273-410ml/shift). The documentation was set up for three eight-hour shifts per day unlike the formula documentation that was set up for two 12-hour shifts per day. The total volume in the text of the order did not show accurate shift total volume goals. Based on the order, Resident 20 should have been provided: 196 ml of water on the day shift, 392 ml on the evening shift, and 392 ml on the night shift for a total 24-hour volume of 980 ml/day. The documentation showed the 24-hour total water volumes administered were: 450ml (530ml less than they required) on 02/01/2025, 02/02/2025, 02/3/2025, 02/4/2025, 02/05/2025, and 02/08/2025; 300 ml (680ml less than required) on 02/06/2025, 542ml (438ml less than required) on 02/07//2025, and 934 ml (46ml less than required) on 02/09/2025. -A physician order dated 12/11/2024 directed staff to provide oral care with prescribed oral solution and an oral swab and HOB greater than 60 degrees and suction PRN (as needed). The documentation showed that oral care was never provided. CHANGE OF CONDITION: Review of a Medication Administration Note, dated 02/09/2025 at 2:41 PM, showed to keep HOB at least 30 degrees while tube feeding is running. When it is not elevated properly, resident starts a gurgling sound in their throat. Have stressed importance to staff and resident to keep HOB elevated at all times. Review of a Medication Administration Note, dated 02/10/2025 at 4:52 AM, showed they administered Tylenol for a temperature of 99.6 and Resident 20 had shallow respirations. Review of Resident 20's Kardex, dated 02/10/2025, showed under Alerts/Safety: staff to provide local care to feeding tube site as ordered and monitor for signs or symptoms of infection task for licensed nurses only, not CNAs. The Kardex did not show any directions to staff they were STRICT NPO, had HOB requirements for elevation of 30-45 degrees during tube feeding (or at-all-times), who was responsible for oral care and when, complications/symptoms to monitor for and when to notify the nurse, foley catheter care, or documentation of urine output. Review of an eINTERACT Situation/Background/Assessment/Recommendation (SBAR) Summary for Providers change of condition note, dated 02/10/2025 at 6:07 AM, showed Resident 20 experienced a change of condition related to fever. The documentation showed their vital signs (timed for 7:13 AM) were a very low blood pressure (79/56), Heart rate was very high (138), respirations were very high (28), oxygen saturation was very low at 82% with oxygen on a nasal cannula, and temperature was elevated at 99.8 degrees. The physical assessment showed they had labored and rapid breathing with abnormal lung sounds and a resting pulse greater than 100 beats per minute. The Nursing observations, evaluation, and recommendations showed Resident 20 was transferred out to the hospital after they developed fever, shallow breathing and hyperventilation (breathing too fast). The writer contacted the on-call provider who gave an order for oxygen at two liters per minute, a breathing treatment, and to monitor vital signs every 30 minutes until stable then change to every two hours. They administered Tylenol but it was not effective. The documentation did not indicate what time the actual change was identified, what time the provider was contacted, the exact time of the interventions implemented (and resident response), and what time they were transferred out of the facility. Review of a hospital inpatient progress note, dated 02/11/2025, showed Resident 20 was admitted with septic shock (severe infection) and acute hypoxic respiratory failure due to aspiration pneumonia, hypernatremia (dehydration), acute kidney injury, and severe malnutrition. READMISSION: Review of the Kardex, dated 02/25/2025, showed it had not been updated after readmission. Review of the February 2025 MAR/TARs showed: -A physician order dated 02/13/2025 for tube feeding formula at 70 ml/hour x 20 hours (total volume 1400 ml/day). The documentation for 24-hour shift totals showed: 840 ml on 02/14/2025 and 560ml each day from 02/15/2025 to 02/20/2025. -A physician order dated 02/13/2025 for FWF (free water flush) at 41 ml/hour x 20 hours to provide total volume of 820 ml. The documentation did not show shift volumes administered or total 24-hour volumes. In an observation on 03/03/2025 at 3:55 PM, Resident 20 was in bed, the tube feeding was disconnected as ordered. No suction machine was observed at the bedside. Their HOB was at 15 degrees. There was one oral swab in the top drawer of the nightstand. Resident 20 was not interviewable due to their cognition although they appeared awake and alert. Resident 20 opened their mouth for an observation, their lips and oral cavity appeared dry and unclean. <RESIDENT 22> Review of Resident 22's Quarterly MDS, dated [DATE] showed they had severe problems with cognition, dependent on staff for all ADL cares, and diagnoses included a stroke with hemiplegia (unable to move a side of the body), diabetes, high blood pressure, heart failure, and was not at risk for malnutrition. Resident 22 weighed 149 pounds and did not receive tube feeding. Review of Resident 22's Nutrition Hydration Status risk CP, initiated 01/09/2025 showed Resident 22 had a feeding tube, was NPO, and history of ER visits due to clogged feeding tube. The 01/09/2025 CP interventions included: Aspiration precautions, directions to follow orders for diet and labs, and observe for signs or symptoms of dehydration (i.e., dry mouth, cracked lips, dry skin, and decreased urine output). The CP did not include person-centered goals/interventions for maintaining a patent feeding tube or parameters for monitoring of nutritional status. Review of the Tube Feeding CP, revised 01/09/2025, showed Resident 22's HOB requirement was to be at least 30-45 degrees during tube feeding and for 30 minutes after the tube feeding, provide/maintain good oral hygiene (but did not specify how often and who performed it) and nursing was to record Resident 22's formula intake and water flushes on the MAR/TARs. The CP did not include person-centered interventions to meet all their identified care needs. Review of a nurse progress note, dated 01/17/2025 at 1:48 PM, showed Resident 22 was sent to the emergency room because their feeding tube was clogged, and they were unable to remove the blockage. The resident required ambulance transport to the hospital to have their feeding tube replaced. PHYSICIAN ORDERS: Review of Resident 22's January 2025 MAR/TAR showed: -A physician order dated 01/09/2025, for Diabetisource 1.2 at 78 ml/hour for 20 hours, on at 4:00 PM and off at 12:00 PM (total volume 1560 ml). The order set for documentation showed administration times for 12:00 AM and 12:00 PM. Between 01/10/2025 at 12:00 AM and 01/28/2025 at 12:00 AM, there was no documentation the tube feeding was administered, the boxes were blank for 18 days. -A physician's order, dated 01/09/2025 for feeding tube water flushes 28 ml/hour for 20 hours from 4:00 PM to 12:00 PM (total volume 280 ml per shift) but the total volume shift goal in the text of the order was transcribed incorrectly, did not equal what 28ml/hour for 20 hours would provide (560 ml), and the documentation showed they were administered 280 ml each shift (3 shifts). -A physician's order dated 09/29/2023 for weekly weights and the TAR documentation showed no weights were measured for 01/06/2025, 01/13/2025 and 01/20/2025. Resident 22's weight on 01/27/2025 measured 149 pounds. CHANGE OF CONDITION & DELAYED CARE: Review of Resident 22's blood sugar record from 02/01/2025 to 02/13/2025 showed they began having very high blood sugars. Review of providers progress note, dated 02/12/2025, showed Resident 22's blood pressure at 3:51 PM was 116/67 and heart rate was elevated (102). The documentation showed they reviewed Resident 22's abnormal labs including a very high sodium level (dehydration is the most common cause for high sodium levels) and very high blood sugars. On 02/12/2025 at 6:00 AM the physician ordered one liter of intravenous fluids and then repeat the labs. This was the first ordered intervention to correct the critical sodium level, 30 hours after the Lab Company notified the facility of the critical lab value on 02/10/2025 at 11:37 PM. Review of a nurse progress note, dated 02/12/2025 at 11:45 AM, showed the facility did not have the fluids the provider ordered (a special type of solution used to correct this high sodium level) and the pharmacy would not be able to deliver any for four hours. Review of a nurse progress note, dated 02/12/2025 at 3:40 PM, showed they started intravenous administration of the ordered fluids at 3:30 PM, (39 hours after they were notified of the critical lab value). Review of the nurse progress note, dated 02/13/2025 at 3:47 AM, showed the Lab Company called the facility and reported the repeat sodium level was higher than the sodium result sodium result on 02/10/2025. The nurse called the on-call provider who ordered Resident 22 be transferred to the hospital. READMISSION: Review of the Hospital Post Acute & Transition of Care Orders, dated 02/17/2025, showed n tube feeding orders for Diabetisource AC at 65 ml/hour x 24 hours and water flushes of 150ml every four hours. Resident 22 was diagnosed with a high sodium level, high blood sugar and fluid volume deficet (needed 5.7 liters). Review of the Resident 22's February 2025 MAR of the orders transcribed on readmission showed: -The tube feeding order, dated 02/17/2025, was Diabetisource 1.2 at 78 ml/hour x 20 hours on at 4pm and off at 12:00 PM (total volume 1560ml/day), the same tube feeding order they had before they went to the hospital for dehydration and uncontrolled blood sugars, and no volume totals documented. -The Water flush order, dated 02/17/2025, for 50ml/hour x 20 hours from 4:00 pm to 12:00 PM (total of 1000 ml/day), and no total volumes documented. -The order for the lab to monitor the potassium was not transcribed to the admission orders and was not drawn two to three days after admission. During an observation on 02/24/2025 at 12:00 PM, Resident 22 was awake in bed, their tube feeding was running, and the HOB did not appear to be at least 30 degrees or more. Resident 22's lips were dry, very chapped, with large pieces of dry, dead skin hanging off their lips. Their teeth appeared to have a film of debris covering them. -At 12:02 PM, Staff CC, LPN, entered the room with a small medicine cup of clear liquid and did not appear to notice the HOB was not at 30 degrees. At 12:03 PM, Staff CC was asked what the HOB elevation requirements were for Resident 22. Staff CC stated the HOB was to be at 30-45 degrees during tube feeding and at least 30 minutes after the tube feeding was stopped, which they were there to do. Staff CC was asked if the HOB was at 30 degrees, and they stated yes. Staff CC was asked how they knew it was 30 degrees; they looked at the bed for a few seconds, stated just a minute, then left the room without stopping the tube feeding. -At 12:05 PM, a CNA entered the room with a meal tray for Resident 22's roommate, realized the roommate was not in the room, and then left the room (with the meal tray) but did not recognize Resident 22's HOB was not elevated to 30 degrees while the tube feeding was running. -At 12:08 PM, Staff N, CNA, entered the room with personal care items for Resident 22. Staff N was asked about the HOB requirements for Resident 22 and replied, 30 to 45 degrees at all times. Staff N was asked if they thought Resident 22's HOB was at least 30 degrees, and Staff N stated, definitely not. Staff N stated they last cared for Resident 22 about 10:30 AM and they always double check the HOB level before they left the room. Staff N stated when they needed to provide cares for Resident 22, they notified the nurse so they could put the tube feeding on hold to perform cares safely, and either the nurse was their care partner, and if not, they notified the nurse when their tasks were completed. -At 12:10 PM, Staff CC returned to the room with an angle gauge. When Staff CC applied the angle gauge to the bed, they found the angle gauge that was already on the bed, hidden under the mattress cover. Staff CC confirmed the HOB was not at 30 degrees and stopped the tube feeing. Staff N stated they didn't know about the gauge on the bed but thought it was a good idea. -Observation at 12:10 PM of the angle gauge on Resident 22's bed showed the angle of the HOB was at 20 degrees. Staff CC was unsure how long it had been less than 30 degrees. -At 12:12 PM, Staff CC began providing Resident 22 oral care and stated the nurses provided the oral care every shift. Staff CC stated they were also there to check Resident 22's blood sugar which was ordered for before meals and at bedtime and then they would disconnect his tube feeding and clear the pump. Staff CC stated the total volumes on the pump showed the previous nurses did not clear the pump on their shift. In an interview on 02/25/2025 at 3:30PM, Staff H, LPN-RCM, stated they were not aware the tube feeding orders were changed at the hospital. In an interview on 02/26/2025 at 10:47 AM, Staff O stated they were not aware of the hospital provider ordered Diabetisource AC but if they had, they would have recommended to proceed with that product due to its carbohydrate nutritional properties which show better blood sugar control. <RESIDENT 40> Review of Resident 40's hospital After Visit Summary dated 12/16/2024 showed their weight measured 133 pounds. Review of the 12/22/2024 Admission MDS showed Resident 40 admitted to the facility on [DATE], had severe cognition problems, required assistance with ADLs, and diagnoses included a respiratory infection, diabetes, dementia, hypokalemia (low amount of potassium in the blood). Resident 40 was not at risk for malnutrition and weighed 135 pounds. Resident 40 had no natural teeth. Review of Resident 40's nutrition CP, initiated 12/16/2024, showed they were at risk for nutritional/fluid deficits due to preferences not to eat or drink. The interventions provided were not person-centered and did not address the risk factors identified in the comprehensive assessment. The CP directed staff to monitor/document/report to MD PRN for signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. The CP did not indicate how often Resident 40 should be weighed, monitor intake and record every meal. RD to evaluate and make diet change recommendations as needed. Review of Resident 40's Kardex, dated 12/18/2024, showed CNAs were informed they were able to eat with supervision but did not provide instructions regarding their diet order, dental status, or when to report to the nurse if they did not consume a certain percent of their meal/fluids for each meal. A physician's order, dated 12/18/2024, directed staff to weight Resident 40 on 12/16/2024, 12/17/2024, 12/18/2024 then weekly for three weeks. Review of the weight record showed their weight measured 135 pounds on 12/17/2024, 12/18/2024, and 12/20/2024. Review of the Nutrition Evaluation, dated 12/26/2024, showed Resident 40's weight was stable and their estimated calorie needs were 1230-1500 kcal per day and 1800 ml of fluid/day. The RD recommended to provide one diabetic meal replacement supplement for additional calories and protein and continue weekly weights. The CP was not updated. Review of Resident 40's weight record showed no weight measurement for 12/27/2024. On 01/03/2025, their weight measured 115 pounds, a 14.8% weight loss in two weeks. Review of Resident 40's progress notes, between 01/02/2025 and 01/10/2025, showed no documented nurse progress notes or skilled charting documentation. There was no documentation to show the facility identified Resident 40's significant weight loss on 01/03/2025, or that the physician and responsible party were notified of the weight loss. The progress notes did not indicate Resident 40 was on alert charting status, did not provide consistent monitoring of their intake, or evaluation for increased need of assistance for eating. In a physician's note, dated 01/10/2025 (untimed), showed Resident 40 had increased confusion and was difficult to arouse. Their physical exam showed Resident 40 had fluid volume deficit. Review of a physician's order, dated 01/10/2025 at 12:28 PM, showed instructions to start intravenous (IV) fluids for rehydration at 75 ml/hour for three days (no number of liters were given) to start at 5:00 PM. The order was confirmed by a nurse at 12:30 PM. Review of the January 2025 MAR showed the 01/10/2025 physician order for IV fluids due at 5:00 PM. The documentation showed 9-other/see nurse notes. Review of the nurse progress showed no nurse progress notes for 1/10/2025 after 2:44 AM when a late entry daily skilled note was entered. The nurse progress notes did not provide documentation to show Resident 40 was ordered IV fluids, why the fluids were not initiated, or Resident 40's change of condition status. Review of a physician's order, dated 01/11/2025 at 12:04 PM, showed to place a peripheral IV for hydration (19 hours after the IV was ordered to start) and a second order to administer IV rehydration at 75 ml/hour for three days. Review of the Peripheral IV Insertion Record, dated 01/11/2025 at 12:30 PM, showed a traveling IV Nurse started an IV access in the left arm. Review of the January 2025 MAR/TAR showed the 01/11/2025 order for IV rehydration. The documentation did not show the volume of fluids administered for each shift to indicate how much fluid Resident 40 received. Review of Resident 40's fluid intake documentation between 01/09/2025 and 01/15/2025 only showed their fluid intake from meals. On 01/10/2025 their fluid intake from all meals was 920 ml and on 01/11/2025 it was 500 ml. Review of Resident 40's Weight Summary Report dated 01/10/2025 showed they had a greater than 10% weight loss in less than 180 days. Review of the Nutrition Hydration Skin Committee Review evaluation dated 01/14/2025 showed Resident 40's weight measured 119 pounds. The documentation showed they only had a 5% unplanned significant weight loss, consumed 25-50% of their meals, and had abnormal labs that showed fluid volume deficit and required IV hydration to correct. They planned to increase Resident 40's diabetic meal replacement supplement to two times a day. The documentation did not show the IDT evaluated Resident 40 to identify why they lost the weight. The CP was not updated. In an interview on 03/19/2025 at 12:45 PM, Resident 40's Responsible Party, RP, stated they not notified of Resident 40's weight loss in the beginning of January but could tell they had lost a lot of weight. RP did not know it was 20 pounds. RP stated on 01/10/2025, the physician said they would start IV fluids because Resident 40 was dehydrated. RP stated [they] came back the next day around lunch time and Resident 40's IV fluids were still sitting at the bedside, and they did not have an IV-line in. They found out the IV had not been started because no one could start IVs. RP stated the facility finally called in a nurse to start the IV on 01/11/2025. RP stated Resident 40 was missing their bottom denture since admission. <RESIDENT 8> Review of the 12/31/2024 Admission Minimum Data Set (MDS), an assessment tool, showed Resident 8 admitted to the facility on [DATE], had mild cognition problems, required assistance with activities of daily living, and diagnoses included a stroke, dysphagia (impaired swallowing), diabetes, and a newly placed feeding tube. Resident 8 was not at risk for malnutrition, weighed 202 pounds, received more than half of their total calorie needs for the week from tube feeding but only received a total of 500 ml's or less for average daily fluid intake for the week. Review of Resident 8's Nutrition Hydration Status CP, dated 12/25/2024, showed they were on aspiration precautions, directed staff to monitor for signs or symptoms of dehydration, and was referred to the RD for evaluation of their nutritional status. The 12/25/2024 intervention for diet order stated, per MD order and was not personalized to show they were NPO (nothing by mouth). The CP did not provide personalized interventions and timeframes/parameters for monitoring. The Comprehensive CP, initiated 12/25/2024, did not show a focus problem for feeding tube status, maintenance, and care. The CP did not show interventions for HOB elevation requirements to prevent aspiration or oral care frequency, who was responsible for oral care, and how it was to be performed. Review of Resident 8's Kardex (care plan directives to the direct care staff- Certified Nursing Assistants -CNAs), dated 12/25/2024, 12/26/2024, and 12/31/2024, showed the same interventions that included bathing preferences, floating heels while in bed, and leisure activities. The Kardex did not show that Resident 8 was NPO status, their tube feeding schedule, HOB elevation requirements, aspiration precautions, oral care responsibilities, or complications/signs/symptoms to monitor for and report. Review of Resident 8's Kardex, dated 01/06/2026 (12 days after admission), showed tasks for feeding tube site care and water flushing per physician orders (duties for licensed staff only). The Kardex did not show interventions for HOB elevation requirements, aspiration precautions, tube feeding complications to monitor for, oral care interventions, or urinary catheter care. In an interview on 02/24/2025 at 12:15 PM, Staff M, CNA, stated they knew the residents who were NPO or who had other special care needs through communication during shift report and by reviewing the Kardex in their POC (Point-of-care electronic documentation system). Staff M stated they were expected to review the Kardex daily to identify changes in the resident's CP that were specific to their job duties. Staff M confirmed that if the Kardex did not have the necessary information to meet the resident's basic care need it was difficult to care for the residents and made some cares more time consuming. In an interview on 03/03/2025 at 12:15 PM, Staff C, Registered Nurse-RN/Resident Care Manager-RCM, stated it was the responsibility of the admitting nurse to initiate the baseline care plan and the Kardex for the direct care staff to meet their basic care needs after admission. It was their expectation it was done by the end of the shift they arrived on or at least by the end of the day. Staff C stated the Interdisciplinary Team (IDT) reviewed new admissions during their clinical meeting and the RCMs were responsible to complete the CPs and other tasks that were incomplete or needed correction. PHYSICIAN ORDERS: Review of Resident 8's Hospital Provider Orders-Nursing Home Transfer, dated 12/25/2024, showed Resident 8's diet was NPO and the tube feeding orders showed Glucerna 1.2 (supplemental nutrition) at 25 milliliters (ml)/hr (hour) now and advance by 15 ml every six hours until goal rate of 85ml/hour, x 16 hours per day and additional water flush of 30 ml every four hours, and monitor intake/output. Resident 8's weight measured 225 pounds. Review of the December 2024 Medication and Treatment Administration Records (MAR/TAR) showed: -A physician's order dated 12/25/2024, Glucerna 1.2 @ 70 ml/hr x 16 hours/day and increase the rate to 85ml/hour in six hours. The tube feeding order was not complete with all required components according to their facility policy. The order was never discontinued and a new order transcribed to show they increased the rate to 85ml/hour six hours after admission on 02/25/2024. The MAR/TARs did not provide documentation to show the total volume of formula administered each shift or the 24-hour totals. The documentation showed the rate of administration was at 70ml/hour (15ml/hour less than ordered) from 12/26/2025 until the order was discontinued on 01/06/2025. -A physician's order dated 12/25/2024, for water flushes: 15-30 ml of water before and after medication administrations. The TARs did not show total volume of water provided each shift for all medications administered. -The MAR/TARs did not show the physician's order, dated 12/25/2024, for water hydration flushes of 30ml every four hours (total 180ml/day) was transcribed or implemented by staff. In an interview on 02/24/2025 at 4:00 PM, Staff G, Licensed Practical Nurse-LPN/ RCM, stated the MAR/TAR did not include the 12/25/2024 order for water hydration and could not state if it was implemented. Staff G stated the MAR/TAR did not show they increased the formula rate to 85ml/hour as ordered on 12/25/2024. Staff G stated the orders were unclear and should have been clarified on admission or during the nurse-to-nurse report with the hospi [TRUNCATED]

Based on interview and record review the facility failed to ensure residents entire drug/medication regimen was managed and monitored to promote or maintain their highest practicable mental, physical, and psychosocial well-being for 3 of 4 Residents (Residents 1, 2, & 38) who received psychotropic medications. Resident 1 experienced harm when the facility continued to administer antipsychotic medication without an approved clinical indication, evaluation of appropriateness, consideration for approved alternative treatments, monitoring, or evidence of non-pharmacological approaches that resulted in psychosocial and physical harm when they were transferred to the hospital due to altered mental status from the adverse effects of antipsychotic medication and was found to have an acute hip fracture the facility failed to identify after a fall. Resident 2 experienced physical and psychosocial harm when they were administered two drugs together that were known to cause potentially severe adverse consequences, developed acute respiratory failure, and required urgent transfer to the hospital. The failure to ensure residents: received psychotropic medications only when necessary to treat specific diagnosed and documented conditions, had relevant non-pharmacological interventions, was provided informed consent that included potential for serious adverse consequences, were adequately monitored for efficacy and adverse effects/consequences, and prevent/identify/respond to adverse consequences that occurred placed all residents at risk adverse events, hospitalization, decline in mental/physical/psychosocial functioning and well-being, prolonged rehabilitation stays, and diminished quality of life. Findings included POLICY Review of the facility's Informed Consent for Psychotropic Drugs policy, revised September 2017, showed the facility would review with the resident or responsible party: the drug/dose/frequency, expected benefits, potential risks, and obtain written consent with signature and date. Review of the facility's Antipsychotic Medication Use policy, revised July 2022, showed residents who were admitted to the facility already taking antipsychotic medications would be evaluated for the appropriateness and indication for use. The Interdisciplinary Team (IDT) would re-evaluate the use at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether the medication could be reduced, tapered, or discontinued. Based on assessment of the residents' symptoms and overall situation, the physician would determine whether to continue, adjust, or stop the medications. <RESIDENT 1> Review of Resident 1's Level I Pre-admission Screening and Resident Review (PASRR), dated 12/27/2024, showed Resident 1 had no serious mental illness indicators or diagnosis of dementia but did have delirium (temporary mental confusion or disorientation that can cause significant changes in a person's behavior and thinking). Review of the 01/05/2025 admission Minimum Data Set (MDS-assessment tool) showed Resident 1 admitted to the facility on [DATE] and was assessed to have moderate cognition problems. Resident 1 diagnoses included a heart rhythm problem and Parkinsons disease (a progressive neurological disease that can cause hallucinations for some people). Resident 1 experienced hallucinations, delusions, and behaviors not directed towards others; and received antipsychotic and antidepressant medications. Review of Resident 1's admission physician orders dated 12/30/2024 showed orders for Doxepin (antidepressant) 10 milligram (mg) every bedtime for depression and Seroquel (antipsychotic) 25 mg every morning and 50 mg every bedtime for hallucinations. Review of the clinical record did not provide documentation to show the facility obtained informed consent prior to the administration of the antidepressant or the antipsychotic. Review of the Antipsychotic Medication Care Plan (CP) dated 12/31/2024 showed Resident 1 was on antipsychotic medication for hallucinations and refusals of care. The interventions were not personalized with relevant behavioral triggers, target behaviors, or person-centered non-pharmacological interventions. The CP showed an update, dated 01/16/2025 (five days after Resident 1 was transferred to the hospital), directing staff to ensure they were safe and return later if they refused care. Review of the At Risk for Side Effects related to Antipsychotics CP, dated 01/08/2025, directed staff to monitor for adverse side effects and report to the physician promptly if observed. Review of the December 2024 and January 2025 Medication Administration Record (MARs) did not provide documentation to show the facility consistently monitored Resident 1 for adverse effects or consequences of either the antidepressants or antipsychotics. Review of Resident 1's clinical record did not show an AIMS (Abnormal Involuntary Movement Scale-a standardized tool used to assess the severity of movement disorders associated with the effects of long-term antipsychotic medication use) was conducted on admission. Review of the facility's Fall Risk management report, dated 12/31/2024, showed Resident 1 had a fall and landed on their buttock trying to get up out of the wheelchair at the nurse station. Review of a physician History & Physical note, dated 12/31/2024, showed Resident 1 was confused, hallucinating, and uncomfortable due to back pain. Review of the facility's Fall Risk management report, dated 01/02/2025, showed Resident 1 had a second fall while staff attempted to stop them from getting up out of the wheelchair unassisted. The staff reported they were scratched by the resident and unable to stop the fall. Review of the physician progress note, dated 01/03/2025, showed Resident 1 displayed expressions or indicators of distress. They were very confused, agitated, attempting to self-ambulate while seated in the wheelchair at the nurse's station, and had discomfort due to back pain. Review of the physician progress note, dated 01/07/2025, showed Resident 1 was very confused, agitated, and hallucinating. Review of the facility's Fall Risk management report, dated 01/08/2025 at 2:15 PM, showed Resident 1 had a third fall and landed on their buttocks while at the nurse station. Review of the clinical record did not provide documentation to show the facility evaluated Resident 1 for the use of the antipsychotic medication after admission or investigated other potential medical causes for delirium and/or behaviors reported to the physician. Review of the Inpatient Hospitalist History & Physical Note, dated 01/11/2025, showed Resident 1 was admitted to the hospital for excessive sedation and mental status changes due to psychotropic medications. They held their antipsychotic, antidepressant, and Parkinsons medications on admission to the hospital. On 01/13/2025, after Resident 1 was more alert, the hospital physical therapist attempted to transfer Resident 1 and [they] were not able to stand, sat back down, had facial grimacing, and guarded their right hip. An x-ray showed Resident 1 had an acute hip fracture which required surgical intervention. In an interview on 02/05/2025 at 10:30 AM, Resident 1's Responsible Party, R1-RP, stated Resident 1 was not on the antipsychotic medication at home, it was started with the antidepressant in the hospital. R1-RP stated Resident 1 had always been careful about substances they consumed; they were vegetarian and preferred more naturalistic care. Resident 1 was sensitive to medications. R1-RP stated Resident 1 would report their frustrations with their Parkinsons disease, chronic pains, and loss of independence. R1-RP stated they were never explained the risks of taking the antidepressant or the antipsychotic medication and were never provided a consent to sign. In an interview on 02/13/2025 at 1:15 PM, Staff C stated they were unable to locate a signed psychotropic consent for Resident 1s use of the antidepressant and antipsychotic. Staff C stated the Resident 1 should have had a behavior CP with personalized target behaviors and non-medication interventions that also showed on the [NAME] to staff but did not. Staff C stated Resident 1's behavior should have been monitored and documented on the MAR each occasion and there should have been monitoring for adverse effects on the MAR but was not. Staff C was not sure if Seroquel was approved for the use of Parkinson's with hallucinations. <RESIDENT 2> Review of the 12/08/2024 admission Minimum Data Set (an assessment tool) showed Resident 2 had no problems with cognition, required assistance with Activities of Daily Living (ADLs), and diagnoses included surgical aftercare following heart surgery, heart failure, diabetes, and anxiety disorder. They were on a scheduled pain medication regime, received PRN (as needed) opioid medications, and antianxiety medications. Review of Resident 2's comprehensive CP did not show a focus problem for anxiety or use of antianxiety medication. Review of the oxygen therapy CP, initiated 01/16/2025, showed Resident 2 required oxygen therapy due to heart failure, respiratory illness, and anxiety. The CP was entered into the clinical record 34 days after Resident 2 was transferred to the hospital in respiratory failure on 12/13/2024. Review of Resident 2's Hospital records showed no previous diagnosis of anxiety or that the resident received anti-anxiety medications prior to admission. Their last heart failure exacerbation (worsening of a chronic condition) was on 11/12/2024 (two days prior to their admission to the hospital for heart surgery). Review of the physician History & Physical, dated 12/03/2024, showed Resident 2 had an extensive history of heart problems and had a coronary artery triple-bypass grafting (CABG x3- at type of open-heart surgery that reroutes blood flow around blocked or narrowed arteries in the heart to improve blood supply to heart muscle and prevent a heart attack) two weeks prior to admission. The documentation showed nursing reported Resident 2 started having shortness of breath, severe chest pain 10/10 at their heart surgical site, anxiousness, dizziness, and pain in their left leg and thigh surgical sites. The physician diagnosis was a possible panic attack/anxiety. The documentation showed they would order Ativan (an antianxiety medication from the benzodiazepine drug class known to cause CNS [Central Nervous System] depression including decreased respiration rate, blood pressure, and level of consciousness) 0.5mg every 12 hours PRN (as needed) for anxiety. Review of the December 2024 MAR showed a physician's order, dated 12/03/2024 at 10:10 AM, for Ativan 0.5mg two times a day (routinely) related to anxiety disorder. The documentation showed the first dose was administered on 12/03/2024 at 8:31 PM (10 hours after it was ordered for their panic attack). Review of the nursing note, dated 12/03/2024 at 10:13 AM, showed the physician order transcribed for Ativan to be given twice daily triggered drug protocol/warnings for moderately severe Drug-to-Drug interactions with oxycodone (a class II-controlled opioid pain medication also known to cause CNS depression). The specified interaction showed that administering Ativan and oxycodone together could cause additive CNS depression (a reaction that occurs when two or more substances that depress the CNS are used together, resulting in potentially dangerous and life-threatening effects including respiratory failure, heart failure, and death.) The note did not show the physician was notified of the Drug-Drug interaction warning or that they discussed the warnings with Resident 2 prior to administering the medications. Review of Resident 2's Psychotropic Drugs Disclosure and Consent, signed 12/03/2024, showed the informed consent for Ativan did not provide the ordered dose, frequency, or associated diagnosis/indication for use. The document did not show the facility discussed the potential risk of Drug-to-Drug interactions including additive CNS depression when taking Ativan with oxycodone. Review of the December 2024 MAR showed a physician order, dated 12/04/2024, for behavior monitoring with associated triggers that were not person-centered or relevant to Resident 2's condition. The documentation showed Resident 2 never experienced behaviors or anxiety triggers. The MAR did not show the facility monitored Resident 2 routinely for adverse effects of Ativan or for severe Drug-To-Drug interactions. The MAR showed Resident 2 was administered Ativan and oxycodone together (or within 30 minutes of each other) on: 12/03/2024 at 7:56 PM (oxycodone) and 8:31 PM (Ativan), 12/06/2024 at 10:19 PM (Ativan) and 10:21 PM (oxycodone), and 12/12/2024 at 10:19 PM (oxycodone) and 10:22 PM (Ativan). Review of the physician progress note, dated 12/13/2024, showed Resident 2 developed respiratory distress at 11:30 AM, had altered level of consciousness, low oxygen saturation (below 88% with the use of high flow oxygen and mask) and elevated respirations (28). They were transferred urgently to the hospital. Review of the hospital physician History & Physical, dated 12/13/2024, showed Resident 2 was admitted for altered mental status, acute respiratory failure, heart failure exacerbation, pulmonary hypertension (high blood pressure of the arteries in the lungs), and pleural effusion (water on the lungs). In an interview on 02/19/2025 at 3:25 PM, Resident 2 stated they had never been diagnosed with an anxiety disorder, their anxiousness was the result of their inability to breathe almost constantly, but especially when lying flat. While they were at the facility their shortness of breath waxed and waned but was always worse at night. Staff would lay the head of their bed down flat, and they would immediately have the feeling of being strangled and suffocating. Resident 2 stated the staff would not raise their head of bed immediately, instead would tell them Calm down, take slow deep breaths in through the nose and out through the mouth while Resident 2 stated they became more and more anxious because they could not breathe. Staff 2 stated the CNAs did not know how to take care of someone who had heart surgery including following sternal precautions. Resident 2 stated the day after their admission, the physician saw them during one of their shortness of breath episodes and ordered them a pill for anxiety, which they agreed to try but was told it would be an as needed pill. Resident 2 was not aware they were administered Ativan every morning and evening between 12/03/2024 and 12/13/2024 and stated as each day went by, they were more and more lethargic, felt foggy and confused, and eventually was unable to speak for themselves. Resident 2 began to cry unconsolably and was unable to speak more than 3-4 words without gasping for air, so the interview was stopped. After Resident 2 was able to catch their breath (at six minutes), they stated they were never told they were getting the anxiety pill every day, they were told they would need to ask for it if they needed it. Resident 2 stated some staff would bring their pills but never say what all of them were even when asked. Resident 2 stated the staff would try to bring them oxycodone, but they told the staff they didn't want to take it because their hospital physician told them to only take it if they absolutely needed it. Resident 2 became tearful again and stated the nurses would bring in their medicine cup and say it was their Tylenol (acetaminophen-mild pain reliever) but never recalled a time they said they were giving them the anxiety pill, because they would have refused it. Resident 2 stated no wonder I felt so drugged. What were they trying to do to me? Resident 2 stated they did not remember anything about the two days prior to their transfer to the hospital. In an interview on 02/13/2025 at 1:00 PM, Staff D, Physician, stated they ordered the Ativan as PRN, but their condition improved so they scheduled the Ativan routine. Staff D stated they did not recall a notification of a pharmaceutical warning for Drug-Drug interaction, but their risk assessment and plan would be documented in their progress note. Staff D stated they expected the licensed nurses to monitor for adverse effects and notify them if observed. Staff D stated it was their expectation that the nurses read their progress notes, assessment, and plan, and ensured they followed the recommendations documented in their note. Staff D stated they did not investigate other potential medical causes for Resident 2's shortness of breath and continued complaints of severe chest pain, like obtaining labs or x-rays for instance. <RESIDENT 38> Review of the 01/29/2025 admission MDS showed Resident 38 admitted to the facility on [DATE]. They had severe cognition problems, required maximum assistant with ADLs, and was incontinent. Resident 38 had no behaviors and diagnoses included surgical repair of a hip fracture, dementia, difficulty swallowing, and knee pain. Resident 38 received antipsychotic and antidepressant medications. Review of the comprehensive CP showed no focus problems or interventions for behaviors, depression, psychosis, or use of psychotropic medications. Review of Resident 38's hospital After Visit Summary physician orders, dated 01/23/2025, showed instructions to stop giving Seroquel, the antipsychotic medication. Review of Resident 38's Psychotropic Medication Consent showed the same consent form used for both Seroquel and Trazodone medications. The consent was signed by their Responsible Party on 01/23/2025 and did not show the dose, frequency, and indication for use of each of the two medications. Review of the clinical record did not show an AIMS was completed upon admission. Review of Resident 38's January and February 2025 MAR/TARs showed physician orders dated 01/23/2025 to administer Seroquel 12.5 mg every morning and 25mg every evening at bedtime for unspecified dementia without behavioral disturbance, psychosis, mood disorder, or anxiety and administer Trazodone 25mg every night at bedtime for insomnia. The MAR showed Resident 38 received the Seroquel every morning and evening and the Trazodone every evening. The MARs did not show an approved diagnosis for the use of the antipsychotic, identified triggers and behavior monitoring, or monitoring for adverse effects of the medication. The MAR did not provide documentation to show the facility monitored Resident 38's hours of sleep, target behaviors for insomnia, or monitored for adverse side effects of the antidepressant medication. In an interview on 03/19/2025 at 12:15 PM, Staff C, RN-RCM, stated the facility should have clarified the admission orders or hold the Seroquel until the orders were clarified. In an interview on 03/19/2025 at 3:45 pm, Staff K, Social Services Director, stated antipsychotic medications required appropriate indications for use, and dementia without behaviors was not an acceptable diagnosis for the use of the Seroquel. Staff K stated Resident 38's diagnosis for the Seroquel should have been reviewed and clarified prior to administration. There should have been person-centered CPs with associated target behaviors and behavior monitoring, behavior interventions, and monitoring for adverse effects for antipsychotic and antidepressant medications but did not. REFER TO F610, F658, F684, F689, F697, and F758. Reference WAC: 388-97-1060 (3)(k)(i). .

Based on interview and record review the facility failed to ensure residents were assessed and person-centered pain care plans (CPs) were developed/implemented and revised to meet their pain management needs for 3 of 5 sample residents (Residents 1, 2, & 13) reviewed for pain. Resident 2 experienced harm when the facility failed to accurately clarify and transcribe admission orders for pain medications, ensure scheduled pain medications were administered timely, evaluate for the underlying cause of sudden onset of severe chest pain after open heart surgery, monitor for adverse effects of opioid use, was transferred to the hospital in acute respiratory failure, and found to have broken chest wires (internal fixation hardware in place to hold the chest together after open heart surgery) that required surgical intervention to repair. Resident 1 experienced harm when their complaints of pain went unaddressed, their behavioral signs of pain were not evaluated, were not monitored for post-fall injuries, was transferred to the hospital, and found to have a new hip fracture that required surgical intervention. These failures placed all residents at risk for adverse events, uncontrolled pain, diminished quality of care/quality of life. Findings included . <POLICY> Review of the facility's Pain Assessment and Management policy, revised October 2022, showed the pain assessment was used to help staff identify pain in the resident and to develop interventions that were consistent with the resident's goals, care needs, and addressed the underlying causes of the pain. --The facility would anticipate their need for pain interventions based on their clinical conditions know to be risk factors for pain. --To recognize pain the staff would monitor each shift (and more frequently if needed) for pain by observing the resident (during rest and movement) for physiological signs of pain (including increased blood pressure, heart rate, and respirations, or somnolence) and behavioral (non-verbal) signs of pain (including: behaviors such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in physical functioning/activities, appetite changes, and insomnia.) They would ask the resident about their pain and use standardized pain scale tools based on their cognitive status. --The facility would gather information from the resident or representative regarding pain history, characteristics, and non-medication interventions. --When opioids were use for pain management, residents were monitored for effectiveness, adverse effects, and opioid overdose. --Due to the risk of fatal respiratory depression, opioids and benzodiazepines (antianxiety medications) were not administered together unless a clinical indication for the resident was documented, and they were carefully monitored. --Acute pain or significant worsening of chronic pain should be assessed every 30-60 minutes after onset and reassessed until relief was obtained. <RESIDENT 2> Review of the 12/08/2024 Admission Minimum Data Set (MDS-assessment tool) showed Resident 2 admitted on [DATE], had no problems with cognition, required assistance with Activities of Daily Living (ADLs), and diagnoses included surgical aftercare following heart surgery, heart failure, diabetes. Resident 2 had shortness of breath with activity, at rest, and when lying flat. Resident 2 had surgical incisions, and they were on a scheduled pain medication regime, received PRN (as needed) medication, opioid medications, and antianxiety medications. Review of the Pain CP, dated 12/02/2024, showed non person-centered interventions to: anticipate need for pain relief and respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions; review for alleviating of symptoms, dosing schedules, resident satisfaction with results, impact on functional ability, and impact on cognition; Monitor/ document for probable cause of each pain episode and remove/limit causes where possible, monitor/record/report to nurse any non-verbal symptoms of pain: changes in breathing, vocalizations. Notify physician if interventions are unsuccessful or if current complaint is a significant change. Review of the Kardex, dated 12/13/2024, showed no directives to the Certified Nursing Assistants (CNAs) regarding sternal precautions, head of bed elevation due to shortness of breath, pain factors, or symptoms to report if observed regarding pain after heart surgery. Review of Resident 2's hospital Interfacility Discharge Orders and Medication Administration Record (MARs) dated 12/02/2024 showed orders for oxycodone (an opioid narcotic) 5mg tablets, take 0.5-1 tablet (2.5mg-5mg) every six hours as needed for severe pain, lidocaine 4% patch applied topically cut in half and placed on the skin on both sides of the chest surgical incision at bedtime and removed after 12 hours of use, and acetaminophen 1,000mg every six hours for pain. The orders also showed to observe Sternal Precautions. Review of Resident 2's facility Admission physician orders dated 12/02/2024 showed an order for oxycodone 2.5mg every six hours as needed for pain 1-5/10 (mild-moderate pain), an order for oxycodone 5mg every six hours as needed for pain 6-10/10 (moderate-severe), and lidocaine 4 % patch (apply to painful area, apply at bedtime and remove in the morning). The oxycodone and lidocaine patch orders were not accurately transcribed and/or clarified. The Sternal Precautions order was not transcribed to the admission orders. Review of the December 2024 MAR for 12/03/2024 showed Resident 2 was due for their routine acetaminophen at 12:00 AM and the medication was administered at 3:39 AM (three and a half hours late). Review of the nursing note dated 12/03/2024 at 9:39 AM showed Resident 2 was given oxycodone 5mg for pain rated 6/10. The note did not indicate the site of the pain or show non-medication interventions attempted and response. Review of the physician History & Physical, dated 12/03/2024 (untimed) showed Resident 2 had an extensive history of heart problems, congestive heart failure, and had an open-heart surgery two weeks prior to admission. The documentation showed nursing reported Resident 2 developed shortness of breath (SOB), anxiety, and severe chest pain 10/10 at their chest surgical site. They also had pain in their left leg and thigh surgical sites. The documentation did not show new orders were provided to investigate the underlying cause of their sudden onset of severe chest pain and shortness of breath. Resident 2 was ordered Ativan (a benzodiazepine antianxiety medication) for a panic attack. Review of December 2024 MAR for 12/03/2024 day shift documentation did not show non-pharmacological interventions were implemented, additional pain medication alternatives were ordered, the time and administration of Ativan for the panic attack. Review of the physician progress note, dated 12/04/2024, showed Resident 2 continued to have intermittent SOB and severe surgical site pain. Resident 2 also had pain and drainage from their left leg surgical site. Review of a physician progress note, dated 12/06/2024, showed nursing reported Resident 2 was complaining about chest pain, chest tightness, and shortness of breath. A new order was written for breathing treatments. Review of the December 2024 MAR for 12/06/2024 showed: -Their 12:00 AM scheduled acetaminophen was not administered until 3:15 AM (over three hours late). At 5:04 AM Resident 2's pain was 8/10 and was given oxycodone. -Their 6:00 PM scheduled acetaminophen was not administered until 7:26 PM (over one hour late). At 10:21 PM, Resident 2 was given oxycodone for moderate pain. Review of a nursing skilled evaluation note, dated 12/06/2024 at 9:58 PM, showed Resident 2 had shortness of breath and chest pain 5/10, sharp, and constant. Review of the December 2024 MAR for 12/11/2024 showed their 12:00 AM scheduled acetaminophen was due but was not administered until 1:10 AM at the same time as oxycodone for pain 5/10. Review of the nurse skilled evaluation, dated 12/11/2024 at 8:34 PM, showed Resident 2 had constant chest pain (not rated), sharp and aching. Relaxation techniques and position changes not effective. Resident 2 given oxycodone at 10:00 PM (two hours after they documented pain) for pain 5/10. Review of Resident 2's Medication Administration Report, MARs, and progress notes for December 2024 showed Resident 2 received their scheduled acetaminophen one hour late (or more) 14 doses of 44 total administered. The oxycodone was administered 13 times. Six of the 13 oxycodone doses were administered after late administrations of their scheduled acetaminophen. Additionally, the MARs did not provide documentation to show the facility monitored for adverse effects of opioid medications, or the use of both opioids and benzodiazepines together. Review of the clinical record did not provide documentation to show the facility evaluated for the underlying cause of Resident 2's acute onset of severe pain at their chest surgical site that started on 12/03/2025, carefully monitored their use of opioids, or identified the potential risks of administering both opioids and benzodiazepines together. Review of the nurse progress note dated 12/13/2025 at 12:17 PM showed Resident 2 was unable to stay awake and their oxygen saturation was low. They were instructed by the physician to call 9-1-1 and Resident 2 was transferred to the hospital. In an interview on 02/19/2025 at 2:30 PM, Resident 2 stated the night shift staff were uncaring and did not listen. Resident 2 stated the staff did not follow or know what sternal precautions were. Resident 2 stated on the first night, they had to use the restroom, so they put on the call light. The staff took so long to answer, they were incontinent in their bed. The staff told Resident 2 they were going to change their bedding. Resident 2 told the CNA they would need assistance to transfer to the wheelchair so they could make the bed, but the staff said No they were going to change the bedding with Resident 2 in the bed. Resident 2 told the staff they could not lay flat and needed to avoid rolling on their side due to their sternal precautions. The staff just started lowering the head of the bed which caused Resident 2 to begin having significant shortness of breath, and then the staff started rolling Resident 2. Before Resident 2 could get their heart pillow (special pillow used after open heart surgery to apply support to the chest when moved) to their chest, the staff began to roll [them] to their right side, they felt and heard a pop in their chest, and then extreme pain in addition to their already worsening shortness of breath. Resident 2 stated they told the staff about their sternal pain and clicking /popping noises from their chest the staff told them That is normal. Resident 2 stated they also had severe pain in their leg due to an infection in a surgery site they got at the facility and now required ongoing wound care every week. They rarely got their Tylenol on time which made it hard for them to get ahead of the pain. Resident 2 stated after they went to the hospital and saw their surgeon, they discovered Resident 2 had fractured sternal wires which made the plate became unstable. Resident 2 had to have another surgery to repair the wires and plate. In an interview on 02/13/2025 at 1:10 PM, Staff D, Physician, stated they did not order diagnostic tests or further investigate Resident 2's continued shortness of breath and chest pain. They ordered Ativan for their panic attack and Resident 2's breathing improved. <RESIDENT 1> Review of Resident 1's hospital History & Physical, dated 12/18/2024, showed Resident 1 had a new fracture of the lower spine with complications that caused pain due to pressure on their spinal cord and spinal stenosis (a condition of the spine that causes pain usually in the back and neck, numbness of the arms/legs/feet, weakness and cramping of the limbs, difficulty walking, loss of balance, and difficulty controlling bladder/bowel function). The documentation showed that Resident 1 had been unable to get out of bed due to uncontrollable lower back pain for the two weeks prior to hospitalization and surgical intervention was not an option. Review of the 01/05/2025 Admission Minimum Data Set (MDS-assessment tool) showed Resident 1 had moderate cognition problems, had no problems understanding others, and was usually able to make themselves understood. Resident 1's diagnosis included Parkinsons disease (progressive brain disease) and a fracture of the spine. Resident 1 required staff assistance for all activities of daily living (ADLs). Resident 1 had frequent pain that effected their sleep routine and day to day activities, their highest level of pain during the previous five days was 8/10 (0=no pain and 10=severe pain) but had no routine scheduled pain regime and had not received any non-medication interventions or PRN (as needed) pain medications. Review of Resident 1's Pain care plan (CP), dated 12/30/2024, showed non-personalized interventions that directed staff to anticipate need for pain relief and respond immediately to any complaint of pain, monitor/document probable cause of each pain episode and remove/limit causes where possible, notify the physician if interventions were unsuccessful or if there was a change in pain complaints, and observe and report changes in usual routine, sleep patterns, decrease in functional mobility, decrease in range of motion, and withdrawal or resistance to care. The CP did not show person-centered non-medication interventions to help with pain relief or any CP updates after it was initiated. Review of the Kardex (care instructions for direct care staff), dated 01/11/2025, directed the Certified Nursing Assistants (CNAs) to monitor Resident 1 for oral pain and report the nurse. The Kardex did not show Resident 1's pain problem related to their fracture of the spine or chronic neck, knee, and back pain. The Kardex showed no direction for the CNAs to monitor for expressions of distress or non-verbal signs of pain and offered no non-pharmacological pain relief interventions the CNAs could implement. Review of the facility's Fall Risk Management Report, dated 12/31/2024 at 3:30 PM, showed Resident 1 fell after trying to stand from the wheelchair without assistance. The report did not show a post-fall pain evaluation was conducted or consistent alert status monitoring for injuries. Review of Resident 1's physician History & Physical note, dated 12/31/2024, showed Resident 1 reported they were uncomfortable due to back pain. The documentation did not provide the characteristics of the pain. Review of the Occupational Therapy note, dated 12/31/2024 at 10:04 AM, showed Resident 1 reported they had constant pain to their neck and low back that limited their functional abilities. Sitting down, remaining still, change in body position all helped to relieve their pain. Their pain was worsened by prolonged activity. Their pain at rest and with movement was 5/10 and described the pain as aching. Review of the facility 's Fall Risk Management Report, dated 01/02/2025 at 4:12 PM, showed Resident 1 was attempting to stand without assistance and fell . The report did not show a post-fall pain evaluation was conducted or consistent post-fall alert monitoring for injuries. Review of the physician progress note, dated 01/03/2025, showed Resident 1 was confused, agitated, attempting to self-ambulate by getting up from the wheelchair, and uncomfortable due to back pain. Review of a Physical Medicine Rehabilitation Physiatry initial evaluation (a medical specialty that focuses on the diagnosis, prevention, and treatment of disabilities to restore function, reduce pain, and improve quality of life), dated 01/03/2025 at 3:38 PM, showed Resident 1 reported pain 7/10, their back was bothering them, their right knee was sore, and they had discomfort with urination. The providers plan showed they would provide orders for routinely scheduled acetaminophen (pain reliever) 1,000 mg (milligrams) twice daily and a topical pain relief cream twice daily. They ordered a urine analysis (UA) on 01/02/2025 to investigate the urination discomfort and if the UA was negative, they would administer a steroid injection in the right knee (due to arthritis-a painful joint disorder) if Resident 1 was agreeable and a candidate. Review of a physician order, dated 01/05/2025, showed routine orders for acetaminophen 1,000 milligrams twice daily and topical pain cream for back pain twice daily. The order was scheduled to administer the first dose on 01/06/2025 at 8:00 AM, (three days after they complained of pain 7/10). Review of the December 2024 and the January 2025 Medication Administration Records (MAR) showed between 12/30/2024 and 01/05/2025, Resident 1 was not provided any non-medication interventions or as needed medications for pain, including when Resident 1 reported: uncomfortable back pain to the physician on 12/31/2024 and 01/03/2025, constant pain and pain rated 5/10 to the occupational therapist on 12/31/2024, and pain 7/10 the physiatrist 01/03/2025. Review of the physician progress note, dated 01/07/2025, showed Resident 1 presented with expressions of distress including confusion, agitation, and hallucinations. Review of a nursing advanced skilled evaluation dated 01/08/2025 at 1:22 PM, (a late entry for unknown date and time) showed Resident 1 displayed expressions of distress that included disorganized thinking, anxiousness, agitation, and behaviors. Review of the facility's Fall Risk management report, dated 01/08/2025 at 2:15 PM, showed Resident 1 had a fall and landed on their buttocks after trying to get up out of the wheelchair. The report did not include a post-fall pain evaluation or evidence of consistent post-fall alert monitoring for injuries. Review of the medication administration note, dated 01/08/2025 at 4:05 PM, showed Resident 1 was provided ibuprofen (pain medication) 600 milligrams. The documentation did not show what non-medication interventions were attempted, their assessed pain level, or the site of their pain. In an interview on 02/05/2025 at 10:30 AM, Resident 1's Responsible Party, R1-RP, stated Resident 1 was seen by a pain specialist on 01/03/2025 who asked Resident 1 for permission to administer a steroid injection in their knee to help with the pain. The specialist said they would return the next week with the injection but never came back. R1-RP stated Resident 1's pain was not managed, and they did not feel most staff took the time to allow Resident 1 to communicate their pain needs. R1-RP stated Resident 1 would complain about not being able to lay down between mealtimes for pain relief and was always stuck in the wheelchair. R1-RP stated they never saw Resident 1 in their bed, and they visited daily. R1-RP stated Resident 1's medication for hallucinations and Parkinson's caused them to become progressively lethargic and barely able to talk at. R1-RP stated on 01/11/2025, after it got so bad, they called 9-1-1 themselves to have Resident 1 transferred to the hospital. R1-RP stated the hospital held the sedating medications, Resident 1 became more clear and able communicate. That was how they found Resident 1 had a hip fracture and had to have surgery. In an interview on 02/13/2025 at 2:30 PM, Staff C, Registered Nurse, Resident Care Manager, stated when residents complained of pain, the nurse should be notified as soon as possible so the resident could be assessed and pain interventions implemented. Residents were assessed for pain after falls during their initial evaluation by the nurse after the fall and a post fall pain evaluation. In an interview on 02/24/2025 at 1:00 PM, Staff II, Physiatrist, stated the orders for the scheduled medications should have been transcribed on 01/03/2025 but were not. Staff II stated they typically stopped by the nurse to notify them if a resident complained of pain but could not recall whether they had and was not able to find documentation of that in their notes. <RESIDENT 13> Review of the 02/24/2025 Admission MDS showed Resident 13 admitted [DATE], was non-English speaking and required an interpreter, had cognition problems, and required assistance with ADLs. Resident 13 diagnoses included a serious heart infection, pneumonia, diabetes. Resident 13 had constant pain rated 8/10 (as the worst pain they experienced in the previous five days) and was on a scheduled pain medication regime. Resident 13 had Pressure Ulcer/Pressure Injuries (PU/PI) on both of their heels on admission. Review of the pain CP, dated 02/18/2025, showed non-personalized directives for staff to monitor/record/report to the nurse complaints of pain or request for pain treatment and encourage the use of non-pharmacological pain relief interventions: repositioning, relaxation, bathing, heat or cold application. Review of the Kardex, dated 02/20/2025, did not show directives regarding Resident 13's pain, location, and non-pharmacological pain interventions. Review of the February 2025 MAR showed: -A physician order, dated 02/18/2025, for a strong routine pain medication. The documentation showed the medication was not administered on 02/18/2025 at 8:00 PM, 02/19/2025 at 8:00 AM and 8:00 PM, and on 02/20/2025 at 8:00 AM. -A physician order, dated 02/18/2025, for a routine medication for nerve pain that also was not administered on 02/18/2025 at 8:00 PM, 02/19/2025 at 8:00 AM and 2:00 PM. -A physician order, dated 02/19/2025, for non-personalized non-medication pain interventions. The documentation showed no interventions were implemented. -A physician order, dated 02/18/2025, for acetaminophen every six hours scheduled routinely. The documentation showed Resident 2 did not get the medication on 02/18/2025 at 6:00 PM, 02/19/2025 at 6:00 AM, 12:00 PM or 6:00 PM. The progress notes documentation showed medication on order. In an interview on 02/20/2025 at 9:15 AM, Staff FF, Licensed Practical Nurse (LPN), stated Resident 13 admitted on [DATE] and they had not received their strong routine pain medication from the pharmacy, and it was not available in their emergency medication kit. Staff FF stated they called the pharmacy, and the pharmacy stated they never received a hard copy prescription from the facility and would not be able to fill it until it was received. Staff FF stated they were sending the pharmacy a prescription. Staff FF stated Resident 13 should have received all their medications timely and if they had not arrived from the pharmacy, the nurse should contact the physician to notify them and obtain further orders to hold the medications or administer alternative medications. Staff FF stated acetaminophen was an over-the-counter medication and always on hand and should have been administered. In an observation and interview on 02/20/2025 at 9:20 AM, Resident 13 was lying in bed, appeared restless (moving their knees up and then down every couple of minutes), and showed facial grimacing. Resident 13 stated through verbal and non-verbal communication (in a non-English language understood by the surveyor) they had pain in both their heels, the left heel pain was 8/10 and the right heel pain was a 5/10. Resident 13 had no pillows on their bed to help keep their heels floated and the heels were directly on the bed. Review of the February 2025 MAR for 02/20/2025 at 9:50 AM, showed Staff FF had documented Resident 13 had no pain. In an interview on 02/20/2025 at 9:35 AM, Staff FF stated they had not asked Resident 13 if they had pain because they did not speak their language. Staff FF stated they were not sure what the facility policy was regarding translation services, but Resident 13 did not have translation information in their room. In an interview on 02/20/2025 at 11:20 AM, Staff C (who spoke the non-English language fluently) stated Resident 13 should have information for the staff to communicate basic needs like pain, hunger, and bathroom as well as information for the translation line but did not. Staff C stated Resident 13 should have received all their ordered medications timely but did not. Refer to F655, F684, F689, F758 Reference WAC: 388-97-1060 (1).

Based on observation, interview, and record review the facility failed to develop and implement a resident-centered fall prevention care plan (CP) to reduce their specific risk factors for falls, consistently provide adequate supervision, and ensure residents were consistently monitored for post-fall injuries for 3 of 6 Residents (Residents 1, 8, & 11) reviewed for falls. Resident 1 experienced harm when they fell out of their wheelchair at the nurse's station and sustained a hip fracture. These failures placed all residents at risk for avoidable future falls, adverse events, physical injuries, pain, functional decline, and diminished quality of care/quality of life. Findings included . <POLICY> Review of the facility's Managing Falls and Fall Risk policy, revised [DATE], showed the facility would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The facility, physician, and consultant pharmacist would identify and adjust medications known to increase the risk of falls or indicate rationale why the medications could not be adjusted, even for a trial period. Review of the facility's Assessing Falls and Their Causes policy, revised [DATE], showed the facility would timely notify the physician and family when a fall occurred. They would monitor for delayed complications and document their findings in the clinical record. The facility would initiate an incident report with details defining the fall including the preceding chain of events to identify potential causes for the fall. The physician would examine the resident after a fall. A Post-Fall Evaluation would be conducted. After the fall, the facility would document in the clinical record: the condition in which they were found, assessment data, medical interventions implemented, notifications of physician and family, completion of a fall risk assessment, appropriate interventions taken to prevent future falls, and their response to the interventions. Review of a The Fall Prevention Program (undated, one page document) showed the facility would place blue tags on the doors that said FALL PROGRAM, blue arm bands on the residents that say Resident on the fall program, non-skid socks were available for residents on the fall program, a blue information sheet above the patient's bed that would list their specific fall intervention codes (D=Dysum, T=Tipper bars, L=low bed, FW=Footwear, FM=Floor mat, and assistive device they needed), and a fall binder would be kept each nurse's station. The nurses would also enter orders for the specific fall interventions and add the tasks into the POC (Point-of-Care -electronic documentation system for the Certified Nursing Assistants, CNAs). Review of the facility's Alert Charting/Skilled Charting Guidelines, updated [DATE], showed when a resident fell , nurses were required to monitor and document their status by placing them on Alert Charting with vital signs every shift for 72 hours to monitor for: pain, injury, change in level of consciousness or mentation, problems with balance or functional abilities, and implement nursing interventions to prevent falls. If there was an injury with the fall, they would also do routine neurological checks (for head injury or unwitnessed fall) and skin evaluations. <RESIDENT 1> Review of the [DATE] Admission Minimum Data Set (MDS-an assessment tool) showed Resident 1 admitted to the facility on [DATE] and was assessed to have moderate cognition problems, hallucinations, and behaviors. Resident 1 diagnoses included atrial fibrillation (a cardiac-rhythm problem known to increase fall risk), a fracture of the spine, Parkinson's disease (a progressive neurological disorder that can cause hallucinations and increase fall risk), and hallucinations. Resident 1 required staff assistance for all activities of daily living (ADLs) and had occasional incontinence. Resident 1 had frequent pain that effected their sleep and day-to-day routine, their highest level of pain was ,d+[DATE] (per pain scale 0=no pain and 10=extreme pain), and no routine scheduled pain medication. Resident 1 had falls that resulted in fractures prior to admission, one non-injury fall since admission, and medications associated with high fall risk included antipsychotics and antidepressants. Review of Resident 1's Fall CP dated [DATE] showed non-personalized interventions dated [DATE] to: announce themselves when approaching resident, ensure nonskid footwear were on, ensure the call light was within reach and answered promptly, encourage call light use, explain all procedures and purpose prior to starting tasks, and monitor for side effects of any medications that could cause gait disturbances, sudden drop in blood pressure and pulse, weakness, dizziness, sedation, fatigue, seizures, fainting, or vertigo. Review of Resident 1's Kardex (quick reference CP interventions and alerts for CNAs) dated [DATE] showed none of the [DATE] Fall CP interventions were present on the Kardex for the CNAs to implement. FALL #1: Review of a nurse progress note dated [DATE] at 5:04 PM showed Resident 1 had a fall at the nurse's station after trying to stand up from their wheelchair without assistance. The documentation showed they would encourage Resident 1 to remain in highly supervised area when in their wheelchair. Review of the progress notes did not provide documentation to show Resident 1 was consistently monitored on alert charting every shift for 72 hours after the fall on [DATE]. Review of the facility's Fall (Witnessed) Risk Management Report dated [DATE] at 3:30 PM showed their investigation was not thorough or complete. The investigation did not include the preceding chain of events/circumstances regarding the fall and no root cause analysis to identify the unmet care need or reason Resident 1 tried to stand without assistance. The investigation did not provide documentation to show a fall risk assessment was conducted, the CP was updated to prevent future falls, or they monitored Resident 1's response to the interventions. Review of the Kardex dated [DATE], [DATE], and [DATE] did not show any fall interventions for CNAs to implement. FALL #2: Review of the facility 's Fall (Witnessed) Risk Management Report dated [DATE] at 4:12 PM showed Resident 1 was attempting to stand without assistance in their room, the CNA saw Resident 1 attempt to stand and tried to assist but Resident 1 scratched them and they were not able to stop them from falling. Their plan was to have Resident 1 seen by mental health services, place them on the Fall Prevention Program to increase supervision, alert charting for behaviors, monitoring for a change in condition or latent injuries, and update the CP. Review of the progress notes did not provide documentation to show a fall event occurred on [DATE] at 4:12 PM, notification to the physician and responsible party of a fall, new interventions implemented, or consistent post-fall alert charting every shift for 72 hours after the fall. Review of the physician progress note on [DATE] showed Resident 1 was confused, agitated, and made multiple attempts to walk independently despite redirection to sit back in the wheelchair. Resident 1 was seated in the wheelchair at the nurse's station during the encounter and was uncomfortable due to back pain. The documentation did not show they evaluated Resident 1 for a fall and there were no changes made to their plan. Review of a Physical Medicine Rehabilitation Physiatry (a medical specialty that focuses on the diagnosis, prevention, and treatment of disabilities related to the brain, nerves, bones, muscles, and joints to restore function, reduce pain, and improve quality of life) Initial evaluation dated [DATE] at 3:38 PM showed Resident 1 reported pain ,d+[DATE] and described their back pain as bothersome, their right knee as sore, and had pain when they urinated. Resident 1 reported they fell (date not specified) but were not injured. The provider planned to schedule acetaminophen (pain medication) routinely throughout the day and would order a pain medication cream to apply to the skin. A UA (urinalysis- a test used to diagnose urinary tract infection) was ordered on [DATE]. Review of the Fall CP showed an update on [DATE] to keep resident in a highly visualized area when in the wheelchair (four days after the Fall #1 and two days after Fall #2); mental health referral and Fall Prevention Program (two days after Fall #2). The CP showed the updates were not timely. Review of the Kardex dated [DATE] showed the updates: on the Fall Prevention Program (from the intervention for the fall on [DATE]) and to keep them in highly visible areas when up in the wheelchair (the intervention from the fall on [DATE]) Review of a physician progress note dated [DATE] showed Resident 1 was very confused, a very high fall risk, and continued to try to self-ambulate. Review of a therapy progress note dated [DATE] at 5:17 PM showed Resident 1 ambulated 35-feet with minimal assistance for balance and safety. Resident 1 ambulated a total of 60 feet. FALL #3: Review of the facility's Fall (Witnessed) Risk management report, dated [DATE] at 2:15 PM showed Resident 1 was at the nurse's station in their wheelchair, stood up, fell , and landed on their buttocks. The documentation showed one staff member (coming on shift) reported they saw the resident stand and fall but could not get to them in time. A typed interview statement with Staff R, CNA, showed they tried to change Resident 1 before the end of their shift but Resident 1 refused so they left them in the wheelchair at the nurse station for safety. The interventions and conclusion, dated [DATE], showed they would place auto-lock brakes on the wheelchair, place Resident 1 on alert charting, and update the CP. Review of the clinical record did not show physician orders were obtained for their specific Fall Prevention Program interventions or auto-lock brakes for the wheelchair. Review of the nurse progress notes for [DATE] did not provide documentation to show a fall occurred, that the physician and responsible party were notified, that new interventions were implemented, or that consistent post-fall alert charting was done every shift for 72 hours after the fall. Review of the physical therapy progress note dated [DATE] at 4:27 PM showed therapy attempted to work with Resident 1 but they were unable to get Resident 1 to stand (using maximum assist of two staff), they resisted standing and kept sitting back down. The documentation did not show the therapy staff notified nursing or the physician of their new onset of inability or unwillingness to stand. Review of the physician note dated [DATE] showed Resident 1 had worsening confusion and agitation. The nursing staff reported to the provider they needed one-to-one care; they were still a fall risk and tried to leave the wheelchair on multiple occasions. The provider documented Resident 1 is staying by the nurse station most of the time. Review of a nurse progress note dated [DATE] at 2:22 PM showed Resident 1's Collateral Contact (CC) arrived to visit, called [DATE], and Resident 1 was transferred to the hospital. In an interview on [DATE] at 10:27 AM, Resident 1's Responsible Party (R1-RP) stated after resident 1 fell , the facility did nothing about it. They only received one notification of a fall, on [DATE] but were not notified of the falls on [DATE] and [DATE]. Resident 1 was left to sit up in the wheelchair all day, in the halls or at the nurse station, and was not allowed to lay down for naps. R1-RP stated they visited every day and sometimes twice a day and there were many occasions they arrived to find Resident 1 in the wheelchair either at the nurse's station or down the hall towards their room and there were no staff around. On one visit a staff member put a blue wrist band on Resident 1's wrist and when we asked why, they said 'so the staff knew they were a high fall risk'. The next day when we were in to visit the blue band was gone and we never saw it again. They were at the facility [DATE] just before dinner time and noticed Resident 1 was not doing well; they were so groggy they could barely talk and looked out-of-it. R1-RP stated they were out of town on [DATE] so their Collateral Contact (CC) went to check on Resident 1. R1-RP stated CC found Resident 1 in the wheelchair at the nurse's station, slumped over to the side, and thought Resident 1 had died . CC had to go find help because there were no staff at the nurse's station. After CC found staff who said they would lay Resident 1 down, CC went outside and called R1-RP to report what occurred. R1-RP directed CC to call 911 and then call R1-RP back. R1-RP was on speaker phone and could hear the paramedics repeatedly calling out Resident 1's name to get them awake. R1-Rp stated at the hospital they found Resident 1 was too sedated from their psychotropic medications and had a hip fracture. Review of the Inpatient Hospitalist History & Physical Note dated [DATE] showed Resident 1 was admitted to the hospital for mental status changes due to psychotropic medications, a fever, an elevated white blood cell count, and an abnormal UA. They held their antipsychotic, antidepressant, and Parkinsons medications on admission to the hospital. On [DATE], after Resident 1 was more alert, the hospital physical therapist attempted to transfer Resident 1 and they were not able to stand, sat back down, had facial grimacing, and guarded their right hip. An x-ray showed Resident 1 had an acute hip fracture which required surgical intervention. In an interview on [DATE] at 2:30 PM, Staff C, Registered Nurse-Resident Care Manager (RCM), stated Resident 1 had three falls while a resident at the facility according to the electronic risk management system: a fall on [DATE] at 3:30 PM, a fall on [DATE] at 4:12 PM, and a fall on [DATE] at 2:15 PM. Staff C was unable to locate documentation to show the fall events on [DATE] and [DATE] were recorded in the medical record and alert charting was completed. Staff C stated the CP updated after the fall were not done timely and there could have been more relevant CP interventions after the first fall since Resident 1 was already at the nurse's station when they fell . Staff C stated nurses were expected to document the event in the nurse progress notes, place the resident on Alert charting (for a minimum of 72 hours), and ensure a relevant intervention was updated in the CP before the end of their shift. Staff C stated the nurses knew how to update the CP and Kardex and it was not done timely. Staff C stated the RCMs, or Staff B, Director of Nursing, DNS, reviewed the documentation to ensure the post fall steps were completed. Staff C was unable to locate the lab result report for the UA ordered [DATE]. Staff C stated they would investigate. No further information was provided. In an interview on [DATE] at 1:00 PM, Staff D, Physician, stated they were unaware of Resident 1's falls but would need to review their documentation. Staff D stated if they were notified of a fall, they would have addressed it in their visit note. Staff D stated it was their expectation the facility notified them of each fall in a timely manner and that the licensed nurses or Resident Care Managers reviewed their provider notes after each visit and followed their recommended plans they documented at the end of their progress notes. In an interview on [DATE] at 8:40 AM, Staff R, CNA, stated they did not know what the facility's Fall Prevention Program was or why some name tags on the name plates were blue and some were white. Staff R stated they knew who a fall risk was by looking at their Kardex every day and notifications during shift change. They stated for every resident that was a high fall risk, they made sure their beds were in the lowest position (most of the time), and they had fall mats on the floor. They also did 15-minute checks, ensured the doors stayed open, and residents could not be alone in their room in their wheelchairs, they needed to be at the nurse's station to be monitored. They had never seen residents wear blue wrist bands. <RESIDENT 8> Review of the [DATE] Admission MDS showed Resident 8 had moderate cognition problems, required assistance for ADLs, had frequent bowel incontinence, and diagnoses included stroke, diabetes, obstructive sleep apnea, and a newly placed feeding tube. Resident 8 had falls prior to admission but no falls since they admitted . Review of the [DATE] Death in facility MDS showed Resident 8 passed away. Review of the Fall CP dated [DATE] showed they were at risk of falls and had non-personalized fall interventions that included: appropriate footwear always, call light within reach and answered promptly, monitor for medication side effects, refer to therapy, and report falls to the provider. In an interview on [DATE] at 4:41 PM, Resident 8's responsible party, R8-RP, stated after Resident 8's roommate discharged ; Resident 8 started falling because there was no one in the room to call for help for Resident 8. R8-RP stated Resident 8 told them their call light was often out of their reach. They also experienced long call wait times and by the time staff arrived they were already incontinent. R8-RP stated Resident 8 fell on [DATE]. R8-RP stated they were contacted by someone at the facility and told Resident 8 fell and asked if they could put side rails on the bed, but nothing was done. R8-RP stated Resident 8 fell again after the first fall and hit their head. The nurse did not know Resident 8 fell until they did their rounds. Review of the facility's mandatory reporting log for [DATE] showed Resident 8 had two falls on [DATE], the first fall was at 8:21 PM and the second fall was at 10:30 PM. Fall#1: Review of the facility's fall investigation dated [DATE] at 8:21 PM showed Resident 8 was found lying on the floor beside their bed. Resident 8 reported they were getting ready for bed and slid off the bed. They were evaluated for injuries and assisted back into bed. The new intervention was to get them a wider bed. Fall#2: Review of the facility's fall investigation dated [DATE] at 10:30 PM (two hours after the first fall) showed Resident 8 was found lying on the floor beside their bed, again. Resident 8 stated they were trying to go to the bathroom and fell . They placed a fall mat on the side of the bed. Review of the typed-in resident statement showed Resident 8 stated they were trying to go the bathroom and fell to their right side. The one staff typed-in statement showed 'they found them on the floor, they said they rolled out of bed'. The investigation did not show written, signed/dated witness statements were obtained, details of the scene including whether the call light was on or not, analysis of the prior chain of events, identification of Resident 8's unmet care need, or a plan on how to better provide more prompt toileting assistance. The investigation did not include completed neurological checks or post-fall monitoring. The new intervention was to get them a wider bed, the same intervention from the first fall, add them to The Fall Prevention Program, and placed a fall mat on the floor next to the bed. Review of a SBAR notification to the provider, dated [DATE], showed Resident 8 fell . There was no description or time of the fall indicated on the notification. They requested to put side rails on the bed and floor mats on the floor on the side of the bed. The physician signed the response on [DATE]. Review of a Fall CP update, dated [DATE], showed Resident 8 was on the Fall Prevention Program. The CP did not show updates that included: fall mats, side rails, low bed, or a wider mattress. Review of the Kardex, dated [DATE], [DATE], [DATE], and [DATE] showed no fall care plan interventions for CNAs to implement. Review of Resident 8's physician orders showed an order, dated [DATE] for a larger mattress to allow more room for bed mobility and care to help reduce the risk of falls. The physician orders did not show orders for side rails, low bed, or fall mats were transcribed and implemented. Review of a Fall CP update, dated [DATE], showed Resident 8 was provided a wider mattress (four days after the falls). Review of the Resident 8's progress notes did not provide documentation to show fall events occurred on [DATE] or: notification to the physician and responsible party of the falls, new interventions implemented, or consistent post-fall alert charting every shift for 72 hours after the falls. <RESIDENT 11> Review of the [DATE] Quarterly MDS showed Resident 11 had cognition problems, required assistance with ADLs, and diagnoses included diabetes, depression, chronic lung disorders, and muscle weakness. Resident 11 had two or more non injury falls since their prior assessment. Review of the Fall CP dated [DATE] showed Resident 11 was at risk for falls or injury due to impaired balance and mobility. The CP showed they fell on [DATE]. The Fall CP interventions included: an intervention dated [DATE] to keep call light within reach; an intervention dated [DATE] to keep the right side of the bed against the wall; [DATE] to ensure the bed was in the lowest position before leaving the room; an intervention on [DATE] for the Fall Prevention Program; [DATE] to place a perimeter mattress to define bed edges; and a fall intervention dated [DATE] for a bariatric alternating pressure mattress. Review of a nurse progress note dated [DATE] at 12:57 AM, showed Resident 11 fell from their bed. Resident 11 reported they were trying to adjust themselves in their bed but leaned too far over to the left, fell , and landed on their left side. After they were assessed for injury, they were assisted back to bed, educated on call light use, lowered the bed to the lowest position, and ensured the bed brakes were in the locked position. The documentation did not show the physician and responsible party were notified. The documentation showed there was not consistent post fall alert charting documented every shift for 72 hours after the fall. Review of Resident 11's Kardex dated [DATE] directed staff to encourage use of the call light for assistance and to ensure they left the bed in the lowest position prior to leaving the room. There were no other interventions for fall prevention on the Kardex. During an interview and observation on [DATE] at 8:10 AM, Resident 11 was in bed. There were no other staff in the room. Their bed was not in the lowest position and not with the right side of the bed against the wall. Between the bed and the wall on the right side was an IV pole and their oxygen concentrator. The mattress was not a perimeter mattress. There was a blue piece of paper with nothing on it-covering another blue piece of paper on the wall at the head of the bed. Resident 11 stated they had not fallen in a while and was doing good at staying off the floor. They did not know they had a blue sign at the head of their bed, so they did not know what it said. The sign was not reachable due to the bed and medical equipment. In an interview on [DATE] at 8:40 AM, Staff R, CNA, Staff R stated the blue sign on the wall in Resident 11's room was information about their transfers and bed mobility. Staff R was not aware Resident 1's right side of the bed was supposed to be against the wall. <THE FALL PREVENTION PROGRAM> In an interview on [DATE] at 1:15 PM, Staff C, Registered Nurse-RN, stated when residents had a second fall, they were placed on the Fall Prevention Program. Staff C stated they were unsure if there were documented protocol. After a resident had a second fall, they would be placed on the Fall Prevention Program: they would have a blue sign in their room with their fall interventions on them, they would have blue name tags on the outside of their doors. Staff C stated they obtained physician orders for fall interventions that required an order (like side rails, low beds, or beds against the wall). Staff C stated they have never seen a fall binder at the nurse station or blue wrist bands used, and the facility did not have a structured clinical systems meeting for falls (like they did for Nutrition/Skin weekly meetings) or other ongoing monitoring process for residents with repeated falls, but did discuss falls that occurred the prior day (or weekend) during their morning clinical meeting. In an interview on [DATE] at 9:30 AM, Staff JJ, CNA, stated they were unsure why some name plate name tags were blue, and some were white. They did not know the specifics of the Fall Prevention Program but knew that they would look at the Kardex to tell them if the resident had interventions for fall prevention. In an interview on [DATE] at 6:40 AM, Staff KK, LPN, stated they were unsure what the significance was of the blue name tags versus the white name tags on the name plates, but they would find out. No further information was provided. In an interview on [DATE] at 2:45 PM, Staff A stated some of the components on the Fall Prevention Program were not done at the facility including the nurses' putting orders in for fall interventions and tasks into the CNAs POC documentation program, they did not keep a fall binder at the nurse stations, and did not place blue wrist bands on residents. In an interview on [DATE] at 11:50 AM, Staff I, RN, stated they knew which residents were fall risks by looking in their room to see if they had fall mats by their bed. Staff I stated after a resident fell , they were required to document the event, initiate an investigation, report the fall to the physician and responsible party, and implement an intervention to help prevent further falls. Staff I stated they knew how to update the CP but did not know how the interventions transferred over to the Kardex for CNAs to implement. Staff I stated their system to educate the oncoming staff of the CP updates with new interventions was verbally during shift report. Refer to F610, F658, F697, F758. REFERENCE WAC [DATE] (3)(g).

Based on interview and record review, the facility failed to accomodate the needs of one of three residents reviewed (Resident 2) for accommodation by ensuring they had the preferred equipment needed to enable them to leave their room. The resident was not permitted to leave their room unless accompanied by a person other than a facility staff member and expressed the need for a better fitting wheelchair. Failure to accommodate the resident's needs placed this resident at risk for loss of autonomy and a diminished quality of life, and resulted in psychological harm when the resident suffered loss of control, and ongoing distress as evidenced by feelings of agitation. Findings included The facility document, Resident Rights Under [NAME] State Law, dated September 2010 and updated July 2015, documented residents of the facility had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Center, to make choices about aspects of the resident's life in the Center significant to the Resident, and to be free from verbal, physical and mental abuse, corporal punishment and involuntary seclusion. Resident 2 first admitted to the facility on [DATE], and most recently readmitted [DATE], with multiple diagnoses, including congestive heart failure and lymphedema, for skilled nursing care. The Minimum Data Set assessment, dated 07/23/2023, documented Resident 2 had mild cognitive impairment and was able to make their needs known, and required staff assistance for bed mobility and transfers. A Power-Mobility Indoor Driving Assessment, Mobility Device and Driver Experience Checklist, dated 02/06/2023, documented Resident 2 had used the power chair for 3+ years, spent most of the day up in the chair, and determined Resident 2 was able to drive independently with no restrictions, with a score of 98%. A Power-Mobility Indoor Driving Assessment, Mobility Device and Driver Experience Checklist, dated 03/27/2023, documented a passing score of 100% and determined Resident 2 was able to drive independently with no restrictions. The evaluator noted the resident took her time when parking to set up in the proper location, when driving backwards could be hesitant but did not bang into the wall, and navigated around obstacles, including medical carts, other patients, and food carts. A 04/10/2023 4:03 PM therapy note documented Resident 2 had gone into the therapy gym at 9:20 AM to let staff know that the footrest (a single footplate) had fallen off the resident's power wheelchair. Therapy staff documented having told the resident it was unsafe for the resident to use the powerchair without the footrest for safety, and noted resident's response that they could not be in bed all day. A 04/10/2023 12:50 PM nursing note documented Staff D, a Licensed Practical Nurse, observed Resident 2 bump the wheelchair in a doorway and injured the toes on their right foot. First aid was provided, notifications made, and Resident 2 was sent out to the emergency room for additional evaluation. A 04/10/2023 document entitled, Risks and Benefits, documented resident's right and choice to continue to use the power wheelchair with the broken footrest. The document set out verbal consent by the resident, the resident's family member, and signed by a provider and Staff B, a Registered Nurse and the Director of Nursing Services (DNS). A 04/11/2023 12:23 Social Services note documented the resident's family member was informed that Resident 2 was unable to use their electric wheelchair while the footrest was being fixed. A 04/18/2023 communication note documented that facility staff determined, after a care conference, that Resident 2 would only have access to the power wheelchair while in their room, where it could tilt but would not have any driving capabilities. An update to the Resident's Care Plan, dated 04/18/2023, documented Resident 2 would not be able to drive the electric wheelchair, and staff may not drive Resident 2 in the electric wheelchair, and that a non-staff escort must meet Resident 2 in their room and walk with them in and out of the facility. The care plan further delineated that, a family member or outside staff may supervise Resident 2 in the electric wheelchair in the facility, and the family member or outside staff must stay with the resident at all times while Resident 2 drove the electric wheelchair. Review of the clinical record documented the footrest of Resident 2's electric wheelchair had not yet been repaired as of 08/17/2023. On 07/28/2023 at 9:39 AM, Collateral Contact 2 (CC-2), a family member, stated facility staff had procrastinated on getting the footrest repaired and said the work order was not sent in until 07/13/2023. Resident 2 was not allowed outside of their room unless a non-facility employee escorted them. They were told the resident was a danger to themself and to others, and an order was put in their file from 04/17/2023 that basically they could not come out of their room until Therapy decided otherwise. CC-2 said it had caused upset to Resident 2 and an outside agency had to provide someone to go in there and spend time with the resident and to go around the building with them. On 07/28/2023 at 10:02 AM, Collateral Contact 3, a State Employee, said Resident 2 was not allowed to be out of their room unless someone else, who was not a facility employee, accompanied the resident. CC-3 said there were a lot of restrictions being put on the resident. CC-3 said the situation had required the expansion of contracted services in order for staff to escort the resident to activities in the facility and stay with the resident until they went back to their room. On 08/02/2023 at 3:21 PM, Staff E, the Director of Rehabilitation, said a manual wheelchair that would fit the resident was put into the resident's room, but the resident would not use it. When asked, Staff E said it was not designed for the resident, and the resident did not like the manual wheelchair because it would not recline nor did it have back support. When asked whether Resident 2's ability to operate the power chair had been assessed, Staff E said the resident was tested three times and scored high enough to pass. When asked, Staff E said the paperwork to request a replacement of the footrest was submitted on 07/06/2023. An observation on 08/10/2023 at 4:10 PM Resident 2 operated the power chair accompanied by the contracted staff/companion. Resident was observed to operate the power chair at a slow speed and turned the chair in wide arc to maneuver around corners and through the doorway. On 08/10/2023 at 4:15 PM, Collateral Contact 4 (CC-4), a contracted staff/companion, said Resident 2 was really upset about not being allowed to go anywhere with facility staff. CC-4 said Resident 2 used to go outside and to the activity room, and they liked a lot of the people at the facility. CC-4 said it seemed like Resident 2 was really depressed when they could not leave their room on their own anymore, and that it took months to talk them into getting out of bed and the resident was still really upset about it. CC-4 said the facility would not let the resident come and go out the front door, that instead they had to use the door at the end of the hall. CC-4 said they were not given a reason but that was all that was allowed. CC-4 said they did not see how this could be right. On 08/10/2023 at 4:30 PM, Resident 2 said the day the footrest fell off, they went to the Therapy Department and told Therapy staff about it. And then later that day, they caught their foot in a doorway and broke their toes. Resident 2 said, They told me they would get the footrest repaired. It is still broken. Then they wanted me to use a manual wheelchair, but I have back pain and leg swelling and it doesn't lean back. Then they told me I cannot go anywhere outside of my room without someone with me who does not work here. So I have to wait for my family member or an outside staff to come in for me to go anywhere. Resident 2 said, I'm pissed. I can't go anywhere, I can't go to the activity room. They used to let me use the roll-on scale in the shower room, now I'm not allowed to go in there in my chair anymore. I feel like a prisoner in my own room. When asked if they had told anyone at the facility how the situation made the resident feel, Resident 2 said they did not believe the facility leaders cared how that made the resident feel. When asked, Resident 2 said they were not advised of anything they could do to regain the use of their power chair in the facility, or when they could be re-evaluated. On 08/17/2023 at 1:33 PM, Staff F, Social Services, said during care conferences communication with the resident and their family member would break down when things started to go in the wrong direction. Staff F said communications with the resident's POA occurred by email and phone. When asked about assessment of Resident 2's need for psychosocial support, Staff F said they used to be close to Resident 2 but after the last care conference the resident thinks Staff F took their (facility leadership's) side and does not talk to Staff F anymore. Staff F said Resident 2 asked them not to come to the care conferences anymore and Staff F has not talked with the resident since then. On 08/17/2023 at 2:02 PM, Staff G, a Certified Nurse Assistance (CNA) and Restorative Aide, said one time Resident 2 had bumped into the back of their leg with the power chair which caused a bruise. When asked, Staff G said the resident apologized. Staff G said since then they gone to the resident's room to work with Resident 2 and said they did not have any problem with Resident 2. On 08/17/2023 at 2:47 PM, Staff D said they observed Resident 2 when the resident's foot was injured. Staff D said they thought the resident miscalculated the turn to get through the doorway. When asked, Staff D said they had not seen the resident drive too fast or in an unsafe manner or had not seen the resident have close calls with staff or another resident. On 08/17/2023 at 3:30 PM, Staff B confirmed that Resident 2 was not permitted to leave their room on their own unless they were in the manual wheelchair. Staff B said a state employee had made arrangements for someone from an outside agency to accompany Resident 2 where the resident wanted to go in the facility. Staff B was not sure if other diagnostics or evaluations had been done to determine a medical reason for any possible change in the resident's ability to operate the power chair. Staff B said Resident 2 had passed the mobility chair evaluations done by the Therapy Department. When asked, Staff B acknowledged that Resident 2 had been so depressed that they refused to get out of bed for about a month after the restriction was imposed on their use of the power chair, and that it took some time to talk the resident into getting out of bed again. When asked how the facility was meeting Resident 2's psychosocial needs Staff B said they had tried to honor the resident's requests as long as staff could push them in the manual chair. When asked what attempts have been made to mitigate the current restrictions, Staff B said I know there are things we can do better, we will try harder. We can think outside the box. Reference WAC 388-97-0860 (2)

Based on observation, interview, and record review, the facility failed to implement interventions (skin assessments/treatment and nutritional support) for one of seven residents (#69) reviewed for pressure ulcers. Additionally, the facility's failure to consistently provide pressure relieving interventions for Resident #69 caused harm to the resident due to the development of additional pressure ulcers on the right 4th and 5th toe and right outer ankle area. Findings included . Review of Resident #69's admission Minimum Data Set (MDS, a required assessment tool) showed the resident was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further showed the resident was cognitively intact and was able to make needs known. SKIN ASSESSMENTS / AUDITS Review of Resident #69 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #69's medical record (Admission/Readmission Nursing Evaluation) dated 12/16/2021, documented the resident had a Stage III pressure ulcer (a full thickness bed sore, but has not gone deep enough to expose underlying muscle, tendon, cartilage or bone) on the right buttock, measuring six inches in length and six inches in width, with tunneling (when a wound has progressed to form passageways underneath the surface of the skin). There were no other skin assessments or measurements found in the resident's medical record or progress notes. During an interview on 01/12/2022 at 2:52 PM, Staff Assistant Director of Nursing (ADON), stated Resident #69 had a stage IV pressure ulcer (PU) and had been getting weekly skin assessments/audits. The ADON further stated the Resident Care Manager (RCM) was responsible for doing the weekly skin audits and measuring the wounds. When asked to provide the documentation of the skin assessments/audits the ADON stated she would have to look for them. When asked how the facility would know if Resident #69's wounds were getting better or worse without any measurements of the wound, the ADON stated, We wouldn't. During an interview at 3:56 PM, Staff ADON stated she was unable to locate any additional skin audits/assessments and the admission skin assessment was the only documented skin audit done by the facility in the five weeks since the resident's admission. Review of Resident #69's December 2021 Treatment Administration Record (TAR) and January 2022 TAR showed that staff had documented skin audits as being completed on 12/18/2021, 12/25/2021, 01/01/2022, and 01/08/2022 and indicated no new skin impairment. The dates the skin audits were documented as being completed had no corresponding skin evaluations. During an interview on 01/13/2022 at 9:39 AM, Staff Interim Director of Nursing, stated the expectations for documenting and assessing wounds and/or pressure sores were for the Registered Nurse (RN) to do a full skin check on admission and weekly. NUTRITION RECOMMENDATIONS A review of the facility's Registered Dietician's (RD) assessment and recommendations, dated 12/20/2021, showed Resident #69 had an inadequate oral intake related to increased nutrient needs. The dietician's recommended interventions were to have staff administer the following: a multivitamin with minerals every day, pro-stat (a high protein, oral dietary supplement that promotes wound healing) to be administered three times a day, provide a health shake with every meal due to the resident's poor appetite, and increased nutrient needs. Furthermore, the dietician noted a discrepancy in the documentation for the resident's height and staff were to recheck to ensure accuracy. (Resident noted height was 62-64 inches however in the medical records the height was documented as 48 inches). Review of the December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 01/12/2022 at 2:52 PM, Staff ADON said the process for implementing dietary recommendations was first to inform the provider, and if approved the unit manager would put the orders into the residents' medical records. When the ADON was shown the RD's recommendations for Resident #69 from 12/20/2021, Staff ADON stated, It would be my expectation that these [recommendations] would have been brought to the provider and implemented with his/her ok. Review of Resident #69's Progress Notes dated 12/16/2021 through 01/13/2022, documented no attempts to contact a provider to obtain orders for the RD recommendations. UNITED WOUND HEALING Review of Resident #69's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes dated December 2021 showed no documentation that any attempt to contact UWH was made by the facility's staff or that the provider was notified that UWH had not evaluated or treated Resident #69. Review of the provider's 12/21/2021 progress note indicated as part of the provider's plan of care for resident #69, the resident was being followed by UWH. Review of a physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 01/12/2022 at 2:52 PM, when asked about the referrals to UWH and her expectation for newly admitted residents with a stage IV pressure ulcer, Staff ADON stated that the reason for the second referral to UWH was that the resident was not being followed by the wound team (UWH). Additionally, Staff ADON stated, the expectation would be a referral to United Wound Healing the day of admit or within a couple of days and [the resident] to be seen when they are [UWH] in the facility next time. During an interview on 01/13/2022 at 9:39 AM, when Staff Interim Director of Nursing (Interim DON), was made aware Resident #69 had an initial referral for UWH consult on 12/20/2021 and was not seen by them until 22 days later and when asked what the expectation was for implementing wound care orders, Staff Interim DON stated, For her [Resident #69] to get the appropriate care the moment she gets here. SPECIALTY AIR MATTRESS An observation on 01/13/2022 at 7:58 AM showed Resident #69 laid in bed on a Protekt Aire 2000/3000 air mattress with settings as follows: bed in static mode, normal pressure, weight dial set at 350 lbs. Review of the vital sign record (weights) for Resident 69 showed a weight of 194 pounds documented on 12/16/2021. Review of the operation manual for the Protekt Aire 2000/3000, undated, showed the following: Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase comfort of the patient, determine the patient's weight, and set the control knob to that weight setting, and in static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. Review of the Care Plan showed no documentation of any settings for the Protekt Aire 2000/3000 mattress for Resident #69. Review of the Kardex report (a document placed at the resident's bedside that instructs staff on the care needs and services to be provided to the resident) showed no documentation of any settings for the Protekt Aire 2000/3000 mattress for Resident #69. During an interview on 01/12/2022 at 2:11 PM, Staff CNA5 stated they were familiar with the care of Resident #69 and was aware of the sore the resident had near the buttock area; however, when asked if any training was provided on the resident's specialty mattress, Staff CNA5 stated that they had not received any training on the mattress the resident used. During interviews at 11:24 AM and 12:08 PM, Staff LPN7 stated she did not know what the settings of the air mattress were supposed to be, and she would check the care plan. However, at 12:08 PM Staff LPN7 said she was unable to find any settings for Resident 69's air mattress nor were there any settings documented in the resident's orders, care plan or TAR. Furthermore, Staff LPN7 stated, The resident has skin issues, then they should be care planned for it. During an interview at 2:52 PM, Staff ADON stated that agency staff, who are unfamiliar with Resident #69's care, would find out about the resident care needs in shift report, or within the resident's care plan. When asked about training for the specialty air mattress Staff ADON stated it did not require any kind of training and it only had a weight setting. When asked if the different modes meant anything Staff ADON stated, The intermittent rotates the air and the static just stays the same. During a follow up interview at 3:56 PM, Staff ADON, stated the weight setting had been turned down to the appropriate weight and that staff training on the specialty mattress was going to be initiated. NEW PRESSURE AREAS During an interview on 01/12/2022 at 2:06 PM, Resident #69 said she is unsure of how often she gets baths and that the aides apply some cream to her groin area, but they never apply any lotion to her legs. During an observation on 01/12/2022 at 2:14 PM, Resident #69's right outer ankle had a round spot the size of a half dollar, dark brown in color; the fourth toe had a black spot on the top, approximately the size of a pencil eraser, no pressure relieving interventions for her heel. During an observation on 01/13/2022 at 7:58 AM, Resident #69's right fourth toe had a dime size (corrected after closer observation from 01/12/2022) black spot on the top of the toe at the base of the toenail. The fifth toe had a pinpoint black spot on the end of the toe, towards the underside of the toe, no pressure relieving interventions for her heel or toes. At 8:15 AM, in an interview with Staff CNA7, when asked how she would find out about the care of her residents she said she would ask the other CNA's or her nurse. When asked if Resident #69 had any open sores on her body or any special skin care needs Staff CNA7 stated, No. At 8:24 AM, in an interview with Staff CNA6, she said she was aware of the open sore on her right buttock area. When asked if Resident #69 had any special care needs because of her open sore Staff CNA6 stated, Probably to be rotated to keep pressure off of that side and a pillow underneath her butt. At 9:39 AM, in an interview with Staff Interim DON, stated that she was not aware Resident #69 had black spots on her toes and discoloration on her ankle. The Interim DON and this surveyor walked down to the resident's room and looked at her right leg and toes. Looking at the resident's right outer ankle Staff Interim DON stated, That is definitely not a bruise. This surveyor informed the Interim DON her staff was made aware of and observed this yesterday, 01/12/2022, and asked what her expectations would be of her staff after having been notified and observed the resident's skin. Staff Interim DON, stated, Incident report, notify provider .I am concerned about observing the resident today and her not having any intervention in place to reduce pressure on the toes and ankle. Yes, that should have been put into place yesterday. The facility caused harm to Resident #69 by failing to ensure staff caring for the resident were informed and were knowledgeable about her care, by failing to recognize developing pressure areas and intervene in a timely manner, by failing to implement nutritional recommendations in an at-risk resident with an existing pressure ulcer, and by failing to communicate with the resident's provider that the previously ordered referrals/interventions had not been put into place for the resident. Reference WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to analyze contributing risk factors and implement the necessary interventions to prevent accidents for one of three residents (Resident # 85) reviewed for falls. This failure placed the resident at increased risk of harm related to avoidable falls and resulted in harm for Resident #85 due to a significant injury sustained from a fall. Findings included . RESIDENT #85 REFER TO F641, F657, AND F725 FOR ADDITIONAL INFORMATION Review of admission Minimum Data Set (MDS, a required assessment tool), dated 03/15/19, showed Resident #85 admitted on [DATE] with multiple health conditions to include [MEDICAL CONDITION], high blood pressure, orthostatic [MEDICAL CONDITION] (drop in blood pressure when standing up which can lead to [MEDICAL CONDITION]), fracture of left upper arm, muscle weakness, [MEDICAL CONDITION] (damage or disease affecting peripheral nerves causing numbness and burning pain), [DIAGNOSES REDACTED] (episodes of low blood sugar), and arthritis. The MDS showed Resident #85 was able to make his need known and used a walker and a wheelchair for mobility. Resident #85 was not steady on his feet and required extensive assistance with activities of daily living (ADLs). Review of a hospital record prior to admitted d 03/04/19, showed Resident #85 went to the emergency department due to weakness and pain which caused him to fall in his motor home. Resident #85 fractured his left arm and scraped both of his legs. Hospital records show that Resident #85 was hospitalized for [REDACTED]. FALL #1 During an observation and interview on 03/26/19 at 10:53 AM, Resident #85 laid in bed with left arm in a sling. Resident #85 stated that he had fallen a few days prior while he was trying to reach something on the floor. Resident #85 stated that the wheelchair cushion had slipped from underneath him and he fell next to his bed. He further stated that the fall was unwitnessed, and that the nursing staff had not checked him for injury or neurological/blood pressure abnormalities. Review of Resident #85's nurse progress note dated 03/22/19 showed that the resident had an unwitnessed fall in his room due to slipping from the wheelchair on 03/22/19. This note further showed that Resident #85 declined neurological/blood pressure abnormality monitoring after this fall. Resident #85 was assessed for range of motion and the physician was notified. Review of the incident investigation report dated 03/22/19 showed that Resident #85 was attempting to stand, slid off his wheelchair and was found on the floor by facility staff; however, the incident investigation report did not identify Resident #85's specific risk factors that contributed to the falls including need for increased supervision, wheelchair safety, Resident #85's safety awareness, and mobility function related to acute fracture of left upper arm. Review of Resident #85's care plan dated on 03/09/19 showed that Resident #85 was high risk for falls related to gait/balance problems. The stated care plan goal for fall risk was that Resident #85 would not sustain serious injury. Interventions in care plan related to falls indicated that Resident #85 required prompt response for all requests for assistance, anticipate and meet resident needs, and provide education to Resident #85/family/caregiver regarding safety reminders on what to do in the case of a fall. In addition, the care plan did not identify Resident #85's need for increased supervision related to a fall history and Resident #85's compromised functional ability due to fractured left arm in sling. During an interview on 04/03/19 at 1:03 PM, Staff M, Registered Nurse/Resident Care Manager (RN/RCM), stated that Resident #85's care plan was not updated with new interventions for the fall on 03/22/19 to include education to Resident #85 and encouraging Resident #85 to lock wheelchair brakes for safety. FALL #2 During an interview on 03/27/19 at 08:45 AM, Resident #85 stated that he had just returned from the hospital because he had leaned forward in his wheelchair and his wheelchair cushion had slipped from under him. Resident #85 further stated that he had fallen on his left side and sustained a rib fracture. Review of emergency department encounter note dated 03/26/19 at 11:06 PM showed that Resident #85 had sustained a rib fracture. During an observation and interview on 03/28/19 at 08:34 AM, Resident #85 had a grabber (assistive device which allows picking-up items from a distance) in bed with him. Resident #85 further stated that if he had received the grabber prior to his second fall, he would not have fallen a second time. Observation of Resident #85's cushion did not show any device or straps to secure it within a wheelchair. Resident #85 also stated that his wheelchair belonged to the facility, and that he, prior to his first fall, had reported it was slippery. Resident #85 stated that therapy made no alterations to his wheelchair or cushion after he provided this information. During an interview on 04/03/19 at 10:29 AM, Staff S, Nursing Assistant Certified (NAC), stated that she was unaware of Resident #85's falls. Staff S, NAC, also stated that she was unaware of how Resident #85 had fallen. Staff S, NAC, further stated that she would need to consult Resident #85's Individual Service Plan (ISP, a care plan that provides information to staff on how to care for residents) to check what interventions were in place to prevent further falls. In addition, Staff S, NAC, stated that Resident #85 was unsteady on his feet, utilized a wheelchair, and was able to use a call light to request help. Review of an incident report dated 03/26/19 showed that Resident #85 was heard yelling for help from his room and was discovered lying on his back with his wheelchair behind him. Resident #85 was placed on alert monitoring for neurological/blood pressure abnormalities and physician was notified. This investigation further showed that Resident #85 was transported to the emergency department. During an interview on 04/03/19 at 12:29 PM, Staff M, RN/RCM, stated that the risk factors and root cause for Resident #85's initial fall were not identified. Staff M, RN/RCM, further stated that the failure to determine risk factors and root cause could have contributed to Resident #85 sustaining a second fall. Additionally, Staff M, RN/RCM, stated that more information should have been gathered at the time of Resident's #85's initial fall. Staff M, RN/RCM, also stated that Resident #85's second fall could have been prevented if the risk factors and root cause for the initial fall was more thoroughly assessed. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent harm. The failed practice was evidenced by; lack of timely and thorough physical assessments, failure to timely identify and treat critical laboratory results, ineffective communication between nursing staff and physician(s), failure to ensure adequate hydration, and prevent skin injuries. Additionally, the facility leadership failed to address chronic staffing issues which contributed to failure in sustaining safe and effective clinical systems. The cumulative effect of these failures resulted in neglect and/or actual harm to Residents #'s (1, 7, 9, 13, 14, &15) reviewed for changes in medical conditions. The facility leadership was notified of repeat resident harm during abbreviated surveys on 11/16/18 and 12/19/18, despite having awareness the facility failed to take action and protect residents from repeat harm and/or neglect. This constituted an Immediate Jeopardy and indicated the facility's system to prevent neglect was deficient. Findings Included: According to the Centers for Medicare & Medicaid Services, §483.5, Neglect, 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. RESIDENT #13 Resident #13 sustained repeated harm during his stay at the facility between 11/02/18 and 01/08/19. The facility leadership was informed by the state agency during abbreviated surveys on 11/16/18 and 12/19/18 of identified harm related to skin and dehydration involving Resident #13. Resident #13 admitted on [DATE] with [DIAGNOSES REDACTED]. According to MDS (Minimum Data Set, a comprehensive assessment) dated 07/09/18 Resident #13 required extensive assistance with bed mobility, eating, toileting and personal hygiene. Resident was at risk for dehydration and skin problems related to decrease mobility, chronic and acute medical conditions including [MEDICAL CONDITION] also known as[DIAGNOSES REDACTED] which causes watery diarrhea. SKIN/DEHYDRATION Between 07/02/18 and 11/16/18, Resident #13 developed right heel pressure injury according to facility records. Weekly skin assessment and/or measurements were missing between 07/31/18 to 09/17/18. The facility did not have evidence showing resident was assessed and monitored for dehydration although resident demonstrated decreased oral intake, had weight loss according to intermittent documentation in the progress notes between 07/13/18 and 01/08/19. On 11/13/18, Resident #13 was admitted to the hospital from the facility. The resident was found dehydrated, in septic shock (potentially fatal medical condition when there is organ damage in response to infection) related to a urinary infection, acute kidney failure and high potassium levels. According to the hospital notes, on 11/13/18 the resident had pus coming out of the urinary meatus (tip of the penis). According to an incident report dated 09/25/18 and a progress note on 09/27/18, Resident #13 developed a new unstageable wound to the left heel. Between 09/25/18 and 11/13/18 weekly skin measurements and assessments were missing. On 12/19/18, state surveyor(s) identified a new skin injury to the ischial area (bony prominence) of which facility was unaware of. Resident #13 remained at the facility between 12/19/18 through 01/08/19. CRITICAL LABS Nursing notes on 01/07/19 at 9:06 PM, showed Resident #13 had a critical potassium level of 6.3. The same note indicated staff attempted to reach the physician at 7:03 PM without success. Approximately fifteen hours later Resident #13 became unresponsive and was sent to the emergency room (ER) on 01/08/19 around 10:00 am. According to the ambulance records, resident's blood pressure was low 81/51 (average normal range 120/80 to 140/90). Admitting ER [DIAGNOSES REDACTED]. On 01/08/19, between 6:10 PM and 6:50 PM, Resident #13 was observed in the ER laying on a gurney. During an interview on 01/08/19 at 6:10 PM, Resident #13 was alert and oriented, was able to make self-understood and understood others. Resident said while he was at the facility, he did not receive enough fluids between meals and had to yell for help when he was thirsty or needed help because staff would clip the call light out of his reach. Resident #13 demonstrated inability to lift his right arm more than a few inches off the bed. Resident #13 also stated he did not have a shower in over two weeks and there was only one nurse who looked at his urinary catheter periodically. Resident #13 also reported the facility was understaffed. During the same observations on 01/08/19 between 6:10 PM and 6:50 PM, it was revealed Resident #13 had dry and flaky skin throughout the body and throughout the mouth. Resident #13's lips were dry and finger nails were long. A thick yellow plaque was noted on the front and the bottom teeth. The gums were a bright red color and swollen. Observation of the bony areas of Resident #13 found approximately 50% of the skin on the right heel looked purple and blue in color, resembling a deep tissue injury. On the front of both thighs, there were longitudinal red skin marks at least 7 cm long, resembling imprints from a brief. Both buttocks were excoriated and bright red with a few areas missing the top skin layer. On the left abdomen, there were three sutures. Further skin observations were completed with assistance of Staff CC F, ER Registered Nurse, at 6:42 PM on 01/08/19. The penis was eroded and the tip was split in half approximately one inch on both sides of the penis. Upon closer assessment of the eroded penis, the ER nurse said it was not a fresh injury. There was pus drainage present around the urinary catheter insertion site. There was stringy sediment in the catheter tubing. These findings were compared against facility assessments prior to this hospitalization . Findings included: -Facility record review, on 01/09/19, showed that, on 01/03/19, the coccyx wound has resolved. -Shower record, reviewed on 1/15/19, showed that between 12/12/18 and 12/31/18, resident had not been showered. - According to record review (Admission/Readmission Nursing Evaluation dated 11/2/18 at 4:00 PM) and obsevations showed Resident #13 remained with abdominal sutures since the admission, or for over two months. No orders were found specifying how to care for the sutures. On 01/09/19 at 3:22 PM, Staff V, Care Manager was asked to research the sutures present on Resident's readmission on November, (YEAR). No further information was provided. -Review of Admission/Readmission Nursing Evaluation, signed and dated on 07/03/18, did not show any disfigurement or penile injuries to the male genitalia and/or the urethra. -Admission/Readmission Nursing evaluation with a date of 11/02/18 at 4:00 PM did not identify any skin problems around the urethra/penile area. On 1/09/18 at 3:39 PM Staff V, Licensed Nurse stated he did not believe Resident #13 readmitted with a split penis in November, (YEAR). Additionally, the emergency room records showed the resident had elevated BUN (blood urea nitrogen, kidney function blood test) at 107 (8-25 is the average normal) and Creatinine 2.25 (0.70-1.30 average normal). The laboratory tests indicated dehydration. Resident's baseline creatinine level was 1.2-1.9 according to a physician's note dated 11/30/18. RESIDENT #7 CRITICAL LABS Resident #7 was neglected and/or there was serious disregard for consequences when facility, nursing staff, and facility physician were not aware of critical laboratory results and the resident's condition was not monitored, as evidenced by lack of vital signs. Resident #7 was admitted on [DATE] for rehabilitation after a hospitalization . Resident had [DIAGNOSES REDACTED]. On 01/11/19 around 3:00 PM, electronic record review identified Resident #7 had a critically low hematocrit level of 21 (HCT is a blood test that measures red blood cells in a person's blood, red blood cells carry oxygen to the body's organs; normal average levels are 34-46). The HCT result was dated 01/10/19 at 5:13 PM. This was a decrease from an HCT of 24 on 01/07/19. On 01/11/18 at 3:04 PM, Staff T, Licensed Nurse, said she was not aware of critical HCT results. Staff T reported she started the shift at 6:00 AM. Staff T, LN, said that during the shift report with the night nurse, she was not informed about critical labs. Staff T said the physician had not been notified yet. Further record review with Staff T did not yield or provide any vital signs or evidence that resident was assessed while she had critical laboratory results. RESIDENT #9 DEHYDRATION RISK Resident #9 was neglected when she was NPO or nothing by mouth, did not receive adequate fluids for over nine hours, and vital signs were not obtained to monitor resident's condition as part of the standard of care. Resident #9 admitted to the facility on [DATE] for rehabilitation after a hip surgery. Resident was at risk for dehydration after developing an ileus (lack of movement in the intestines), according to the nursing notes on 01/10/19. Observations on 01/11/19, between 3:00 PM and 3:37 PM, revealed Resident #9 in bed on her back with eyes closed. Resident had dry, cracked lips and mouth. A pole in the corner of the room had a one liter bag hanging with approximately 1/4 of clear fluid remaining. Resident #9 had a peripheral IV (intravenous line) in the left arm. The fluids were not infusing into the IV line. A family member at the bedside was concerned about the fluid intake and reported that between 9:00 AM to 3:35 PM, the resident did not have anything to drink or eat and no IV fluids. Staff T, LN, on 01/11/19 at 3:37 PM, said she started her shift at 6:00 AM. Staff T said that resident is NPO (nothing by mouth) due to an ileus and constipation, and it appears to be getting worse. Staff T said IV fluids were stopped sometime during the night shift and confirmed that no fluids had infused between 6:00 AM and 3:35 PM. Staff T said that the fluids were not infusing because the physician orders [REDACTED]. Staff T was unable to locate VS for 01/11/19. Staff I, Nurse Manager, said the resident should have had vital signs done every four hours. Staff T, LN stated that she was assigned 19 residents with acute needs and it was impossible to assess and follow up on every resident. RESIDENT #15 CRITICAL LABS Former Resident #15 was neglected when facility did not recognize ongoing acute changes of condition between 12/22/18 and 12/27/18. The resident was not thoroughly assessed and monitored according to standards of care, resulting in actual harm. Resident #15 was admitted to the facility on [DATE] for rehabilitation and had [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] (a blood thinner). The use of this medication requires periodic blood tests called INR (International Normalized Ratio, measures how long it takes blood to form a clot). The average therapeutic range is between INR 2-3. On 12/26/18 Resident #15 had a critical INR of 9.8, according to the nursing notes and laboratory report. The resident was at risk for bleeding due to levels being three times the norm. The resident remained with critical labs and without intervention for at least 21 hours. The physician became aware of critical INR levels on 12/27/18, around 10:20 AM, according to the physician and nurses notes. On 1/09/19 at 2:16 PM, Staff O, LN, explained it was common for the physician(s) not to return call timely. Staff O said that according to her experience, a call back could take up to four hours. According to the record on 12/26/18 at 1:40 PM, Staff O, LN placed the call to the answering service for INR of 9.8. Further record review showed, on 12/27/18 at 11:52 AM, Resident #15 had frank blood in the urinary catheter and was unresponsive. Resident #15 was then sent to the emergency room . The ambulance record showed that the resident had a blood sugar level of 30, a blood pressure level of 92/56 (normal 120/80-140/90), and a heart rate of 58 (normal range is 60-100). On 12/27/18 around 12:08 PM, Resident #15 was admitted to the ER with an increased INR level, registering at (10.9), as documented in the ER records. The resident was diagnosed with [REDACTED]. Baseline kidney function laboratory results and the hospital emergency room results were compared. The previous baseline creatinine (kidney function) results of 2-3 were documented in the facility physician notes on 12/23/18. The emergency room records on 12/17/18 showed worsened kidney function as evidenced by creatinine levels of 7. CHANGE OF CONDITION MONITIORING /VITAL SIGNS Review of events leading up to the emergency hospital transfer showed that Resident #15 had early signs of condition change as evidenced by abnormal vital signs (objective data) at least four days prior. On 12/22/18 at 9:15 AM, Resident's blood pressure (BP) was 75/51, and on 12/23/18 at 3:23 PM, it was still low at 98/52. Further record review did not find evidence that the physician was notified of abnormal vital signs. There was no evidence in the nursing progress notes showing ongoing nursing physical assessment (gathering information through observation, inspection, and palpation in order to make an accurate clinical judgement). SKIN On 12/21/18, Resident #15 was admitted with a bruise on the left thigh, a pea-sized open wound, and a red tailbone area, according to the facility admission notes. Further record review found that treatment and/or monitoring orders for the identified skin problems were started four days after the admitted (on 12/25/18). Facility records did not show ongoing daily assessment of the skin condition(s). RESIDENT #14 Resident #14 was neglected when critical laboratory results were not reported to the physician for three days. CRITICAL LABS Resident was admitted on [DATE] for rehabilitation and had [DIAGNOSES REDACTED]. Record review showed that on 01/01/19, Resident #14 had a critical potassium level of 5.7 (average normal is 3.5-5.2) and an HCT level of 23.4 (average normal is 34-46). On 1/03/19 at 10:10 AM, physician notes documented that critical laboratory values from three days ago were not reported. On 01/08/19 at 12:40 PM, Staff I, Licensed Nurse, said critical labs were missed and not reported for three days. RESIDENT #1 Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing progress notes dated 09/25/18 at 1:31 PM showed Resident #1 complained of nausea twice. [MEDICATION NAME], a medication for nausea, was administered without effect. Note stated, No BM (bowel movement) today, given a suppository, evening nurse made aware. Review of nursing progress note dated 09/26/18 at 9:42 PM states patient continues to have abdominal discomfort and nausea. Given enema, suppository, MOM (Milk of Magnesia), with minimal effect. Had a small BM yesterday. Message sent to ARNP (Nurse Practitioner) and MD (Physician) to request a KUB (type of abdominal x-ray) to rule out obstruction. Not able to participate fully with therapy due to abdominal discomfort. No BM today. Barely eating her meals. Called the MD this evening and left a message for the on call doctor, but no doctor called back. Night nurse aware. Review of a nursing progress note dated 09/27/18 at 1:14 PM showed Resident #1 was seen by the ARNP related to ongoing abdominal discomfort and nausea. The ARNP ordered a KUB which was not able to be done at the facility. The resident was transferred to the emergency room for further evaluation. Refer to F713 for additional information related to physician services. 01/09/18 at 1:45 PM Staff KK, Physician/Medical Director, said that nurses should call the physician right away with abnormal lab results. Staff KK explained that staff could reach the physician by calling the answering service which then would contact the physician if it was urgent and the physician would respond within 30 minutes. Staff KK said that facility staff did not have direct phone numbers to the physician/providers. Staff KK said they started the answering service because nurses could not differentiate between urgent and critical situations. STAFFING On 12/19/18, facility was informed about failed practices relating to staffing. During intermittent observations, care mangers were observed passing medications. One of the responsibilities of a nurse manager included doing weekly skin assessments and measurements and attend Interdisciplinary Team meeting to review the wound progress, nutrition and hydration. 1/10/19 at 9:20 AM. Staff O, Licensed Nurse Care Manager was observed working in the role of a primary nurse (providing direct care). Staff O, LN said she was assigned 17 residents and they all needed skin measurements done today. Staff O, LN said she was not able to complete all of the skin measurements because of extra responsibilities. Staff O, LN, reported that care is often missed on the post-acute care unit due to high acuity. Staff O said that one nurse may be assigned up to 19 residents on the post-acute unit. Staff S, Licensed Nurse Care Manager, was observed working as a primary nurse on 1/9/19 at 1:01 PM and on 1/10/19 at 09:35 AM. During interviews, Staff S said she/he was pulled from the management role to pass medications at least four times in the last two weeks which created a backup in nurse manager duties like skin rounds and IDT meetings and caused staff burnout. On 01/10/19 at 9:35 AM, Staff S was passing medications. Staff S said skin measurements were likely not going to be done today. Staff I, Licensed Nurse Care Manager on 01/10/19 at 12:15 PM was observed passing medications. Staff I said on Thursdays normally care managers came in early to do skin rounds. Today skin rounds were not done because care managers are working the floor. On 01/10/19 at 10:12, Staff W, CNA said she was assigned 15 residents and had to do 4-5 showers in an eight hour shift. Staff W said she could not get all of the showers done. Staff W when she needed a second person she had to go to other units to look for help. Staff W reported it was impossible to turn residents every two hours with the current assignment. On 01/09/19 at 9:17 AM, Staff X, CNA was observed working on the post-acute unit. Staff X said she was assigned 15 residents. Staff X said someone called in sick and she was the only aid on the floor. Staff X said this has been an ongoing problem. Staff X said most residents needed a two person assistance. Staff X said, I can't get to residents on time with this many residents, the nurse is very busy, sometimes I can't feed residents or get them water or turn them. On 01/09/19 1:05 PM, Staff P, Licensed Nurse reported nurse to resident ratio on the post-acute unit was unsafe and the nurses got so busy they did not have time to enter [MEDICATION NAME] orders. During intermittent observations and interviews on 01/10/19 it was identified that facility had two working Hoyer lifts and one sit to stand for the entire facility. Staff W, spoke on condition of anonymity, and explained because there were not enough lifts we can't get residents out of bed sometimes until noon.

Based on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors. The facility did not administer insulin within appropriate time frames and according to standard of care for 6 of 15 residents (Resident #s 13, 19, 21, 22, 23, & 25) reviewed for using high-risk medications. Resident #13 did not receive medication to correct a critical laboratory value, resulting in an omission error, which constituted actual harm. Findings included: RESIDENT #13 Nursing note, dated 01/07/19 at 9:00 PM, identified that Resident #13 had a critical potassium level of 6.3 mmol/L(chemical that is critical to the function of nerve and muscle cells, including those in the heart. A potassium level higher than 6.0 can be dangerous and usually requires immediate treatment.) The same record showed there was an order for [REDACTED]. Resident #13 became unresponsive and was sent to the emergency room (ER) on 01/08/19 at approximately 10:00 AM. Initial hospital assessment and laboratory results showed potassium increased up to 6.6, and resident had [MEDICAL CONDITION] (low heart rate). On 01/09/19 at 1:10 PM, Staff U, Licensed Nurse (LN), stated she was on duty at 6:00 am on 1/08/19. Staff U said during change of shift report with the night nurse abnormal labs were not discussed. Staff U stated the resident did not receive the medication and she was not sure why it was not given on night shift. On 01/09/19 at 1:17 PM, Staff B, Director of Nursing Services (DNS), said he was aware of the omitted medication for Resident #13. Staff B, was asked if a medication error report or an investigation was initiated, Staff B replied no. INSULIN ADMINISTRATION ERRORS The facility scheduled [MEDICATION NAME] (fast acting insulin, peak time of 15 minutes) to be administered at 7:30 AM, 1100 AM and 4:00 PM, which did not match the scheduled meal times of 7:00 AM, 12:00 PM, and 5:00 PM. Based on observation, interview and record review of insulin administration during dinner meal were conducted on 1/13/19, approximately between 4:40 PM and 5:30 PM. It was identified the insulin was not given at appropriate times, placing residents at risk for not getting full therapeutic benefits of the drug and risk for adverse effects. Review of Resident #13's medical record showed a physician's orders [REDACTED]. Review of Resident #13's MAR (Medication Administration Record) showed Resident #13 received [MEDICATION NAME] at incorrect times in relation to meal times on 43 occasions in (MONTH) (YEAR). Review of physician's orders [REDACTED]. Review of Resident #13's MAR for (MONTH) (YEAR) showed that [MEDICATION NAME] was administered over one and a half hours late 18 times and over three hours late five times. RESIDENT #21 During interview on 01/13/19 at 5:05 PM, Staff BB, Registered Nurse (RN), stated that Resident #21 had already eaten dinner, Staff BB further stated that Resident #21 had not yet received insulin. RESIDENT #19 During interview on 01/13/19 at 5:26 PM, Staff DD, Licensed Nurse, stated that Resident #19 had not yet received dinner. Review of Resident #19's MAR indicated [REDACTED]. Staff DD further stated that this medication was administered an hour early. RESIDENT #22 Review of Resident #22's medical records dated 01/13/19 showed that six units of [MEDICATION NAME] were administered at 4:47 PM, or 40 minutes early. RESIDENT #23 Review of Resident #23's medical record for 01/13/19 showed that Resident #23 had not yet received dinner and was provided four units of [MEDICATION NAME] at 4:00 PM, or an hour early. RESIDENT #24 On 01/13/19 at 4:40 PM resident received [MEDICATION NAME] insulin. At 5:25 PM observation no tray no food at bedside, Staff DD said resident did not eat yet. Resident received insulin 45 minutes early. RESIDENT #25 On 1/13/19 at 5:27 PM Resident #25 was in the room waiting for dinner. Resident #25's MAR indicated [REDACTED]. During interview on 1/13/19 at 4:52 PM, Staff BB, stated that [MEDICATION NAME] administration is scheduled for 4:00 PM and that dinner is provided at 5:00 PM. Staff BB further stated that fast acting insulin should be provided prior to meals. On 1/13/19 at 5:30 PM, Staff F, Nurse Manager said that resident food trays had not yet been delivered to resident rooms.

Based on interview and record review the facility failed to ensure availability of physician(s) for emergent care such as critical labs and acute changes of condition. Physicians communicated with nursing staff using a third party answering service. This failure resulted in neglect and/or harm to Resident #'s (1, 13 & 15) related to delay in identifying critical labs and/or changes in medical condition and taking action to ensure medical intervention took place. This failure also placed other residents at risk for not receiving emergent medical interventions. Findings included: RESIDENT #15 On 12/26/18 at 1:40 PM, progress notes showed Resident #15 had critical INR 9.8 (International Normalized Ratio, blood coagulation test, therapeutic levels are normally between 2-3), and was at risk for bleeding. The same note showed Staff O, Licensed Nurse contacted the answering service to get to get a hold of a provider/physician. The resident remained with critical labs for at least 21 hours without intervention(s) by the provider/physician. On 12/27/18 at 10:20 AM, the physician became aware of critical INR when she came to the facility, according to the progress notes. During this time the physician was also informed about a failed attempt to contact her through the call service the day prior for critical labs. Review of progress notes showed on 12/27/18 between 10:20 AM and 11:52 AM during rounds Resident #15 was found with blood sugars of 38, and was bleeding through the urinary catheter. Resident #15 was sent to the emergency room . The ambulance records showed Resident #15 had decrease level of consciousness, had low blood pressure (92/56) and slow heart rate (56). Resident arrived to the emergency room approximately at 12:08 PM on 12/27/18. Upon arrival resident had hematuria (bleeding in urine). The INR level was 10.9. Resident was diagnosed with [REDACTED]. Resident also showed worsened kidney function. RESIDENT #13 Resident #13 remained with critical potassium levels for approximately 15 hours. Progress note on 01/07/19 at 9:06 PM showed Staff JJ, Licensed Nurse attempted to call Staff KK, Physician at 7:03 PM to inform of critical potassium level 6.3, but did not receive a call back. Potassium is a chemical that is critical to the function of nerves and muscle cells, including those in the heart. Normal levels are 3.5-5.3, a level higher than 6.0 can be dangerous and usually requires immediate treatment. Approximately fifteen hours later Resident #13 became unresponsive and was sent to the emergency room (ER) on 1/08/19 around 10:00 AM where he was found with slow heart beat and increased potassium at 6.6 (normal level 3.5 - 5.3). RESIDENT #1 Resident #1 readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing progress notes dated 09/25/18 at 1:31 PM showed Resident #1 complained of nausea twice without relief. On 09/26/18 at 9:42 PM nursing notes showed patient continues to have abdominal discomfort and nausea. Given enema, suppository, MOM (Milk of Magnesia), with minimal effect. Has a small BM yesterday. Message sent to ARNP (Nurse Practitioner) and MD (Physician) to request a KUB (type of abdominal x-ray) to rule out obstruction. Not able to participate fully with therapy due to abdominal discomfort. No BM today. Barely eating her meals. Called the MD this evening and left a message for the on call doctor, but no doctor called back. Night nurse aware. Approximately 15 hours later, according to nursing notes on 09/27/18 at 1:14 PM Resident #1 was seen by the ARNP. The resident was transferred to the emergency room for further evaluation. Resident #1 experienced delay in treatment. Refer to F600 Neglect, for additional information related to Resident #1 Six out of six nurses interviewed reported unsuccessful attempts in contacting the physicians/providers. On 01/08/19 at 12:40 Staff I, Licensed Nurse said there was no direct phone number to call physicians for emergencies. On 01/09/19 at 1:10 PM, Staff U, Licensed Nurse reported facility used answering service since (MONTH) (YEAR). Staff U said there was no direct phone number for a physician for emergencies. Staff U explained that nurses called the answering service and then tell them about the problem and ask the answering service to contact the physician. Staff U said the average response time to get a call back was anywhere from an hour to four hours. On 01/09/18 at 1:01 PM, Staff S, Licensed Nurse said physicians do not call back right away, it's been an ongoing issue. Staff S said last Friday it took two hours to get a call back from a physician/provider. On 01/09/19 at 2:16 PM, Staff O, Licensed Nurse said the physician response averaged anywhere between 30 minutes to an hour and could take longer. Staff said she personally experienced instances where she called the answering service multiple times and there was no response or call back. On 01/09/09 at 2:05 PM, Staff P, Licensed Nurse said it takes up to two hours to hear back from physician after calling the answering service. On 01/09/19 at 2:00 PM, Staff Z, Licensed Nurse reported that sometimes it took hours for providers to call back. Staff Z said there was no direct access to the physician and/or medical director for emergencies. This has been an ongoing issue for months. On 01/09/19 at 1:45 PM, interview with Staff AA, physician/Medical Director. Staff AA confirmed there was no direct access to the physician/ providers. Nursing staff was expected to contact the answering service. Staff AA explained a nurse would contact the answering service with a concern, the answering service screened the call and then contact the physician. Staff AA said if the situation was urgent the provider would respond within 30 minutes. The ineffective communication process and lack of access to a physician for emergencies resulted in harm to Resident #13 &15.

Based on interview and record review the facility failed to ensure sufficient fluid intake to maintain proper hydration and health for _ of 3 Residents. This failure resulted in actual harm to Resident #2 and #3. Findings include: Facility policy titled Hydration Program updated (MONTH) (YEAR) included the following instructions: - Residents are to be offered a minimum of 480 ml of fluid at each meal unless contraindicated by order for fluid restriction. -The nurses observe for signs and/or symptoms of dehydration including loss of appetite, dry mucous membrane, amber urine, decreased urine output, mental confusion and low blood pressure. RESIDENT #2 Resident #2 readmitted to the facility on [DATE] following hospitalization for a urinary tract infection and surgical pain. Minimum Data Set (MDS, a comprehensive assessment) on 10/02/18 showed Resident #2 required extensive assistance with eating. Resident #2 was at risk for dehydration due to problems with chewing, swallowing, and feeding difficulty. Resident was on mechanically altered diet, had poor appetite, and consumed less than 50%, according to Registered Dietician (RD) assessment on 10/4/18. The same assessment showed resident's fluid needs ranged between 1175-2435 ml. Laboratory values of residents kidney function at the time was noted to be a BUN 12 and creatinine of 0.6 (generally normal levels). On 11/08/18 at 1:38 PM, Staff L, RD explained that intake of fluid should be at least 75% of the minimum recommended number or approximately 1631 ml (55 ounces) Record review of resident's fluid intake between 10/17/18 and 10/25/18, found nine entries showing average intake between 240-320 ml (approximately 8-10 oz). On 10/25/18 Resident #2 was sent to the emergency room for low blood pressure and a very low blood sugar of 26 (normal range 70-110), according to the hospital notes dated 10/25/18. Physician #1 identified Resident #2 appeared disheveled and had dry mouth. Physician #2 in a hospital note dated 10/25/18 documented resident #2 was found with very dry mucous membranes. When resident arrived to the emergency roiagnom on [DATE] he was thirsty and was asking to drink as documented in the hospital notes. On 10/25/18 laboratory results showed worsened kidney function, [DIAGNOSES REDACTED]. On 10/25/18 Resident was found with a BUN of 37 and cretonne of 3.22 compared with cretonne of 0.66 on 10/16/18 as documented in the hospital physician notes. The hospital notes showed resident did not have evidence of [MEDICAL CONDITION] based on ultrasound studies on 10/11/18 and on 10/27/18. Physician #3 on 10/26/18 determined Resident #2 had acute kidney injury likely due to poor oral intake of fluids combined with use of [MEDICATION NAME] (diuretic, a water pill). On 10/28/18 in the hospital notes MD #3 mentioned that Resident #2's cretonne levels and [MEDICAL CONDITION] responded to intravenous fluids, supporting the rationale that acute kidney injury was related to dehydration. RESIDENT #4 On 11/13/18 Resident #4 admitted to the hospital with [REDACTED]. Review of nursing notes prior to hospital admission on 11/13/18 revealed resident was exhibiting signs and symptoms of dehydration and a condition change. On 10/23/18, 10/24/18, and 10/25/18 resident had low blood pressure readings of; 80/43, 100/52, 108/51 and 100/48, according to nursing notes. Record review did not find evidence of a thorough physical assessment including evaluation to determine if resident was making adequate amount of urine. Hospital notes titled Emergency Documentation dated 11/13/18 showed resident had hypovolemia which contributing to the septic shock. In the emergency room , the resident was observed with dry mucosa and [MEDICAL CONDITION]. Resident was diagnosed with [REDACTED]. Further review of hospital notes showed Resident's baseline cretonne fluctuated between 1.2 and 1.9 for the past 6 months according to hospital note on 11/18/18. Laboratory results on 11/13/18 at 2:15 PM showed Resident #4's BUN was significantly above the baseline and was at 118 (normal range 6-23), the cretonne was 2.55 ( normal range 0.60-1.20). The physician notes showed after resident was given intravenous fluid in the emergency room it displayed down trending cretonne, or the kidney function was improving due to fluid intake. Record review for Resident #2 and #4 did not find interventions to prevent dehydration and found lack of urinary output monitoring. On 11/7/18 at 2:15 PM Staff D was asked about process for monitoring intake and output. Staff D stated that licensed nurses should be documenting intake and output every shift when residents have urinary catheters or at risk for dehydration.

Based on observation, interview and record review, it was determined that the facility failed to have a system in place to prevent and treat pressure injuries for 3 of 4 Sampled Residents (#s 1,3,4 &5) reviewed for pressure injuries. These failures resulted in harm for Resident #1 due to development of three stage III (full thickness tissue loss) and one unstageable pressure injury (full thickness tissue loss) resulting in amputation. Resident # 4 sustained harm after developing unstageable pressure injury to the left foot. Resident #3 and #5 did not receive ongoing monitoring of pressure injuries. Findings include: According to National Pressure Ulcer Advisory Panel, pressure ulcers that reach full thickness, that is stage III or IV, deep tissue injury or those that are unstageable are considered never events; that is they should never happen. Facility policy and procedure titled Skin Integrity updated (MONTH) (YEAR) included the following guidance: -The licensed nurse is to document skin impairment that includes measurements of size, color, presence of odor, exudates and presence of pain associated with skin impairment in nurse's notes and on the Weekly Wound Evaluation -Evaluates environment, mobility equipment, functional and cognitive ability medications and labs to identify interventions to promote healing/resolution of skin impairment -Initiates Alert Charting -The DNS and/or designee complete a comprehensive review of resident's medical record to evaluate if the pressure ulcer was avoidable or unavoidable. This evaluation is documented in the nursing notes. RESIDENT #1 Resident #1 admitted on [DATE] for rehabilitation following a fall with traumatic injuries including right kneecap fracture. Resident was at risk for developing pressure injuries related to immobility, [MEDICAL CONDITION], diabetes, and behavior problems related to [DIAGNOSES REDACTED]. According to Admission/Readmission Nursing Evaluation dated 6/27/18, and MDS (Minimum Data Set, a required comprehensive assessment) dated 7/04/18 showed Resident #1 admitted to the facility without pressure injuries or skin problems. Between 7/08/18 and 10/25/18 Resident #1 developed four pressure injuries, according to facility incident reports, wound Physician notes, Nurse Practitioner, nurses' notes, weekly skin evaluations and interview with Staff B, Director of Nursing on 11/7/18 at 4:05 PM. Three stage III pressure injuries developed on the left and right buttocks between 7/08/18 and 10/18/18. A right heel pressure injury identified on 7/19/18 became infected became worse and unsalvageable subsequently leading to above the knee amputation. 1) Right Heel Pressure Injury According to initial physical therapy evaluation notes signed 6/30/18, Resident#1 had right kneecap fracture which was treated using a brace. The brace was in use between 6/27/18 and 7/11/18 as indicated in the weekly therapy notes. The resident was also on bed rest. Review of nurses' notes and treatment records did not find evidence the skin integrity around the brace was monitored at least daily. Interview with Staff B, Director of Nursing (DNS) on 11/16/18 at 10:45 AM confirmed that the order for monitoring the brace was not on the Treatment Administration Record (TAR.) An incident report dated 7/19/18 showed a wound physician found resident with a deep tissue injury on the right heel measuring 3x3. The facility incident report indicated resident was primarily bed and wheelchair bound and concluded it was caused by friction. The report did not determine whether deep tissue was avoidable or unavoidable and what other factors contributed to its development. According to facility weekly skin measurements the right heel wound increased in size on 7/25/18 and measured 5x4 cm. The wound remained stagnant for eleven weeks (from 7/25/18 to 10/11/18). The measurements ranged between 4.5x4 cm and 5x5x0.2 cm. The facility failed to recognize the wound was not improving and failed to implement strong interventions. The treatment orders were not accurately transcribed and were not clear, placing nursing staff at risk for misunderstanding the instructions. On 8/23/18 wound physician treatment plan specified to apply skin prep around the wound edges and to apply iodine. The TAR did not show the skin prep order was carried out. On 9/13/18 the wound physician changed the treatment to silver [MEDICATION NAME] and the iodine treatment should have been discontinued. The treatment administration records showed the iodine was not discontinued and nursing applied [MEDICATION NAME] concurrently with [MEDICATION NAME] between 9/14/18 and 10/18/18. On 10/18/18 the wound physician changed the treatment to mixture of santyl and [MEDICATION NAME] (antifungal) powder. The order was transcribed incorrectly on 10/19/18 and read mix Santyl ointment and [MEDICATION NAME] (oral antibiotic) 250 mg capsule and apply to right heel. Nursing notes between 7/19/18 and 10/25/18 did not reflect weekly interdisciplinary team reviewed effectiveness of all interventions and/or treatments and their outcomes. The nursing notes did not show that the area was monitored daily. The nursing notes did not identify that the wound was stagnant for extended period of time. The nursing documentation lacked the following minimal requirements for assessing pressure injuries: - description of pressure reducing support surfaces in use and its effectiveness - description of the peri-wound - diabetic control - psychosocial barriers to wound healing - pain - blood flow to the affected area such as pedal pulses, sensation, temperature, [MEDICAL CONDITION], skin color, capillary refill -signs of infection On 10/18/18 the heel wound measured 7x7x06 cm and had foul odor and on 10/23/18 measured 10.5 x 8.0 x0.6 cm. The wound physician notes showed the right heel wound has decompensated significantly and resident was at risk [MEDICAL CONDITION] and amputation as a life-saving procedure. On 11/13/18 at 1:06 PM Resident #1 was observed in bed with a dressing over a right leg stump covered with a dressing. Resident said they took my leg it was some kind of a bed sore .and it got infected. 2) Left buttock Facility incident report dated 7/08/18 showed Resident #1 developed in-house wound over a bony prominence, on the left upper buttock measuring 13x5 cm. Weekly skin evaluations identified this wound as a pressure injury. On 7/21/18 the nursing staff noted the buttocks have purulent odor/drainage, redness warmth. The pressure injury was stage III according to physician notes on 10/11/18. There was no further information on how the purulent drainage was treated. There was no nursing documentation of measurements and assessment on the weekly skin evaluation section of the electronic records between 8/30/18 and 10/25/18. 3) Left buttock On 7/08/18 left lower buttock wound measured 5 x 5 cm. The weekly skin found various anatomical terminology used to describe skin problems. The affected anatomical locations included; left medial buttocks wound, left distal medial gluteus, and left gluteal fold. The following measurements were recorded: 7/25/18 2 x 2 x 0.2 8/03/18 2 x 2 x 0.2 8/10/18 3 x 3 x 0.1 8/14/18 7 x 4 x 0.2 8/30/18 6.7 x 1.8 x 0.2 9/04/18 3.50 x 1.5 x 0.20 9/11/18 3 x 2 x 0.20 9/18/18 3.5 x 1.5 x 0.20 10/04/18 3.5 x 2.5 x 0.4 10/11/18 5 x 2 x 0.4 10/18/18 5 x 2 x 0.4 10/23/18 5 x 2 x 0.2 Physician notes contained other skin measurements specific to the left buttocks area: Left, Medial Gluteus stage III 8/02/18 10 x 4 x 0.3 cm 8/23/18 7 x 3 x 0.2 8/30/18 6.7 x 1.8 x 0.2 9/06/18 3.5 x 1.5 x 0.2 9/13/18 3 x 2 x 0.2 10/11/18 5.1 x 1.5 x 0.6 10/18/18 5 x 2 x 0.4 the wound worsened Left, Distal Medial Gluteus Stage III 8/2/18 2 x 2 x 0.2 cm 8/23/18 0 x 0 x 0 8/30/18 0 x 0 x 0 Facility staff did not use consistent anatomical terminology for pressure injury locations creating inadequate monitoring process for wound progress. 4) Right buttock On 7/08/18 a wound was noticed on a bony prominence of the right upper buttock measuring 8 cm x 4 cm according to an incident report. Facility weekly skin evaluation included measurements for the right buttock, right gluteal and right gluteal fold. A stage III pressure injury was documented on 7/25/18. On 8/03/18 documented showed the area healed. The area reopened on 10/18/18 and was identified as a stage III pressure injury and remained unhealed through 10/25/18. The following measurements were found on the weekly skin evaluations related to the right buttock area. 7/13/18 20.70 cm 7/25/18 2 x 2.0 x 0.1 cm 8/03/18 2 x 2 x 0.1 cm 8/14/18 0 x 0 x 0 cm 10/18/18 2 x 2 x 0.3 cm According to physician notes dated 10/11/18 and interview with DNS on 11/07/18 at 4:05 PM Resident #1 developed pressure injuries to the buttocks when resident went to a medical appointment in the wheelchair sometime in (MONTH) (YEAR). The resident remained in her wheelchair for extended period of time and sustained deep tissue injury which progressed into open wounds. On 11/07/18 at 4:05 PM, Staff B was asked about pressure relieving devices in use prior to development of the buttock wounds. The DNS said the resident had a roho cushion that she brought from home. The DNS was unable to confirm if staff were checking the roho cushion for deflation on a regular basis. RESIDENT #4 Resident admitted on [DATE] with [DIAGNOSES REDACTED]. Nursing notes on 7/02/18 and Initial Admission and Readmission document dated 7/02/18 stated that Resident #4 had unstageable pressure ulcers on both heels. Nursing notes described bilateral heels with necrotic tissue. The MDS on 7/09/18 showed resident admitted with stage I and stage II pressure injury which contradicted initial nursing assessment. The MDS assessment did not show presence of venous or diabetic ulcers. Staff C, corporate nurse on 11/20/18 at 1:00 PM clarified that Resident #4 had [MEDICAL CONDITION] and [MEDICAL CONDITION] to the right foot. At the time of admission to the facility the left heel had small area of [DIAGNOSES REDACTED] and no open areas to the right heal. Staff C said the assessment on the admission document was inaccurate. 1) Inaccurate wound staging and lack of monitoring of the right heel Between 7/11/18 and 7/31/18 weekly skin measurements identified right heel skin condition as a 'pressure ulcer. Between 7/31/18 and 9/17/18 there were no weekly skin measurements found in the facility records. 2) Left outer side of the foot Resident #4 admitted with abnormal thickening of the skin on the left heel and no open areas. Weekly skin evaluation dated 7/19/18 showed Resident #1 had a pressure ulcer on the left outer side of the foot. Weekly skin evaluation dated 7/24/18 showed the left outer side of the foot measured 1.5 x 0.1 cm and identified the skin problem as a pressure ulcer. There were no further measurements or information in the progress notes related to the identified pressure injury. 3) Left heel On 9/25/18 facility incident report showed resident developed skin damage over a bony prominence. The documentation showed Resident #4 had black brown discolored area on the left heel. Progress note dated 9/27/18 at 12:26 PM showed resident had new unstageable wound to the left heel. The investigation did not determine whether the skin injury on the bony area was avoidable or unavoidable. An order entry on the TAR with start date of 9/28/18 showed a treatment order to the Left Heel for Unstageable Wound to Left Heel. Progress notes on 10/18/18 documented that the left heel remained the same. Between 9/25/18 and 11/13/18 there were no wound measurements documented in the clinical record. There were no comprehensive weekly interdisciplinary notes that included all of the identified skin conditions. The left heel remained unhealed through 11/13/2018 as documented in the hospital notes. Resident #4 was found with eschar present on the left heel and the wound was unstageable. The hospital records showed Resident's feet emitted a foul order. 4) Right buttock Initial admission skin evaluation on 7/02/18 and MDS on 7/09/18 did not show that resident had a skin problem on the buttocks. An order on the TAR with a start date of 9/07/18 identified resident had excoriation and/or a pressure ulcer. The entry read excoriation to buttocks. Related to PRESSURE ULCER. The nursing notes did not show what interventions were in place and what pressure relieving measures were used. Nursing notes did not show ongoing assessment and characteristics of the affected skin. A Device Informed Consent dated 9/19/18 showed alternating pressure mattress used to aid and accelerate healing process of buttocks due to immobility. On 9/20/18 an entry in the nursing notes read pressure injury to right buttocks remains the same this week. There were no follow up measurements recorded and no information whether the area healed or not. There was no documentation in the nursing notes describing if the area was avoidable or unavoidable. Progress notes on 10/18/18 showed the buttocks wound remained the same. Between 10/01/18 and 11/13/18 the treatment to the buttocks was omitted seven times as evidenced by holes or lack of documentation on the TAR. RESIDENT # 3 Resident #3 admitted on [DATE] with existing pressure injuries to the left gluteal area and right outer ankle. The resident had [DIAGNOSES REDACTED]. Resident had no sensation in the lower extremities. Observations on 11/07/18 at 1:55 PM, 11/08/18 at 8:50 AM at 2:07 PM, and on 11/16/18 at 2:07 PM, Resident #1 was in bed on his back. Both heels were not floated and came in direct contact with the mattress. 1) Right ankle Observations on 11/07/18 at 1:55 PM and 11/16/18 at 2:07 PM found dressing undated dressing to the right ankle. On 11/16/18 at 2:07 PM Staff I, CNA was asked about resident's footwear. Resident #3 and Staff I pointed out a pair of sketchers. Resident said he wore them when he was up in a wheelchair. Resident said he periodically left facility and was out for hours. The shoes had hard edges and were shaped in a way that would put pressure over already damaged skin on the right ankle area and the surrounding skin potentially impeding blood flow. Resident said that was the only pair of shoes he had and he needed diabetic shoes. Observations of the resident's wheelchair revealed unpadded foot rest. Nursing notes did not find daily nursing assessments/monitoring of the right ankle wound. 2) Right ischial (bony prominence) area There was a delay in initiating treatment to the right ischial area and the initial skin assessment did not accurately reflect resident's skin condition at the time of admit. Initial facility skin assessment on 10/19/18 did not show that resident admitted with a skin problem to the right ischial area. Observations on 11/07/18 at 1:55 PM identified an open area on the right ischium (bony prominence). The area was approximately a quarter size ulcer with pink wound bed resembling stage II pressure injury. The wound was open to air. Resident reported that yesterday he waited 3-4 hours to be turned. On 11/08/18 at 8:51 AM review of Resident #3 Q2 hour turn schedule documentation dated 11/07/18 showed resident did not have any refusals and was turned twice, at 7:00 AM and 9:00 AM. Staff H on 11/07/18 at 2:10 PM was asked about right ischial area treatment. Staff H said she thought it was a scab and did not know if there was a treatment and referred to Staff D. Staff D was interviewed at 2:15 PM and said there should be a medi-honey dressing but it was not on because it falls off. Right ischial area was observed with Staff D on 11/07/18 at 2:15 PM. Staff D said she saw resident's skin on 10/19/18 and on 10/22/18 and thought she recalled seeing the same open area on 10/22/18 and said it was just an excoriation at the time. Staff D said she was going to do a late entry. Record review with staff D on 11/07/18 at 2:20 PM found a treatment order was obtained two days late on 11/2/18. RESIDENT #5 Resident #5 admitted on [DATE] and was at risk for developing pressure injuries due to [DIAGNOSES REDACTED]. On 11/07/18 at 1:45 PM resident was observed with a fracture boot on the right foot. Record review did not find a pressure injury risk assessment completed at the time of admit. The treatment record did not show that staff were assessing the skin under the boot at least daily. Staff B on 11/08/18 at 8:29 AM said the wounds should be monitored daily until resolved. RCMs should obtain and record weekly measurements on the weekly skin evaluation forms and there should be weekly interdisciplinary notes describing if the wound is better or worse. Anonymous Staff F and Staff G were interviewed between 11/07/18 and 11/16/18. Staff F and Staff G reported ongoing problems with inconsistencies in skin measurements, lack of accurate documentation related to pressure injuries and wounds. Left, Medial Gluteus stage III 8/02/18 10 x 4 x 0.3 cm 8/23/18 7 x 3 x 0.2 8/30/18 6.7 x 1.8 x 0.2 9/06/18 3.5 x 1.5 x 0.2 9/13/18 3 x 2 x 0.2 10/11/18 5.1 x 1.5 x 0.6 10/18/18 5 x 2 x 0.4 the wound worsened Left, Distal Medial Gluteus Stage III 8/2/18 2 x 2 x 0.2 cm 8/23/18 0 x 0 x 0 8/30/18 0 x 0 x 0 Facility staff did not use consistent anatomical terminology for pressure injury locations creating inadequate monitoring process for wound progress. 4) Right buttock On 7/08/18 a wound was noticed on a bony prominence of the right upper buttock measuring 8 cm x 4 cm according to an incident report. Facility weekly skin evaluation included measurements for the right buttock , right gluteal and right gluteal fold. A stage III pressure injury was documented on 7/25/18. On 8/03/18 documented showed the area healed. The area reopened on 10/18/18 and was identified as a stage III pressure injury and remained unhealed through 10/25/18. The following measurements were found on the weekly skin evaluations related to the right buttock area. 7/13/18 20.70 cm 7/25/18 2 x 2.0 x 0.1 cm 8/03/18 2 x 2 x 0.1 cm 8/14/18 0 x 0 x 0 cm 10/18/18 2 x 2 x 0.3 cm According to physician notes dated 10/11/18 and interview with DNS on 11/07/18 at 4:05 PM Resident #1 developed pressure injuries to the buttocks when resident went to a medical appointment in the wheelchair sometime in (MONTH) (YEAR). The resident remained in her wheelchair for extended period of time and sustained deep tissue injury which progressed into open wounds. On 11/07/18 at 4:05 PM, Staff B was asked about pressure relieving devices in use prior to development of the buttock wounds. The DNS said the resident had a roho cushion that she brought from home. The DNS was unable to confirm if staff were checking the roho cushion for deflation on a regular basis. RESIDENT #4 Resident admitted on [DATE] with [DIAGNOSES REDACTED]. Nursing notes on 7/02/18 and Initial Admission and Readmission document dated 7/02/18 stated that Resident #4 had unstageable pressure ulcers on both heels. Nursing notes described bilateral heels with necrotic tissue. The MDS on 7/09/18 showed resident admitted with stage I and stage II pressure injury which contradicted initial nursing assessment. The MDS assessment did not show presence of venous or diabetic ulcers. Staff C, corporate nurse on 11/20/18 at 1:00 PM clarified that Resident #4 had [MEDICAL CONDITION] and [MEDICAL CONDITION] to the right foot. At the time of admission to the facility the left heel had small area of [DIAGNOSES REDACTED] and no open areas to the right heal. Staff C said the assessment on the admission document was inaccurate. 1) Inaccurate wound staging and lack of monitoring of the right heel Between 7/11/18 and 7/31/18 weekly skin measurements identified right heel skin condition as a 'pressure ulcer. Between 7/31/18 and 9/17/18 there were no weekly skin measurements found in the facility records. 2) Left outer side of the foot Resident #4 admitted with abnormal thickening of the skin on the left heel and no open areas. Weekly skin evaluation dated 7/19/18 showed Resident #1 had a pressure ulcer on the left outer side of the foot. Weekly skin evaluation dated 7/24/18 showed the left outer side of the foot measured 1.5 x 0.1 cm and identified the skin problem as a pressure ulcer. There were no further measurements or information in the progress notes related to the identified pressure injury. 3) Left heel On 9/25/18 facility incident report showed resident developed skin damage over a bony prominence. The documentation showed Resident #4 had black brown discolored area on the left heel. Progress note dated 9/27/18 at 12:26 PM showed resident had new unstageable wound to the left heel. The investigation did not determine whether the skin injury on the bony area was avoidable or unavoidable. An order entry on the TAR with start date of 9/28/18 showed a treatment order to the Left Heel for Unstageable Wound to Left Heel. Progress notes on 10/18/18 documented that the left heel remained the same. Between 9/25/18 and 11/13/18 there were no wound measurements documented in the clinical record. There were no comprehensive weekly interdisciplinary notes that included all of the identified skin conditions. The left heel remained unhealed through 11/13/2018 as documented in the hospital notes. Resident #4 was found with eschar present on the left heel and the wound was unstageable. The hospital records showed Resident's feet emitted a foul order. 4) Right buttock Initial admission skin evaluation on 7/02/18 and MDS on 7/09/18 did not show that resident had a skin problem on the buttocks. An order on the TAR with a start date of 9/07/18 identified resident had escoriation and/or a pressure ulcer. The entry read exocoriation to buttocks. Related to PRESSURE ULCER. The nursing notes did not show what interventions were in place and what pressure relieving measures were used. Nursing notes did not show ongoing assessment and characteristics of the affected skin. A Device Informed Consent dated 9/19/18 showed alternating pressure mattress used to aid and accelerate healing process of buttocks due to immobility. On 9/20/18 an entry in the nursing notes read pressure injury to right buttocks remains the same this week. There were no follow up measurements recorded and no information whether the area healed or not. There was no documentation in the nursing notes describing if the area was avoidable or unavoidable. Progress notes on 10/18/18 showed the buttocks wound remained the same. Between 10/01/18 and 11/13/18 the treatment to the buttocks was omitted seven times as evidenced by holes or lack of documentation on the TAR. RESIDENT # 3 Resident #3 admitted on [DATE] with existing pressure injuries to the left gluteal area and right outer ankle. The resident had [DIAGNOSES REDACTED]. Resident had no sensation in the lower extremities. Observations on 11/07/18 at 1:55 PM, 11/08/18 at 8:50 AM at 2:07 PM, and on 11/16/18 at 2:07 PM, Resident #1 was in bed on his back. Both heels were not floated and came in direct contact with the mattress. 1) Right ankle Observations on 11/07/18 at 1:55 PM and 11/16/18 at 2:07 PM found dressing undated dressing to the right ankle. On 11/16/18 at 2:07 PM staff Staff I, CNA was asked about resident's footwear. Resident #3 and Staff I pointed out a pair of sketchers. Resident said he wore them when he was up in a wheelchair. Resident said he periodically left facility and wasout for hours. The shoes had hard edges and were shaped in a way that would put pressure over already damaged skin on the right ankle area and the surrounding skin potentially impeding blood flow. Resident said that was the only pair of shoes he had and he needed diabetic shoes. Observations of the resident's wheelchair revealed unpadded foot rest. Nursing notes did not find daily nursing assessments/monitoring of the right ankle wound. 2) Right ischial (bony prominence) area There was a delay in initiating treatment to the right ischial area and the initial skin assessment did not accurately reflect resident's skin condition at the time of admit. Initial facility skin assessment on 10/19/18 did not show that resident admitted with a skin problem to the right ischial area. Observations on 11/07/18 at 1:55 PM identified an open area on the right ischium (bony prominence). The area was approximately a quarter size ulcer with pink wound bed resembling stage II pressure injury. The wound was open to air. Resident reported that yesterday he waited 3-4 hours to be turned. On 11/08/18 at 8:51 AM review of Resident #3 Q2 hour turn schedule documentation dated 11/07/18 showed resident did not have any refusals and was turned twice, at 7:00 AM and 9:00 AM. Staff H on 11/07/18 at 2:10 PM was asked about right ischial area treatment. Staff H said she thought it was a scab and did not know if there was a treatment and referred to Staff D. Staff D was interviewed at 2:15 PM and said there should be a medi honey dressing but it was not on because it falls off. Right ischial area was observed with Staff D on 11/07/18 at 2:15 PM. Staff D said she saw resident's skin on 10/19/18 and on 10/22/18 and thought she recalled seeing the same open area on 10/22/18 and said it was just an escoriation at the time. Staff D said she was going to do a late entry. Record review with staff D on 11/07/18 at 2:20 PM found a treatment order was obtained two days late on 11/2/18. RESIDENT #5 Resident #5 admitted on [DATE] and was at risk for developing pressure injuries due to [DIAGNOSES REDACTED]. On 11/07/18 at 1:45 PM resident was observed with a fracture boot on the right foot. Record review did not find a pressure injury risk assessment completed at the time of admit. The treatment record did not show that staff were assessing the skin under the boot at least daily. Staff B on 11/08/18 at 8:29 AM said the wounds should be monitored daily until resolved. RCMs should obtain and record weekly measurements on the weekly skin evaluation forms and there should be weekly interdisciplinary notes describing if the wound is better or worse. Anonymous Staff F and Staff G were interviewed between 11/07/18 and 11/16/18. Staff F and Staff G reported ongoing problems with inconsistencies in skin measurements, lack of accurate documentation related to pressure injuries and wounds.

Based on interview and record review, the facility failed to ensure implementation of its policy for use of an assistive device to prevent accidents while ambulating one of two residents (discharged Resident #1) reviewed for falls. Staff ambulated Resident #1 to the bathroom without using a gait belt as per facility policy. This failure resulted in harm to Resident #1 who bumped into a railing, lost balance and fell , resulting in a fractured femur. Findings included: Record review of the facility's policy titled Gait Belt dated 02/2003 showed that staff were to use a gait belt to transfer and ambulate residents unless contraindicated on the resident's care plan. Use of the gait belt included when ambulating a resident even if a walker or other assistive device was in use. Record review showed Resident #1 readmitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 02/05/18 revealed the resident was at risk for falls related to deconditioning (muscle weakness). Review of Physical Therapy's evaluation completed on 02/06/08 revealed the resident was at risk for falls related to balance, gait and strength impairment. Review of a facility investigation dated 02/07/18 at 5:00 AM revealed Staff F, Certified Nursing Assistant (CNA), assisted Resident #1 to the bathroom. Resident #1 walked with a walker into the bathroom. The resident bumped into a handrail next to the toilet, attempted to turn, lost his balance and fell to the floor with his right leg bent under him. Resident #1 immediately complained of 10/10 pain and transferred to the emergency room for evaluation. During interview at 10:15 AM on 02/20/18, Staff B, Director of Nursing, (DNS), clarified that Staff F, CNA, did not use a gait belt when she walked with the resident to the bathroom. Review of Resident #1's emergency room record dated 02/07/18 showed X-Rays revealed a right femoral neck fracture. During interview at 9:30 AM, Staff C, CNA, stated that staff were required to use a gait belt for all transfers and when walking with a resident using a walker. During interview at 9:35 AM, Staff D, CNA, stated that staff had to use a gait belt for all transfers. She added it was important to use one when walking with residents using a walker so you had a good hold on them. During interview at 9:40 AM on 02/20/18, Staff A, Administrator, stated that staff were required to use a gait belt for all transfers. Reference WAC 388-97-1060 (3) (g)

Based on observation, interview, and record review, the facility failed to provide an individualized approach for exhibited problematic behaviors for 1 of 3 sample residents (#1) reviewed for dementia care. The facility did not utilize interdisciplinary team (IDT) approach in behavior management and did not deliver person centered care to holistically meet the needs of Resident #1 as well as the needs of other residents. The facility failed to identify behavioral triggers and did not recognize Resident #1's behaviors were intrusive and impeded other residents' rights to privacy and quality of life. Failure to manage Resident #1's behaviors based on comprehensive assessment and without individualized interventions, allowed the resident to exhibit unsafe behaviors and subjected Resident #2 ,#5, #6 & #9 to unsolicited intrusion of privacy when the resident entered rooms uninvited. Resident #1 continued demonstraing unmet needs through agitation and experienced diminished quality of life. This failure constitued actual harm according to a reasonable person concept. Findings include: According to CMS, Dementia is not a specific disease, it is a descriptive term for a collection of symptoms that can be caused by a number of disorders affecting the brain. People with dementia have significantly impaired intellectual functioning that interferes with normal activities and relationships. They lose the ability to solve problems and maintain emotioanl control and may experience personality changes and behavioral problems such as agitation. Person centered care is based on an individualized approach tailored to all relevant considerations for that individual, including physical, functional, and psychosocial aspects. The facility Behavior Management Policy and Procedure stated in part that residents exhibiting new behaviors would be forwareded to IDT via the 24 hour report communication, and staff was to implement behavior monitoring flowsheet(s). The behavior monitor flow sheet included number of behaviors, triggers, interventions, and outcomes, and was to be completed as indicated when behaviors were exhibited. The IDT would then review the comprehensive assessments and the care plans for appropriate [DIAGNOSES REDACTED]. The IDT would review resident records and behavior flow sheets to evaluate whether the current care plan was effective. The behavior flow sheets were totaled each month and the IDT evaluated behaviors of residents referred to the IDT. Resident #1 Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the hospital records, the resident was a smoker and was on a nicotine patch during his hospitalization . Resident #1's 9/2016 comprehensive care plan described cognitive loss related to the [DIAGNOSES REDACTED]. The goal for this problem was that Resident #1 would have minimal psychosocial harm related to cognitive loss. Interventions included providing a routine, encourage verablization of needs, monitor for possible pscyhosocial harm. The care plan included a problem with wandering behaviors. The goal for this problem was Resident will be safe and aimless wandering will be replaced with diversional activities. Interventions for this problem included to assess potential causes for wandering, provide diversional activities, folding, rummaging box, be alert to triggers creating negative responses such as hunger, thirst, pain, toileting needs, lack of social interactions or boredom, and to record behaviors on the Behavior Tracking Form. On 11/15/16 Resident #1 was observed by facility staff kissing with another resident as indicated in the facility incident investigation. The facility did not evaluate this incident thoroughly to identify possible consequences of the resident's behavior. See F225 for additional information. During observation and interview on 1/13/17 at 2:07 p.m., Resident #5 said Resident #1 wandered in and out of her room a number of times. Resident #5 was unable to recall specific dates or times but remembered Resident #1 came into the room uninvited at night on one occasion. Resident #5 said she felt startled. Resident #5 was asked if she reported this to facilty staff she said no everyone knows it. During observations and interview, Resident #2 was in bed covered with a blanket. Resident #2 was asked if anyone came into her room uninvited. Resident #2 said I am a widow and said a male individual came into her room and sat on her bed and she kicked him out. Resident #2 was unable to provide a description of the individual and denied being feaful. Resident #2 was unable to provide specific information or details. During observations and interview on 1/17/17 at 3:05 p.m., Resident # 9 said a few times in the past a younger man came into her room uninvited and opened her closet and touched personal items. Resident #9 described Resident #1's physical features. During observations and interview on 1/17/17 at 3:24 p.m., Resident #6 said Resident #1 came in and out of her room several times in the past. Resident #6 did not know why he came into her room. Resident #6 said she previously filed a grievance report with the facilty. According to nurses notes on 12/4/16 and 12/6/16, Resident #1 was trying to enter other residents' rooms. When staff attempted to redirect, Resident #1 verbalized a desire to do something or a need to be helfpul. During this time a nurse noted resident slept intermittently during a shift. There was no further assessment done to explore sleep as a contributing factor to behaviors. A timeline of behaviors documented in the nursing notes showed Resident #1 had an increase in agitation and behaviors starting on 12/11/16 escalating on 12/20/16 and 1/12/17. Between 12/11/16 until 1/12/17, Resident #1 demonstrated aggression, agitation, had noted episodes of delusion and required redirection for pacing, wanting to cut off the wanderguard, was yelling, and had confusion as documented in the nursing progress notes. On 12/11/16 Resident #1 was yelling, kicking clothes and luggage in the hallway. The roomate was removed for safety reasons. On 12/12/16 a new order was given for [MEDICATION NAME], the new dose was given on 12/13/16 according to the medication administeration record (MAR). Resident #1 showed agitation and wanted staff to cut off the wanderguard. Resident #1 was difficult to redirect. On 12/13/16 Resident #1 had increased ammonia levels and continued pacing and asking staff to remove the wanderguard. (Elevated blood ammonia levels is a condition related to [MEDICAL CONDITION], caused by liver disease. The elevated ammonia levels cause mental status changes and subsequent behavior changes). Although the resident had an underlying dementia, the elevated ammonia levels could result in [MEDICAL CONDITION], a sudden onset of mental status and behavior changes, and once the ammonia levels are brought to normal levels in the blood, the [MEDICAL CONDITION] would resolve, although, the dementia continues. Resident #1 was prescribed an increased [MEDICATION NAME] dose on 12/13/16. Between 12/13/16 and 12/17/16, the resident had one medium bowel movement recorded on 12/14/16, although additional doses were given. [MEDICATION NAME] is given to increase bowel movements in order to remove excess ammonia from the body. [MEDICATION NAME] is typically given until two or three soft stools are produced daily. Resident #1's ammonia levels continued to increase between 12/13/16 and 12/19/16. There was no evidence in the records to show lack of daily bowel movements was considered as contributing factors to behaviors. Resident #1 had a history of [REDACTED]. There was no nursing assessment or interventions documented in the nursing notes on 12/17/16 and 12/18/16 regarding Resident #1's behaviors and any response to any interventions that may have been implemented. On 12/20/16 at 10:20 p.m., Resident #1 lit a piece of paper on fire with a lighter and dropped the paper on the carpeted floor in the hallway. At that time the facility completed an investigation and did not identify any care needs that may have contributed to the behavior of lighting a piece of paper on fire with a lighter and dropping it on the floor. The facility confirmed with the resident's brother that Resident #1 was a prior smoker. Resident #1's need to smoke was not recognized as a possible conributing factor for obtaining a lighter. Record review of the resident record did not find evidence of an IDT behavior evaluation after two significant events that had potential for serious consequences. (Possible sexual assault toward another resident and lighting a fire in the facility). There was no evidence showing if the IDT implemented relevant, individualized actions following the two significant incidents provoked by behaviors. Record review ot the resident record, found Resident #1 had one behavior monitoring flow sheet for the month of December 2016. This flow sheet did not reflect behaviors described in the nurses notes in the month of December 2016. See F514. The behavior flow sheet for December 2016 listed sexual comments or actions in the behavior section. In the section titled trigger on the same flow sheet effects of disease . cares . other as listed. Behavior flow sheets identified interventions as redirect . reapproach, remind, educate . ensure privacy & dignity notify RCM (resident care manager) or (social services) S.S . The form was blank and did not list behaviors demonsrated by the resident in December 2016. On 1/6/17 Resident #1 was exit seeking and agitated according to nursing notes. On 1/11/17 Resident #1 was awake throughout the night, anxious, had confusion and paced in the hallway according to the nursing notes. On 1/12/17 Resident #1 had increased agitation and said to a nurse that he would murder everyone here tommorow according to SS notes. Resident #1 was sent to the emergency room and returned on 1/13/17. Record review found Resident #1 was not placed on the alert charting log until 1/16/17. See F514. On 1/13/17 at 2:50 p.m., observations revealed Resident #1 standing in the hallway. Staff F was providing 1:1 (one resident per one care staff) supervision after the resident threatened to kill everyone at the faciltiy. Staff F was asked why Resident was on 1:1 and Staff F said I don't know. When asked if she was instructed on what to look for during 1:1 supervision, Staff F said not and said I dont' know . he keeps walking. On 1/17/17 at 1:58 p.m. Resident #1 was walking in the hallway independently. At this time the resident was supposed to be on a 1:1 supervision, however there was no employee in sight who was assigned to do 1:1. On 1/17/17 at 2:27 p.m. Resident #1 continued independently walking in the hallway wtihout a 1:1. Observations were shared with Staff B. Staff B indicated she was aware and left to get an employee. Resident #1 on 1/18/16 at 3:20 p.m. was ambulating in the hallway. Resident #1 was able to follow directions and participated in the interview conducted in his room. Resident #1 said he liked to meditate and liked tennis. When asked about his day he said I just sit here. On 1/18/16 at 3:35 p.m. CC2 said resident #1 was not violent, just bored and did not get attention from staff until he started a fire recently and facility placed him on 1:1 supervision. CC2 said facility staff did not know what to do with Resident #1 and his behaviors. CC2 said facility staff called up to eight times a day about his behaviors and sought advise from CC2. Staff H was interviewed regarding the facility behavior management system on 1/17/17 at 4:01 p.m. Staff H explained the behavior management process included assesing residents during scheduled MDS (Minimal Data Set, a comprehensive assessment tool) and if behaviors or utilization of [MEDICAL CONDITION] medications were identified, the facility initiated behavior monitoring flow sheets. Behaviors were documented by nursing staff and nurses charted by exception. The flow sheets were located in the alert charting books. Staff H said the facility held weekly behavior meetings. Staff H said IDT relied on nurses' notes and behavior tracking sheets, and the alert charting log for determining which residents needed to be brought to the behavior review meeting. Staff H said SS could make suggestions on managing behaviors if they were aware there was a problem. When asked about Resident #1's behavior management, Staff H said a psychiatrist was scheduled to see the resident tommorow. Staff H said Resident #1 resorted to being a janitor and if he saw a dirty room he would go in and try to clean it. When asked Staff H what target behaviors were identified after the incidents on 11/15/16 and 12/20/16, Staff H answered a psychiatrist was consulted and recommended starting a [MEDICAL CONDITION] medication, however, the family member was not in agreement. Staff H said in December 2016 staff monitored the behaviors listed on the behavior flow sheet. Staff H was unable to locate weekly IDT notes for Resident #1. The facility did not adequately identify appropriate activities to assist the resident with boredom and prevent escalating behaviors.

Based on record review and interview, the facility failed to provide necessary care and services to promote healing of a pressure ulcer acquired in the facility for 1 of 4 residents (Former Resident #1) reviewed for pressure ulcers. The facility failed to provide evidence of evaluating the effectiveness of care plan interventions and/or revising the interventions in a timely manner to prevent worsening of the pressure ulcer. The facility failed to timely notify the physician when the condition of Resident #1's pressure ulcer initially was not showing signs of improvement. These failures resulted in harm for Resident #1 who required hospitalization for wound care including surgical debridement and [DEVICE]. Findings include: Closed record review revealed Resident #1 admitted to the facility during 6/2012 for therapy following surgical repair of a right [MEDICAL CONDITION]. Review of an admission skin assessment dated [DATE] revealed the resident did not have pressure ulcers when admitted . Review of the resident's record revealed a care plan dated 7/6/12 for Fracture - Trauma Care that identified impaired physical mobility as a risk for impaired skin integrity due to immobility. Interventions, in part, included turn and reposition every two hours and pressure reducing mattress. Review of a facility form "Pressure Evaluation" dated 6/29/12 revealed the resident developed two Stage II pressure ulcers (partial thickness skin loss). One was located on the right ischium (lower buttock) documented as 3 centimeters (cm) by 1 cm. The ulcer resolved on 7/10/12. The second Stage II pressure ulcer was noted also on 6/29/12 on the left ischium. Review of weekly documentation of the above pressure ulcer showed the following measurements/treatments: 6/29/12 - 1.5 by 2 cm (no depth), Stage II, pink/beefy red wound bed, no drainage. Treatment cleanse with normal saline, apply skin prep, cover with [MEDICATION NAME], change every 3 days and as needed. 7/3/12 - 2.3 by 2.0 cm, (depth not indicated), Stage II, serosanguineous drainage, minimal amount, same treatment. 7/10/12 - 2.5 by 2.3 cm (depth not indicated), Stage II, sero-sanguineous drainage, minimal amount, same treatment. 7/17/12 - 4.1 by 3.5 cm (depth not indicated), Stage not identified, 30% eschar (thick leathery necrotic (dead) tissue), 10% slough (necrotic tissue in the process of separating from viable portions of the body), serous drainage, minimal amount, red surrounding skin, wound edges hard, painful to touch. Discovered on 7/14/12 (documentation dated 7/17/12 during weekly wound rounds), treatment change obtained for Santyl and foam dressing. 7/17/12 - new - left ischium ulcer split - 1.5 by .5 cm, undetermined Stage, 100% slough, red surrounding skin. Discovered on 7/14/12 and same treatment as above. Review of "Pressure Ulcer Care Plan" dated 6/29/12 (date the pressure ulcers were discovered) revealed, in part, the same interventions as identified on the care plan for Fracture/Trauma for turning and repositioning every two hours and pressure reducing mattress. The care plan also included an intervention to notify the physician of failure to demonstrate progress in healing after 14 days. There was no evidence the interventions already in place were evaluated for effectiveness given that the resident developed two pressure ulcers on 6/29/12. There was no evidence of care plan revision and/or addition of new interventions until 7/16/12 after the pressure ulcer on the left ischium/buttock had worsened. During interview on 9/6/12 at 12:20 p.m., Staff C (care manager) confirmed the physician was not notified when Resident #1's wound increased in size, showed drainage and no sign of progress in healing after 14 days. Staff C stated there was no indication for a change in treatment or notification of the physician because the amount and characteristics of the drainage had not changed. Staff C stated the physician assessed the resident's wound on 7/17/12 and identified it as a boil and/or abscess and recommended a wound clinic evaluation for possible incision and drainage. Review of a hospital record dated 7/19/12 revealed Resident #1 was admitted to the hospital on [DATE] following evaluation of the pressure ulcer in the hospital's wound clinic. Documentation showed a [DIAGNOSES REDACTED]. A culture revealed the wound was infected; the wound was surgically debrided and a [DEVICE] placed to promote healing. During interview on 9/6/12 at 12:20 p.m., Staff C and A (director of nursing) stated Resident #1 was not consistently compliant with turning and repositioning while in bed and the resident spent many hours out of bed in the wheel chair. Review of the resident's care plan revealed the issue of resident non-compliance was not included; there was no evidence risks were discussed with the resident and no evidence of interventions for increased pressure relief while the resident was in bed or in the wheel chair. During the above interview, Staffs A and C confirmed additional interventions for pressure relief for the bed and wheel chair were not implemented until after the further decline of the pressure ulcer noted on 7/14/12. An air loss mattress was obtained on 7/16/12 and a Roho wheel chair cushion was implemented on 7/17/12. During interview in another facility on 8/31/12 at 11:05 a.m., Resident #1 recalled her stay in the named facility. She recalled the "sore hurting some" for two weeks but then it changed to "stinging" the day before she went to the hospital. Resident #1 did not recall not wanting to turn when she was in bed; she did not recall being told it was not good for the sore to sit in the wheel chair for long periods until a therapist at the hospital told her to raise herself up and down in the chair to relieve pressure. Resident #1 stated she made the appointment for the wound clinic independent of the facility.

Based on observation, interview and record review, the facility failed to timely treat 1 of 1 Sampled Residents (#73) who had a urinary tract infection and an indwelling urinary catheter. Delay in treatment resulted in continued high fever and malaise, which constituted harm for this resident. Findings include: RESIDENT #73: Resident #73 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED].) According to a nursing assessment dated [DATE], the resident was hospitalized again from 1/17 to 1/21/11 for treatment of [REDACTED]. Observation: During an interview of the resident on 3/3/11 at 9:15 a.m., and during wound care observation on 3/7/11 at 10:55 a.m., the resident had a foley catheter in place (a tube to drain urine from the bladder) which was connected to a drainage bag hanging on the side of the bed. Progress Notes/Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of progress notes dated 2/2/11 at 6 p.m. indicated Resident #73 complained of a headache and feeling cold. Assessment of vital signs revealed a fever of 101 degrees. The next day, on 2/3/11 at 11:50 a.m., Resident 73's temperature was 104 degrees. A urine "dip stick" (quick) test revealed abnormalities indicating a possible urinary tract infection. The physician, who was in the facility at the time, ordered an antibiotic ([MEDICATION NAME]) to treat the infection. Progress notes written 2/3/11 on the "evening" shift indicated the resident would be given the [MEDICATION NAME] as soon as it arrived from the pharmacy. At that time, the resident had a fever of 102.2. A new medication, [MEDICATION NAME], which was ordered 2/1/11, was also started on that shift to increase the resident's appetite. A progress note dated 2/4/11 at 1 p.m., indicated the resident's fever increased to 102.6. The note indicated the licensed nurse had called the pharmacy and was told the [MEDICATION NAME] would be delivered by 1 p.m. that afternoon. A separate progress note dated 2/4/11, "evening", noted the [MEDICATION NAME] was not in yet. A note at 11 p.m. stated that the [MEDICATION NAME] was unavailable and that the pharmacy had promised to deliver it at 1 p.m. but had not done so. The note indicated the resident stated, "I'm not feeling good," and that she was "showing no reaction to the new medication, [MEDICATION NAME]. " A progress note on 2/5/11, "day", indicated the Licensed Nurse (LN) called the pharmacy and was told the [MEDICATION NAME] needed to be held due to interaction with [MEDICATION NAME]. The LN called the physician who ordered the [MEDICATION NAME] to be held until the course of [MEDICATION NAME] was completed. The note indicated the resident felt "ok, but tired." The resident's MAR indicated [REDACTED]. Communication with Pharmacy and Physician: Record review revealed a fax message from the pharmacy dated 2/3/11 which read, "[MEDICATION NAME] can potentiate (increase) [MEDICATION NAME] ([MEDICATION NAME]) effects causing [MEDICAL CONDITION], coma and death. Please consult MD, recommend holding [MEDICATION NAME] until 2 weeks after [MEDICATION NAME] therapy is complete and refax MD orders so [MEDICATION NAME] can be processed." Another faxed communication in the record dated 2/4/11 from the pharmacy entitled, "YOUR ORDER CANNOT BE PROCESSED," read, "Level 1 drug interaction with [MEDICATION NAME]. Concurrent use may result in hypertensive crisis. Manufacturer recommends at least 14 days between switching therapies. Suggest switching to a different antibiotic. Please clarify with MD." No evidence was present in the record to indicate licensed staff either responded to the fax from the pharmacy or contacted the physician prior to 2/5/11 at 11:40 a.m. when the physician ordered, "Hold [MEDICATION NAME] until [MEDICATION NAME] therapy finished." The MAR indicated [REDACTED]. During interviews on 3/8/11 at 3 p.m. and 3/10/11 at 10:25 a.m., Staff B, DNS, stated that the pharmacy should have called the facility regarding the reason for not sending the medication rather than "just sending a fax." Staff B acknowledged that the time period between the physician ordering the antibiotic and the beginning of therapy (more than 2 days) was not acceptable. During an interview on 3/11/11 at 2:30 p.m., Staff C stated the facility had provided the surveyor with copies of all faxed information from the pharmacy to the facility. The facility did not provide evidence that licensed staff responded to pharmacy communication requests and/or contacted the physician in a timely manner. The urine culture report dated 2/7/11 confirmed Resident #73 had a urinary tract infection. Resident #73 was at risk for [MEDICAL CONDITION] as indicated by her history. Her fever and urine test indicated the probability of a urinary tract infection but the antibiotic ordered by the physician was not given until more than two days after it was ordered. During this time, Resident #73, who was at risk of again developing [MEDICAL CONDITION], experienced fevers up to 104 degrees and "did not feel well." .

Based on observation, interview, and record review the facility failed to ensure full range of motion was maintained for 1 of 4 sample residents (#3). This failure resulted in development of a contracture to the right leg, which constituted harm. Findings include: Review of Resident #3's record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital physical therapy note dated 7/6/10 revealed Resident #3's range of motion was within functional limits with the exception of decreased right hip range of motion due to pain and weakness. There was no documentation of contractures noted on this form. Review of a facility form titled, "Nursing Admission Evaluation," (from admission 7/8/10) revealed Resident #3 had a total of 14 staples to three incisions on his right hip. The form revealed Resident #3 had actual pain and the movement in his right hip/knee was limited. Review of a facility form titled, "Pain Evaluation" dated at the time of admission, revealed the resident had pain in the right hip and leg as a result of recent surgery. The form indicated the pain affected the resident's activities of daily living, his sleep, his mobility, and his rehabilitation. Review of a physical therapy note dated 7/9/10 revealed he was able to walk more than 100 feet with restorative nurses aides using a front wheeled walker. The note indicated Resident #3's lower extremity strength was within functional limits except his willingness to move was reduced due to pain. There was no documentation of an existing contracture. Review of Resident #3's Activities of Daily Living care plan dated 7/14/10 revealed he did not walk and required a wheelchair for mobility. He received both physical and occupational therapy and could only bear his full weight while working with therapy. The care plan indicated the resident required assistance with activities of daily living due to contractures, fracture, surgery, and dementia. The care plan indicated the resident was at risk for further decline as a result of his medical condition, but did not indicate he was at risk for contractures. Review of a facility form titled, "Interdisciplinary Team Meeting" dated 7/15/10 revealed Resident #3 was alert and oriented to self and family members only. The note indicated the resident "does not make needs known." It also indicated the resident refused to get up and noted that this was possibly related to pain. There was no notation that his pain and behaviors were to be evaluated. Review of Resident #3's Comprehensive Assessment ((MDS) dated [DATE] revealed the resident had both short and long term memory loss, had moderately impaired cognitive skills for daily decision making, resisted care, and had moderate pain on a daily basis. The assessment also indicated the resident had limited range of motion of the leg on one side. Review of Interdisciplinary Team Meeting notes dated 7/28/10 revealed Resident #3 was standing at the parallel bars with physical therapy and the goal was to get him walking more. Review of interdisciplinary progress notes revealed on 7/21/10 the resident was cooperative with care except some resistance with turning. He was noted to be confused to all but self. Many other interdisciplinary progress notes indicated Resident #3 resisted care, refused dressing changes, became combative and agitated, and stayed in bed. Review of interdisciplinary progress notes revealed on 8/16/10 a doppler study could not be performed because Resident #3 was unable to completely stretch his legs flat on the bed. Review of interdisciplinary progress notes revealed on 8/29/10 the resident would not straighten out his right leg. A physical therapy note dated 8/31/10 revealed, "Increasing pain from severe right heel ulcer causing increased tone at right leg in flexion pattern. This has resulted in decline in bed mobility, transfers and standing because of weakness and loss of ROM at right knee." Review of interdisciplinary progress notes revealed on 9/6/10 and 9/7/10 the resident seemed to be unable to straighten his legs out. On 9/9/10 physical therapy noted in the interdisciplinary progress notes that Resident #3 had, "Gradual loss of ROM (range of motion) at right knee because of increasing tone in right lower extremity despite therapeutic efforts." The note indicated the resident frequently resisted treatment. During an interview on 9/20/10 at 3:15 p.m. Staff F indicated at one point during therapy Resident #3 was standing. Staff F indicated Resident #3's leg was getting tight due to increased neurologic stimulation that caused increased muscle tone. Staff F indicated Resident #3 frequently declined therapy. During a follow up interview on 9/28/10 at 10:25 a.m. Staff F indicated Resident #3 had pain and said, "His foot was hypersensitive." He indicated it was very painful for Resident #3 to move his leg or have pressure to his foot. Staff F indicated Resident #3 became resistive when staff moved his leg. The facility failed to ensure Resident #3 did not develop a decline in range of motion after admission to the facility as a result of failing to control his pain. (Refer to F309 related to Resident #3's lack of pain management) The resident's decline in range of motion to his right lower extremity was avoidable because it occurred as a result of inadequate pain control that caused him to refuse care and to refuse to participate in physical therapy. This constituted harm for Resident #3.

Based on observation, interview, and record review the facility failed to recognize non-verbal signs and symptoms in the presence of severe pain and provide adequate pain relief for 1 of 6 sample residents (#3) reviewed for pain. This failure resulted in continued presence of pain, which constituted harm for this resident. Findings include: During an interviews on 9/28/10 at 10:00 a.m. when asked how often Resident #3 had pain, Staff G replied, "Always." Staff G believed his heel hurt. During an interview on 9/28/10 at 10:10 a.m. Staff M indicated Resident #3 did not want to be touched in the lower parts because of pain. During an interview on 9/28/10 at 10:25 a.m. Staff F indicated Resident #3's foot was "hypersensitive" and that movement of his leg and pressure to his foot were painful. Towards the end of his stay in the facility Resident #3's leg was very painful and the resident became resistive when staff moved his leg. Staff F indicated that just sitting there you could tell he had pain. During a telephone interview on 10/5/10 at 12:00 p.m. Collateral Contact indicated Resident #3 would tell the family that he had pain and they could tell he was in pain even when he did not verbally express pain because he exhibited behaviors such as showing tension in his face and in his body, drawing his knee up, and hitting his knee. When the resident had more severe pain he became oppositional with staff and would yell at them to leave him alone. She indicated the pain was mostly in his right leg and right heel, but more in the leg than heel. She indicated she talked to staff about his pain every time she visited the resident, but one nurse told the family that Resident #3 could only have pain medication every few hours and none in between those times. The Contact indicated if family asked for an as needed pain medication, they would get him something. She visited the resident usually four to five times each week after work, usually at about 4:15 p.m. She said, "They sure weren't working to see what would work" (with his pain). Review of Resident #3's record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of a facility form titled, "Nursing Admission Evaluation," revealed Resident #3 had actual pain and movement in his right hip/knee was limited. In addition to the right hip incisions, review of the 7/8/10 skin evaluation form revealed Resident #3 had a three by four cm (centimeter equals approximately 1/2 inch) area on his right heel that was described as purple, mushy and blister like. Review of a facility form titled, "Pain Evaluation" dated at the time of admission, revealed the resident had pain in the right hip and leg from recent surgery. The pain was described as chronic, a five on a 1 to 10 pain scale (which according to the pain evaluation form meant the resident could not be distracted from the pain, there was no relief with conservative strategies, and the resident may show restlessness and rhythmic movements, draw legs up, clench his jaw, moan, and be aggressive). The form indicated the pain affected the resident's activities of daily living, his sleep, his mobility, and his rehabilitation. Review of a facility form titled, "Pain Management Flowsheet," dated beginning 7/8/10 revealed the location of Resident #3's pain was his right hip and on one occasion it was identified as back pain. The intensity varied from none to a "6" on a scale of 1 to 10 (with 10 being the most severe). There was no documentation regarding the resident's right heel on this form. Review of a facility form titled, "Interdisciplinary Team Meeting" dated 7/15/10 revealed Resident #3 was alert and oriented to self and family members only. The note indicated the resident "does not make needs known." It also indicated the resident refused to get up and noted that this was possibly related to pain. There was no notation that his pain and behaviors were to be evaluated. Review of Resident #3's Comprehensive assessment dated [DATE] revealed the resident had both short and long term memory loss, had moderately impaired cognitive skills for daily decision making, resisted care, and had moderate pain on a daily basis. The facility analysis (RAP) dated 7/15/2010 revealed staff members were to anticipate his needs.There was no analysis of his pain, either from the hip or heel. Review of Resident #3's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. When included in the documentation, the medications were noted to be effective. On 7/14/10 the resident's pain medication order was increased to include a stronger dose of pain medication every eight hours in addition to the as needed dose for breakthrough pain. Many of the as needed medications were noted to have been given at 4:00 p.m. From 8/1/10 to 8/28/10, the resident received 17 doses of the as needed pain medication and 15 of the 17 doses were given at 4PM. From 9/1/10 to 9/9/10, the resident was given 6 doses of the as needed pain medicatin and 5 of those were given at 4PM. Review of interdisciplinary progress notes revealed between 7/16/10 and 9/7/10 multiple entries indicating that Resident #3 complained of pain with movement, was confused, was uncooperative with staff, refused dressing changes, and told staff to leave him alone. Review of social service notes dated 8/24/10 and 8/30/10 revealed the resident had some agitation and combativeness but it was not determined to be a new behavior. A follow up social service note dated 8/31/10 indicated the resident had increased agitation, combativeness, and was refusing care. According to this note the behavioral care plan was updated. Review of the behavior care plan, updated 8/31/10, revealed an intervention to "assess for pain issues, hunger, discomfort, constipation, etc." Even though the resident's agitation, resistance, and combativeness were noted by social service, there was still no documentation that nursing recognized the non-verbal signs and symptoms of pain. A physical therapy note dated 8/31/10 revealed, "Increasing pain from severe right heel ulcer causing increased tone at right leg in flexion pattern. This has resulted in decline in bed mobility, transfers and standing because of weakness and loss of ROM at right knee." On 9/9/10 physical therapy noted in the interdisciplinary progress notes that Resident #3 had, "Gradual loss of ROM (range of motion) at right knee because of increasing tone in right lower extremity despite therapeutic efforts." The note indicated the resident frequently resisted treatment. An interdisciplinary note dated 9/12/10 indicated the resident was calmly resting in bed. The note indicated he denied pain, but noted that with movement of the right or left leg he became angry. On 9/12/10 a progress noted indicated the resident's Power of Attorney had concerns regarding the resident's right foot and pain. On 9/13/10 the resident was transported to the hospital. Review of the hospital nursing care record dated 9/13/10 revealed Resident #3 received 4 mg of [MEDICATION NAME] (pain medication) twice in the emergency room for restlessness and complaint that his foot was bothering him. The facility failed to ensure Resident #3's pain was controlled. By failing to recognize non-verbal signs and symptoms of pain, the facility failed to anticipate and provide for his need for pain control. These failures resulted in harm to Resident #3 who experienced recurring severe pain. This is a repeat citation from a Statement of Deficiencies dated 6/21/10.

Based on interview and record review the facility failed to prevent the development of a pressure sore and failed to provide necessary treatment to promote healing for two pressure ulcers for 1 of 5 sample residents (#3) reviewed for pressure sores. This failure resulted in harm to Resident #3 who developed a Stage IV pressure ulcer to his left heel after admission to the facility and the two pressure sores the resident was admitted with worsened. This constituted harm for this resident. Findings include: Review of Resident #3's record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with wounds to his right foot, right heel, and left leg. Review of Resident #3's "Nursing Admission Evaluation" (from 7/8/10) noted he had a "stasis" ulcer, he had a history of [REDACTED]. Review of his "Admission Body Assessment" revealed a "4 x 3 cm (centimeter) mushy purple blister like" area to the left heel (according to staff interview it was actually on his right heel) and a 1.0 cm open area to the resident's left third or fourth toe (the records were unclear which toe). There was no note to indicate the resident had a "stasis" ulcer on this assessment form. It did reveal that Resident #3 had an area to his left shin that measured 5 x 3 cm and it was identified as an abrasion. The 9/2/10 ulcer evaluation form indicated the area on the left shin was resolved. Review of Resident #3's care plan for skin dated 7/11/10 revealed the resident had an unstageable pressure ulcer to his right heel, multiple venous wound areas, bruises, and lacerations. Interventions included pressure reduction mattress, pressure relieving device to his wheelchair, elevate/float heels off of bed and use pillows between boney prominences as needed, heel protectors, and turn and reposition every two to three hours as needed. Review of Resident #3's Comprehensive assessment dated [DATE] revealed he had a Stage IV pressure ulcer to his heel. Interventions identified included pressure relief cushions and mattresses, weekly head to toe skin checks, daily checks with treatment, and keeping his heels bridged while in bed. According to the assessment the resident had a history of [REDACTED]. Review of interdisciplinary progress notes revealed multiple instances when Resident #3 resisted care, refused dressing changes, was confused, and was agitated or combative during care (including 7/16/10, 7/19/1, 7/21/10, 8/9/10, and others). There was no documentation that any of the refusals involved care or treatment to the resident's left heel. LEFT HEEL Review of Resident #3's admission assessments revealed no documentation of a pressure area on his left heel. Review of an interdisciplinary progress note dated 7/25/10 (17 days after admission) revealed that Resident #3 had a foam dressing to his left heel, but there was no documentation of a wound to this heel. Then, according to an interdisciplinary progress note four days later on 7/29/10, Resident #3's left heel was noted to be mushy. Review of an ulcer evaluation form and interdisciplinary progress note dated 8/2/10 (25 days after admission to the facility) revealed Resident #3 had an unstageable pressure area to his left heel that was mushy to touch and measured 4 x 6.5 cm. Interventions included keeping pressure relief device in place, soft boots, and bridging the area. The wound to the resident's left heel was not re-evaluated until 8/31/10 (29 days later) when it was noted that it remained unstageable but had decreased in size to 0.5 x 1.0 cm. The was no documentation that the ulcer was re-evaluated until 9/13/10 (13 days later). According to an interdisciplinary progress note dated 9/13/10 revealed the ulcer to the resident's left heel measured 1 x 1 cm. Treatments included applying [MEDICATION NAME] to the left heel, leaving it open to air, blue heel boots to each foot, bridging heels off of bed, and keeping pressure relief device on the left heel. Review of a hospital podiatry note dated 9/15/10 revealed the wound to the resident's left heel was noted to be a Stage II pressure ulcer. Right HEEL Review of a facility ulcer evaluation form dated 7/8/10 revealed the resident had a 3 x 4 cm purple mushy blister like area to the resident's right heel (during an interview on 9/28/10 at 12:55 p.m. Staff B indicated that while the admission nursing form identified the left heel as the site of Resident #3's pressure ulcer, it was actually located on his right heel). The ulcer was checked weekly through 7/29/10 and according to notations the size remained unchanged but the ulcer showed improvement. On 8/2/10 the ulcer was noted to have increased to 7 x 5.4 cm and was evaluated as a Stage IV pressure ulcer. Interventions included keeping the area free from pressure, application of Silver Alginate dressings, and use of a soft boot. While review of treatment records revealed weekly skin checks were generally performed, there was no further thorough evaluation of the ulcer for 29 days until 8/31/10, even though Resident #3 was at risk for development of pressure ulcers and venous stasis ulcers. According to the evaluation on 8/31/10 the ulcer was noted to be a Stage IV pressure ulcer that measured 4.6 cm by 4.0 cm and was being treated with Silver Alginate dressings. On 9/8/10 the ulcer increased in size to 9 x 5.2 cm and on 9/13/10 it decreased to 6.8 x 4.6 cm. The ulcer continued to be cleansed with [MEDICATION NAME] and the area was dressed with Silver Alginate dressings. Review of interdisciplinary progress notes revealed multiple notes that the resident refused dressing changes to his right heel. The resident's refusal of necessary treatment and services to his right heel related to his not wanting staff to touch or move his lower painful extremities. Refer to F309 for the facility's lack of pain management related to Resident #3's lower extremities. LEFT THIRD TOE Review of Resident #3's Admission Body assessment dated [DATE] revealed a 1 cm open area to a toe on the resident's left foot. Review of an evaluation form dated 7/8/10 there was an old 1 cm open area with a 1 cm slit that was almost healed to the resident's left third toe. It was re-evaluated on 7/15/10, 7/22/10, and 7/29/10 and noted to remain at 1 cm but was noted to show improvement. Treatment included monitoring and application of a [MEDICATION NAME] dressing. Review of an Ulcer Evaluation form dated 8/2/10 revealed a notation that the resident had an unstageable area with black/brown eschar to the left third toe that measured 2 x 1.3 cm. and was noted to be a pressure area. Interventions included keeping the area clean and free from pressure. There were no evaluation notations after 8/2/10 until 8/31/10. Review of the evaluation form dated 8/31/10 revealed the area measured 0.5 x 0.5 cm and was unstageable. Review of an ulcer evaluation form dated 9/7/10 revealed the ulcer measured 0.4 x 1.2 cm and was unstageable. It was cleansed with [MEDICATION NAME] and left open to air. Review of an interdisciplinary progress note dated 9/13/10 revealed it increased in size to 0.5 x 1.5 cm. Review of a hospital podiatry note dated 9/15/10 revealed the wound to the resident's left third toe was noted to be deep with exposed bone. The facility identified the resident at risk for pressure ulcers and developed care plan interventions related to alterations in skin, comfort, and behavior. According to staff interview and record review Resident #3 was often resistive to care and refused dressing changes to the ulcers on his feet. Resident #3's resistance to care related to the pain he felt in his lower extremities (Refer to F309 for Resident's lack of pain management) which resulted in the worsening of two pressure sores he was admitted with and the development of a left heel ulcer 25 days after admission. This is a repeat citation from a Statement of Deficiencies dated 9/3/10.