Every finding on record at Alderwood Park Health and Rehab of Cascadia

Based on observation, interview, and record review, the facility failed to ensure that 5 of 5 residents (3, 4, 9, 16, and 26) reviewed for limited Range of Motion (ROM) received necessary care and services. The facility failed to ensure residents received appropriate restorative nursing services programs as ordered. This failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life.Findings included . Review of the facility policy titled, Restorative Nursing, revised 09/10/2025, stated to promote the residents optimum function, a program will be developed by identifying, care planning and monitoring of a residents assessment and indicators.the program must be supervised by a licensed nurse. the licensed nurse will conduct an evaluation on a routine basis, including progress towards goals, and response to the program. <RESDIENT 3>Resident 3 was admitted to the facility on [DATE] with diagnoses that include hemiplegia (paralysis affecting one entire side of the body) to dominant right side of body, and end stage renal disease with dependence on renal dialysis (life-sustaining treatment that removes waste products and excess fluid from the blood). The Quarterly Minimum Data Set (MDS – an assessment tool) dated 12/14/2025, documented no refusal of care, substantial to maximum assist for assistance with personal hygiene, bed mobility and transfers. There was no restorative nursing or therapy coded on the assessment. Review of Resident 3's care plan focus dated 11/07/2025, documented that the resident required restorative nursing program related to decline in mobility, range of motion (ROM), physical weakness, and was at risk for contractures (permanent tightening of muscles, tendons, or skin that limit joint movement). The interventions included the following:- if resident refuses, see refusal care plan and follow directives as indicated, - monitor for decline in function, - monitor for pain, and report, - passive/active assist with ROM to elbow, shoulder, wrist, 1-2 sets with 5-10 repetitions 3-6 times a week,- Sit to stand with sit to stand lifts ten times, (Hold standing 1- 3minutes) 1 set with 10 repetitions 3-6 times a week,- review the restorative program routinely to validate the effectiveness and adjust as needed. Review of Resident 3's entire care plan, print date 01/12/2026, showed there was no refusal of care plan as directed in the restorative interventions. Review of Resident 3's restorative documentation for November 2025, December 2025 and January 1st – 12th of 2026 had the following documentation of the restorative program:- November 2025 the program was offered three times, the resident declined twice and accepted once with 5 minutes of exercise, - December 2025 the program was offered once with 5 minutes of exercise, and two documentations that the resident was out of the facility, - January 2026 (1st – 12th) the program was offered once with 10 minutes documented. Review of Resident 3's progress notes 11/01/2025 – 01/12/2026, there was no documentation of any monitoring, refusal, or assessment of the restorative program. In an observation and interview on 01/13/2026 at 8:31 AM, Resident 3 was observed sitting in their wheelchair in their room. The resident's right arm and hand were dangling between their legs; the limb was a discolored reddish/purplish tone. Resident 3 stated they are unable to feel or move their right upper limb after they had a motorcycle accident. Resident 3 stated when they first arrived at the facility, they worked with the therapy department and were working on standing on their own or with a transfer pole. Resident 3 stated they cannot do that anymore. They stated they are not getting any therapy currently and would prefer to, as their goal was to be able to care for themselves. In an observation on 01/14/2026 at 7:58 AM, Resident 3 was sitting on the side of their bed, feet on the floor, their right arm hanging between legs, dangling. In an interview on 01/14/2026 at 9:04 AM, Staff G, Director of Rehabilitation, stated that Staff B, Director of Nursing (DNS) has been responsible for the restorative nursing program at the facility. In an observation and interview on 01/14/2026 at 9:50 AM, Resident 3 was sitting on the side of the bed, feet on the floor. Their right arm was dangling, their fingers on their right hand were partially curved closed. Resident 3 was asked if they were able to straighten their fingers out, they used their left hand to pry fingers out, then placed the right hand on the mattress so the fingers to the right hand would be straight out. Resident 3 was asked if that was painful, and they responded yes, it is. In an interview on 01/15/2026 at 1:04 PM, Staff H, Restorative Aid (RA)/Nursing Assistant Certified (NAC) stated they are responsible for completing restorative nursing programs Sunday – Thursday, then another aid will work Friday and Saturday. Staff H stated they have roughly 34 residents on restorative nursing programs, around 17 on the [NAME] Hall, and 17 on the Central Hall. Staff H was asked if they can complete the restorative programs for all individuals throughout the week and they responded, most of the time. Staff H stated they are not asked to work at NACs on the floor but are pulled to assist with two person transfers often. Staff H stated that if a resident refused, they were to document in the electronic medical record. Staff H stated if a resident continued to refuse, they would notify the licensed nurse responsible for the restorative nursing program. Staff H was asked how Resident 3 was participating in their restorative nursing program. Staff H stated they are tricky due to a room move, and that they are out of the facility three times a week for dialysis, and so therefore they have not really got around to offering them the program. Staff H was asked who the licensed nurse was that they report to, and they responded that Staff B, DNS had been entering the new program into the medical record, and that the MDS nurse that was out on leave was working on the programs, but they were not sure when that person was to return. In a joint interview on 01/16/2026 at 8:15 AM, Staff I, Resident Care Manager (RCM)/Licensed Practical Nurse (LPN), and Staff B, DNS, were asked if they were aware of the discoloration to Resident 3's right arm, and the potential contraction of their right fingers. Staff I stated, I think I mentioned to the provider that their arm was off color, I do not believe I documented that though. Staff B stated they were unaware of the discoloration or potential contraction of the right fingers, they were made aware of the resident observation, and that they had reported pain. <RESIDENT 9> Resident 9 was admitted to the facility on [DATE], with diagnoses to include spinal stenosis, muscle wasting and atrophy. Review of the physical therapy notes on 08/09/2025 showed the Physical Therapist (PT) established an restorative program for Resident 9 which included bilateral lower extremity ([NAME]) exercises both lying down and while seated in the wheelchair. The note included that PT communicated with the RA personnel and provided education/training. Resident 9 verbalized understanding that they had been discharged from therapy and would begin a restorative program for [NAME] exercise per recommendation. Review of the quarterly MDS assessment, dated 11/25/2025, showed Resident 9 utilized a wheelchair and had limited range of motion to one side of their upper extremity. The resident did not reject care. Review of Resident 9's current care plan directed staff to provide a restorative nursing program (RNP) related to muscle weakness, low activity tolerance and maintain strength beginning 08/13/2025. The care plan goal showed the resident would tolerate hip ROM, knee ROM, and ankle ROM for 2 sets of 10 repetitions, three to six times a week. The interventions included to monitor for decline in function, refer to therapy as needed and review the restorative program routinely to validate effectiveness and adjust the program as indicated. In an observation and interview on 01/12/2026 at 8:59 AM, Resident 9 was lying in bed with a left arm brace on and stated the staff doesn't move them around enough or turn them. Resident 9 stated their back pain would be improved with more exercise. The resident stated therapy cut them off and they did not get restorative. The resident stated they did not know why they were not getting therapy. In an interview on 01/16/2026 at 9:46 AM, Resident 9 stated they didn't get exercise after they were taken off PT related to money and they felt they were in a state of decline. Observations on all dates of the survey (01/12/2026, 01/13/2026, 01/14/2026, 01/15/2026 and 01/16/2026), showed Resident 9 was not observed to receive RNP services. Review of Resident 9's clinical record showed the resident did not receive an RNP as recommended by PT and care planned. In an interview on 01/16/2026 at 10:14 AM, Staff H, Restorative Aide, stated Resident 9 did not have a restorative program. In an interview on 01/16/2026 at 11:11 AM, Staff B, DNS, stated Resident 9 was to have an RNP three to six times a week. Staff B reviewed the clinical record and stated the order had been incorrectly placed under the goal portion of the care plan so Resident 9 had not received any restorative services yet. In an interview on 01/16/2026 at 11:32 AM, Staff L, Restorative Aide stated Resident 9 did not have an RNP. <RESIDENT 4> Resident 4 was admitted to the facility on [DATE], with diagnoses to include pelvic fracture, kyphosis (excessive outward curvature of the spine), muscle weakness and pain in the left leg, and difficulty walking. Review of the physical therapy notes on 12/09/2025 showed the PT established an RNP for Resident 4 which included bed mobility exercises, sit to stand with their front wheeled walker (FWW) five times, lying to sitting at edge of bed once for functional maintenance to improve their functional mobility. Review of Resident 4's current care plan directed staff to provide a RNP related to prevention of a decline in activities of daily living (ADL's) beginning 12/22/2025. The care plan goal directed staff to work on bed mobility lying to sitting for one set and transfers sit to stand with FWW one set for 5 reps, three to six times per week. The interventions included to monitor for decline in function and review the restorative program routinely to validate effectiveness and adjust the program as indicated. In an interview on 01/13/2026 at 8:47 AM, Resident 4 stated they fell at the facility and broke their pelvis. The resident stated they used to get therapy daily on the other unit, and not on this unit. Resident 4 stated they chalked that up to their insurance running out. The resident stated they had to ask for exercise, and they were only getting it maybe twice a week. In an interview on 01/14/2026 at 8:12 AM, Resident 4 was resting in bed and stated, They don't do anything with me. (Staff L, RA) took me to the gym once this week and did not know what to do with me. I can't get there (gym,) myself. I need exercise. In an interview on 01/16/2026 at 10:14 AM, Staff H, RA, stated Resident 4 was on their caseload for standing with a walker, sitting on the edge of the bed. Staff H stated they had only got to their RNP twice this week. Staff H stated they were supposed to get RNP three times a week and they did not refuse their restorative program. In an interview on 01/16/2026 at 11:11 AM, Staff B, DNS stated Resident 4's RNP was implemented on 01/09/2026. In an interview on 01/16/2026 at 11:32 AM, Staff L, RA, stated they just started working with Resident 4 two weeks ago. <RESIDENT 16> Resident 16 re-admitted on [DATE] with diagnosis to include reduced mobility with quadriplegic cerebral palsy (most severe form of cerebral palsy with entire body impairment), muscle weakness, osteoarthritis. Review of Resident 16's quarterly MDS assessment, dated 12/10/2025, showed Resident 16 utilized a wheelchair and had limited range of motion both sides of their lower extremities. The resident did not reject care. Review of Resident 16's current care plan directed staff to provide a RNP related to cerebral palsy and muscle weakness beginning 08/30/2022. The care plan goal showed the resident would tolerate upper and lower extremity passive range of motion (PROM - staff completes the movement for the resident) times 5-10 reps, three to six times a week. The interventions included to monitor for decline in function, refer to therapy as needed and review the restorative program routinely to validate effectiveness and adjust the program as indicated. In an interview on 01/16/2026 at 10:29 AM, Resident 16 stated they received their RNP sporadically and were supposed to get their RNP on Monday, Wednesdays and Fridays. Review of the clinical record did not show an RNP. In an interview on 01/16/2026 at 11:11 AM, Staff B, DNS stated Resident 16 was getting their RNP once a week and received it twice this week. In an interview on 01/16/2026 at 11:32 AM, Staff L, RA, stated they do resistance bands and ROM with their legs. Staff L stated Resident 16 did not refuse their RNP. <RESIDENT 26> Resident 26 admitted on [DATE] with diagnoses to include spinal stenosis (narrowing of spaces in the spine causing pain, numbness, weakness), spondylosis (wear and tear on the vertebrae and discs), weakness and muscle wasting. Review of Resident 26's quarterly MDS assessment, submitted 01/02/2026, showed Resident 26 utilized a wheelchair and had limited range of motion both sides of their lower extremities. The resident did not reject care. Review of Resident 26's current care plan directed staff to provide a RNP related to quadriplegia beginning 09/02/2022. The care plan goal showed the resident would tolerate the restorative program. The RNP was for PROM lying, left upper extremity active assist to PROM to the shoulder 3-6 times a week, and PROM to bilateral hips 2 sets for 10 reps, three to six times a week. The interventions included to monitor for decline in function, refer to therapy as needed and review the restorative program routinely to validate effectiveness and adjust the program as indicated. In an interview on 01/16/2026 at 10:29 AM, Resident 26 stated they received their RNP sporadically, once or twice a week rather than three times a week. Review of the clinical record did not show an RNP. In an interview on 01/16/2026 at 11:11 AM, Staff B, DNS stated Resident 26 received RNP on 01/07/2026, 01/09/2026 and 01/14/2026 and was getting their RNP two to three times a week. In an interview on 01/16/2026 at 11:32 AM, Staff L, RA stated they do exercises with Resident 26. Staff L stated Resident 26 did not refuse their RNP. In a follow up interview on 01/16/2026 at 11:33 AM, Staff B was asked how the restorative nursing program worked here that the facility. Staff B stated as therapy recommended programs, they were initiating them in the electronic medical records for the aids to complete. Staff B stated that since the primary restorative aid was a family member, they were unable to directly supervise the program. Staff B stated previously the MDS nurse was the primary responsible party to manage the programs, assess if they were effective and document and update as needed. Staff B stated the MDS nurse who was responsible has been out on leave since mid-October 2025. The other MDS nurse worked remotely and was unable to supervise. Staff B confirmed they have only been discontinuing, or changing the program, and that was all they had done. Reference: (WAC) 388-97-1060 (3)(d)(j)(ix)

Based on interview and record review, the facility failed to ensure thorough investigation and resolution of grievances for one of one resident facility groups. This failure resulted in continued dissatisfaction among residents regarding how their grievances are being addressed and had the potential to impact residents quality of life. Findings included .Review of the facility policy titled: Grievance Process, with a revised date of 08/2025, documented that the Nursing Home Administrator or Designee was responsible for the grievance process including tracking and conclusion. The policy stated grievances would include the date received, summary of the resident grievance, steps to investigate the grievance, statement whether the grievance was confirmed or not confirmed, communication with the individual making the grievance to determine if resolution was satisfactory and maintained. Review of the facility grievance logs for the prior six months showed: August 2025 there were a total of 14 grievances logged. 5 of the total grievances were from the facility resident council and included concerns regarding communication, care, missing items and dietary grievances. September 2025 there were a total of 16 grievances logged. 8 of the total grievances were dietary grievances and 4 of those were from the resident council. October 2025 there were 11 total grievances logged November 2025 there were 4 grievances logged. An ongoing grievance form was found to have been created for dietary grievances from the resident council and were no longer being individually logged. December 2025 there were 3 grievances logged. In a group resident council interview on 01/13/2026 at 2:09 PM the following concerns were voiced: Resident 65 stated they used to come talk to you and get a written summation of what was done when you wrote a grievance and that has not happened for several years. The resident stated they were aware this was written in the regulation. Resident 65 stated Staff C, Social Services Manager was the grievance official but did not talk to us and stated, I never even get interviewed about my concerns. Resident 62 stated 'I don't even know that they have seen my grievances. There was no follow up for my grievances. No one comes to even talk to me about it, so nothing changes. Resident 62 stated they have repeatedly asked for less carbohydrates on their trays and less repetition. Resident 57 stated I never hear back about my grievances. No one talks to me about them.nothing happens. Review of a sample of resident grievances for the prior six months showed that the facility grievance investigations were incomplete. The facility failed to consistently identify the summary of the resident grievance, steps to investigate the grievance, statement whether the grievance was confirmed or not confirmed, providing written resolution and communication with the individual making the grievance to determine if resolution was satisfactory and maintained. In an interview on 01/15/2026 at 11:31 AM, Staff C stated the grievances come to social services, directly from residents or sometimes staff will help residents fill them out. There was also a mailbox outside the social service office so people can drop forms in. Staff C stated the issues are routed to the department that was involved but keeps the forms. Staff C stated the forms needed to be redone and we talk about the issues as a team and make a plan. Staff C stated there was follow up with the residents, and for the resident council specifically, they made the ongoing form and were meeting every month. Staff C acknowledged that the current grievance forms were not showing that the process was being followed. In an interview on 01/16/2026 at 10:44 AM, Staff A, Executive Director stated grievances were reviewed in the facility stand up meeting and assignments made to address them and the paperwork remained with social services. Staff A stated they had not been following up regarding completion of the forms and had not been providing residents with a copy of the resolution of their grievances. Staff C was aware of the ongoing grievance concerns from the resident council group and stated the facility was working to address those concerns, acknowledging the documentation was not clear with respect to what was being done. Reference WAC 388-97-0460, 0920 (5)

Based on observation, interview and record review, the facility failed to ensure infection prevention practices were followed for 1 of 2 residents (Resident 7) reviewed for wounds, and for 1 of 4 residents (Resident 68) reviewed for transmission-based precautions. These failures placed residents at risk for infection due to cross contamination. Findings included .Review of the facility policy titled: Hand Hygiene, with a revised date of 09/2025 stated all healthcare workers perform hand hygiene at critical moments during resident care which included moving from soiled to clean tasks, contact with objects in the resident environment and following Personal Protective Equipment removal. Resident 7 admitted [DATE] with diagnoses which included pressure ulcers requiring wound care and enhanced barrier precautions. Review of Resident 7's wound care orders on 01/13/2025 documented the wound was dressed with a wound vacuum dressing changed three times per week (and as needed) which included cleansing with a prescribed wound cleanser, applying skin sealant and protective dressing around the wound, inserting a pre-cut foam to the wound bed and attaching suction at a prescribed strength with tubing connected to a cannister that collects wound drainage. An observation of wound vacuum dressing change was conducted on 01/13/2026 at 11:48 AM, Staff E, Registered Nurse and Staff F, Licensed Practical Nurse, were observed to enter Resident 66's room wearing appropriate personal protective equipment (gown, gloves, surgical mask) and prepared supplies for wound care. Staff E was observed to ask the resident roommate for permission to borrow their overbed table, and then picked up the roommates personal water pitcher, moved it to another table, and then rolled the table over to Resident 66's side of the room and began to place clean dressing supplies on top of the overbed table without disinfecting the surface. In a continued observation, at 11:55 AM, Staff F was observed to drop a package of gauze pads on the floor, pick it up, and place it back on the overbed table. Staff E was observed to remove the soiled vacuum dressing and foam and change gloves without performing hand hygiene between glove change. There was a smaller upper wound. Staff E sprayed wound cleanser into the wound and used their gloved right hand and gauze to cleanse inside the wound bed. Staff F opened a package of wound treatment and handed to Staff E, who placed the wound treatment into the wound with the same glove used during the wound cleansing, then applied the outer dressing to cover. Staff E changed gloves again without performing hand hygiene. Staff E applied wound cleanser to wound and inserted gloved hands into the wound to cleanse and then moved to applying the clean dressing without changing gloves. Staff E applied the exterior dressing pieces around the wound and then changed gloves without performing hand hygiene. Staff F was observed to respond to a walkie talkie inside of their uniform pocket, replace it, and did not change gloves and perform hand hygiene before resuming assistance with clean packages for Staff E. Staff E did not perform hand hygiene until removing gloves just prior to exiting the room. In an interview on 01/13/2026 at 1:50 PM, Staff E and Staff F acknowledged, but had not been aware of their breaks in infection control during the wound care. Staff E stated they should have cleaned the overbed table with disinfectant wipe prior to use. Staff E stated they believed they had changed gloves when required and had not been aware of need for hand hygiene between glove changes. Staff F verbalized that the outside of the package of gauze touched the floor, but the gauze inside did not. Staff F acknowledged that they should have changed gloves after touching an item from their pocket. In an interview on 01/15/2026 at 1:15 PM, Staff B, Director of Nursing Services stated the facility conducted infection control in-services and wound training and would be reviewing with nurses. <RESIDENT 68> Resident 68 was admitted to the facility on [DATE] with diagnoses to include abscess (collection of pus that has built up within the tissue of the body) of right lower limb, surgical aftercare following surgery on the skin, urinary tract infection (infection of any part of the urinary system) and protein calorie malnutrition (insufficient intake of protein and calories). Review of Resident 68's Physician's orders showed Enhanced Barrier Precautions (EBP) were to be used every shift related to chronic wounds, initiated on 12/19/2025. EBP precautions meant staff would need to wear a gown and gloves when assisting with dressing, bathing, wound care, incontinence or toileting care and changing linens. Review of Resident 68's care plan showed EBP were to be used to reduce the risk of Multi Drug Resistant Organism (MDRO) transmission related to their right thigh wound, initiated on 12/15/2025. Review of Resident 68's Kardex (a guide the care staff use to help direct the resident care) dated 01/14/2026 showed their care was to include EBP. Review of Resident 68's Treatment Administration Record (TAR) dated December of 2025 showed EBP were documented as being followed every shift. Review of Resident 68's Treatment Administration Record (TAR) dated January of 2026 showed EBP were documented as being followed every shift. During all observations on 01/12/2026, 01/13/2026, 01/14/2026, and 01/15/2026, Resident 68's room did not have EBP signage present or a Personal Protective Equipment (PPE) bin available. No staff were observed to obtain or use PPE for the care of Resident 68. In an interview on 1/14/2026 at 10:07 AM, Staff P, NAC stated they reviewed the Kardex to know what assistance a resident requires. Staff P stated Resident 68 was incontinent of bowel and bladder and required brief changes and incontinent care. Staff P stated they had not noticed if Resident 68 had any wounds and had not used EBP precautions during provided cares. In an interview on 01/15/2026 at 11:09 AM, Staff E, Registered Nurse (RN), stated they knew if a resident required EBP there would be specific precaution signage on the room door, and it would be in their care plan. Staff E confirmed they had signed Resident 68's TAR dated 01/15/2026 that they had followed EBP. Staff E confirmed there was no EBP signage or PPE bin present for Resident 68's room and had not followed precautions. In an interview on 01/16/2026 at 11:17 AM, Staff D, Staff Development Coordinator/Infection Preventionist (SDC/IP), stated they update orders and care plans for resident's who require EBP. Staff D stated there would be EBP signage outside of the door, PPE bin present and a trash bin inside the room to dispose of PPE used. Staff D stated staff should review the Kardex and care plan to know if a resident required any kind of precautions. Staff D stated their expectation was when staff enter an EBP room they would follow the signage and wear gown and gloves when needed. Staff D verified Resident 68 had orders for EBP related to their chronic wounds and confirmed they were responsible to complete audits to ensure precautions are being followed. Reference WAC 388-97-1320 (1),(2)(b),(5)

Based on observation, interview and record review, the facility failed to ensure that 3 of 3 residents (Residents 9,16 and 26) reviewed for respiratory care, were provided care consistent with professional standards of practice. Failure of the facility to ensure oxygen (O2) delivery per physician's order, monitor, assess and address resident responses to O2 therapy (Resident 9), and ensure ordered Continuous Positive Airway Pressure (CPAP, non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) equipment was in place when ordered, and to ensure CPAPs were cleaned and parts replaced per manufacturers recommendations. These failures placed residents at risk of respiratory infection, respiratory distress, lack of restful sleep and diminished lung condition.Findings included .According to the facility policy titled, BiPap/CPAP Administration, dated 09/12/2025, showed the facility would provide non-invasive ventilation using BiPap or CPAP therapy in accordance with physician orders and professional standards of practice. The procedure directed the nurses to obtain a physician's order specifying, mode, pressure settings, mask type and size, oxygen flow rate if applicable, frequency of use. The nurses were directed to document therapy initiation and resident response and any adjustments made. The policy directed staff to clean equipment per manufacturer guidelines.<RESIDENT 9> Resident 9 was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD-group of diseases that cause airflow blockage and breathing problems), obstructive sleep apnea (OSA - residents repeatedly stop and start breathing while they sleep) and chronic respiratory failure with hypercapnia (buildup of carbon dioxide in the blood from poor ventilation treated with oxygen and CPAP) . Review of a progress note dated 07/24/2025 at 2:20 PM, Staff B, Director of Nursing Services, (DNS) documented Resident 9 expressed interest in attempting to get another CPAP as theirs was taken a long time ago. Provider was notified and ordered to refer the resident to pulmonology to obtain a new sleep study. Review of a progress note written by Staff K, Admissions Coordinator dated 07/25/2025 at 8:26 AM showed a referral was sent to pulmonology for history of BiPap (device that has two different pressure levels) /CPAP use and resident's request to use one again. Staff K documented they would follow up with the clinic regarding referral and schedule an appointment once received. Review of the clinical record showed no further progress notes regarding follow up to obtaining the CPAP. Review of the July, August, September and October Treatment Administration Record's (TAR's) showed an alert at the top of each page that showed referral to pulmonology related to resident wanting a CPAP. Review of a progress note dated 11/21/2025 at 3:03 PM showed Resident 9 was on supplemental oxygen use via nasal canula on 2 liters per minute (L/min) and a local vendor dropped off a BiPap machine. Review of the admission Minimum Data Set (MDS - an assessment tool) assessment dated [DATE] showed Resident 9 did not use oxygen, BiPAP or CPAP and did not refuse care. Review of the physician's orders dated 11/21/2025 included Oxygen at 2 liters per minute (LPM) continuously per nasal cannula via 02 concentrator and document if the resident was anxious or in distress every shift for Chronic Respiratory Disease and BiPAP at 18 cm H20 Inspiration; 8cmH20 expiration for tidal volume of oxygen at 2L/min. BIPAP scheduled start at 2200 and discontinued at 0600 to meet goal of 8 hours each night, every shift for OSA. Review of Resident 9's care plan did not address the residents' BiPap supply vendor, contact information, brand of BiPap, manufacturers guidelines and when the equipment was required to be replaced. The care plan did not address cleaning the humidifier chamber. In an interview and observation on 01/12/2026 at 9:05 AM, Resident 9 was resting in bed without oxygen on. An oxygen concentrator was at the foot of the bed in the off position. The resident had BiPAP at bedside with no filter in it. Resident 9 stated they had sleep apnea, and the staff had never cleaned their machine. The resident stated they got on the staff about the cleaning last week and they did not understand why the nurses did not check the water level. Resident 9 stated that staff must expect them to put their oxygen and CPAP (resident referred to the BiPAP as CPAP) on because they don't help them. The resident stated they cannot get to their oxygen or CPAP as they were weak, and the machines were located out of their reach at the end of their bed. In an interview on 01/15/2026 at 8:25 AM, Resident 9 was in bed on their right side without oxygen on. The resident stated they were not happy with what was going on at the facility and they did not get their CPAP on again last night. The resident stated the last time the CPAP was on, was a week ago. The resident stated the CPAP machine was a few weeks old and they did not have one here before this despite asking the nurses for one for months. The resident stated they had very bad sleep apnea and they were afraid they would be found dead in bed. The resident said they had required a CPAP for many years and they must wear it. They said the staff would check in and ask them what time they wanted their CPAP on, but then they would not come back to put it on them. The resident said they had instructed the nurses that if they came in and saw them asleep, to still put it on them. Resident 9 stated they had not observed cleaning of the water reservoir, tubing, mask or headgear. The CPAP remained located at the foot of the bed, out of their reach with no filter in place. In an observation on 01/16/2026 at 9:46 AM Resident 9 was lying in bed on their right side, without oxygen on. The resident stated they were really upset that the staff don't put their CPAP on or clean it. The resident stated, the staff rarely check their oxygen saturations and they could die. Resident 9 was observed without oxygen on for all observations on 01/12/2026, 01/13/2026, 01/14/2026, 01/15/2026, and 01/16/2026. Review of the clinical record showed oxygen saturations were not routinely monitored to assess response to oxygen therapy. Oxygen saturations were checked 7 days in November, 4 days in December and 3 days in January as of 01/16/2026 at 12:27 PM. In an interview on 01/16/2026 at 11:11 AM, Staff B, DNS, was asked about conflicting BiPAP cleaning orders and the care plan lacked BiPap parts replacement schedule. Staff B was informed Resident 9 was concerned about the lack of oxygen saturation monitoring and the last documented 02 sat was 01/10/2026. Staff B was made aware the resident was observed without oxygen on 01/12/2026 although nurses documented they were on 2 liters of oxygen. The documentation on 01/13/2026, 01/14/2026 and 01/15/2026 day shift showed NA which reflected medication not available. Staff B stated they would need to look into that. In an interview on 01/16/2026 at 1:15 PM, Staff K, Admissions Coordinator stated they called to order a CPAP for Resident 9 in July, but the prior settings were outdated, and the vendor would not send a CPAP. Staff K stated there were no pulmonary appointments available for months. <RESIDENT 16> Resident 16 re-admitted on [DATE] with diagnosis to include OSA. Review of Resident 16's physician orders dated 03/01/2024, showed CPAP/BiPAP Machine Non-Disposable Tubing Care and headset frame, Soak CPAP tubing and headset frame in warm soapy water x 20 minutes, rinse with clean water, and then let air dry one time a day every Sat for CPAP tubing care. Review of Resident 16's care plan dated 03/05/2024 did not address the residents' CPAP supply vendor, contact information, brand of CPAP, settings, manufacturers guidelines and when the equipment was required to be replaced. The care plan did not address cleaning the humidifier chamber. <RESIDENT 26> Resident 26 admitted on [DATE] with diagnosis to include OSA. Review of the physician order dated 03/01/2024 directed nurses to place Resident 26's CPAP at 16-20 centimeters (cm) H2O on room air with humidification. The nurse was to empty and rinse reservoir tank prior to filling it with fresh distilled water and turning on CPAP at bedtime and discontinue at 8:00 AM. Review of a physician order dated 12/09/2025 showed CPAP/BiPAP machine daily care was to remove mask from head gear. Clean mask and cushion with warm soapy water or with a CPAP wipe one time a day. Review of a physician's order dated 10/03/2025 showed CPAP/BiPAP machine non-disposable tubing care to be completed Sunday morning and nurse to wash tubing, reservoir, mask in warm soapy water rinse items thoroughly with cold water and let air dry. CPAP tubing should be hung up while drying every Sunday day shift. Review of Resident 26's care plan dated 07/05/2022 did not address the residents' CPAP supply vendor, contact information, brand of CPAP, settings, manufacturer's guidelines and when the equipment was required to be replaced. The care plan did not address cleaning the humidifier chamber. In an interview on 01/15/2026 at 1:48 PM, Staff D, Infection Preventionist stated the Nurses are to follow manufacturer's instructions and orders for CPAP cleaning and part replacement. They stated CPAP directions should be on the orders and care plans. In an interview on 01/15/2026 at 2:59 PM Staff J, Registered Nurse, stated orders regarding CPAP cleaning and equipment changes should be in the TAR. Staff J stated they were unsure of when the parts are to be replaced. In an interview on 01/15/2026 at 3:02 PM, Staff F, Licensed Practical Nurse (LPN) stated they did not know who changes the CPAP tubing as they just clean the water reservoir. Staff F stated they would go ask for clarification. Staff F came back and stated CPAP tubing was supposed to be cleaned daily. Staff F said they did not know when headgear and mask were to be cleaned or when supplies were to be changed/replaced. In an interview on 01/16/2026 at 11:00 AM, Staff R, LPN stated CPAP tubing was cleaned once a week on days and evenings. Staff R further stated the tubing was washed on Sundays and head gear was washed once a week. Staff R stated the mask was to be wiped down with warm water only, once a day. Staff R stated there were days they had missed their cleaning. In an interview on 01/16/2026 at 11:56 AM, Staff I, LPN/Resident Care Manager stated nurses wash the CPAP's weekly and it goes on the TAR. Staff I stated the facility was not responsible for changing the tubing or other parts and the vendor was. Staff I stated the vendors come in and change the equipment out and the nurses just needed to wash the tubing with soap and water. In a follow up interview on 01/16/2025 at 1:11 PM, Staff B, DNS stated they had taken pictures of the CPAP's and would obtain the device manuals then revise the care plans and orders to include the manufacturer's recommendations and instructions. No additional information was received. This is a repeat deficiency from 01/07/2025. Reference: WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to consistently provide supervision, verbal cues or assistance with meals per the individualized assessments and plan of care and did not develop a process to document if supplements, alternative meals, or snacks were offered for 1 of 3 residents (Resident 58) reviewed for nutrition. Resident 58 experienced a severe weight loss of 18 pounds (lbs.), a 8.73 percent (%) of body weight in less than a month. This failure placed residents at risk of further weight loss, decline in nutritional status and decreased quality of life. Findings included . Review of the facility provided policy, Nutrition and Hydration, last revised 09/09/2025, showed the facility shall ensure each resident receives adequate nutrition to support their overall health and maintain clinically acceptable parameters. Care and services shall be based on the resident's comprehensive assessment. Serve at least three meals daily, if a resident declines a meal or specific item, offer a nutritionally similar alternative. Provide snacks between meals and at bedtime based on resident preference and/or clinical need. Ongoing visual observations of the resident's ability to consume and benefit from food and fluids, including the resident's self-feeding ability.Review of the State Operations Manual (SOM), Appendix PP- Guidance to Surveyors for Long Term Care Facilities, revised/issued on 07/23/2025 defined severe weight loss as greater than 5% in one month.Resident 58 was admitted to the facility on [DATE] with diagnoses to include Parkinson's (progressive brain disorder that primarily affects movement), unspecified protein-calorie malnutrition (form of undernutrition characterized by insufficient intake of protein and calories necessary for maintaining health), need for assistance with personal care and dementia (loss of cognitive function that interferes with daily life and activities) .Review of Resident 58's admission Minimum Data Set (MDS- an assessment tool) assessment, dated 12/21/2025, documented the resident had a Brief Interview for Mental Status (BIMS - a structured cognitive interview) score of 03 which indicated the resident had significant cognitive impairment. The assessment also showed Resident 58 required partial to moderate assistance with eating which indicated the resident needed physical assistance.Review of Resident 58's Mini Nutritional assessment, dated 12/10/2025, documented the resident had a score of 07 and indicated they were malnourished, with a moderate decrease in food intake, and had difficulties feeding themselves and preferred finger foods.Review of Resident 58's nutrition care plan, dated 12/10/2025, documented that they were at risk for nutritional decline with decreased ability to use utensils, and the Mini Nutritional assessment indicated they were malnourished. Nutritional interventions were to encourage family to visit at mealtimes, and if they consumed less than 50% of a meal, a snack or alternative would be offered. The care plan included interventions to monitor weight/weight changes, monitor/evaluate meal percentage intake via intake records and observation, update the resident advocate as indicated and provide feeding/dining assistance as needed. Review of Resident 58's Activities of Daily Living (ADL) care plan, dated 12/10/2025, documented they required supervision or touch assistance for eating finger foods, with verbal cues. There were no interventions in place to address what assistance the resident needed if they were not provided or served finger foods. Review of Resident 58's Kardex (a guide the care staff use to help direct the resident care), dated 01/13/2026, documented they required supervision or touch assistance for eating finger foods with verbal cues. There were no instructions for assistance needed if the meal provided was not finger foods or for snacks, or an alternative to be provided if they ate less than 50% of their meal. Review of Resident 58's weights documented on 12/10/2025, the resident weighed 207.4 lbs. and on 01/03/2026, the resident weighed 189.3 lbs. This was an 8.73% decrease in body weight in 24 days. In a continuous observation on 01/13/2026 from 8:37 AM until their breakfast tray was removed, Resident 58 was observed sitting up in their wheelchair, trunk and upper body leaning to the right, with their breakfast on the table in front of them. Staff entered the room, set up the resident's meal and then left the room, observation showed no supervision, verbal cues or assistance were provided to the resident. In an interview on 01/13/2026 at 10:12 AM, Collateral Contact (CC) 1, Resident 58's spouse/Power of Attorney (POA), stated the resident needed assistance to eat and had told facility staff they required assistance, but were unsure if the staff had assisted the resident to eat when they were not there at mealtimes. CC1 stated they felt the facility staff put pressure on them to come in at mealtimes to assist the resident. CC1 stated the resident did not like to eat in the dining room and preferred to eat in their room and would need assistance. CC1 stated they believed the resident had lost weight. CC1 stated they were unaware if Resident 58 had been weighed since they were admitted to the facility. CC1 stated they had not been informed of any information related to their weight status. In a continuous observation on 01/14/2026 from 8:29 AM until 8:47 AM, Resident 58 was observed sitting up in their wheelchair, trunk and upper body leaning to the right, with their breakfast tray in front of them. Observation showed no staff supervision, verbal cues or assistance was provided to the resident.In an interview on 01/16/2026 at 10:13 AM, Staff S, Nursing Assistant Certified (NAC)/Staffing Coordinator, stated they reviewed care plans to know what assistance and care a resident required. Staff S stated they had cared for Resident 58 and was aware they had trouble with their hand motor skills during meals. Staff S stated the resident preferred to eat in their room and they would set up the meal and stop by to give verbal cues if needed. Staff S stated if the spouse was not there at mealtimes, they would try to take them to the dining room. Staff S stated they were unsure if any snacks or alternatives were to be given and would document any snacks or alternatives given into their meal monitor included in the meal documentation. Staff S stated they would not document snacks or alternatives separately and were unable to explain how to tell if a resident had eaten a meal, was provided a snack, or an alternative. Staff S stated they obtain the resident weight, gave the information to the nurse, and the nurse documented the resident's weight in their medical record. Staff S stated they were unable to see if a resident had lost weight since they do not input the information into the medical record.In an interview on 01/16/2026 at 10:25 AM, Staff T, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated Resident 58 needed extensive assist and was very forgetful. Staff T stated staff were to set up Resident 58's meal and supervise to see if they required verbal cues and provide assistance if needed. Staff T stated they review meal monitor documentation to know how much a resident was eating. Staff T stated they thought the Registered Dietitian (RD) would inform the resident representative of their weight loss or tell the RCM to do it but was unsure of the facility process. Staff T stated they thought they could look at the meal monitor to see if a snack or alternative was offered but were unsure about specific documentation related to whether a snack or alternative been offered or consumed. Staff T stated they were unsure if the care plan had an intervention to offer snacks or alternative if less than 50% of the meal was consumed. Staff T stated they were unsure about what assistance was needed if the food provided to Resident 58 was not finger foods.In an interview on 01/16/2026 at 10:37 AM, Staff B, Chief Nursing Officer (CNO), stated their expectation for staff was to follow the standards of care, make sure resident needs were being met, and the care plan was followed. Staff B stated Resident 58 usually ate in their room and was encouraged to eat in the dining room. Staff B stated supervision and light touching assistance with meals meant staff were to set up the meal, check in and give verbal cues or assist the resident if needed. Staff B stated the spouse would come in to assist the resident with meals. Staff B stated the MDS assessment should have been followed, which indicated partial to moderate assist with eating, and the information did not make it to the care plan. Staff B stated if the RD had an intervention in the care plan to offer snacks or alternatives for a resident if they ate less than 50% of their meal, there should have been a separate task set up for staff to be able to document information related to supplements, snacks or alternatives. Staff B stated there was no way to know if the resident was offered snacks or alternatives with the current documentation. Staff B confirmed the care plan was unclear related to the assistance Resident 58 required if not provided finger foods for meals. Staff B stated their expectation was the resident's POA would have been notified of their weight loss and the notification information would be documented in their medical record. Staff B confirmed they were unable to locate documentation of weight loss notification to Resident 58's POA. Staff B stated they were aware the resident had experienced weight loss but was unaware it was severe. Staff B stated the resident had not triggered on their weekly weight loss report. Reference WAC: 388-97-1060(3)(h)

Based on observation, interview and record review, the facility failed to ensure comprehensive care planning and implementation for 1 of 4 residents (Resident 66) reviewed for impaired range of motion. This failure placed residents at risk for impaired skin integrity and decreased quality of care. Findings included .Review of the facility policy titled, Comprehensive Care Plans and Conferences, with a revision date of 09/2025, stated the facility care plans would reflect the residents' individual conditions, risks, needs, behaviors, cultural values and preferences, and would include measurable goals, interventions and realistic timeframes. Resident 66 admitted [DATE] with diagnosis which included cognitive impairment and a fall with nerve injury and paralysis of the left arm and subsequent severe contracture (fixed shortening and hardening of muscles and other tissues) of the left hand. In an observation on 01/12/2026 at 10:55 AM, Resident 66 was in the hallway in their wheelchair, self propelling by pulling with their feet and using their right hand. The resident's left hand was visible, observed to be severely contracted in a fisted position with thick calloused overgrown appearance of the skin and nails grown in a curved long manner. In an interview on 01/13/2026 at 8:39 AM, Resident 66 was conversational and was asked about their left hand and what kind of care was being done for it. Resident 66 stated I fell about 5 years ago and after that it just started to curl up like this.I have to either get it amputated or just go along like this.they don't touch it, only the doctor can touch it. I just put a sock on it. Review of Resident 66's annual Minimum Data Set (MDS- a required assessment tool) assessment, dated 12/15/2026, showed no behaviors or rejections of care. In an interview on 01/15/2026 at 9:43 AM, Staff Q, Nursing Assistant Certified, stated they normally do nail care for residents while in the shower, after they check if the nurses need to do it, such as diabetic residents. Staff Q stated they (the nursing assistants) do not do anything with Resident 66's hand. In an interview on 01/15/2026 at 9:48 AM, Staff E, Registered Nurse, stated the only thing Resident 66 allowed them to do was cover the hand. Staff E stated they were supposed to offer when they do a skin check and attempt to cut the nails and document if there was a refusal. Review of the care plan related to skin integrity dated 07/25/2022 stated the resident was at risk for alteration in skin integrity due to impaired mobility and left hand contracture. The listed goal of intact skin did not include specific goals related to the contracture or specific risk associated. The interventions included nail care but did not include any contracture care or care related to the resident's left hand. Further record review of the weekly skin audit in the Treatment Administration Record showed only direction to document Y if there was new skin issue or N if none; however, that documentation was not found, only initials of the nurse and a checkmark with no corresponding progress note documentation of the condition of the left hand or any documentation that the resident accepted or refused cares of the hand. In an interview on 01/15/2026 at 11:08 AM, Staff B, Director of Nursing Services, stated Resident 66 became agitated or aggressive when staff attempted hand care, and was resistant. Staff B stated the nurses were supposed to be offering nail care and attempting to clean inside the hand, monitor and document appropriately. In a follow-up written communication on 01/15/2025 (time not documented) Staff B documented they had identified that Resident 66 does allow care of the hand at times by certain staff. Reference WAC 388-97-1020 (1)(2)(a), (4)(b)

Based on observation, interview and record review the facility failed to ensure that 1 of 6 residents (Resident 3) reviewed for the Preadmission Screening and Resident Review (PASRR - a federally required screening of all individuals for Intellectual Disability (ID) or Related Condition and a Serious Mental Illness (SMI) prior to admission) process. The facility failed to ensure a resident with a positive Level 1 PASRR had a Level 2 evaluation completed for a resident that qualified with ID for services. This failure placed residents at risk for unidentified health care needs, lack of services and diminished quality of life.Findings included .Review of the facility policy titled, Pre-admission Screening & Resident Review Process, revised 08/29/2025 stated the facility would necessitate any positive level 1 screens for an in-depth evaluation, and recommendations would be incorporated into a resident's plan of care.Resident 3 was admitted to the facility on [DATE] with diagnoses that include hemiplegia (paralysis affecting one entire side of the body) to dominant right side of body, and end stage renal disease with dependence on renal dialysis (life-sustaining treatment that removes waste products and excess fluid from the blood). The Quarterly Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], documented the resident had intact cognition, moderate depression, and no refusal of care. Review of Resident 3's Level 1 PASRR dated 08/21/2025, showed Resident 3 required a Level 2 evaluation for ID.Review of Resident 3's PASRR Level 2 determination letter dated 08/14/2025, showed the resident did have an intellectual disability or related condition, did meet the requirements for nursing facility, and did require new specialized services in order to acquire skills and behaviors that would enable the resident to function with as much self-determination and independence as possible, and/or in order to prevent or slow the loss of current functional status. Review of Resident 3's medical record showed no evaluation of what services the resident qualified for or required based on the positive Level 2 determination. Review of Resident 3's care plan focus dated 09/19/2025 stated the resident had impaired cognitive function/dementia or impaired thought process related to developmental delay. Interventions were not specific to Resident 3; there was no mention of the positive PASRR Level 2 and did not include any individualized services that the resident qualified for. Review of Resident 3's progress notes from admission date 08/29/2025 to 01/12/2026 showed no documentation the facility had reviewed or inquired about what specialized services Resident 3 qualified for with the positive Level 2 PASRR determination. In observation and interview on 01/13/2026 at 8:31 AM, Resident 3 was observed to have disheveled hair, facial hair was unkempt and appeared scraggly, clothes were dirty and unbuttoned. The residents' breakfast tray was sitting on the bed, there were stains of yogurt, and crumbs on blankets. The residents' conversation was depressive, they would talk about their mother that passed away, it was difficult to keep the resident focused on a question or to get a clear answer. In observation on 01/14/2026 at 9:50 AM, Resident 3 was wearing same clothes as day before, hair was disheveled, facial hair unkempt and scraggly, clothes are stained with food. In observation on 01/15/2026 at 7:48 AM, Resident 3 was wearing same clothes as the last two days before, hair was disheveled, facial hair unkempt and scraggly, clothes are stained with food. In an interview on 01/15/2026 at 10:19 AM, Staff M, Nursing Assistant Certified (NAC) stated they relied on the care plan to ensure they have had the most accurate level of care each resident required. Staff M stated if they noticed something inaccurate, they notified the licensed nurse. Staff M stated when residents refused care they would reapproach and notify the nurse. Staff M stated that Resident 3 liked to stay up in their wheelchair and not be bothered so they just took that as a refusal of care and didn't approach. Staff M was unaware of Resident 3's intellectual delay or related condition. In an interview on 01/15/2026 at 11:24 AM, Staff N, NAC stated they used the care plan as guidance on what level of care each resident required. Staff N stated Resident 3 would refuse care all the time and would just stay in their wheelchair. Staff N stated that Resident 3 was in a lot of pain and would be grumpy so they would not push too hard if they refused to change clothes, or bathe. Staff N was unaware of Resident 3's intellectual delay or related condition. In an interview on 01/15/2026 at 12:28 PM, Staff O, Registered Nurse (RN) stated that Resident 3 would not follow their own care plan, or the fluid restriction they were on. Staff O was unaware of Resident 3's intellectual delay or related condition. In an interview on 01/15/2026 at 1:55 PM, Staff C, Social Services Manager, stated the social services department was responsible for managing the PASRR evaluations, and ensure the care plan was up to date. Staff C stated another social services department employee was working with Resident 3 and was unavailable for questions. Staff C stated they reviewed the medical record and emails and stated the facility had been trying to get services for Resident 3 but was not clear on the progress that had been made since admission. Staff C did confirm there was no documentation in the medical record to reflect the Level 2 evaluation was received, or if there were any recommendations for care. In a joint interview on 01/16/2026 at 11:33 AM, Staff A, Administrator and Staff B, Director of Nursing Services, Staff A stated they thought social services had been trying to get services for Resident 3. Staff A and Staff B were unaware of the lack of information in the residents' medical record, lack of evaluation in the medical record, and lack of individual care plan for Resident 3. Staff A and Staff B were not aware that the staff had not provided appropriate care to Resident 3 due to lack of guidance in the care plan related to the resident's intellectual delay or related condition. Reference WAC 388-97-1975

Based on interview, and record review, the facility failed to ensure a system in which resident's records were complete, accurate, and accessible, for 4 of 4 residents (Residents 1, 5, 34, and 276) reviewed for accurate and complete medical records. The facility failed to ensure the residents medical records contained hospice provider notes and orders, lab monitoring results, and complete blood sugar monitoring for residents. Failure tomaintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and for diminished quality of life. Finding included . Review of the facility policy titled, Resident Medical Record, revised 10/15/2022 stated medical records are maintained on each resident in accordance with accepted professional standards and practice .are complete, accurately documented, clear, concise, complete reflecting resident's responses and outcomes relate to their care, readily accessible, and systematically organized. <RESIDENT 5> Resident 5 readmitted to the facility on [DATE] with diagnoses to include fracture of the pelvis, respiratory failure. Resident 5 readmitted to the facility on hospice (end of life) services starting on 01/14/2025. Review of Resident 5's medical record on 02/25/2025 showed no documentation that the resident had been seen by the hospice nurse or provider since readmission. In an interview on 02/25/2025 at 3:14 PM, Staff Q, Medical Records stated they keep the hospice documentation in a soft file in their office. Staff Q was asked if those records could be reviewed. Staff Q stated they had not pulled that information from the local hospital electronic record system (EPIC) and would have to get those records from there. Staff Q was asked if the licensed staff have access to that hospital electronic record system, Staff Q said No, they stated only a select few at the facility could access that system. In an interview on 02/26/2025 at 1:18 PM, Staff E, Registered Nurse (RN) stated they do not have access to the hospital electronic record system. Staff E stated when the hospice nurses come in for their visits, they rely on the medical records to print the information. In an interview on 02/27/2025 at 11:20 AM, Staff R, RN/Resident Care Manager (RCM) stated when the hospice nurses/providers are in to see a resident they usually will touch base with the floor nurse. Staff R stated all orders must be faxed over so they must wait for those to be received. Staff R stated the floor nurses do not have access to the EPIC system and would not be able to view any documentation from the hospice nurse, unless the medical records print, and scan into the resident's medical record. In an interview on 02/27/2025 at 1:20 PM, Staff B, Director of Nursing Services (DNS) stated that medical records department was responsible to obtain the hospice documentation for the medical record. Staff B was not aware that Resident 5's medical record was not complete and lacked hospice documentation. 50725 <RESIDENT 34> Resident 34 admitted to the facility on [DATE], with admitting diagnoses to include, heart failure, stroke and heart attack. Resident was admitted to hospice services on 12/11/2024. Review of Resident 34's medical record on 02/25/2024 showed no progress notes from hospice agency staff. In an interview on 02/25/2025 at 3:14 PM, Staff Q, Medical Records stated hospice progress notes were not in the residents' electronic medical records (PCC) they were in the hospice electronic record system (EPIC) and only selected staff were able to access EPIC in their facility. In an interview on 02/26/2025 at 11:13 AM, Staff V, Registered Nurse (RN) stated that hospice nurse visits 2-3 times a week sometimes more depending on the status of the resident. The hospice nurse talks to the facility nurses to get updates or to inform of changes on orders. Staff V stated they don't have access to the progress notes of the hospice agency staff. Any new orders were faxed to the facility from the hospice agency and facility will carry out the order. In an interview on 02/27/2025 at 8:44 AM, Staff L, Licensed Practical Nurse/RCM stated that hospice agency communicates any changes through talking to the facility nurse or the RCM. Sometimes they have to remind new hospice staff to check in with facility nurse/RCM to get updates. Hospice agency faxes to the facility any new doctor's orders. 36787 <RESIDENT 276> Resident 276 admitted on [DATE] with diagnosis to include intestinal obstruction, inguinal hernia (tissue protrudes through groin muscle) and anemia. Review of the January 2025 Medication Admininistration Record (MAR)/Treatment Administration Record (TAR) directed the staff to obtain a full set of vital signs, perform wound care to the residents right rear thigh, apply barrier cream to the coccyx, monitor bruising, any side effects of anticoagulant, and monitor for swallow difficulty, shortness of breath and pain. Review of the MAR for dates 01/26/2025 and 01/27/2025 showed no evening documentation of vital signs being obtained, wound care to the residents right rear thigh, barrier cream treatment to their coccyx, bruise monitoring, side effect monitoring, shortness of breath and swallow monitoring, pain monitoring. Review of the February 2025 TAR showed nurses were to check fecal occult blood test twice and notify the provider of the result every shift for blood in stool beginning 02/19/2025 at 2:00 PM. Review of the documentation showed there was no documentation on 02/20/2025 night shift, 02/22/2025 day and night shift, 02/23/2025 day shift and 02/25/2025 evening shift. 37890 <RESIDENT 1> Resident 1 admitted on [DATE] with diagnoses which included diabetes mellitus which required treatment with insulin injections. Review of Resident 1's medical record showed an order for Lantus (insulin) 24 units at bedtime with a parameter stating to hold the medication if the resident's blood sugar was less than 75. Resident 75's record showed they had a blood sugar monitoring device attached to their left upper arm which was not reflected on the resident's care plan. Review of the Medication Administration record for the current month (February 2025) showed documentation that the insulin was administered but there was no corresponding documentation that the blood sugar had been checked and verified to be above 75 prior to the administration of the insulin. In an interview on 02/25/2025 at 1:00 PM, Resident 1 stated they just hold a machine next to their arm and they can see what the blood sugar is, but the resident stated they do not see it themselves and are not aware of any app or program it is downloaded into. In an interview on 02/25/2025 at 1:04 PM, Staff T, LPN, stated the resident's care plan has not been updated to reflect that he has a glucose monitoring system with sensor on his body. Staff T stated there was an order to check the resident's blood sugar once a day in the morning and noted that there were documentations of that result. Staff T stated they did not know if the blood sugar was being checked in the evenings or not. In an observation with Staff T, the resident's blood sugar monitoring device memory was reviewed going back approximately two weeks, which showed that there were results for both the morning and the evening and there were no evening results noted that were below 75. Staff T confirmed that the results found in the resident's monitoring device were not uploaded in any type of software or app, and the device itself is not part of the resident's medical record as it is owned by the resident. In an interview of 02/25/2025 at 1:21 PM, Staff B, DNS, stated they had not been aware of the lack of blood sugar documentation for Resident 31 and stated the order needed to be updated. Refer to WAC 388-97-1720(1)(a)(i)(ii)(iv)(4)(a)

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment. The facility failed to ensure resident transfer equipment was available and in good condition, call lights were functional and in reach (Residents 20 and 34), and provide consistent housekeeping and maintenance for resident rooms and facility flooring, these failures placed residents at risk for injury, unmet care needs and a diminished quality of life. Findings included . <TRANSFER SLINGS> In an interview on 02/24/2025 at 8:26 AM, Resident 9 stated they believed the facility had a shortage of transfer slings, specifically, the shower slings, and stated they believed it was because staff would use them as regular slings to get residents out of bed. In an interview on 02/26/2025 at 10:09 AM, Staff AA, Nurse's Aide Certified (NAC) stated the shower slings were the mesh ones, some were sized Small, Medium, Large, Extra Large, and some are full body size of the beds, we just grab them out of the laundry. Staff AA stated they thought the slings got hoarded in some of the closets, so sometimes it might seem like there are not enough. Staff AA stated if we are out of the regular slings, then yes, I would use a shower sling rather than tell a resident they can't get up. I do think we need more of the horseshoe style slings. There are some residents who are tiny and if I put them in a full body sling, they are not sitting up right. I just guess roughly what size they need. In an observation and interview on 02/26/2025 at 10:16 AM, Staff U, Laundry Aid, stated they laundered and hung-up slings to dry. Slings were observed hanging on hooks in the laundry room. There were six blue mesh shower slings observed hanging on the wall hooks with a size chart visible on some of the slings showing XL up to 500lbs, and some slings the labels were observed too faded to read. In an observation on the opposite side of the room there were fabric transfer slings. One gray sling which was the horseshoe style that was noted to have split seams and frayed edges where the stitching was. A second larger blue fabric sling was also hanging with similarly frayed seams and stitching. Staff U stated all the slings hanging were ready for staff to use. Staff U clarified that the two slings with frayed edges were ready for the staff to use, stating the staff come in and grab the slings they need. Staff U stated they did not feel there was a shortage of slings. Staff U was asked about sizing of slings and assisted to look for the sling size labels on the two regular slings and was observed to pause and run their hands over the areas with the fraying on the edges, then stated I should probably remove these. Staff U stated they were responsible to look over the slings during the laundering process and would notify Staff H to come look at any if they had concerns and stated, I will have (Staff H) look at these. In an observation on 02/26/2025 at 10:47 AM, there were two styles of Hoyer lift transfer machines in the facility, with different configurations of the attachments for the slings. In an interview on 02/27/2025 at 10:43 AM, Staff F, Infection Preventionist, stated the slings in the facility were universal and fit both types of Hoyer (transfer) lifts. Staff H, NAC, Staffing Coordinator, stated the sizes were on the slings, for example the extra-large slings were blue. Staff H stated the facility needed more of the cross slings, but stated if the staff don't know they can just use a full body sling. Staff H stated laundry checks slings and would ask them to look at them, but if there are any rips or tears, they would have to go. In an interview on 02/27/2025 at 1:53 PM, Staff B, Director of Nursing Services (DNS) stated the transfer slings were determined by the resident's weight and there was a chart that hangs in the laundry. Staff B stated the staff should look at the most recent vital signs for the resident's current weight and use the chart to select the appropriate sling, as the color of the straps on the sling corresponded to the chart. Staff B stated there are different types of slings for each lift, they are not all the same. The staff should not just be grabbing them. Staff B stated the laundry should be checking for condition of the slings. Staff B was made aware of the concerns related to sling sizing and availability and of the observation of damaged slings having been hung up for use. 36787 <FLOORING> In an observation on 02/25/2025 at 8:31 AM, the hall floor outside room [ROOM NUMBER] had and L shaped approximately 5-inch by 6-inch gouge down to the sub floor. In an interview on 02/28/2025 at 8:47 AM, Staff Y, Maintenance Director stated they were aware of the gouges in the flooring throughout the halls and rooms and were trying to develop a plan to repair them. Staff Y stated they did have some extra flooring in the attic to use as replacements, but they were unsure if they had enough to replace all the spots. 47047 <CALL LIGHT OPERATION> In an observation on 02/23/2025 at 8:12 AM room [ROOM NUMBER] had their call light on, the call light was visibly lit from a light above the door, however there was no sound. In an interview on 02/23/2025 at 8:15 AM Staff M, NAC, stated the call light sound was intermittent. In an observation on 02/26/2025 at 9:15 AM Staff Y entered room [ROOM NUMBER] and stated to the residents they were there to fix their call light because it was not audible when turned on. In an interview on 02/26/2025 at 9:20 AM Staff Y stated they were repairing the call light in room [ROOM NUMBER] as they were not audible. When asked how many they had to fix in the last month, Staff Y stated about 8-10. Staff Y stated the call light system consisted of three wires that could become disconnected or dirty causing a malfunction in the system. A maintenance report related to call light repairs for the last month was requested. Reviewed the maintenance reports related to call light repairs completed for the month of February 2025 which showed the following: -02/07/2025 Work Order #3007 room [ROOM NUMBER] call light not working- does not light up -02/20/2025 Work Order #3078 room [ROOM NUMBER] call light turns on and then light turns off and sound is still on -02/21/2025 Work Order #3093 room [ROOM NUMBER] call light not working -02/21/2025 Work Order #3086 room [ROOM NUMBER] call light not working -02/23/2025 Work Order #3094 room [ROOM NUMBER] [NAME] Hall call light not making sound -02/24/2025 Work Order #3099 room [ROOM NUMBER] A call light not working -02/25/2025 Work Order #3107 room [ROOM NUMBER] A call light problems with sound and light -02/26/2025 Work Order #3110 room [ROOM NUMBER] A call light not sounding In an interview on 02/27/2025 at 1:33 PM Staff B, DNS, stated they were unaware of an issue with call light functionality and when there was an issue with the call light they were repaired immediately. Staff B stated the amount of call light repairs in the last month was a lot. <ROOM CLEANLINESS> On 02/23/2025 at 9:35 AM observed room [ROOM NUMBER]'s flooring which had multiple small pieces of food like debris and tissues. The heater element under the window had debris and a pepper packet on it. On 02/24/2025 at 9:00 AM observed room [ROOM NUMBER]'s flooring which had multiple food debris on the floor, tissues, a napkin, and a pepper packet sitting on floor next to the heating element. Most of the items were located around the bed nearest to the window on the left side of the bed. On 02/25/2025 at 9:34 AM observed room [ROOM NUMBER]'s heater element to have multiple pieces of debris on top of it. In an interview on 02/27/2025 at 9:49 AM Staff Z, Housekeeping, stated the process for cleaning rooms included wiping down everything in the room, pick up trash, sweeping and then mopping. Staff Z stated they were assigned to clean room [ROOM NUMBER] five days a week. Staff Z stated they try to clean the heating elements inside/out as much as possible, there were a lot of damaged ones from wear and tear. Staff Z, when asked about room [ROOM NUMBER], stated the residents did not refuse their housekeeping services from them. <CALL LIGHT ACCESSIBILITY> Resident 20 admitted to the facility 08/21/2023 with diagnoses that included multiple compression fractures (break in the vertebra), mild cognitive impairment, and multiple falls. In a continuous observation on 02/26/2025 at 8:14 AM until 9:25 AM, Resident 20 was sitting in their wheelchair holding a book, their call light not in reach. The call light was clipped to the foot of the bed with a fall mattress leaning against the side of the bed, which made the call light out of sight and reach of Resident 20. In an interview on 02/27/2025 at 9:01 AM Staff K, NAC, stated Resident 20 used their call light and usually used the call light when needing assistance to use the bathroom, to ask for food/snacks, and their activity supplies. In a review of Resident 20's care plan dated 08/23/2023 showed they were at risk for falls with interventions to reinforce safety awareness by encouraging them to use their call light for assistance and signage placed in their room to remind them to use their call light. 50725 <RESIDENT 34> Resident 34 admitted to the facility on [DATE], with admitting diagnoses to include, stroke and heart attack. Resident was receiving Hospice services. In an observation on 02/26/2025 at 12:56 PM, Resident 34 was sitting on their recliner eating lunch. Their call light was on the resident's bed and not within reach of the resident. In an observation on 02/26/2025 at 1:09 PM, staff assisted Resident 34 back to their recliner after using the bathroom and left the room. Their call light was still on the bed and not within reach of the resident. Record review of Resident 34's care plan on 02/26/2025 under Focus stated: Impaired mobility with risk for falls, related to Gait/balance problems and actual falls. Under the intervention, it stated: Be sure the call light is within reach and encourage to use Joystick for assistance as needed. In an interview on 02/27/2025 at 8:27 AM, Staff V, Registered Nurse, stated that Resident 34 sometimes uses the call light. Refer to WAC 388-97-0880(1)(2), WAC 388-97-0860(2)

Based on interview and record review, the facility failed to ensure resident choices/preferences regarding their bathing schedule were honored for 4 of 6 sampled residents (Residents 31, 50, 69, and 276) and failed to honor Resident 7's preference to lay down after a meal. The facility's failure to accommodate resident choices/preferences related to bathing and daily schedules placed residents at risk for feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life. Findings included . <DAILY SCHEDULE> <RESIDENT 7> Resident 7 admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes mellitus type two (chronic condition in which the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels) and history of stroke. Review of Resident 7's Brief Interview for Mental Status (BIMS- a screening tool for assess cognition) dated 01/25/2025 showed they scored 2/15 indicating severe cognitive impairment. In an observation on 02/26/2025 at 8:28 AM Staff M, Nursing Assistant Certified (NAC) visited with Resident 7, who was in their room, sitting in their wheelchair. After speaking with Resident 7, Staff M told Staff N, NAC, that Resident 7 requested to lay down in their bed. In a continuous observation from 02/26/2025 at 8:28 AM until 9:25 AM Resident 7 was in their room, sitting in their wheelchair. At 9:19 AM Staff N went to speak with Resident 7 and was asked by the nurse to help in another resident's room and left Resident 7 in their room. At 9:25 AM Staff M entered Resident 7's room to assist them in laying down in their bed, almost an hour after they had requested assistance. In an interview on 02/26/2025 at 9:31 AM Staff V, Registered Nurse (RN), stated Resident 7 was up around 7 am for breakfast that morning. In an interview on 02/27/2025 at 9:40 AM Staff K, NAC stated Resident 7's routine consisted of getting up for breakfast and afterward they either attended an activity or laid back down in bed. Staff K stated Resident 7 required the assistance of two staff and a mechanical lift to be transferred into and out of bed. 50725 <BATHING PREFERENCES> <RESIDENT 50> Resident 50 admitted to the facility on [DATE] with diagnoses to include stage 4 pressure ulcer (deep crater-like wound with significant tissue loss), urinary tract infection (UTI-bacterial infection that affects any part of the urinary tract, including the kidneys, ureters, bladder and urethra) and morbidly obese. According to the Admission Minimum Date Set (MDS - an assessment tool) assessment, dated 12/03/2024, the resident was cognitively intact. In an interview on 02/23/2025 at 10:34 AM, Resident 50 stated that they were receiving bed bathes once a week and they were supposed to have it twice a week but that never happens. In an interview on 02/26/2025 at 8:28 AM, Resident 50 stated that a staff member informed them that due to their wound and having a wound VAC (vacuum-assisted closure - a medical device that uses negative pressure to promote wound healing), they cannot have showers and receives bed bath instead. Resident stated that they prefer showers. Review of Resident 50's physician orders on 02/26/2025 showed there were no orders that showers were contraindicated for the resident. Review of Resident 50's care plan print date 02/23/2025 showed a Focus area: Residents' Readiness for Enhanced Health Management. Goal: Residents' preference will be honored. Intervention: Resident prefers showers two times per week in the morning . In an interview on 02/26/2025 at 1:50 PM, Staff W, RN stated they were not sure why Resident 50 was receiving bed bathes instead of showers. In an interview on 02/26/2025 at 2:03 PM, Staff X, NAC, stated that the reason why Resident 50 was getting bed baths and not showers was because of their wound VAC. In an interview on 02/27/2025 at 10:46 AM, Staff L, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated that they receive resident preferences on admission and sometimes the resident will change their minds on their preferences after. Regarding Resident 50, Staff L did not think the shower was contraindicated for them due to the wound VAC and what they stated, was that the resident preferred bed baths rather than showers. Staff L was unaware that the resident's care plan showed they preferred showers, and the resident had verbalized that they preferred showers over bed baths. Staff L stated they would follow up with the resident. In an interview on 02/27/2025 at 2:15 PM, Staff B, Director of Nursing Services (DNS) stated that even if a resident has a wound VAC the staff can provide a shower for the resident. If a resident refuses a shower, then they offer a bed bath. Discussed with Staff B that Resident 50 preferences showed they preferred showers over bed bathes and that the resident was told that due to their wound VAC they would get bed baths instead. Staff B stated they would look into that information. 36787 <RESIDENT 69> Resident 69 admitted to the facility on [DATE] with diagnoses to include cancer, spondylosis (spine condition causing pain), anxiety and weakness. Review of the baseline care plan dated 01/09/2025 showed the resident required extensive assistance of two staff to transfer into bed. The baseline care plan did not include Resident 69's bathing preference. A review of the admission MDS assessment dated [DATE] showed the resident was cognitively intact and choices related to choosing their type of bathing and bedtime were very important. In an interview on 02/26/2025 at 11:57 AM, Resident 69 was in bed and stated they wanted to go to bed last night at 6:30 (PM) and the staff made them wait until 9:00 PM to go to bed and the resident stated I couldn't believe it. Resident 69 stated at first, the nurse told them they had just had their pills, and they might vomit, so it was safer to stay up a bit to let their stomach settle. The resident stated they understood that but questioned why the wait was that many hours. In an interview on 02/28/2025 at 8:14 AM, Resident 69 stated they would like two showers a week but had only had two showers and one bed bath since they admitted on [DATE]. Review of Resident 69's bathing documentation since admission confirmed they had three bathing tasks documented: -01/16/2025 Bed Bath documented at 3:20 PM -01/23/2025 Shower documented at 10:26 AM -01/26/2025 Shower documented at 5:41 PM <RESIDENT 276> Resident 276 admitted on [DATE] with diagnoses to include an intestinal obstruction, inguinal hernia (tissue protrudes through groin muscle) and gait and mobility abnormalities. Review of the admission MDS dated [DATE] showed the resident had mild cognitive impairment and was totally dependent on staff for activities of daily living such as bathing. The MDS also showed the resident was able to be interviewed regarding choices and had stated choices related to bathing were very important. Review of Resident 276's care plan dated 01/15/2025 showed the resident preferred showers twice a week in either the morning or evening. In an interview on 02/25/2025 at 1:02 PM, Resident 276 was sitting up in bed and stated they would like two showers a week, but they get one shower then the next one was a bed bath. Resident 276 stated when they first admitted , they went several weeks without a shower or bath. Review of Resident 276's January bathing records showed the resident received: - 01/15/2025 Bed bath documented at 8:59 PM, - 01/22/2025 Bed Bath documented at 9:59 PM, - 01/26/2025 Shower documented at 9:32 AM, In a joint interview on 02/28/2025 at 9:21 AM, with Staff A, Administrator and Staff B, the lack of honoring residents desire to get out of bed for Resident 9 and 31 and into bed for Resident 69, as well as bathing choices for Resident's 50, 69, 276 were discussed. Staff B stated resident's should be asked their preferences and this should be documented on the care plan. 37890 <RESIDENT 31> Resident 31 was a long-term care resident of the facility with diagnoses which included paraplegia and required total assistance with a mechanical lift for transfers out of bed or to the shower. Review of Resident 31's care plan showed the resident's shower preferences on their care plan had not been updated since 2022 which showed they preferred two showers per week in the evenings. The care plan stated Resident 31 preferred to wake up at 7:00 am and stated when serving Resident 31 breakfast to ask what time they would like to get up into their chair today. Review of the resident's shower documentation for the prior month showed: - 01/30/2025 Bed bath documented at 11:54 AM, - 02/01/2025 Shower documented at 12:51 PM, - 02/04/2025 Shower documented at 1:56 PM, - 02/18/2025 Shower documented at 11:27 AM, - 02/22/2025 Shower documented at 1:59 PM. In an interview on 02/24/2025 at 08:26 AM, Resident 31 stated they preferred getting up out of bed and having shower in the early morning because they liked to be active and attend activities and outings. Resident 31 stated they often had to stay in bed or wait to have their shower until 11:00AM or later because of the aids being busy with breakfast. If it was their shower day, they often had to wait until the afternoon because the aids on the floor are the ones who have to do the showers, and they don't have time until after breakfast or sometimes not until after lunch. In an interview on 02/27/2025 at 1:51 PM, Staff B stated resident preferences were identified when residents admitted to the facility and should be updated on the care plans as they change. Staff B stated staff should be coordinating together to ensure resident preferences for schedules were met. Staff B stated they should be helping; managers should be helping, and staff should be communicating when help was needed. Reference: WAC 388-97-0090(1) (2)

Based on interview and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 7 resident interviews (Residents 3, 9, 22, 50, 57, 59 and 63) and one family interview (Resident 5) in three of three hallways and Resident Council minutes. The facility had insufficient staff to ensure residents received prompt call light response and assistance to meet the needs of the residents in accordance with resident preferences. These failures placed residents at risk for unmet care needs and negative outcomes. Findings included . <PAYROLL STAFFING DATA REPORT (PBJ)> Review of the facility past four quarter reports, dated 01/01/2024 through 12/31/2024, showed the facility had excessively low weekend staffing; there had been no change over the past year. <FACILITY ASSESSMENT> Facility Assessment last updated 07/31/2023 through 07/31/2024, showed the facility had an average of 316 residents annually who required 2-person assistance for daily care, noting a high amount relative to the benchmark. Additionally, the facility had high number of residents who required assistance with bed mobility, transfers, toilet use, eating and hygiene/grooming. Review of the Function-Care Requirements in the Facility Assessment stated the Nursing Assistant Certified (NAC), Licensed Practical Nurses (LPN) Registered Nurses (RN), hospitality aides and non-certified nursing assistants (NA) staff was based on Per Patient Day (PPD) and/or acuity and the facility census and the Director of Nursing Services (DNS) reviewed staffing daily to ensure sufficient staff have been scheduled consisting of the required certification and/or licenses including 16 hours of daily of LPN licensed nurse coverage and meeting PPD state requirement. <STAFFING PLAN> Review of the staffing plan undated, showed the scheduler/human resources would hold the staffing phone Monday through Friday and the on-call nurse would hold the phone on the weekend. Schedules would be posted on the 20th of each month and open shifts available for staff to pick up until the 25th of each month then posted for agency to pick up. <SCHEDULES> Review of NAC and Nursing schedules for February 2025 showed the following: Nurse Schedule 02/2025 - 11 Day shifts needed to be staffed, - 15 Evening shifts needed to be staffed, - 11 Overnight shifts needed to be staffed, - Of those shifts needed to be staffed five of them were for a weekend (Saturday and/or Sunday). NAC Schedule 02/2025 - 48 Day shifts needed to be staffed, - 67 Evening shifts to be staffed, - 19 Overnight shifts needed to be staffed, Of those shifts needed to be staffed 34 of them were for a weekend (Saturday and/or Sunday). <RESIDENT COUNCIL MINUTES> Review of the Resident Council minutes from August 2024 through January 2025 showed the Resident Council had concerns regarding staffing. Review of Resident Council minutes showed: -On 08/27/2024 showed a complaint of a resident having a medical emergency, -On 09/17/2024 showed residents complained they were not getting their medications timely due to not having a swing cart nurse, a wait of 45 minutes to have their call lights answered due to having only one aide, and the facility not being able to keep hospitality aides, -On 11/5/2024 showed two residents complained of their call light not being answered timely with a wait of 45 minutes, -On 12/31/2024 there was a complaint about lack of consistency with staff and medication delivery times, -On 01/28/2025 there was a complaint from a resident about waiting 45 minutes for their call light to be answered. <PERFORMANCE EVALUATION> Review of a performance evaluation for Staff O, NAC, dated 08/09/2024 and signed by the Staff B, Director of Nursing Services, showed a comment under the productivity area that read continues to work short and still gets the job done. <SPEND DOWN> Review of the facility's spend down showed a staffing ladder for a census of 75, 1978.13 hours per week or 275.25/day were allotted for nursing services . <STAFF POSTING> In a review of the staff posting for 02/21/2025, 02/22/2025 and 02/23/2025 showed the following: -On 02/21/2025 the facility had a census of 75 and had 229 hours of nursing services, -On 02/22/2025 the facility had a census 75 and had 202 hours of nursing services, -On 02/23/2025 the facility had a census of 75 and had 220 hours of nursing services. These hours were well below the allotted operating hours listed in the spenddown. <RESIDENT COUNCIL INTERVIEWS> In an interview on 02/25/2025 at 10:30 AM, in resident council, Resident 9 stated the staff help as much as they are able, and it can take a little longer for assistance. In an interview on 02/25/2025 at 10:30 AM, in resident council, Resident 3 stated that they have had to wait up to 45 minutes for their call light to be answered. In an interview on 02/25/2025 at 10:30 AM, in resident council, Resident 25 stated the facility was understaffed. <RESIDENT INTERVIEWS> In an interview on 02/23/2025 at 10:43 AM, Resident 63 stated the facility has had random call ins and was short staffed. Resident 63 stated it had taken anywhere from 8-11 minutes to get assistance and sometimes could be more. Resident 63 stated they wait for medications, their bedding to be changed or getting needed items. In an interview on 02/23/2025 at 12:44 PM, Resident 59 stated they needed more help at mealtime, the call light wait time was too long to have their brief changed. In an interview on 02/23/2025 at 11:17 AM, Resident 22 stated they had waited between 20-30 minutes to have their call light answered for brief changes, especially during mealtimes when everyone was busy. In an interview on 02/23/2025 at 10:50 AM, Resident 50 stated they had waited around 30 minutes for their call light to be answered. Resident 50 stated the facility did not have enough staff. <FAMILY INTERVIEW> In an interview on 02/23/2025 at 10:26 AM, Collateral Contact 2 (CC 2-Resident 5's representative), stated they knew the facility to be understaffed all the time. CC 2 stated they had received phone calls from Resident 5 who stated they were waiting to use the bathroom, and it was taking a long time. <STAFF INTERVIEWS> In an interview on 02/25/2025 at 10:30 AM, in resident council, Resident 57 stated they had waited a long time for their call light to be answered to get back into bed after meals. In an interview on 02/27/2025 at 8:25 AM, Staff H, Staffing Coordinator/NAC, stated they staff to the census and to the acuity of the residents. Staff H stated Staff B had a formula/spreadsheet they used to determine staff to resident ratios based on census. Staff H stated they currently had two openings for NAC's. Staff H stated they work alongside another NAC for staffing, and they coordinate together so if there is a shortage they can come in to work as an aide, but they are only one person so if there are more than one call out, they reach out to agency to fill the spot. Staff H stated that weekend staffing issues are related to call outs. In an interview on 02/27/2025 at 1:35 PM, Staff B, stated they staff to census and to acuity. Staff B stated they have two staffing coordinators which cover the schedule if there are call outs or a need. Staff B stated they discuss staffing at their morning meetings and recently hired a recruiter. Staff B stated there were some NAC's that started and left right away because they were not prepared to work in a skilled nursing facility. In an interview on 02/28/2025 at 8:51 AM Staff A, Administrator, when asked about the PBJ reports for the last four quarters reporting low weekend staffing, stated a lot of other facilities cover the course of their weekend staffing with exempt employees and they do not. Staff A stated they had eight NAC openings and three LPN openings and fill in with agency. Reference: (WAC) 388-97-1080 (1)

Based on observation, interview, and record review, the facility failed to ensure staff were com-pliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 5 nurses (Staff C) during medication administration, 1 of 1 resident (Resident 50) during catheter care, and for 1 of 1 resident (Resident 14) reviewed for transmission-based precautions (TBP) of a resident who had tested positive for Respiratory syncytial virus (RSV). The facility failed to ensure staff followed appropriate infection control practices during medication administration and performed appropriate hand hygiene during urinary catheter care. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards. This failure placed all residents and staff at risk for potential infection. Findings include . Review of the facility policy titled, Infection Prevention and Control Program, revised 10/15/2022 stated that the facility will design and implement an infection control program that will identify and reduce the risk for acquiring and transmitting infections among residents, staff, and visitors and maintain a safe, sanitary environment .monitor compliance with standards of practices including hand hygiene, transmission based precautions (TBP), and use of PPE. Review of the facility policy titled, Hand Hygiene, revised 02/11/2022 stated hand hygiene was the single most important procedure for preventing the spread of infection . opportunities for hand hygiene before providing personal care to a resident, before and after cleaning soiled body site, after contact with any objects in the immediate vicinity of the resident, after leaving the resident room, after removing gloves, and after assisting with toileting . aspects of hand hygiene were to wear gloves when there was potential to have contact with blood or other potential infectious materials. Review of facility TBP, titled, Droplet Precautions, dated 08/10/2023 states everyone must clean hands and wear mask before entering. All staff are instructed to wear eye protection with respiratory symptoms and gown and gloves if potential contact with secretions was likely . droplet precautions use for respiratory viruses. <TRANSMISSION BASED PRECUATIONS> Resident 14 admitted to the facility on [DATE] with diagnoses to include high blood pressure, peripheral vascular disease (condition that affects the blood vessels outside the heart and brain, and reduced blood flow), and chronic kidney disease. Review of Resident 14's medical record showed they had tested positive for RSV on 02/22/2025. In observation on 02/23/2025 at 8:36 AM, room [ROOM NUMBER] had Resident 14's name on the door as well as a TBP sign that directed staff the resident was on droplet isolation precautions, in that staff were to wear a mask, and a gown, gloves and eye protection if the resident had respiratory symptoms. The door was halfway open, and the resident could be heard to have a continuous cough. In an observation on 02/23/2025 at 9:52 am, Staff E, Registered Nurse (RN) was observed entering Resident 14's room with a mask and gloves on, they did not have gown or eye protection on. In an observation on 02/25/2025 at 8:54 AM, Staff D, Nursing Assistance Certified (NAC) was observed to enter Resident 14's room (continued to be placed on droplet precautions) with gown, gloves and mask on, they did not wear eye protection. At 9:11 AM, Staff D exited the room and was not observed to replace their surgical mask and proceed to provide care to others. In an observation and interview on 02/26/2025 at 7:39 AM, Staff E, was observed to enter Resident 14's room (continued to be placed on droplet precautions) with only a mask and gloves on. At 7:44 AM, Staff E exited the room and was not observed to replace their surgical mask. Staff E stated they had an extra in their pocket, Staff E was not aware they should have worn a gown and eye protection while providing care to the resident. <MEDICATION ADMINISTRATION> Resident 72 admitted to the facility on [DATE] with diagnoses to include diabetes and bacteremia (blood infection). In an observation on 02/23/2025 at 12:20 PM, Staff C, Licensed Practical Nurse (LPN) was observed to enter Resident 72's room with an insulin (medication injected into the skin to regulate blood sugar levels) pen (sharps device used to deliver medication through a needle). Staff C was not observed to perform handy hygiene. Staff C asked Resident 72 if they could inject the insulin, Resident 72 responded same location and held up their right arm. Staff C then took their bare hand and pulled the residents shirt sleeve up, pinch the skin with the bare hand and injected the pen into Resident 72's arm without wearing in PPE. Staff C was then observed to place the cap back on the end of the pen and exit the room without performing any hand hygiene. Staff C was not available to interview. <HAND HYGIENE> Resident 50 admitted to the facility on [DATE]. Resident had a foley catheter (a flexible tube inserted into the bladder to drain urine) and a colostomy (surgical procedure that creates an opening (stoma) in the abdominal wall to divert stool from the colon into a receptacle) bag. In an observation on 02/25/2025 at 10:10 AM, Staff S, NAC and Staff H, NAC, were donning (putting on) gowns and gloves to provide a bed bath for Resident 50. Staff H emptied colostomy bag and after disposing the stool, Staff H took their gloves off and donned new gloves. Did not observe Staff H washed hands or used alcohol-based hand rub (ABHR) prior to donning clean gloves. Staff S provided catheter care and peri care (the practice of cleaning the genital and perineal area) to Resident 50. Staff S took their right-hand glove off then donned new gloves without using ABHR, then continued washing resident's peri area. With the same gloves, Staff S and Staff H, repositioned resident to the right side of the bed using a draw sheet and turned resident to their left side. Using the same gloves, Staff S placed a clean brief under the resident, then Staff S took their gloves off, went to the sink to wet some more wash cloths and without washing hands or using ABHR, donned new pair of gloves. Both staff continued to wash residents' upper body, applied lotion and placed the sling under the resident. Resident was transferred to their wheelchair using the Hoyer lift. Staff H, using the same gloves, wiped the Hoyer lift with disinfectant wipes. In an interview on 02/25/2025 at 10:50 AM, Staff S informed me that they usually use hand sanitizers after they take their gloves off but because Resident 50 just moved into the room, the supplies in the room was not set up and there weren't any hand sanitizers close by for staff to use. In an interview on 02/27/2025 at 9:54 AM, Staff F, LPN/Infection Preventionist stated Resident 14 had been placed on droplet precautions on 02/18/2025 when they developed respiratory symptoms. Staff F stated their expectation and education to all staff was that they were to wear a mask, gown, gloves, and eye protection for all droplet precaution residents. Staff F stated as a facility they had been always wearing surgical mask, so staff were expected to remove all their PPE when exiting a droplet isolation room and to place a new mask on prior to providing care to any other residents. Staff F was advised of observations made during survey process and stated that was not their expectation or how they had trained the staff. Staff F was asked about hand hygiene in the facility, and stated staff should be performing hand hygiene every time before and after they remove their gloves. Staff F stated that during insulin administration the expectation was all nurses were performing hand hygiene and wearing the appropriate PPE, specifically gloves when handling any sharps. In an interview on 02/27/2025 at 1:20 PM, Staff B, Director of Nursing Services stated all staff should be wearing the appropriate PPE, for any TBP resident they have in the facility. Staff B stated they were not aware staff were not wearing the appropriate PPE when providing care to Resident 14. Staff B stated for any insulin administration, or handling of any sharps, licensed nurses should be performing hand hygiene and wearing gloves as all times. Staff B was not aware that a licensed nurse had been observed to administer insulin with a sharp's device with no gloves. 50725 This is a repeat deficiency from SOD dated 03/26/2024. Refer to WAC 388-97-1320(1)(a)(c)

Based on observation, interview and record review, the facility failed to review and revise the care plans to accurately reflect resident conditions and needs for 3 of 16 residents (Residents 34, 50 and 56) reviewed for care planning. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . According to the facility policy titled Care Plans, revision date 10/15/2022, the team of qualified persons monitors the residents' condition and effectiveness of the care plan interventions and revises the care plan quarterly, annually, with a significant change assessment or more frequently as needed with the input by the resident and/or the representative, to the extent possible, based upon the following: .Change in the resident condition, . visual problems. The facility policy titled Indwelling Catheters, revision date 04/12/2022 showed: Good hygiene is maintained at the catheter-urethral interface: cleaned daily with soap and water. The care plan reflects intervention to reduce or prevent urinary tract infections (UTI-bacterial infection that affects any part of the urinary tract, including the kidneys, ureters, bladder and urethra),). <VISION> <RESIDENT 34> Resident 34 admitted to the facility on [DATE], with admitting diagnoses to include, stroke and heart attack. Resident was receiving Hospice services. According to the Significant Change Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], resident had severe cognitive impairment. In an interview and observation on 02/24/2025 at 8:18 AM, Resident 34 was sitting on their recliner with their breakfast tray in front of them when an unidentified staff member came in with brown sugar and placed it on resident's tray. Resident 34 asked the staff where the brown sugar was and then stated they were blind and could not see. Unidentified staff then asked resident where their eyeglasses were and resident informed staff that their eyeglasses did not work. The unidentified staff then left the room and the resident informed surveyor that they can't see the food on their plate and wanted someone to help them eat. Review of Resident 34's care plan, print date 02/24/2025 showed a focus area: Resident 34 has physical limitation struggles with their eyesight. The resident will need large print materials during activities. No other care plan regarding resident's poor eyesight was noted. In an interview on 02/25/2025 at 9:05 AM, Resident 34 stated that they cannot see much, they stated that they can see black and the flowers on surveyor's top. In an interview on 02/25/2025 at 12:50 PM, Staff V, Registered Nurse (RN) stated that Resident 34 can feed themselves if they were awake enough and that the resident has a colorful plate so they are able to see it. Staff V stated they set the resident's tray up and inform them where things were on their tray. Staff V stated they don't update care plans, the Resident Care Manager (RCM) does. In an interview on, 02/26/2025 at 1:45 PM, Staff O, Nursing Assistant Certified (NAC) stated that Resident 34 required assistance with toileting, transfer and dressing. As an agency staff they stated that they got resident's information by reading the Kardex, report from the other NAC and nurses or they asked questions with the staff that knows the resident. Staff O stated that resident wore eyeglasses but was not aware that resident had poor eyesight and did not see that in the Kardex. In an interview on 02/27/2025 at 8:30 AM, Staff L, Licensed Practical Nurse (LPN)/RCM, was aware of Resident 34's poor eyesight but was unable to locate a care plan regarding the resident's eyesight. Staff L stated that resident's poor eyesight should have been care planned. <FALL MAT ALARM> In an observation on 02/24/2025 at 12:06 PM, Resident 34 was sitting in their recliner, eyes closed, neck pillow around their neck. There was an alarming fall mat noted at the side of the bed, not under resident's feet. In an observation on 02/24/2025 at 2:42 PM, Resident 34 was lying on the bed with eyes closed, fall mat on the floor at the side of the bed. In an observation on 02/26/2025 at 08:15 AM, Resident 34 was sitting in their recliner, fall mat was not positioned under their feet. Resident stated it does not bother them to have the fall mat because it helps them get the staff to see them right away. Review of Resident 34's progress notes on 02/26/2025 at 9:59 AM, showed the resident had falls on 11/16/2024, 11/29/2024, 12/03/2024, 12/24/2024 and 2/08/2024. Review of Resident 34's care plan on 02/26/2025 showed a Focus area: Impaired mobility with risk for falls, related to Gait/balance problems and actual falls. Interventions: Safety Device; Fall mat to prevent injury related to potential falls, initiated on 02/09/2025. Use of sensor mat alarm in front of recliner when awake and/or at bedside during hours of sleep. In an observation on 02/27/2025 at 8:25 AM, Resident 34 was sitting up on their recliner, fall mat was not positioned under their feet. In a joint interview on 02/28/2025 at 10:02 AM with Staff A, Administrator and Staff B, Director of Nursing Services (DNS), Staff B stated that Resident 34's fall matt alarm was an intervention they placed to prevent the resident from falling. It does not alarm in the resident's room. Staff A stated the alarm let the staff be aware when the resident attempts to get up. They were not aware that it was not being placed in front of the recliner when the resident was up sitting up in the recliner. <INDWELLING CATHETER> <RESIDENT 50> Resident 50 admitted to the facility on [DATE], was hospitalized and readmitted on [DATE]. Diagnoses to include, UTI, stage 4 pressure ulcer (deep crater-like wound with significant tissue loss) with a wound VAC (vacuum-assisted closure - a medical device that uses negative pressure to promote wound healing) and morbidly obese. According to the Admission MDS assessment dated [DATE], the resident was cognitively intact. In an interview on 02/23/2024 at 10:47 AM, Resident 50 stated that lack of catheter care and peri care was the reason why they had UTI. Review of Resident 50's physician orders on 02/24/2025, Resident 50's showed that the resident had an indwelling catheter (thin, flexible tube inserted into the bladder through the urethra to collect and drain urine). Review of Resident 50's care plan, print date 02/23/2025, showed a Focus area: Resident has indwelling catheter related to pressure wounds. Interventions included: Position catheter bag and tubing below the level of the bladder, cover with privacy bag, secure with leg strap and empty catheter bag every shift. This care plan was initiated on 11/27/2024. Interventions did not show peri-care (the act or washing the genital and anal area). Another Focus showed: Resident has sepsis infection related to UTI. Goal stated, resident's UTI will resolve without complications by review date. This care plan was initiated on 02/18/2025. Interventions did not mention anything about peri-care. In an interview on 02/26/2025 at 1:50 PM, Staff W, RN stated that the NACs were the ones that provided catheter care for residents and sometimes the nurses assist as well. Staff W stated catheter care, including peri-care was done every shift. Staff W was not able to show me in the Kardex (a quick reference for nurses or NAC's regarding residents' information and care) or care plan that peri-care was included in the catheter care for Resident 50. Staff W stated they would look into that. In an interview on 02/26/2025 at 2:03 PM, Staff X, NAC stated catheter care involved emptying the catheter bag every shift. Staff X was unable to provide any additional catheter care information. Review of Resident 50's clinical record on 02/26/2025 at 2:26 PM, Resident 50's showed no documentation that resident had received catheter care with peri-care since 02/14/2025. In an interview on 02/27/2025 at 10:46 AM, Staff L, LPN/ RCM stated that the expectation on indwelling catheter care with peri-care should be done every shift and should be documented under TASK in resident's electronic chart. In an interview on 02/27/2025 at 2:15 PM, Staff B stated that catheter care/peri-care documentation was under the task tab in resident's electronic records. When Resident 50 was readmitted from the hospital the admitting nurse did not click the Task to reinstate the catheter care. Staff B stated they had reinstated it on 02/26/2025. <PRESSURE ULCER> In an observation on 02/24/2025 at 12:07 PM, Resident 50 was laying on their back with head of the bed elevated. Review of Resident 50's care plan on 02/25/2025 showed a Focus area: Resident has potential alteration in skin/tissue integrity related to obese, need extensive assist, impaired mobility, history of chronic pressure ulcer. This was initiated on 11/27/2024. Interventions showed: Avoid friction and shearing. Brief removed from under resident to prevent rubbing. Further review of the care plan showed another Focus area that stated: Resident has actual pressure ulcer stage 4 on sacral area, open wound to lateral lower leg and multiple blister areas to right hip, blister to left thigh. This was initiated on 01/07/2025. Interventions included moisture management: Keep the skin clean and dry especially around the wound of sacral area due to drainage from wound. Frequent repositioning and addresses any underlying causes like poor circulation, moisture build-up, causing friction. The resident requires air mattress pressure relieving/treatment wheelchair cushion. In an observation on 02/25/2025 at 8:30 AM, Resident 50 was in bed awake, lying on their back. In an observation on 02/25/2025 at 10:10 AM, Resident 50, was lying on their back and was getting ready to receive a bed bath from Staff S, NAC and Staff H, NAC. The resident was wearing an incontinent brief. When asked why resident was wearing an incontinent brief, Staff S stated that it absorbs the moisture from the wound in the resident's sacrum and the catheter leaks sometimes. The resident was observed requiring 2-person extensive assist to be turned to their side. After staff completed care the resident was transferred to a wheelchair without a pressure relieving cushion in place. In an observation and interview on 02/26/2025 at 8:28 AM, Resident 50 was lying on their back with head of the bed elevated. They stated that the doctor at the wound care clinic stated they might have a bone infection from their wound. The resident stated that staff does not offer to turn them on their sides. The resident stated that when they were at the hospital, they were turned every two hours using positioning wedges. In an observation at 02/26/2024 at 10:42 AM, Resident 50 remained in the same position as the prior observation at 8:28 AM, lying on their back with head of the bed elevated. In an interview on 02/26/2025 at 1:50 PM, Staff W, RN stated that Resident 50 goes to wound care clinic every Tuesdays and they change the wound VAC dressing there and the facility changes the wound VAC dressing every Friday. Staff W stated repositioning was one of the interventions for residents with pressure ulcers. In an interview on 02/26/2025 at 2:03 PM, Staff X, NAC stated that Resident 50 was not supposed to have incontinent briefs on due to their wound and they check them 2-3 times during the shift to make sure the resident was dry. Staff X stated that resident does not like to lay on their side especially on their left side due to shoulder pain. In an interview on 02/27/2025 at 10:46 AM, Staff L, LPN/RCM stated that positioning for residents with pressure ulcers should be standard of care and that all the residents should be repositioned. Regarding Resident 50 not having pressure relieving cushion on their wheelchair, Staff L stated that they had a wheelchair cushion in the past, but it did not fit well, so they were working on obtaining another one. In an interview on 02/27/2025 at 2:15 PM, Staff B stated that repositioning or turning of residents should be standard of practice and staff were expected to turn and reposition residents. Informed Staff B that Resident 50 had not been turned to their sides and that resident verbalized that they have not been turned ever in the facility, Staff B stated that they will go talk to the staff about that. When asked regarding resident not having a wheelchair cushion, Staff B stated that therapy department found a cushion and had placed it on resident's wheelchair. 47047 <RESIDENT 56> Resident 56 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression and anxiety. Review of Resident 56's care plan dated 08/24/2024 showed they used a hypnotic medication related to insomnia. Review of Resident 56's Order Summary Report as of 02/26/2025 showed they were not prescribed a hypnotic medication. Review of Resident 56's electronic medical record showed they had been prescribed a hypnotic medication at admission, which was discontinued on 10/17/2024. In an interview on 02/27/2025 at 2:15 PM Staff B, DNS, stated resident care plans should be revised when there are changes in a residents condition/care needs. This is a repeat deficiency from SOD dated 03/26/2024 Refer to WAC 388-97-1020(2)(a-f)(5)(b)

Based on observation and interview, the facility failed to ensure a system was in place to accurately reconcile controlled medications in 1 of 5 medication carts reviewed for narcotic storage/reconciliation. This failure placed the facility at risk for potential loss and/or drug diversion of the controlled medication. Findings included . Facility policy titled Management and Destruction of Controlled Substances dated 11/28/2017 showed: The two licensed nurses visually inspect and counts each scheduled medication . and verifies the quantity on hand matches the declining inventory record. If any discrepancy is identified both nurses remain on duty and the Chief Nursing Officer is notified. In an observation and interview on 02/24/2025 at 1:45 PM, Staff V, Registered Nurse was counting the narcotic medications for [NAME] Cart. Page 24 of the narcotic book showed 1 tablet left but there was no narcotic medication in the cart. Page 30 of the same narcotic book also showed 1 tablet left but there was no narcotic medication in the cart. Staff V stated that the count was off on the book and those pages should show zero. Staff V stated that they will inform the Resident Care Manager (RCM) so they can start the investigation. In an interview on 02/24/2024 at 2:55 PM, Staff L, Licensed Practical Nurse/RCM stated that they have figured out the discrepancy. Staff L explained that the licensed nurses (LN) that gave the last doses forgot to sign them out of the narcotic book, but it showed in the Medication Administration Record (MAR) that the LN's signed their initials indicating they gave the medications. Staff L will be reaching out to those LN's to sign the narcotic book. Staff L stated the process for counting narcotics was supposed to be the LN's look at every page of the book to ensure accuracy and any discrepancies they report to the RCM. In an interview on 02/27/2025 at 2:00 PM, Staff B, Director of Nursing Services (DNS) stated that it's an expectation that when counting narcotics the LN's look at every page of the book and any discrepancies be reported to the RCM or DNS. Staff B stated they were able to reconcile the narcotic book for [NAME] Cart. Refer to WAC 388-97-1300(2)

Based on interview and record review, the facility failed to ensure 2 of 5 sampled residents (5 and 34) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure a medical provider assessed and documented a rationale for extended use of an as necessary (PRN) psychotropic medication for use over 14 days and failed to monitor for appropriate symptoms. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Finding included . Review of the facility policy titled, Psychoactive Drug Use, revised 10/15/2022, stated that the clinical rational should be documented in the medical record .justification should include description of symptoms, why the resident symptoms need to be managed by a psychoactive drug, description of the treatment, and why the present dose was necessary to manage the symptoms. <RESIDENT 5> Resident 5 readmitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (condition in which the brain does not function properly due to an underlying metabolic imbalance), depression and anxiety. The significant change Minimum Data Set (MDS - an assessment tool) assessment, dated 01/18/2025 showed the resident had sever impaired cognition. Review of Resident 5's physician orders showed that the resident was prescribed lorazepam (antianxiety medication) as needed every four hours, with an end date of April 28th, 2025. Review of Residents 5's electronic medication/treatment administration record (EMAR/ETAR) for January of 2025 showed the resident received the as needed anti-anxiety medication five times, with no monitoring of their symptoms. Review of Resident 5's EMAR/ETAR for February 2025 showed the resident received the as needed anti-anxiety medication 10 times, with no monitoring of their symptoms. In an interview on 02/26/2025 at 1:18 PM, Staff E, Registered Nurse (RN) stated the floor staff will usually obtain the consent for a psychotropic medication prior to administering, however the nurse managers were the ones to update the orders, ensure accurate monitoring was in place and update the care plan. In an interview on 02/27/2025 at 11:20 AM, Staff R, RN/Resident Care Manager (RCM) stated that for all PRN psychotropic medications they use a 14-day end date, then have the provider reassess. Staff R stated however if the resident was on hospice services the providers pick their own end date, usually around 90 days. Staff R was asked for rational and assessment for Resident 5's extended use of the PRN psychotropic and stated they had not reviewed any. <RESIDENT 34> Resident 34 admitted to the facility on [DATE], with diagnoses to include, stroke and heart attack, depression and anxiety. Resident was receiving Hospice services. According to the Significant Change MDS assessment dated [DATE], resident had severe cognitive impairment. Review of Resident 34's physician orders showed that the resident was prescribed lorazepam (anti-anxiety medication) PRN for anxiety with an end date of 03/03/2025. Review of Resident 34's January 2025 EMAR/ETAR showed the resident received a dose of lorazepam on January 06, 2025, with no behaviors documented. Review of Resident 34's February 2025 EMAR/ETAR showed the resident received a dose of lorazepam on February 24, 2025, with no behaviors documented. In an interview on 02/26/2025 at 11:13 AM, Staff V, RN stated that when a hospice resident gets started on a psychotropic medication, the hospice nurse was the one that obtains the order from the hospice provider and the consent from the resident or family member. Then the hospice nurse faxes the order to the facility, and they process the order. Staff V was unsure if they keep the consents in residents' electronic chart. Staff V stated that PRN psychotropic medications suhs as lorazepam were usually ordered for 90 days. In an interview on 02/27/2025 at 8:44 AM, Staff L, LPN/RCM stated that residents who get started on psychotropic medications such as lorazepam, were discussed and reviewed in their Interdisciplinary Team meetings in the morning. Hospice residents with PRN psychotropic medications were usually prescribed for 90 days. Staff L stated they were not aware of the Center for Medicare and Medicaid Services (CMS) guidelines of initial 14-day duration for PRN psychotropic medication prescription. In an interview on 02/27/2025 at 2:00 PM, Staff B, DNS, stated that initiation of PRN psychotropic medications should be for 14 days even if resident was on hospice and if they need to extend the medication there must be a note from the provider on the reason why the medication was extended. Staff B stated that they will review all residents who has PRN psychotropic medications to ensure they were following the guidelines. Refer to WAC 388-97-1060(3)(k)(i)

Based on observation and interview, the facility failed to ensure that drugs and biologicals were removed when expired in 2 of 5 medication carts, and 1 of 2 medication refrigerators. The facility failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe physical or psychological dependence) controlled medications were in a separate locked permanently affixed compartment not accessible to others. Additionally, 2 medication carts were found unlocked without a nurse close by. These failures placed residents at risk for receiving expired medication and vaccines, and risk of having unintended access to drugs that should have been securely stored. Findings included . Facility policy titled Medication Management, revised date 10/15/2022 showed: Unlocked medication/treatment carts are under nurse control at all times. Medications and treatment supplies are not used beyond their expiration dates. Medications are discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner. <UNLOCKED MEDICATION CART> In an observation on 02/23/2025 at 7:55 AM, 2 medication carts at [NAME] Nurses Station were unlocked. I opened the top drawer of one of the medication carts and it showed over the counter medication containers. On top of the other unlocked medication cart had 5 bubble packed medicine cards (a method of organizing medications into individual doses, sealed in compartments with protective bubbles). There were no nurses in the vicinity. In an observation on 02/23/2025 at 7:57, AM Staff E, Registered Nurse (RN) approached the medication carts and locked both medication carts. Then another male nurse came to the carts and placed the bubble packed medications inside the medication cart. <CONTROLLED MEDICATION STORAGE> In an observation on 02/24/2025 at 12:25 PM, Staff L, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), unlocked the small refrigerator in Central nurse's station. Refrigerator was not affixed to the floor. Inside the refrigerator was a plastic container that contained a box of Lorazepam liquid medication (Scheduled IV medication to treat anxiety). Plastic container was not affixed to the refrigerator. <EXPIRED MEDICATIONS> In an observation on 02/24/2025 at 12:47 PM, Staff L, LPN/RCM, opened the locked refrigerator at [NAME] Nurses station. In the refrigerator were 2 multi-dose vials of opened Afluria (flu vaccine). One vial was dated 01/13/2025 and the other vial was dated 01/24/2025. Both vials passed the 28-day expiration date. In an observation on 02/24/2025 at 1:45 PM, [NAME] Medication cart had 1 expired medication. It was loratadine 10 milligram (mg) tablets. Expiration date showed 01/2025. In an observation on 02/24/2025 at 2:00 PM, Swing Medication Cart had 1 expired medication. It was Simethicone 80 mg chewable tablet. Expiration date showed 12/2024. In an interview on 02/24/2025 at 2:00 PM, Staff E, RN stated that the night shift nurse was supposed to be checking the medication carts for expired medications. In an interview with Staff F, LPN/Infection Control Nurse, on 02/27/2025 at 9:54 AM, Staff F stated they were responsible for tracking vaccines and checks them weekly. The night nurse was supposed to also be checking vaccines and expired medications and discarding them if they expired. Staff F stated they were not sure how the expired vaccines got missed. In a joint interview on 02/28/2025 at 10:02 AM, Staff A, Administrator and Staff B, Director of Nursing Services (DNS), Staff B stated they were not aware that the container with scheduled IV medication in the refrigerator should be in a firmly affixed container. Refer to WAC 388-97-1300(2)

Based on interview and record review, the facility failed to provide timely laboratory results to meet the needs of two of five residents (1, 5 and 279) reviewed for medication usage. These failed practices had the potential for negative complications related to delay of obtaining and follow up of laboratory results along with a risk for medical complications, related to a lack of monitoring chronic medical conditions and delayed identification and treatment of underlying health conditions. Findings included . Review of the facility's policy titled Laboratory, Radiology, Transfusion, and other Diagnostic Services revised [DATE], showed lab services are provided to detect risk for disease, stratify a person into disease or non-disease state, in which the population is ., monitor a condition. Services are to be accurate and timely. Services are considered timely if laboratory tests are completed and results provided to the facility or the resident physician within time frames normal for appropriate intervention. The facility meets or has an agreement to obtain laboratory services from an entity. The facility is responsible for providing and obtaining laboratory, radiology and other diagnostic services only when ordered by the attending physician. Timeliness of providing and reporting results of laboratory, radiology and other diagnostic services Promptly notifying the attending physician of the findings: 1). High alert-within 1 hour, or 2). Medium alert-within ,d+[DATE] hours , or 3). Low alert-within ,d+[DATE] hours <RESIDENT 277> Resident 277 admitted on [DATE] with diagnoses to include rib fracture, diabetes, kidney disease, anxiety and depression. In an interview on [DATE] at 8:34 AM, Resident 277 was in bed and stated they had a UTI (urinary tract infection), and the staff doesn't believe that they did. Resident 277 had tears streaming down their cheeks. They said, I have a UTI. I have told several nurses, and they have not tested me. I know my own body. I have burning on urination, a classic sign. Even my daughter talked to them, and they will not test me. I have urgency too. Review of a progress note for Resident 277 on [DATE] at 12:57 PM, showed the resident complained of nausea, had an emesis, urinary burning and they had a history of UTI's with symptoms of nausea, vomiting and dysuria (discomfort with urination). Review of a progress note for Resident 277 on [DATE] at 2:08 PM, showed the physician ordered staff to collect UA (urinalysis), C&S (culture and sensitivity, a test to see what bacteria is present and determine the most appropriate medication) if indicated. Review of a progress note for Resident 277 on [DATE] at 1:53 PM showed the resident reported they had a history of UTI with past symptoms of nausea, vomiting and dysuria. Review of a progress note for Resident 277 on [DATE] at 12:43 PM showed the resident reported stinging with urination, UA results currently pending. Review of a progress note for Resident 277 on [DATE] at 1:02 PM showed the contracted lab was called to inquire the whereabouts of the UA with C & S that was sent to the lab on [DATE], the lab technician stated, That lab order was cancelled because the specimen would have expired before arriving to the contracted laboratory in Denver This writer inquired as to why the facility and medical provider were not notified of the cancelled UA order to which the lab technician stated, You should have been. I am sorry about that. Resident, POA (power of attorney), and provider notified that the UA specimen sent to the lab on [DATE] was not processed as per order. In an interview on [DATE] at 11:53 AM, Staff B, Director of Nursing (DNS) said the Resident 277's sample was shipped to Texas on [DATE]. The nurses called and were told they need to collect another sample. Staff B said they had issues with the contracted lab and would love to change providers, but they had called other local labs, and no one would call them back. Staff B said they want a local lab provider so they can drop off specimens and have quicker turnaround time rather than shipping labs to Texas or Florida. Staff B said they had just found out the lab wouldn't process a stool sample for Resident 279 because the specimen cup was too full. In an interview on [DATE] at 8:47 AM, Staff F, LPN Infection Preventionist stated Resident 277 had a possible infection on Tuesday the 18th. The lab was notified of the STAT (immediately) CBC (Complete Blood Count) and CMP (Complete Metabolic Panel), and to check the stool for Norovirus per the medical record but it was not ordered by the provider as STAT. Staff F said that on [DATE] at 11:00 AM, the lab picked up the stool sample. Staff F said our lab takes a long time for cultures . It is ridiculously long. Staff F said they called the lab on [DATE] and was told the results would be available on Saturday [DATE] or Sunday [DATE]. Staff F said on [DATE] at 12:58 PM, their note said test not performed due to overfilled. Staff F said their lab draw days were Tuesday, Thursday and Sunday. They said anything outside of those days , the lab would need to be stat or unscheduled pickup. Staff F said If you obtain a UA or stool sample, you would put in in the lab's electronic portal and the lab would pick it up but there was a lag time depending on where there the lab courier drivers are. Staff F said they used to be able to call the lab and they would pick up the specimen and drop it to the nearby hospital lab to be processed. Staff F said the lab stopped picking up lab specimens and dropping them off at the hospital lab that some time ago. They said now they ship the sample to Denver or one of their other out of state labs and the lab turnaround time is very slow. In an interview on [DATE] at 8:47 AM, With CC 1 (collateral contact 1, contracted lab phlebotomist [person who draws blood for testing]) stated they would pick up stool and urine samples if they were at the facility (Tuesdays, Thursdays and Sundays). CC 1 said that lab result turnaround times depends on the test.CC 1 stated that if there was an issue with the timeliness or integrity of the sample, the lab should be contacting the facility for sure to let them know. At 9:16 AM, CC 1 said the lab wouldn't have been able to be in that late on a Friday so (Resident 277's) urine sample would be picked up on Sunday [DATE]. CC1 said there was a stat person in Seattle who should have picked up the sample Saturday, but they did not pick it up. CC 1 stated Must have been a high volume of lab pickups and they couldn't get here to pick up the sample. In a follow up interview on [DATE] at 9:14 AM, Staff F, IP stated they got another UA for Resident 277 on [DATE] as they were symptomatic. Staff F said the lab was still pending and they would call the lab this morning on all of this. Staff F confirmed there were no preliminary urine results which is the standard on either of these UAs for Resident 277. Staff F said the nurses should be following up when lab results are not back, and this should be documented as well. <RESIDENT 279> Resident 279 admitted on [DATE] with diagnoses which included septic shock (widespread infection causing low blood pressure and organ damage), and nutritional deficiency. Review of a late entry progress note for Resident 279 dated [DATE] at 1:04 PM, showed the provider ordered to test Resident 279's stool or emesis (vomit) for Norovirus (highly contagious stomach illness with vomiting and diarrhea). The stool was collected, and the lab provider was notified of the STAT (urgent) lab and to pick up the stool specimen. Review of a late entry progress note for Resident 279 dated [DATE] at 4:59 AM, showed the provider ordered to test the residents stool for C-Diff (Clostridium difficile, (a bacterical infection of the colon which can be a side effect of antibiotic therapy, and can be spread by person to person contact.), ova and parasites (test to look for intestinal parasites and their eggs). Orders were added to a stool sample in process at the lab. Review of a progress note for Resident 279 on [DATE] at 9:33 AM, showed a call was placed to the lab to inquire about the stool results. The lab stated the specimen was sent out of state and results would probably be available on Saturday ([DATE]) or Sunday ([DATE]) Review of a progress note for Resident 279 on [DATE] at 12:58 PM, showed a fax was received from the lab with a message that showed test not performed due to being overfilled. The plan was for the nurse on duty to call the lab to clarify. In an interview on [DATE] at 8:13 AM , Staff C, Licensed Practical Nurse (LPN) was asked about the enteric sign posted outside room [ROOM NUMBER]. Staff C stated Resident 279 had possible norovirus and their lab was pending. Review of a progress note for Resident 279 on [DATE] at 11:45 PM, the nurse documented the resident was feeling better, so they requested the norovirus test be cancelled. Review of a progress note for Resident 279 on [DATE] at 1:47 PM showed the provider was into review the resident and ordered to proceed with the ova and parasite stool sample, only if loose stools continued. 37890 <RESIDENT 74> Resident 74 admitted [DATE] with diagnoses which included surgical aftercare with intravenous antibiotics and wound care. Resident 74 was not longer a resident at the facility. Review of Resident 74's progress note on [DATE] at 11:58 AM showed the primary nurse reported the resident had greater than three loose watery stools this day shift and the provider had ordered a stool culture to rule out Clostridium Difficile. The stool culture was collected and sent by courier to the facility's contracted lab on [DATE]. Resident 74 was placed on contact isolation while the stool culture was pending. Contact isolation resulted in signage being placed on the resident's door indicating to staff and visitors that the resident was on contact precautions and instructed staff to don and doff the appropriate Personal Protective Equipment (gowns, gloves) and to perform hand washing with soap and water for cares. Review of Resident 74's progress notes dated [DATE] at 11:22 AM showed the facility placed a call to their contracted lab to request the result whereabouts as the stool specimen was sent to the lab on [DATE]. Per the contracted lab technician, The specimen was received yesterday and is in process. Resident 74 and the provider were updated that lab was still processing the stool specimen and the plan stated to continue Contact Precautions every shift while stool culture is pending. A progress note dated [DATE] at 12:18 PM, stated the facility reveived a fax from the contracted lab stating that specimen must be re-ordered and re-collected related to the specimen being past stability. The noted stated the provider and Resident 74 were notified of the issue and that new stool collection was required. The resident remained on contact isolation. A progress noted dated [DATE] at 03:16 PM, showed the Resident's stool culture result was received which showed they were negative for Clostridium Difficile and the contact precuations were removed. In an interview on [DATE] at 2:05 PM, Staff B, DNS, stated the contracted lab was not reliable, specimens collected were sent to Denver with no local option, and the facility was contantly having to call to find out about late results. Staff B stated they have been told that the lab could not do anything to speed up process times that have resulted in samples being out of the time range for accuracy and needing to be re-collected. Staff B stated the facility was in the process of looking for lab services that were local. In a follow up interview on [DATE] at 9:50 AM, Staff B, DNS stated they had been aware of issues with their lab and there were no local labs to draw their labs. Staff B stated the preliminary urine results take as long as the C & S. Reference WAC [DATE] (2)(b)(i)

Based on observation, interview and record review, the facility failed to provide the necessary assistance for oral care, and bathing for 3 of 5 residents (Residents 20, 69 and 276) dependent on staff to ensure their needs were met. This failed practice placed residents at increased risk for increased risk for embarrassment, diminished dignity, negative outcomes including poor quality of life and psychosocial harm. Findings included . According to the facility policy, Activities of Daily Living (ADL)'s- AM (morning) cares revised 11/14/2017 showed AM care is provided to refresh the resident, provide cleanliness, comfort, and neatness, to prepare the resident for breakfast, to assess the resident's condition and needs and to promote psychosocial wellbeing. Staff were to assist the resident as needed to brush teeth or dentures. The ADL's-PM/HS (bedtime) care showed care at bedtime prepared the resident for sleep and assist the resident as needed with oral hygiene. <BATHING> <RESIDENT 69> Resident 69 admitted on [DATE] with diagnoses to include cancer, spondylosis (spine condition causing pain), anxiety and weakness. Review of the baseline care plan dated 01/09/2025 showed the resident required extensive assistance of two for bathing. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident was cognitively intact and required extensive assistance for bathing. In an interview on 02/28/2025 at 8:14 AM, Resident 69 stated they would like two showers a week but had only had two showers and on bed bath since they admitted [DATE]. Review of Resident 69's bathing documentation since admission confirmed they had three bathing tasks documented (01/16/2025, 01/23/2025 and 01/26/2025). <RESIDENT 276> Resident 276 admitted on [DATE] with diagnoses to include an intestinal obstruction, inguinal hernia (tissue protrudes through groin muscle) and gait and mobility abnormalities. Review of the admission MDS dated [DATE] showed the resident had mild cognitive impairment and was totally dependent on staff for activities of daily living such as bathing In an interview on 02/25/2025 at 1:02 PM, Resident 276 was sitting up in bed and stated they would like two showers a week, but they get one shower then then next one was a bed bath. Resident 276 stated when they first admitted , they went several weeks without a shower or bath. Review of Resident 276's bathing records confirmed the resident received a bed bath on 01/15/2025 and 01/22/2025 then a shower on 01/26/2025. 47047 <ORAL CARE> <RESIDENT 20> Resident 20 admitted to the facility 08/21/2023 with diagnoses that included multiple compression fractures (break in the vertebrae), mild cognitive impairment, and high blood pressure. In a review of Resident 20's care plan dated 08/21/2023 showed they had upper and lower dentures with an intervention to provide care as per activity of daily living personal hygiene, rinse dentures and place them every morning. There was notation of Resident 20 having dental implants. In an interview on 02/23/2025 at 8:54 AM Resident 20 stated they sleep with their dentures in their mouth and would like to have them removed and cleaned nightly. In a review of Resident 20's Brief Interview for Mental Status (BIMS- a screening tool for assess cognition) completed on 01/17/2025 showed they scored 8 out of 15, indicating moderately impaired cognition. In a review of Resident 20's Kardex (guide which resident specific directing care) as of 02/23/2025 showed they had upper and lower dentures and required assistance with oral care and required their dentures to be soaked and reminders to brush implants as well. In a review of dental notes dated 06/12/2024 showed Resident 20 had red tissue under their dentures, with a moderate amount of food in their dentures, and recommendations were for staff to remove the residents' dentures at night to soak and to assist the resident with brushing around their implants. In a review of dental notes dated 11/11/2024 showed Resident 20 had heavy a heavy amount of plague and their gums around the implants were red. Recommendations included assisting Resident 20 with brushing of the lower implants. In a review of dental notes dated 02/11/2025 showed Resident 20 had a moderate amount of plague. Recommendations continued to be for staff assisted brushing and denture removal with nightly soak. In an interview on 02/28/2025 at 8:28 AM Staff D, Nurse Aide Certified (NAC) stated they did not assist Resident 20 in getting up for the day, and did not provide any oral care to them since the start of their shift. In an interview on 02/28/2025 at 8:28 AM Staff G, NAC stated they assisted Resident 20 in getting up out of bed and dressed this morning, they washed their face. Staff G stated they did not provide any oral care to them, and they had their dentures in their mouth. In an interview on 02/28/2025 at 8:35 AM Staff B, Director of Nursing Services (DNS), stated Resident 20 required assistance with oral care. In an interview on 02/28/2025 at 9:21 AM, Staff B stated they were not aware of any issues with oral care or bathing not being completed. Staff B said the bathing expectation is that staff are to offer bathing per resident preferences and continue to offer bathing daily until the resident accepts bathing. Staff B stated nursing staff were to document any refusals and acceptances. Staff B stated they did not have a shower policy, and it was a standard of care. This is a repeat deficiency from SOD dated 03/26/2024. Reference: WAC 388-97-1060 (2)(C)

Based on observation, interview, and record review the facility failed to ensure the daily nurse staffing information was being posted in a place readily accessible to residents/visitors and included the required information on 2 of 6 days (02/22/2025 and 02/23/2025) of the recertification survey. This failure placed residents, family members and visitors at risk of not being fully informed of current staffing levels and resident census information. Findings included . In observations on 02/23/2025 at 7:45 AM the facility's daily nursing staffing was found posted on a wall near the entrance of the building. The nurse staffing information was dated for 02/21/2025. There was no other staffing forms found. In review of the posted staffing on 02/23/2025 at 7:45 AM, dated 02/21/2025, showed total actual hours worked for day shift was completed and evening and night shift were blank. In an interview on 02/27/2025 at 8:25 AM, Staff H, Staffing Coordinator stated they were responsible for posting the daily staffing daily and if they were not working on the weekend would rely on another staff to complete it. Staff H stated they prepare the staff posting for the weekend and place them behind the one for Friday. Staff H stated they did not know why there was not completed staff postings for Saturday 02/22/2024 or Sunday 02/23/2025. In an interview on 02/27/2025 at 9:47 AM, Staff B, Director of Nursing Services stated Staff H was responsible for the staff postings along with the other staffing coordinator and should be posted in the morning, placed up front, and then updated with actual hours as the shift starts. Staff B was unaware that there was no staff posting completed for 02/22/2025 or 02/23/2025. No associated WAC

Based on observation, interview and record review the facility failed to ensure a physician order was obtained and routine cleaning was provided for a CPAP machine (non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) for 1 of 4 residents (Resident 1) reviewed for respiratory care. This failed practice placed the resident at risk of respiratory infection, respiratory distress, lack of restful sleep and diminished quality of life Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with exacerbation (COPD - group of diseases that cause airflow blockage and breathing problems), obstructive sleep apnea (OSA - residents repeatedly stop and star breathing while they sleep) and chronic respiratory failure. Review of Resident 1's progress note dated 11/11/2024, showed Resident 1 had their CPAP machine brought into the facility from their home. Review of Resident 1's Admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], showed no CPAP machine was coded. Review of Resident 1's current care plan showed a diagnosis of OSA with no care planned use of a CPAP machine. In an observation and interview on 01/06/2025 at 12:25 PM, Resident 1 had a CPAP machine on their nightstand next to their bed. Resident 1 stated the staff had not cleaned their CPAP machine. Review of Resident 1's Order Summary Report (consolidated view of all orders placed for a resident) printed on 01/07/2025, showed no order for a CPAP machine usage or an order for weekly cleaning. In an interview on 01/07/2025 at 4:14 PM, Staff A, Licensed Practical Nurse/ Resident Care Manager, stated they did not know Resident 1 had a CPAP machine and confirmed the resident did not have an order for the use of a CPAP machine. In an interview on 01/07/2025 at 4:55 PM, Staff B, Registered Nurse, Director of Nursing Services, stated they had found the progress note where Resident 1 had their CPAP brought into the facility. Staff B confirmed there was no order for Resident 1's CPAP machine usage or cleaning. Refer WAC 388-97-1060 (3)(J)(vi)

Based on observation, interview and record review the facility failed to immediately report and take action for 2 of 2 (Residents 8 and 9) related to a witnessed event where a night shift, male caregiver was leaning over with their hands on either side of a female resident's (Resident 8) face with the resident stating stop, and insisting to change the resident despite being told the resident had been changed, and additional allegation of sexual abuse of a female resident (Resident 9) reviewed for allegations of abuse. In addition, the facility failed to ensure that grievances alleging staff mistreatment and or abuse were followed-up on timely to determine the need for reporting and/or additional interventions for 4 of 7 (Residents 2, 3, 4, and 5) with allegations made through the grievance log. The facility was found to have an immediate jeopardy (IJ) due to the lack of immediate reporting and timely interventions for Resident 8 and Resident 9. On 04/13/2023 at 9:18 PM, the facility was notified that their deficient practice was identified and constituted failed practice at the level of an IJ in F-tag 609. The facility removed the immediacy on 04/16/2023, after suspension of the alleged staff pending the facility's investigation and completing an all-staff in-service on mandated reporting of abuse and neglect prior to working in the facility. Findings included . (Staff M, Nursing Certified Assistant [NAC]) Review of the facility's policy titled, Abuse, revised 10/15/2022, showed that allegations of verbal .and neglect of the resident as well as mistreatment, injuries of unknown source, exploitation, deprivation of goods and services by staff . were reported to the CEO (Chief Executive Officer) immediately and to the state agency. The results of an alleged abuse investigation are reported in accordance with state regulation within five working days of the incident or in accordance with State law. If the alleged violation was verified, appropriate corrective action was taken by the facility. Review of the Nursing Home Guidelines, aka The Purple Book, October 2015 (sixth edition) showed: A mandated reporter included but was not limited to an employee of the Department; a law enforcement officer, an employee of a facility; a social worker or health care provider and an operator of a facility. For the purposes of reporting abuse .neglect .a nursing home employee (or other mandated reporter) was required to make a report if he or she had reasonable cause to believe the incident occurred. Examples of reasonable cause may include the individual observed the incident or heard the victim state it happened; or the individual heard about an incident from a permissive reporter who had direct knowledge of the incident; and Immediate telephone reporting was required when there was reasonable cause to believe abuse, neglect . had occurred. Federal law requires the facility to report all allegations of abuse or neglect. This would include taking reporting any allegation from residents or others with a history of making allegations. <Resident 8 and Resident 9> Review of a report made to the State Agency, dated 04/13/2023, showed that on 04/12/2023 at 10:30 PM, Resident 8 was heard repeatedly saying stop, in a distressed voice. The report noted that an older male caregiver was observed leaning very close over Resident 8's face, like they were going to kiss the resident. The report noted a male caregiver stated they needed to change Resident 8. The female caregiver who witnessed the incident informed the male caregiver they had already changed the resident. The report noted Resident 8 had stated a male caregiver made them uncomfortable, and they had their hands where they should not be. The report documented Resident 8 had stated a man had slept with their roommate (Resident 9) and made a lot of noise which made Resident 8 uncomfortable. The report noted Resident 9 was asked if they slept with a man and Resident 9 had replied, yes. The report noted that the Nursing Assistant Certified (NAC) Instructor was informed of the residents' statements. The report noted that the NAC Instructor indicated they would look into the situation and would let the charge nurse know what happened. In an observation and interview on 04/13/2023 at 5:30 PM, Resident 8 was lying in bed and stated that they had been molested as a child and did not want a male caregiver. Resident 8 stated they felt sorry for the male caregiver's wife after they, went to bed with her, and pointed to their roommate. Resident 8 stated they did not think men should come in and have sex with Resident 9. Resident 8 stated their light was out, but their roommate's light was on and could see through the privacy curtain. Resident 8 stated there was a person who knew what was going on as they heard them telling the male caregiver to get out of their room. In an interview on 04/13/2023 at 5:52 PM, Staff D, Registered Nurse/NAC Instructor contracted by the facility, stated the prior night, a male caregiver (NAC), Staff M, had reported for the nightshift was going to provide personal care for Resident 8 who wanted a female caregiver. Staff D stated Staff E, Nursing Assistant Registered/NAC Student enrolled in a contracted training program, stepped in, and the male caregiver left the resident's room. Staff D stated Resident 8 had been confused during the day and had told Staff E; that a male caregiver had slept in their room. Staff D stated that the male caregiver was soft spoken and would lean close to the residents when talking. Staff D stated that was the extent of what occurred. In an interview on 04/13/2023 at 6:02 PM, Staff E, stated at the end of their shift they provided Resident 8 with personal care. Staff E stated as they walked down the hallway, they heard Resident 8 making a lot of noise. Staff E stated that they stepped into the resident's room and saw a man leaning over the resident as the resident was saying stop. Staff E stated the male caregiver was leaning over the resident with both of their hands on each side of the resident's face, while Resident 8 held their blankets up over their chest and repeatedly told them to stop. Staff E stated they had asked the resident if everything was okay and Resident 8 had said, No, I do not want him to change me, make him go away, I am scared. Staff E stated the male caregiver became upset and had said that they were the only one that could provide personal care for Resident 8. Staff E stated Resident 8 told them to make sure the male caregiver did not touch them and was very uncomfortable with the noises the male caregiver made with their roommate, Resident 9. Staff E stated they had asked Resident 9 if the male caregiver had slept with them and Resident 9 had said yeah, rather nonchalantly. Staff E stated it sounded like Resident 9 had said they had sex, but it was hard to tell. Staff E stated they immediately reported what they saw and heard to their instructor, Staff D. In an interview on 04/13/2023 at 6:32 PM, Staff N, Administrator, stated that they were unaware of Resident 8's report and would identify who the male caregiver was and ensure to remove them from the facility pending their investigation. <Resident 2, Resident 3, Resident 4, and Resident 5> Review of a Grievance Report, dated 01/13/2023, showed Resident 2, stated a NAC was often rude to them during care. Review of a Grievance Report, dated 02/03/2023, showed that a report a staff member perceived another staff member to be rude to Resident 4, when the staff member had slammed a mug down and in an unprofessional manner loudly stated, Thanks for telling me. Review of a Grievance Report, dated 02/03/2023, showed Resident 5, stated a NAC was rude, lazy, and not providing resident care appropriately. Review of a Grievance Report, dated 02/16/2023, showed Resident 3, stated a staff member was always telling them to shut up, and was rude and made the resident cry. Review of the January and February 2023 Incident Logs showed no logged incidents or investigations of the residents or staff allegations of potential resident verbal abuse. In an interview on 04/10/2023 at 10:42 PM, Staff N, stated they were not following their process as they should have when asked about the grievances of staff rude behaviors and allegations of inappropriate care. Staff N stated they were going to check to see if there was education provided to the staff; however, supplied no further information. Reference: (WAC) 388-97-0640 (4)(5)(a)(6)(a)

Based on observation, interview and record review the facility failed to ensure one of three residents (#1) did not develop an avoidable Stage IV Pressure Injury (PI). This failed practice caused extensive tissue damage, pain and discomfort for Resident #1. Findings included . Review of the facility's policy titled, Skin Integrity, updated May 2019 showed the following: · Ongoing evaluation continues weekly with the Licensed Nurse (LN) completing a full body skin audit. Completion of the skin audit was documented on the Treatment Administration Record (TAR) with their initials, and either a - sign (indicated no skin impairment present) or + sign (indicated skin impairment present). · The residents wounds were evaluated weekly by Center clinicians .Pressure wounds . are evaluated, measured, and findings documented in the medical record. This evaluation included pain associated with the wound during wound care. If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorated, the Physician and Resident's Representative were notified; · The facility evaluated resident's compliance with Plan of Care (POC). When the resident chose to not have specified treatments or interventions implemented. The Center discussed the following with the resident, the resident's responsible party and documented in the medical record if the resident does not make sound choices. The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A PI was a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury could present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. A Stage 2 PI was described as a partial-thickness skin loss with exposed dermis (layer of skin beneath the first layer of skin). The wound bed was viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) was not visible and deeper tissues were not visible. Granulation tissue (new connective tissue), slough (necrotic/dead tissue) and eschar (a dry, dark scab or falling away of dead skin) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 4 PI was described as a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varied by anatomical location. If slough or eschar obscured the extent of tissue loss this was an Unstageable Pressure Injury. Unstageable PI was described as an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could not be confirmed because it was obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 PI would be revealed. Stable eschar (i.e. dry, adherent, and intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident #1 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of the resident's Care Plan, showed a focus problem with an initiated date of 05/24/2019, which included the resident had a history of [REDACTED]. if the resident refused showers, she would talk with him, and at times the resident responded better to male caregivers Review of the June 2020, TAR showed the resident had a weekly skin audit on day shift every Wednesday which was initiated on 04/29/2020. The nurse did not document a plus or minus but documented a check mark noted on 06/03/2020, 06/10/2020, 06/17/2020 and 06/24/2020. Review of the Quarterly Care Conference Note dated 06/18/2020 at 4:11 PM, showed the resident had not had any significant changes in the past quarter and had no skin integrity issues though he was at risk for skin breakdown related to his incontinence. Review of the Weekly Skin Evaluations dated 06/21/2020 showed, a Licensed Practical Nurse (LPN) noted an oval shape abrasion on the resident's left trochanter (hip) measured 0.5 cm (centimeter) x 1.0 cm. Review of a Skin Evaluation dated 06/22/2020, a Registered Nurse (RN) documented an oval shape Stage II pressure injury to the resident's left trochanter which measured 1.0 cm x 1.4 cm. The wound was noted to be pink, beefy red with minimal serosanguineous (blood mixed with serous liquid) drainage. Further review of the TAR showed on 06/21/2020, daily a dressing change of normal saline, dry and apply dressing to the resident's left hip was initiated. Documentation showed the resident refused the dressing change on 06/22/2020 (but was later done per the nursing progress notes) and 06/29/2020. Review of the progress note dated 06/22/2020 at 11:45 AM, showed the resident was yelling and swatting as the nurse removed the dressing from the resident's left hip. The resident slept for an hour then the nurse was able to apply a dressing with only verbal agitation. Review of a nursing progress note dated 06/23/2020 at 2:50 PM, showed the resident complained the area was tender to touch when the wound dressing was reapplied after his shower. Review of the Care Plan showed a focus problem dated 06/25/2020, which identified the resident had an actual impairment to his skin integrity related to incontinence. The interventions included the resident frequently refused care and to continue to offer assistance and alert the nurse of all refusals. Review of a nursing progress note dated 06/29/2020 at 4:30 AM, showed the resident allowed a male aide to provide the resident with a shower and that the resident responded better to the male aide. Review of a nursing progress note dated 06/29/2020 at 12:57 PM, showed the resident refused a skin check but had received a shower earlier and at 10:34 PM, the resident refused a dressing change to his left hip. No attempted interventions where noted to have been tried in response to the resident's refusals. Review of the Weekly Skin Evaluation dated 07/02/2020, showed an unstageable 0.7 cm x 1.0 cm PI to the resident's left trochanter. The PI was described as being pink and beefy red, but the wound bed was not visible due to scabbing. Review of the 07/02/2020, Nutrition Hydration Skin Committee Review Form showed a recommendation to initiate Pro-Stat (a protein supplement) daily. Review of the July 2020 Medication Administration Record [REDACTED]. Review of the Weekly Skin Evaluation dated 07/09/2020, showed a 1.3 cm x 1.2 cm PI on the resident's left trochanter. There was 100% slough covering the wound and the wound bed was not visible. Review of a Progress Note dated 07/14/2020 at 3:40 PM, showed the dressing to the left hip was not in place, the wound bed appeared yellow and had a small open area that appeared to be a hole. The Licensed Nurse was unable to measure the wound due to the resident yelling, I said no, don't touch it, it hurts. Review of a Progress Note dated 07/14/2020 at 4:04 PM, showed the Nurse Practitioner would view the resident's wound on Thursday, when she would be at the facility and that a pressure relief mattress should be put in place. Review of the Device Informed Consent form dated 07/15/2020, showed a low pressure air mattress to promote wound healing was obtained (three and a half weeks after the development of the resident's pressure injury). Review of the Weekly Skin Evaluation dated 07/16/2020, showed the left trochanter PI measured 1.2 x 1.0 cm with 100 % slough and was unstageable. Review of the 07/16/2020, Nutrition Hydration Skin Committee Review Form, showed the wound was larger that week, new orders for a low air loss mattress was obtained and nutritional interventions included to add a multi vitamin with minerals and increase the Pro-Stat to twice daily. Review of the July 2020 MAR indicated [REDACTED]. Review of the July 2020 TAR, showed the resident refused the wound treatment on several dates throughout the month. Additionally, on 07/20/2020, a new wound treatment was ordered. (Approximately, one month after the wound developed and declined to an unstageable wound.) Review of the Nurse Practitioner's progress note dated 07/23/2020, showed the resident had, been at the facility for years and did well if nursing takes great care with providing care. Air mattress ordered immediately when pressure ulcer was brought to provider's attention . Nursing had reported this area seemed very painful to patient and pain medication was ordered earlier in the week. Review of the Weekly Skin Evaluation dated 07/23/2020, showed a 5.3 cm x 3.5 cm unstageable PI on the resident's left trochanter. The wound was an irregular square in shape and the wound bed was black/brown with 100% slough. Review of the Medical Record including the MAR, TAR and Progress Notes did not show care planned interventions were attempted when the resident refused wound treatments. Additionally, Resident #1 was not offered an as needed pain medication prior to his wound care treatments until 07/23/2020. Review of the Weekly Skin Evaluation dated 08/06/2020, showed a 4.3 cm x 5.0 cm x 2 cm (depth) Stage IV PI on the resident's left trochanter. The wound was described to have 3 centimeters of tunneling to the bone, viewed at 11 o'clock. The wound was covered with 75% yellow slough with moderate purulent foul odor drainage. In a phone interview on 10/21/2020 at 2:55 PM, the resident's family representative stated that she was unaware of the resident having a prior wound to his left hip. She stated that she did not recall being notified the resident refused his dressing changes and stated that she, Never received a call and if they had called, I have pretty good luck. The resident's representative stated that when the resident was in the hospital the wound to his left hip was bothering him and it hurt. In a phone interview on 10/27/2020 at 1:46 PM, Staff B, RN, Resident Care Manager (RCM), stated that when a PI was identified the nurse on shift does an incident report and notified the provider and or the Power of Attorney. Staff B stated the nurse would also assess the PI and collaborate with the resident's physician, who would also assess the resident's PI. Staff B stated that a specialty mattress would be initiated when a skin impairment was identified and/or for residents identified with fragile skin who are at risk for skin break down. Staff B stated she was unsure why there was a delay for Resident #1 to receive a specialty mattress. Staff B was asked why the interventions for refusals of care were not noted to be implemented when the resident refused his dressing changes. Staff B stated that the floor nurses did not utilize the care plan. Staff B confirmed the facility did not utilize care planned interventions for Resident #1 refusal of care. In a phone interview on 10/27/2020 at 2:23 PM, Staff A, RN, stated that if they find a skin impairment they implement a dressing with what they have available until they received a physician order. Staff A, stated that they change the mattress first to an air mattress and care planned for the aides to reposition and change the resident's brief frequently. Staff A, stated that Resident #1 had refused his dressing changes but was able to do the dressing in the shower and would document on the TAR. Staff A, stated that the RCM would be the one who usually initiated the air mattress, updated the care plan and any further interventions. In a phone interview on 10/29/2020 at 2:35 PM, the Director of Nursing Services (DNS), stated that her expectations when a resident refused care, was first to follow the resident's care planned interventions and to reapproach the resident. The DNS stated that sometimes the LN would document their approach and results, and hopefully the LN would be looking at the care plan, seeing interventions and charting their attempts. In an interview and observation on 11/04/2020 at 1:17 PM, Resident #1 was sitting up in his wheelchair in the hallway with a surgical mask in place. The resident stated that he had not had a dressing change in the last two days and thought the wound had healed. The resident stated that it was uncomfortable and had to be careful with the way he slept. In an observation on 11/04/2020 at 2:02 PM, Staff B, attempted to change the resident's wound dressing. The resident stated no, when asked about the wound change. The resident declined all attempts to change the dressing. In an interview on 11/04/2020 at 3:42 PM, the Administrator stated that the resident had Okayed his dressing change. She stated that they had offered him Magic Cups, (a fortified frozen dessert), his family had talked with him and also conversed with the resident about a local restaurant. In an observation on 11/04/2020 at 3:45 PM, the resident's dressing was observed to have a red brown drainage when removed. The wound appeared to be approximately the size of the end of a pencil which tunneled to an unobservable depth. The staff cleansed the wound with normal saline and packed the wound with a packing product, [MEDICATION NAME]. During the dressing change, Resident #1 stated it hurt when the wound was packed. The facility failed to prevent an avoidable Stage IV PI, failed to utilize Care Planned interventions when the resident refused, and failed to ensure timely interventions were implemented to aid in prevention of a Stage II pressure injury which progressed to an Unstageable PI and then to a Stage IV PI. These failures caused the resident undue pain, discomfort and extensive tissue damage to his left hip. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent avoidable pressure ulcers for one of two residents (#1) reviewed for pressure ulcers. The failure resulted in harm to Resident #1, who developed avoidable pressure ulcers to both heels and the sacrum (bottom). Findings included . Review of the facility's policy titled, Skin integrity, dated (MONTH) 2019, showed the facility completed the Braden Scale (an assessment tool) to determine pressure ulcer risk which was done weekly for three weeks after admission and with changes in condition. The policy also stated the Plan of Care would be developed based on the assessed risk factors. The Resident Assessment Instrument (RAI) manual defined a Deep Tissue Pressure Injury (DTPI) as: a persistent non-blanchable deep red, maroon or purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that was painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. The injury resulted from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If there was necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures were visible, this indicated a full thickness pressure ulcer (also known as a pressure injury). Resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Braden scale assessment on admission showed a score of 16, which identified the resident was at mild risk for pressure ulcer (PU) development. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was not able to participate in interviews and was assessed to have both short term and long term memory problems, difficulty focusing and disorganized thinking. The MDS further showed the resident exhibited no behaviors or rejected care. The resident required extensive assistance of two staff for bed mobility and transfers and was not identified as having any PUs. Review of the resident's skin at risk baseline care plan, showed the resident was at risk for skin breakdown. Interventions included the resident had a pressure reducing mattress, required two person assistance for bed mobility, staff were to keep the resident's skin clean and dry, staff were to apply barrier cream, and to educate the resident/family/caregivers of causative factors and measures to prevent skin injury. Review of the Braden scale dated 12/08/19, showed the score had decreased to 11 which indicated at high risk for PU development. There were no updates to the resident care plan to include an increased need for turning, positioning or pressure offloading when the resident showed a change in condition. Review of a progress note dated 12/8/19 at 3:05 PM, showed the resident's oxygen saturations were low and oxygen was administered. The note stated that, the resident has been in bed sleeping all morning, responsive when approached and goes back to sleep. Review of a progress note dated 12/08/19 at 9:50 PM, stated the day shift had reported the resident laying in bed through day, lethargic and difficult to arouse .observed what appeared to be serosanguinous (containing or related to both blood and liquid parts of the blood) fluid on bed linen beneath right heel .found ruptured fluid filled sack with dry purple wound base .left heel had intact fluid filled area with purple base .coccyx with large red/pink non-blanchable area with open areas to the left and right buttock cleft. Repositioned side to side with heels floated. Review of a progress note dated 12/09/19 at 2:14 AM, showed the resident's condition continued to decline and the resident was transferred to the Emergency Department (ED) at 1:00 AM on 12/09/19 where he was diagnosed with [REDACTED]. Review of hospital records dated 12/09/19 at 11:26 AM, showed a wound consultation occurred while the resident was in the ED and identified on the right heel there was an intact area of brown eschar (non viable tissue) measuring 5 centimeters (cm) by 6 cm, the left heel had an intact purplish area measuring 3 cm x 4 cm, and the sacrum (the upper back part of the pelvic area) had a large area of purplish maroon discoloration with surrounding redness with scattered open areas and a boggy texture. The wounds on both heels, and sacrum were all identified as unstageable deep tissue injuries present on admission .The injury(s) have already occurred and will likely worsen before it improves. The resident re-admitted to the facility on [DATE]. Interventions on admission included for the resident to wear protective heel boots on both heels at all times. In an observation and interview on 01/02/20 at 11:59 AM, Resident #1 was up in the wheelchair in his room, Staff G, Registered Nurse (RN), was attempting to apply an oxygen cannula and the resident was pulling at the tubing, resisting and threw it onto the floor. There were no heel boots observed on the resident. The resident's heels were observed wrapped in gauze, the right heel dressing was saturated and the wrapping was coming loose around the heel. Staff G removed the old dressing in order to re-wrap it. The entire surface of the lower and posterior (towards the back) portion of the right heel was covered with black eschar. There was flaking skin surrounding the wound and drainage on the old dressing was serosanguinous. The resident's son was present and waiting to take the resident on an outing. The resident's son stated the wounds had just shown up one day as far as he knew, when his dad was not moving as much. The son stated the resident was often resistive and stated the staff need to keep coming back for things. In an interview on 01/03/20 at 10:00 AM, Staff F, Nursing Assistant (NA), stated Resident #1s care plan showed he needed two person assist and was not aware of any other specific positioning program. Staff F stated Resident #1 never used to refuse care (prior to his hospitalization ), but since his re-admission he felt like he was more aggressive and less accepting, adding that he did not want to wear his heel boots. The resident's heel boots were noted to be on the counter next to the sink. In an interview on 01/03/20 at 2:09 AM, Staff D, NA, stated residents care plans were in the computer but stated sometimes it is not all there so I am not always quite sure or how I can take care of them. Staff D stated she had cared for Resident #1 the day prior to the discovery of his PUs. Staff D stated he had been up in his wheelchair all day and she did not know she should be offloading (shifting his position) in his wheelchair. Staff D stated she had been told the resident liked to sit up in the dark, so she just left him that way. She stated she never saw his skin that day. In an interview on 01/03/20 at 10:54 AM, Staff E, NA, stated she cared for Resident #1 the day before and on the day the PUs were discovered. Staff [NAME] stated she was used to the resident being resistant to care but on that day he was more lethargic and not resisting anything so she stated it was easier to give him care. She stated he had a change in condition and was not fully awake. She stated she was aware the resident had skin issues and she stated she had communicated that she felt he needed more care, stated she had passed it on in her shift to shift reports and other shifts had passed on that he had redness on his bottom but doesn't recall exactly how long it was there. Staff [NAME] stated she thought there should be more information in the care plans, but she said she was told that positioning was just a standard of care. Staff [NAME] stated on 12/08/19 she remembered that there was drainage on the bed when she came on shift at 2:00 PM and then they (she and the nurse) found that he had ulcers on both heels and one had popped. She stated he went to hospital soon after that. In an interview on 01/03/20 at 4:00 PM, the Director of Nursing Services (DNS) stated that the resident had a decline in condition and was found to have been having a [MEDICAL CONDITION] infarction which resulted in poor tissue perfusion. The DNS stated she felt the ulcers were unavoidable related to his impaired mobility, poor perfusion and that the progression of the ulcers once the resident went to the hospital was related to him receiving blood thinners and lack of positioning in the ED. The DNS did not dispute that the resident developed the ulcers in the facility and acknowledged that descriptions of dark purple bases to both heels consistent with the definition of deep tissue injury prior to the resident being transferred to the ED. The facility failed to implement increased interventions to mitigate the increased risk for PU development identified when the resident experienced a change in condition with decline in mobility and decline in perfusion of the tissues related to a cardiac event. The resident's decline in status required that the facility adjust the plan of care and increase interventions such as turning, positioning and offloading pressure to the resident's heels in response to his newly identified high risk, The resident developed avoidable bilateral heel ulcers which were described consistent with the RAI definition of suspected deep tissue injury and a sacral pressure ulcer which was described an non-blanchable redness upon discharge to the hospital. Reference (WAC) 388-97-1060 (3)(b)

Based on interview and record review the facility failed to ensure the necessary care and services related to notification of change, medication administration and the obtaining of timely laboratory/diagnostic test results for two of five residents (31 and 54) reviewed. This failed practice caused harm to Resident 54 related to the delay of physician notification, antibiotic administration and hospitalization . Additionally, the failure to obtain timely test results impacted the facility's ability to adequately provide nursing care management for Resident 31 and placed other residents at risk for decreased quality of care. Findings included . DELAY OF CARE SERVICES Resident 54 was a long-term care resident with [DIAGNOSES REDACTED]. Review of the 5-day Minimum Data Set (MDS) assessment showed Resident 54 was alert, oriented and able to make his own decisions. During an interview on 06/08/18 at 9:07 AM, Resident 54 stated he started getting sick on the morning of 05/10/18. Resident 54 stated he had a doctor's appointment on 05/15/18 and the doctor sent him to the hospital where he was diagnosed with [REDACTED]. Review of the night shift nursing progress note dated 05/11/18, Res (resident) woke up with complaint of sore throat, temperature (T) 99.1 degree Fahrenheit (F), thick cream colored mucous drainage from nose, on alert charting for cold symptoms. Further review of the nursing progress notes showed: · 05/11/18 day shift, T 99.2 F, diminished lung sounds, and thick mucous; · 05/12/18 night shift, T 99.3 F and mucous drainage from nose; · 05/12/18 day shift, T 99.3 F and decreased lung sounds with audible expiratory (when a resident breathes out) wheezes; · 05/12/18 (late entry for 05/11/18) T 100.1 F, resident had a runny nose and complaints of headache, decrease lung sounds with expiratory wheezing; · 05/12/18 evening shift, T 99.2; · 05/13/18 night shift, T 99.5 and productive cough; and · 05/14/18 night shift, T 100.9 and resident had an increased cough and congestion. On 05/14/18 at 10:00 AM (3 full days after Resident 54 started showing signs and symptoms of an illness), Staff G, MDS nurse, notified the physician to report Resident 54's illness and the findings of his symptoms. Review of a physician's orders [REDACTED]. Review of the chest x-ray results dated 05/14/18, showed the x-ray was performed for shortness of breath. Resident 54 chest x-ray results showed he had a small left pleural effusion (excess fluid that builds up around the lung) with left lower lobe airspace disease. Review of a physician's telephone order dated 05/14/18 at 7:00 PM, directed the Licensed Nurse to start [MEDICATION NAME] (an antibiotic) 875 milligrams by mouth twice a day for 7 days. Review of a nursing progress note dated 05/14/18 evening shift, showed the antibiotic was not available, but the pharmacy would satellite the medication. The resident continued to have an elevated temperature of 100.3 F. Review of the medical record showed the resident did not receive the antibiotic. Review of a nursing progress noted dated 05/15/18 evening shift, showed the resident was sent to the emergency room from doctor's office. Review of the hospital documentation date 05/22/18, showed Resident 54 was admitted to the hospital for 7 days with a [DIAGNOSES REDACTED]. During an interview on 06/13/18 at 8:40 AM, Staff F, Licensed Practical Nurse (LPN), stated if a resident had a change of condition she would perform an assessment of the resident, notify the responsible party, notify the physician, and place the resident on alert charting to monitor their condition. At 8:54 AM, Staff E, Resident Care Manager (RCM), stated if a resident becomes ill, the physician should be notified the same day. Staff E stated if a resident does not receive a prescribed medication the physician should be notified for further instructions. During an interview on 06/13/18 at 1:39 PM, the Director of Nursing Services (DNS), stated if a resident had a change of condition, the physician should be contacted the same day. The DNS stated when a medication was not available the Licensed Nurse should notify the physician for further directions. The DNS was informed Resident 54 did not received the prescribed medication. Review of the medication error report dated 06/18/18 showed, The medication error was a probable component of contributing factors that lead to Resident 54's hospitalization . Perhaps, the illness itself may not have been prevented if the correct processes were followed .his illness may have been treated at the center and not progressed to requiring hospitalization . RESIDENT CARE MANAGER Review of the facility's job description titled, Resident Care Manager, updated (MONTH) (YEAR) showed the Resident Care Manager's essential function included to assist the Director of Nursing Services with managing, supervising, coordination and participating in resident care programs. Resident 31 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review showed on 03/30/18, the resident had seen the neurology physician who had ordered multiple laboratory and diagnostic testing to determine the possible causative factor for the resident's severe leg weakness and numbness. Review of the resident's medical record showed no evidence the facility had the results of the ordered tests and procedures. Record review showed on 04/26/18, the neurology physician had consulted with the neuromuscular clinic regarding the resident's severe [MEDICAL CONDITION] and again ordered multiple laboratory and diagnostic tests to determine the possible causative factor for the resident's severe leg weakness and numbness. In an interview on 06/08/18 at 7:03 AM, Staff A, LPN, RCM, stated that the facility does not get the result of the laboratory results processed from (specific named) laboratory, and the CT (computed tomography) scan would have been done with (specific named) diagnostic imaging. Staff A, stated the facility was responsible for case management of the residents, she trusted the specialist and the nurse practitioner who sees the resident to address the results of the ordered tests. Staff A, stated she could not find the test results in the resident's medical record. In an interview on 06/08/18 at 9:53 AM, Staff A, stated that she had received copies of the resident's CT and Duplex (ultrasound) and the resident was negative for a [MEDICAL CONDITION]. Staff A, confirmed she had not had access to the resident's tests results prior to obtaining them from an outside source. The facility failed to obtain laboratory and diagnostic tests results in order to adequately provide nursing case management for the resident. Refer to F755 CFR 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures Reference (WAC) 388-97-1060 (1)

Based on interview and record review the facility failed to provide pharmaceutical services including all procedures that assure accurate acquiring, dispensing and administration for all medications in the facility for two of five residents (54 and 61) reviewed resulting in medication errors. These failures possibly contributed to the unnecessary hospitalization of Resident 54, the potential for risk for additional medication errors, unmet care needs and decreased quality of life. Findings included . Record review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, IC3: Ordering and Receiving Medications from the Dispensing Pharmacy, dated (MONTH) 2011 showed medications are ordered as followed: · If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery within 4 hours, · Timely delivery of new orders is required so that medication administration is not delayed. The emergency kits are used when the resident needs a medication prior to pharmacy delivery, · If after hours, medications should be ordered as outlined in the Emergency Pharmacy Service and Kits Policy. Record review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, IC5: Emergency Pharmacy Service and Emergency Kits, dated (MONTH) 2011 showed: · Emergency pharmacy service is available on a 24 hour basis. Emergency needs for medications are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. An emergency supply of medications including antibiotics (AB) and products for infusion are supplied by the provider pharmacy, · If the medication is not available, calls/faxes to the pharmacy, using the after-hours emergency number, · The dispensing pharmacy is called if an emergency arises requiring immediate pharmacist consultation about appropriateness of therapy or drug information. RESIDENT 54 Resident 54 was a long term care resident with a [DIAGNOSES REDACTED]. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] showed the resident was alert, oriented and able to make decisions. Resident 54 did not refuse care. Review of a physician's orders [REDACTED]. (an antibiotic) 875 milligrams (mg) by mouth twice a day for 7 days as a result of a chest x-ray that showed the resident had a small left pleural effusion (excess fluid that builds up around the lung) with left lower lobe airspace disease. Review of the nursing progress note dated 05/14/18, the Licensed Nurse (LN) documented At 9:15 PM new order faxed to pharmacy, but medicine was not available in Cubex (a medication dispensing system), at 11:00 PM called pharmacy about the new order. They told me because it faxed after hour (sic), so that's why it is not available in cubex. Pharmacy will satellite the new medication tonight. Review of the E-Box (Cubex) inventory list showed there were ten tablets, single packed doses, of [MEDICATION NAME] 875 mg. Review of the Medication Administration Record [REDACTED]. Review of an untimed nursing progress noted dated 05/15/18, documented, [MEDICATION NAME] not received last night, did not start [MEDICATION NAME]. It further showed Resident 54 was sent to a doctor's appointment. The doctor's office sent the resident to the emergency room for evaluation. Resident 54 was readmitted back to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 06/08/18 at 9:34 AM, Staff X, Pharmacist, stated the pharmacy is available 24 hours a day and delivers medication twice a day on Monday through Friday and once a day on the weekends. Staff X stated the protocol for receiving new orders was to fax the order to the pharmacy and then it would be delivered. Staff X stated there was a cut off time to delivery and if this happened the nursing staff would have to call us to ensure the medication comes out on the next delivery. Staff X went on to state if the medication was not received the medications could always be 'satellited' to the building via a local pharmacy that they were contracted with. Staff X stated if it was an emergency the nursing staff could always take the drug out of the cubex and it was re-stocked at par level daily. Staff X stated the [MEDICATION NAME] should have been stocked if it was on the inventory list. In an interview on 06/13/18 at 8:42 AM, Staff F, Licensed Practical Nurse (LPN), stated if a resident had a new order for an AB, she would fax the pharmacy to notify them of a new order and take it out of the cubex if it was needed promptly. If the AB was not in the cubex she would call the pharmacy and have them satellite the AB. If the medication was still unavailable for some reason, she would call the physician to get further direction. Staff F stated the pharmacy was open and available 24 hours a day. On 06/13/18 at 12:51 PM, Staff G, MDS coordinator identified that there should be 10 tablets of [MEDICATION NAME] available in the Cubex. Review of the facility medication error investigation dated 06/18/18 documented, The root cause of this medication error is a combination of pharmacy services lacking, providing poor customer service and inadequate clinical guidance as well as nursing lacking education related to the cubex. This medication was available the entire time from the initial order. The nurse attempted to pull it from the cubex but it did not come up under Resident 54's name which gave her the perception that is was not available, her back up plan was to call pharmacy which should have worked as the safety net. When she reported to the pharmacy she was unable to get it: that should have alerted pharmacy that she did not understand the 'add item' step. This step adds medications to the resident's profiles making the medication now available to pull from the cubex, Pharmacy is aware of the medications that are in the cubex, they knew it was available. They reported to her that it was after hours and therefore she could not pull it. In addition, the medication was not sent that night on shift delivery. RESIDENT 61 Resident 61 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day MDS assessment dated [DATE] showed the resident was alert and oriented and he was able to make his needs known. Review of the resident's admission orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the nursing progress notes dated 05/17/18 evening shift documented, Medications have not yet arrived from pharmacy so scheduled meds were pulled from cubex as available. Unable to pull correct [MEDICATION NAME] and reconstitution flow rates were not clear. LN attempted to call pharmacy for further instructions, left message, but no call back. At 11:00 PM LN called on call Medical Doctor (MD) to get instruction or an order to hold missed medication but MD stated they would not authorize the hold even though the timeframe for the administration had passed. LN was told if medication had not arrived by 5:00 AM dose, Staff V, Medical Director would have to make decision on change. Review of the MAR indicated [REDACTED]. On the back of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the facility medication error report dated 06/18/18, document, This DNS (Director of Nursing Services) phoned the pharmacy to identify if a call was made to them (from the nursing department) for instructions regarding flow rate and reconstitution on 05/18/18, they could not verify as they do not save all of the messages but indicated that was very probable that a message did not get returned as that does happen. Pharmacy acknowledged that they should have returned the message from nursing but not all messages get put through and followed up. The pharmacy also verified that the process is that when a new admit comes in, if the medications are unavailable in the Cubex, they are to be satellited. In addition they are suppose to be available 24 hours a day 7 days a week. The root cause of this medication error was lack of follow through from pharmacy services. The pharmacy had already delivered the first run prior to Resident 61 admitting, but the medication was in the Cubex it just was not pre-mixed. In an interview on 06/13/18 at 12:30 PM, Staff Z, Registered Nurse, stated AB's have to be given to the resident within 4 hours and if they were not the physician was notified for further instructions. Staff Z stated the pharmacy was available by fax or phone call and they were open 24 hours a day. In an interview on 06/13/18 at 12:51 PM, Staff G, LPN, MDS Coordinator stated if a medication was unavailable from the cubex, the pharmacy should be called so the medication could be satellited over to avoid a delay in treatment. In an interview on 06/13/18 at 1:51 PM, the DNS stated all new medication orders regardless of what they are get faxed to the pharmacy for delivery. The DNS stated the pharmacy delivered twice a day and the pharmacy was available 24 hours a day. If the nursing staff wanted a medication more urgently they would call the pharmacy to get the local pharmacy to deliver the medication. The DNS stated AB's should be given within 5 hours. The DNS stated Resident 54 and Resident 61's AB should have been in the Cubex and should have been started. This is a repeat citation from 01/04/18 Reference: WAC 388-97-1300 1 (a)(b)ii3(a)5(b)

Based on observation, interview and record review, the facility failed to ensure a resident with a positive Pre-admission Screening and Resident Review (PASRR) Level II evaluation ensured recommendations from a Positive Behavioral Support Plan was implemented and incorporated into the plan of care for 1 of 1 (4) residents reviewed for PASRR evaluations. This failure to ensure a behavioral support plan was implemented caused harm to Resident 4 who experienced plaque build up, bleeding and irritated gums, oral pain and the dentist would not repair a broken bridge until Resident 4 exhibited good oral hygiene which had the potential to impact the resident's sense of self. Findings included: Resident 4 was a long-term care resident with [DIAGNOSES REDACTED]. Review of the Minimal Data Set assessment, dated 12/01/17, showed the resident had short and long-term memory loss, had severe impairment with decision making and required assistance for personal hygiene. Review of a Functional Behavioral Assessment, which was completed by a Behavioral Specialist (BS) contracted by the Developmental Disabilities Administration (DDA), dated 12/18/17, showed the BS was to develop a positive behavior support plan to focus on oral hygiene care and staff training. Further review of the Assessment, identified poor oral care and refusal to participate in activities independently. The BS provided the facility with specific individualized interventions to improve oral care and to participate in activities. For example, to improve oral care the facility should utilize a tilt-in-space wheelchair so the resident would lie back like he does at the dentist office. The BS recommended to make brushing a fun activity for the resident that included an incentive, such as stickers on a board. The assessment also had recommendations to increase the resident's participation in activities. The BS stated Resident 4 has had poor oral care documented by the dentist at each visit over the course of the past year. The assessment stated the resident had a broken bridge and did not like not having his bridge, but the dentist would not replace the bridge until the resident could show good oral care. Further review of the assessment, recommended the staff receive training in positive behavior support strategies and how to support an incentive program for the resident and the BS would provide the training. Review of dental notes, dated 06/15/17, 10/20/17 and 01/16/18, showed the resident had heavy plaque, tissue irritation, bleeding gums and oral pain. The dental visits recommended to brush and floss the residents teeth, at a minimum, twice daily. Review of the care plan revealed the individualized recommendations from the BS were not present. In an observation and interview on 01/25/18 at 11:40 AM, the resident was in bed. Staff E, Licensed Practical Nurse, asked if we could look in his mouth. The resident stated ok, need to go to the doctor and get new teeth. The resident was able to open his mouth wide to see all aspects of his mouth. He had some white matter build up on the left lower teeth (lateral incisor and Cuspid), and some redness to the right upper gums (lateral incisor). The resident stated he had some discomfort on the left upper left side of his mouth. At 4:45 PM, a joint interview was done with the facility Administrator, interim Director of Nursing Services (DNS), Staff G, Corporate Nurse, and Staff F, Assistant DNS. The staff was not able to provide information regarding how the resident's behavioral support plan was implemented at the facility. In a telephone interview on 01/26/18 at 9:00 AM, the DDA worker stated she frequently attempted to speak with nursing staff regarding Resident 4's care. The DDA worker completed a report with a cover letter informing the facility exactly what to do. The report was sent to the facility's Social Services Department and it was their job to implement the plan. In the plan, there were specific interventions to assist staff on how to improve the resident's oral care and participate in activities. Additionally, outside agencies who work with the resident have supplied the facility with interventions and offered staff training to support the Positive Behavior Support Plan. Per the DDA worker, the BS had made multiple requests to schedule staff training without a response from the facility. In a telephone interview on 01/30/18 at 3:36 PM, the facility Administrator was not able to locate any prior PASRR level II comprehensive assessments for Resident 4. The Administrator stated she would have the level II PASRR evaluator send the assessments to the facility (even though the assessment was sent to the facilty). Refer to CFR 483.24(a)(2); F-677 ADL Care for Dependent Residents Reference WAC: 388-97-1975(8)

Based on observation, interview and record review the facility failed to ensure 1 of 1 residents (4) received the necessary care and services to maintain good oral hygiene. The failed practice cause harm to Resident 4 who experienced significant plaque build-up, bleeding gums and oral pain. Findings included: Resident 4 was a long-term care resident with diagnosess of developmental delay and [MEDICAL CONDITION] disorder. Review of the Minimal Data Set assessment, dated 12/01/17, showed the resident had short and long-term memory loss, had severe impairment with decision making and required assistance for personal hygiene. Review of the self-care deficit care plan, dated 12/01/17, directed staff to set the resident up twice daily and as needed for oral care. Review of the care directive, dated 12/04/17, showed the resident required set up assistance for oral care. On 01/10/18, the care directive was updated to reflect the resident required one person assistance to brush his teeth. Review of a dental assistant note, dated 06/15/17, showed Resident 4 had .heavy calculus. Bleeding gums . and recommended to help the resident brush and floss his teeth after each meal. The dental assistant stated if this was not possible than staff should brush and floss the resident's teeth after dinner and rinse with water after each meal. The note stated the resident's teeth and gums might be sore after today's visit. Review of a care conference note, dated 06/27/17, showed the guardian discussed the resident's oral care. The plan was to have the .RCM (Resident Care Manager) to put it on treatment administration record (TAR) grid explained ways to approach There was no additional information on the care conference note, care plan or in the progress notes indicating how to approach the resident when performing oral care. Review of a dentist note, dated 10/19/17, showed the resident had heavy plaque and soft tissue irritation present. The dentist recommended to use [MEDICATION NAME] daily for dry mouth and to brush/floss twice daily. Review of a telephone order, dated 10/20/17, directed staff to use [MEDICATION NAME] swish and spit daily. Further review of the TAR showed the resident refused to have his teeth brushed 8 times in August, 3 times in November, once in September, (MONTH) and December. Record review showed that in (MONTH) (YEAR), the resident's roommate threw away the resident's toothbrush on 09/23/17. The TAR reflected a toothbrush was obtained on 13 days later on 10/06/17. There was no documentation stating the NA performed oral care during the time the toothbrush was gone. The LNs were documenting no electric tooth brush. Review of a Functional Behavioral Assessment, which was completed by a behavioral specialist (BS) contracted by the Developmental Disabilities Administration (DDA), dated 12/18/17, were requested to assess Resident 4 to develop a positive behavior support plan to focus on oral hygiene care and staff training. The BS stated Resident 4 has had poor oral care documented by the dentist at each visit over the course of the past year. The assessment stated the resident had a broken bridge, and the dentist would not replace the bridge until the resident could show good oral care. Resident 4 .dislikes missing teeth very much and does want the bridge replaced . The assessment concluded the nursing staff would have more success if they were taught strategies specific for Resident 4 and if the staff was aware of the severity of the resident's oral concerns. Review of a care conference note, dated 01/10/18, showed the guardian would like staff to do more dental hygiene. The plan was to work with the behavioral team (through a contracting company) for oral care. Review of a dentist note, dated 01/16/18, stated the resident .been complaining of mouth pain. Heavy plaque, tissue red & irritated. Pain likely from gingivitis . The dentist recommended brushing and flossing after each meal at least twice daily, and [MEDICATION NAME] oral rinse swish and spit twice daily. Review of the (MONTH) through 01/24/18, TAR, showed the Licensed Nurse (LN) was to ensure the Nursing Assistant (NA) brushed the resident's teeth twice daily with an electric toothbrush. Additionally the LN ensured the NA flossed the resident's teeth daily at bedtime. In an interview on 01/25/18 at 11:25 AM, Staff D, interim Director of Nursing Services (DNS), stated she had recently worked with Resident 4 and he was tolerating his oral care. Staff D stated the resident did have a history of refusing oral care but not currently. The resident was also compliant with the new oral swish and spit treatment. At 11:32 AM, Staff E, Licensed Nurse (LN), stated the resident had been compliant with oral care. Staff E stated she had not notice his gums bleeding recently. The resident did not open his mouth wide at times and that made it difficult to reach his back teeth. The resident would occasionally refuse the electric toothbrush, but the staff could brush his teeth with a regular one. Staff E stated the resident had [MEDICATION NAME] mouth spray daily and a new oral swish and spit treatment. At 11:40 AM, the resident was in bed. Staff E asked if we could look in his mouth. The resident stated ok, need to go to the doctor and get new teeth. The resident was able to open his mouth wide to see all aspects of his mouth. He had some white matter build up on the left lower teeth (lateral incisor and Cuspid), and some redness to the right upper gums (lateral incisor). The resident stated he had some discomfort on the left upper left side of his mouth. At 2:20 PM, Staff H, Licensed Practical Nurse (LPN), stated the resident did occasionally refuse oral care. The (MONTH) TAR was viewed with Staff H who stated, if he did refuse care, then the nurse would circle their initials on the front of the TAR, and write on the back why the resident did not receive the treatment. Staff H viewed the resident only refused oral care once in December. Staff H stated the [MEDICATION NAME] spray had been used in the past but not the [MEDICATION NAME] swish and spit. At 3:10 PM, Staff A, Social Service, stated she attended the 01/10/18 care conference. Staff A was not very familiar with Resident 4 but stated the guardian was concerned about his oral care. Staff A was not able to provide any information regarding the behavioral plan. At 3:25 PM, Staff C, Registered Nurse, stated resident had occasionally refused oral care. Staff C was asked where was it documented when the resident refused oral care. Staff C stated the NA documented it. The TAR was viewed with Staff C, which indicated the LN was to document the NA provided oral care to the resident. At 3:35 PM, Staff B, NA, stated Resident 4 had refused oral care at times. When this occurred, she would notify the nurse. In a telephone interview on 01/26/18 at 4:30 PM, the resident's sister/guardian expressed frustration with the facility. She had a negative interaction with a unitentifid NA who was cocky and full of attitude. The NA reported they had been informed there was a problem with bushing the resident's teeth. The guardian explained that his gums bleed badly at the dentist's office, the NA replied, well the dentist must be doing something wrong. The guardian reported she was incensed about the attitude she received from the NA. She reported she had gone to care conferences and mentioned her and the dentist's concerns about his teeth for years. The guardian stated how many times do I need to tell them before they will listen and take care of his teeth? The guardian reported she made the nurse show her the bottle of [MEDICATION NAME], that was prescribed by the dentist, and it was still full. The nurse tried to tell me that it was being used, when we looked at it together the nurse admitted that it probably wasn't being used. There was a bag of hand held flossers which was the same package I brought in in (YEAR). He has had scheduled visits with other agencies who said the same thing; his tooth bush was bone dry when they see him. This was unacceptable and they need to brush his teeth. They know what they were supposed to do and they chose not to do it. The guardian stated he is a human being who needs help that's why he is there. In a telephone interview on 01/30/18 at 9:50 AM, the DDA worker stated she had spoken to the facility on [DATE] as part of a follow up on care for Resident 4, this served as an official notice to the facility. We offered a plan, support, staff training and we were a resource for the facility. We were able to start support and offer training on 10/12/17, but the facility never responded to our offers. The BS had yet to see staff brush the resident's teeth. The BS staff had a scheduled visit, which the facility was aware of and the resident was not dressed for the visit. When they asked staff to brush his teeth, so they can observe and offer training, wait times were over an hour and a half. Staff offered nothing but excuses of why they could not perform the oral care. The BS staff stated the resident had a history of [REDACTED]. Resident 4 needed assistance and cueing to brush his teeth. The DDA worker had developed a plan with interventions to assist the resident to brush his teeth, but the facility had not implemented the interventions. The DDA worker notified the Administrator on 01/29/18 about the frequent complaints she received from the company contracted to provide services to the resident. The DDA worker offered training to the staff, but the facility had not responded. The facility failed to provide adequate oral care for Resident 4. The dentist documented on three separate occasions the resident had heavy plaque build-up, bleeding gums and discomfort. The resident would not receive a bridge until there was evidence the resident had good oral care. The behavior assessor identified how important the bridge was to the resident. The facility failed to implement the behavior assessors plan or participate in training to improve the resident's oral care. Refer to CFR 483.20(k)(1)-(3), F 645- PASRR Screening for MD and ID Reference: WAC 388-97--1060 (2)(c)

Based on observation, interview and record review the facility failed to provide pharmaceutical services including all procedures that assure accurate acquiring, dispensing and administration for all medications in the facility for 10 of 14 residents (1, 2, 7, 8, 14, 17, 16, 10,13 and 18) reviewed. These failures resulted in an immediate jeopardy. FINDINGS INCLUDE: MEDICATION ERRORS RESIDENT 1 Review of a facility investigation, dated 12/29/17, stated Resident 1 was diagnosed with [REDACTED]. After completing the end of the month Medication Administration Sheets (MAR) reconciliation, Staff C, Licensed Nurse (LN), found the order was not placed on the MAR indicated [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. RESIDENT 2 Review of a facility investigation, dated 12/11/17, showed Staff J, LN, found two cups of medication in the cart. The medication cups were labeled with Resident 2 and Resident 8's names. The investigation reported the medications had been found in the medication cart labeled with the residents name on the medication cup. Resident 2 had not received her [MEDICATION NAME] (an anti [MEDICAL CONDITION] medication used for muscle discomfort) 900 milligrams (mg), Tylenol 650 mg and [MEDICATION NAME] (a medication used to treat an overactive bladder) 5 mg. Review of the MAR indicated [REDACTED]. RESIDENT 8 Review of the investigation, dated 12/11/17, showed the second medication cup that Staff J found was labeled with Resident 8's name. The investigation report identified the medications were [MEDICATION NAME] (a cardiac medication) 3.125 mg and Atorvastatin (a cholesterol medication)10 mg. Review of the MAR indicated [REDACTED]. Staff I received a written disciplinary action for both incidents involving Resident 2 and 8. Additionally, Staff C, Staff Development Coordinator (SDC) was to complete a medication pass audit on Staff I. RESIDENT 7 Review of a facility investigation, dated 12/12/17, stated Resident 7's medications were found at the bedside. The medications were [MEDICATION NAME] (anti anxiety) 0.25 mg and [MEDICATION NAME] (lowers blood pressure) 10 mg. The [MEDICATION NAME] (a scheduled IV controlled medication) was an as needed medication, but review of record does not identify if the resident was exhibiting any anxious behaviors. Staff E, LN, received in-service education for the med error. The in-service did not identify the significance of leaving a controlled substance at the resident's bedside and the potential for other residents to potentially take the unsecured medication. RESIDENT 14 During a record review on 01/03/17 at 1:30 PM, showed a pharmacy recommendation, dated 08/15/17, to address an [MEDICATION NAME] (anti-ulcer) order. On 09/01/17, the Nurse Practitioner (NP) agreed with the pharmacy recommendation. The order was marked as processed on 09/01/17. The MAR indicated [REDACTED] Review of the MAR indicated [REDACTED]. In an interview on 01/03/17 at 1:45 PM, Staff A, Resident Care Manager (RCM), looked through Resident 14's medical record and reported that papers were put in different sections of the chart by different people. Staff A was unable to explain why the medication was discontinued without an order, nor why the original order was not on the MAR. In an interview on 01/04/18 at 1:00 PM, Staff C reported she had asked the NP to address the medication error by writing a new order for [MEDICATION NAME]. The pharmacy request was dated 08/15/17, the order was not addressed until 09/01/17 and as of 01/03/17 the order was still not correct, nor addressed by the RCM of the unit. Additional review of Resident 14's medical record showed a physician order [REDACTED]. Resident 14 received sliding scale insulin three times a day, before meals, depending on the blood sugar results. Review of the (MONTH) and (MONTH) MARs showed the Licensed Nurse (LN) did not accurately administer Sliding Scale insulin or document the resident's blood sugars. The LN did not document the resident's blood sugars at bedtime on 11/12/17 or 11/19/17. The LN did not administer the correct dose of sliding scale insulin on 12/02/17 and 12/03/17 7:30 AM shift; on 12/19/17 Noon; and on 12/21/17 4:00 PM. Further review of the MAR indicated [REDACTED]. On 12/24/17 at 4:00 PM, the blood sugar was illegible, but the LN documented 5 units of sliding scale insulin was administered. Review of the state reporting log showed Resident 14's missed blood sugars and sliding scale insulin errors were not investigated. In an interview on 01/04/18 at 4:16 PM, Staff A confirmed the resident did not receive the correct the dose of insulin, the LN did not document the blood sugar results the blood sugars were not legible. RESIDENT 17 Review of a facility investigation, dated 12/26/17, reported Resident 17 did not receive a 1:30 PM, dose of [MEDICATION NAME]. The error was noted at 5:30 PM, the same evening. In an interview with Staff C reported she had just gotten busy with many other residents and did not even realize the mistake until a medication review was done. RESIDENT 10 Review of the physician orders [REDACTED]. - Licensed Nurse (LN) was to administer sliding scale insulin at bedtime per the blood sugar results - if sliding scale insulin was administered at bedtime the LN was to check the resident's blood sugar at 3:00 AM - the resident's blood sugar was checked before meals and if the blood sugar was below 90, the LN was to hold the insulin - routine insulin was administered with meals - the LN was to call the physician if the resident's blood sugar was below 70 or above 349. Review of the MAR, showed the LN administered Humalog when the resident's blood sugar was below 90 on 11/11/17 (midday). The LN did not administer the prescribed sliding scale insulin at bedtime on 11/3/17, 12/02/17 and 12/04/17. The LN did not contact the physician when the resident's blood sugar was above 349 or below 70 on 12/05/17, 12/07/17, 12/09/17, 12/11/17, 12/14/17, 12/15/17, 12/28/17 and 12/29/17. The LN did not check the resident's blood sugar on 11/25/17 at 5:00 PM and signed that [MEDICATION NAME] 5 units was administered. Review of the (MONTH) through (MONTH) 3, (YEAR) Medication Administration Record [REDACTED]. Further review of the physician orders [REDACTED]. The LN was to check the resident's blood pressure prior to the administration of the medication, and if the systolic blood pressure was above 165, the LN was to call the cardiologist. Review of the (MONTH) and (MONTH) MAR indicated [REDACTED]. The LN did not call the cardiologist with the systolic blood pressure was above 165 on 11/06/17, 11/20/17 (PM shift), 12/11/17, 12/24/17, 12/25/17, 12/28/17 and 12/30/17 Review of the medical record showed the LN did not document in the nursing progress notes of vital sign flow sheet the resident's blood pressure prior to the administration of the blood pressure medication. Additionally, the LN did not document the physician was notified of the abnormal blood sugars. In an interview on 01/04/18 at 11:55 AM, the resident was observed in bed. He stated he did not know why the LN woke him up at 3:00 AM to check his blood sugar. Review of the state reporting log revealed the above medications errors were not investigated. At 2:44 PM the Director of Nursing Services was not aware the LN woke the resident up even though she did not need to check the resident's blood sugar, why the LN did not notify physician orders [REDACTED]. The DNS confirmed no medication error report was done regarding the multiple errors as outlined above. MEDICATION PASS OBSERVATION RESIDENT 16 In a medication pass observation on 01/04/17 at 9:10 AM, Staff H, Registered Nurse (RN), was asked to unlock the medication cart which revealed a clear medication cup in the top right single locked drawer containing 4 small white tablets inside labeled with a black marker with the name Resident 16. In continued observation at 10:30 AM, the clear medication cup remained in the top right single locked drawer. Staff H stated the medications were for Resident 16. They are her pain medications [MEDICATION NAME], I know her, and she usually wants them early, but today when I brought them in she told me she wanted to take them later . that is why you are seeing them there. Record review of the narcotic tracking book revealed Staff H had signed out 10 mg of [MEDICATION NAME] for Resident 16 at 8:00 AM. The medication's pharmacy label identified it was a schedule II narcotic which were required to be stored behind a double lock. Record review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. In a further observation at 1:00 PM, the medication cup was no longer observed to be in the top drawer of the cart. When asked what time the resident received the medication, Staff H stated it was at 9:30 am, before her therapy. When staff H was asked about the entry on the MAR indicated [REDACTED]. She had no response for the reason for pre-charting the effectiveness or for the time discrepancy as the medication was observed still in the drawer at 10:30 AM, stating maybe it was 11:00 AM? She continued to state she could not recall the correct time. At 1:10 PM, Resident 16 stated she had received pain medication but could not recall a time. At 1:40 PM, The Director of Nursing Services (DNS) was made aware of Staff H pre-pouring narcotics, keeping in a single locked drawer and pre-charting both administration and effectiveness of the medications. The DNS had no additional information but would follow up. MEDICATION CART REVIEW RESIDENT 10 The swing cart was observed at 9:27 AM, with Staff D, Licensed Practical Nurse. There were four injectable insulin bottles located in the top drawer of the medication cart. There were two bottles of expired insulin observed for Resident 10. The first bottle was [MEDICATION NAME] with an open date of 11/28/17. The second bottle was [MEDICATION NAME] with an open date of 12/03/17. There was a sticker on the [MEDICATION NAME] bottle that stated to discard after 28 day of being open. Staff D stated both bottles should have been discarded after 28 days of being open. Staff D removed the two insulin bottles from the medication cart. Staff D stated there was a representative from the pharmacy who would come frequently and check the medication carts and remove any expired medications. Staff D stated she had not been aware the last time the pharmacy person came. Staff D stated she would have removed the insulin or alerted us that it was about to expire. Review of Resident 10's MAR indicated [REDACTED]. WEST MEDICATION CART In an observation on 01/04/18 at 09:40 AM with Staff K, Registered Nurse present, the West medication cart was inspected. The cart contained a plastic bag with the name of Resident 3 crossed out in two areas on the label. The bag contents revealed insulin pen needles and a prefilled syringe of Basaglar (type of insulin). The Basaglar did not have a resident name or other identifier affixed. No label was found in the bag. The pen was dated 12/26/17. In an interview on 01/04/18 at 10:00 AM, Staff E, Licensed Practical Nurse put his head down and stated The only person on this medication down here is Resident 18 but she has been here a long time so it should be labeled from pharmacy. She has been on this for many months now. The pen should be labeled with her name if it was for her. Maybe they (other nurses) were just using the needles for Resident 18. I really can't say it is given at HS (bedtime). Staff E went to the med room and there were 5 new Basaglar pens for Resident 18 in the medication fridge. The Basaglar were labeled from pharmacy with a delivery date of 12/19/17. On 01/04/18 at 10:50, Staff E stated he would replace the unlabeled pen with the new clearly labeled Basaglar for Resident 18. In an interview on 01/04/18 at 3:35 PM, the DNS was notified Resident 18's insulin bag contained only a vial of Humalog. No Basaglar Kwik pen was present. The DNS was asked why the unlabeled medication for Resident 3 (east unit resident) was in the west med cart. She stated I think they probably just put the pen in the wrong bag. When asked how misappropriation could be ruled out. The DNS stated I get it, yeah. I will in-service the nurses, no borrowing meds. The Facility's Payless pharmacy policy (MONTH) 2011 titled Medication Ordering and receiving: Medication labels revealed .the residents name, at least, must be maintained directly on the actual product container. The facility failed to ensure a consistent and competent medication administration system throughout the facility resulting in a Immediate Jeopardy situation. CONTROLLED MEDICATIONS On 01/04/18 at 9:07 AM, a medication pass was observed with Staff D, LPN on the Central hall. Staff D stated scheduled II and III controlled medications were reconciled at change of shift. If there was a discrepancy, the Licensed Nurse would start an investigation and notify the Director of Nursing Services. At 12:53 PM, Staff D was asked if the facility ensured all scheduled II -V medications were reconciled. Staff D stated only scheduled II and III controlled medications were reconciled. Staff D opened up the Central medication cart and pulled out a card of [MEDICATION NAME], a scheduled IV medication, and stated they were not reconciled or in a secured area. Staff D pointed to the other cart on the hall (Swing cart) and stated none of the scheduled IV or V medications were reconciled. In an observation of the West and East hall medication carts showed the scheduled IV and V medications were located with the routine medications. The medications were not doubled locked. In an interview with the DNS at 1:35 PM, she stated We keep the scheduled IV's and V's with the residents other medications. She confirmed the scheduled medications were not secured with the other narcotics or counted each shift. At 2:44 PM, the facility Administrator and DNS were interviewed. The DNS was not aware that scheduled IV and V medications were required to be in a secured separately affixed compartment and periodically reconciled. MEDICATION ADMINISTRATION RECORD/MEDICATION TIMES RESIDENT 13 Resident 13 admitted on [DATE] with a complex medical/surgical history and [DIAGNOSES REDACTED]. In an interview on 01/04/17 at 12:00 PM, Resident 13 stated she felt like she had to fight for everything. She tearfully stated that she is very scared about blood clots and knew how important her medications were to prevent more blood clots because I can't walk. She stated the nurses told her she had to wait for the [MEDICATION NAME] (a blood thinning medication) injection because they were busy. She stated she never gets her medications at a consistent time. sometimes it is 9 AM, sometimes it is 10, 11, 12, or later. She stated that she has still not received her dose for 11:00 AM today. In an observation at 12:10 PM, Staff H entered the room and stated to Resident 13 that she would give her the injection and her other medications when she did her dressing change in about an hour. The resident became tearful and stated that is after 1:00 PM! (looks at this surveyor) See what I mean!? NO!, I want you to bring it now! It is already late! Review of the MAR indicated [REDACTED]. If the resident's medication was scheduled for 11 AM, and it was not administered until after 12 PM, it was a late medication per policy. There was no documentation to ensure the resident was receiving her [MEDICATION NAME] every 12 hours as recommended by the manufacturer to ensure a consistent level to treat and prevent blood clots. RESIDENT 10 Review of the physician orders [REDACTED]. The resident's blood sugar was checked before each meal and at bedtime. Review of the (MONTH) MAR indicated [REDACTED]. Further review of the (MONTH) MAR indicated [REDACTED]. The timeframe on the MAR indicated [REDACTED]. Review of the (MONTH) blood sugar results for 5:00 PM and at bedtime showed the same blood sugars documented as follows: -on 12/01 both blood sugars were 243 -on 12/03 both blood sugars were 243 -on 12/05 both blood sugars were 181 -on 12/09 both blood sugars were 176 -on 12/10 both blood sugars were 85 -on 12/11 both blood sugars were 190 -on 12/15 both blood sugars were 334 In an interview on 01/04/18 at 2:44 PM, the DNS was not aware the LN was not accurately checking the resident's blood sugar at bedtime, but documented the same blood sugar at dinner and bedtime. The DNS was going to look into the resident's blood sugar and potential medication errors. The LN did not consistently follow the physician orders [REDACTED]. Review of the (MONTH) and (MONTH) resident's blood sugars showed the resident would not have had the same blood sugar at dinnertime and at bedtime. The MAR indicated [REDACTED]. RANDOM MAR indicated [REDACTED]>In an interview on 01/04/17 at 10:00 AM, Staff H stated that some medication times were set up as AM which meant the medication could be given between 6:00 AM and 2:00 PM, but if there is a specific time then you have an hour before or an hour after. Staff H further stated she had 22 subacute patients and could not get all her medications passed on time. In an observation at 3:00 PM, Staff D LN showed the surveyor the MAR for a Tylenol order to be given three times a day. The order was written once on one page for the morning dose and then on a separate sheet for the afternoon and night doses. Staff D reported it was too many pages to go through and you can't get organized and keep track of your medication pass. When you have one nurse to give medications to 34 residents and you have to search for each medication, this is an error waiting to happen. The MAR indicated [REDACTED]. Some were scheduled from 0600-1000, or 18- 22 (6:00 PM to 10:00 PM), or were scheduled at an hour (6 am), other orders for the same medication if given more than once a day could be seen on multiple sheets. In an interview with the DNS on 01/04/17 at 4:00 P.M., she reported the MAR indicated [REDACTED]. The DNS stated the computer system was not written by people who give medication so it was not printing as we would normally see our medications scheduled. This is the first month we are trying this and I am trying to delete the extra orders to make it easier. At 5:10 PM, Staff B, LPN, stated the new computer system did not print out on the MAR indicated [REDACTED]. Staff B stated on some of the MAR's it was printed as AM(6, which looked like it was to be administered at 6 AM. Staff B stated this was not correct. Staff B was not able to state what time the medications were actually administered when it appeared on the MAR indicated [REDACTED]. Staff B was not able to offer any additional information. Refer F760 CFR 483.45 (f)(2) Residents Are Free of Significant Medication Errors Reference WAC 388-97-1300 (1)(B)(ii) (c)(i-iv) (2) & -2340

Based on observation, interview and record review, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements. The Administrator failed to ensure compliance related to the pharmacy services including medication errors, misappropriation of medications, delay in the delivery of medication, usage of expired medications and unattended medications being left at the bedside. By not ensuring the facility had a functioning medication system, this resulted in an Immediate Jeopardy situation. Findings include: Failed practice found during the abbreviated survey ending on 01/04/18 was as follows: F 561- 483.10(f)(1)-(3)(8), Self Determination The administration failed to ensure resident's choices were honored regarding bathing and showers. F 583 - 483.10(h), Privacy and Confidentiality The administration failed to ensure privacy was maintained for meetings between a Provider and resident. F 656 - 483.21(b)(1), Develop/Implement Comprehensive Care Plan The administration failed to ensure care plans were developed and revised as necessary to meet the needs of residents. F 657 - 483.21(b), Comprehensive Care Plans The administration failed to ensure facility staff developed individualized care plans. F 658 - 483.21(b)(3)(ii)(iii), Services Provided Meet Professional Standards The administration failed to ensure facility staff provided care and services according to professional standards of practice. F 725 - 483.35(a)(1)(2), Sufficient Nursing Staff The administration failed to ensure the facility had adequate staff to provide basic care and services. This caused harm related to the lack of a functioning medication administration system. F 744 - 483.40(b)(3), Treatment/Service for Dementia The administration failed to ensure appropriate treatment and services were provided to residents with dementia. F 755 - 483.45, Pharmacy Services The administration failed to have a working accurate medication system in place to ensure accurate dispensing, administering, and storage. An immediate jeopardy was identified. F 756 - 483, Drug Regimen Review The administration failed to ensure that all pharmacy recommendations were followed up on. F 760 - 483.45(f)(2), Residents are free from Medication Errors The administration did not ensure drugs were stored in accordance with currently accepted principles. F 761 - 483.45(g)(h)(1)(2), Label/Store Drugs & Biologicals The administration did not ensure drugs were stored in accordance with currently accepted principles. F 773 - 483.50(a)(2)(i), Provide or obtain Laboratory services The administration failed to ensure the facility obtained physician order [REDACTED]. F838 - 483.70(e), Facility Assessment The administration failed to develop a facility wide assessment to determine resources necessary for care and services on a daily basis. F842- 483.70(i)(1)-(5), Resident Records-Identifiable Information The administration failed to ensure resident records were legible and contained the required health information for Licensed Staff be able to provide care and services. Reference (WAC) 388-97-1620(1)

Based on observation, interview and record review the facility failed to ensure 8 of 14 residents (1, 2, 8, 7, 16, 13, 14, & 17) were free from significant medication errors. The lack of a functioning medication system caused harm to residents because licensed staff did not use professional standards nor follow facility policy when administering medications to vulnerable adults. These failures placed residents at higher risk for complications and declines in health status. Findings Include: Review of the facility's Medication Administration Policy, directed the Licensed Nurse (LN) to: 1. The nurse reviews each resident's MAR indicated [REDACTED] 2. At no time is the nurse allowed to pre-pour or pre-chart the ordered medications. 3. The nurse does not borrow medications. 4. Medications are not left at the bedside for the resident to take later. 5. The nurse follows the 5 Rights of Medication Administration. Review of the facility's Flexible Medication Pass policy revealed the following medication administration times, unless the physician specified a certain time for the medication to be administered, was: ~AM med's to be administered between 0700-0930 (2 hour window open to pass=0600-10:30) ~Midday med's 12:00-1300 (2 hour window open to pass med's=11:00-14:00) ~PM med's 15:30-17:00 (2 hours window open to pass=14:30-18:00) ~HS med's 19:30-21:30 (2 hour window to pass=18:30-22:30) (if a physician indicates a specific administration time, in these cases a time will be scheduled) Review of the facility's Controlled Medications policy stated when a dose of a controlled medication was removed from the container for administration but refused by the resident or not given for any reason, it was not placed back in the container. The controlled medication must be destroyed according to facility policy for Controlled Medication Disposal. According to Lippincott Nursing Procedures 7th Ed, defined a medication error as a mistake that occurs during a medication administration process. If a mistake occurs, it doesn't matter whether the patient was harmed or whether there was only a potential for injury; it's still considered a medication error. RESIDENT 1 Review of a physician order, dated 12/08/17, showed Vitamin D3 2,000 IU (international units) to be administered daily. Review of the (MONTH) Medication Administration Record [REDACTED]. RESIDENT 2 Review of a facility investigation, dated 12/11/17, showed Staff J, LN, found a medication cup in the top drawer of the medication cart with [MEDICATION NAME] (an anti [MEDICAL CONDITION] medication used for muscle discomfort), Tylenol and [MEDICATION NAME] (an overactive bladder medication) with Resident 2's name written on the cup. Review of the MAR indicated [REDACTED]. RESIDENT 8 Review of a facility investigation, dated 12/11/17, showed Staff J found a medication cup in the top drawer of the medication cart with [MEDICATION NAME] (a heart medication) and Atorvastatin (a cholesterol medication) with Resident 8's name written on the cup. Review of the MAR indicated [REDACTED]. The investigation revealed Staff I was counseled on the medication errors and would receive a medicaitons pass audit. RESIDENT 7 Review of a facility investigation, dated 12/12/17, showed [MEDICATION NAME] (an anti-anxiety and controlled substance) and [MEDICATION NAME] (a blood pressure medication) were found at Resident 7's bedside. Review of the MAR indicated [REDACTED]. Staff E received in-service education for the medication error, but did not receive any additional interviewing regarding leaving a controlled medication at the resident's bedside. RESIDENT 16 In an medication pass observation on 01/04/18 at 9:10 AM, on the East hall, there were four unidentified white pills (cut in half) pre-poured into a medication cup with Resident 16's name on it. Staff H, LN, was asked what was in the cup. Staff H responded it was an [MEDICATION NAME] (scheduled II controlled narcotic) pill the resident had requested and then decided she wanted it later. Staff H stated that's why it is here. Review of the MAR indicated [REDACTED]. Review of the controlled narcotic ledger showed Staff H had signed the [MEDICATION NAME] out. At 4:30 PM, the Director of Nursing Services stated Staff H would be disciplined regarding the incident. RESIDENT 13 In an interview on 01/04/18 at 12:10 P.M., the resident was visibly upset about not receiving her medications in a timely manner. She reported she received her [MEDICATION NAME] (an anti clotting medication) injection anytime between 9 AM, and as late as after 12 PM. Staff H walked into the resident's room and told her she would administer the [MEDICATION NAME] injection when she changed her dressing. The dressing change was to occur around 1:00 P.M. The resident was then tearful and told Staff H she wanted it now as it was already late. The resident was visibly upset about the lack of a standard time in which she received her medications. The resident reported fears of complications from not receiving her ordered medications on time. Review of the MAR indicated [REDACTED]. The [MEDICATION NAME] was adminstered outside of the scheduled timeframe. At 4:30 PM, the DNS was made aware of the above medication error. RESIDENT 14 During a record review on 01/03/17 at 1:30 PM, revealed a pharmacy recommendation, dated 08/15/17, to address an [MEDICATION NAME] order. It was addressed by the Nurse Practitioner (NP) on 09/01/17 who marked Agree with the pharmacists recommendation. The order was marked as processed on 09/01/17. The MAR indicated [REDACTED] On 11/29/17 the order was discontinued and there was no order found in the chart. In an interview 01/03/17 at 1:45 PM, Staff A, Residential Care Manager (RCM), was unable to explain why the [MEDICATION NAME] was discontinued without an order or why the original order was not on the MAR. In an interview on 01/04/18 at 1:00 P.M. with Staff C, SCD, reported she had asked the NP to address the medication error by writing a new order for [MEDICATION NAME]. The pharmacy request was dated 08/15/17, the order was not addressed until 09/01/17 and as of 01/03/17 the order was still not correct, nor addressed by the RCM of the unit. Additionally, review of the (MONTH) and (MONTH) MARs showed the LN did not accurately administer Sliding Scale insulin on 12/02/17 and 12/03/17 7:30 AM shift; on 12/19/17 Noon; and on 12/21/17 4:00 PM. Review of the state reporting log showed the medication error were not identified or investigated. In an interview on 01/04/18 at 4:16 PM, Staff A, RCM, confirmed the resident did not receive the correct the dose of sliding scale insulin. RESIDENT 17 Review of a facility investigation, dated 12/26/17, reported Resident 17 did not receive a 1:30 PM, dose of [MEDICATION NAME]. In an interview on 01/03/18 at 11:00 A.M., with Staff C, SDC remembered there was a call out, she had just gotten busy with many other residents, and did not even realize the mistake until a medication review was done. Staff C, SDC denied there had been any house wide in-services for the licensed nurses despite the increase in medication errors. Refer to F725 CFR 483.35(a)(1)(2) Sufficient Nurse Staff Refer to F755 CFR 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures Reference WAC 388-97-1060 (3)(k)(iii)

Based on observation, interview, and record review, the facility failed to implement a Dementia Care Plan which had documented interventions with measurable goals for 2 of 2 residents (5,9), reviewed for dementia with behaviors. These failures resulted in harm related to a pattern of behaviors which included intrusive wandering and sexual behaviors. Findings include: RESIDENT 5 Resident 5 had [DIAGNOSES REDACTED]. The MDS assessment identified the resident ambulated independently and was cogntivitly intact. In an interview on 12/28/17 at 12:30 PM, Resident 6 reported that Resident 5 had been wandering into her room and staff were required to remove him at times. The removal process took 20-30 minutes at times because as resident 6 stated there were not always enough staff present. The wandering was so intrusive that Resident 6 resorted to keeping her door closed and placing a privacy sign on her door. Resident 6 reported her concerns to the Administrator but the intrusive wandering continued. Resident 6 reported feeling vulnerable because she was in a wheelchair and resident 5 could ambulate. Resident 6 also stated concerns for other residents who could not speak for themselves since she knew that resident 5 was wandering into other rooms as well. A review of the progress notes revealed multiple notes regarding the resident's wandering into a number of rooms and staff experiencing difficulty re-directing him. A note dated 12/04/17 stated the resident was on 1:1 and was encouraged to read,distract with activity. A note on 12/05/17 stated the resident was having frequent checks, no mention of 1:1 supervision. In an interview on 12/28/17 at 4:30 P.M., the Administrator was made of aware of Resident 6 concerns of Resident 5 wandering into her room. The Administrator reported she had addressed this issue several weeks ago and was not aware the problem persisted. In observations on 01/03 and 01/04/18 the resident had been placed on 1:1 supervision. A review of Resident 5's care directive, which the nursing assistants use, does not address the resident's wandering into other resident's rooms. It assessed the resident as alert, oriented and forgetful. The care plan, with a goal date of 02/13/18, revealed a care plan for wandering which noted the resident's [DIAGNOSES REDACTED]. Interventions included re-direction, Wander guard device, music, and exercise groups. The dementia care plan addressed wandering as an issue and the goals were for the resident to not have injuries, meet daily needs and reduced wandering. The one intervention was to establish and maintain a consistent routine/environment-based on the residents likes. To be re-evaluated in 90 days. In a Fall Review dated 11/19/17, it stated as a root cause for the fall, resident is confused with dementia. Resident was found sitting on the floor. The conclusion was the resident had a failed self transfer and was re-instructed on the use of callight. RESIDENT 9 Resident 9 admitted to the facility (MONTH) (YEAR) with primary [DIAGNOSES REDACTED]. The 11/28/17 care plan showed Resident 9 had the following interventions in place for Dementia: Establish and maintain a consistent routine/environment, provide calm, quiet environment/approach, one on one supervision when OOB (discontinued 12/04/17), close supervision at noc (night), educated about consent and states understanding. Review of Resident 9's progress note dated 11/28/17 eve (evening shift- no exact time) stated Resident approached a confused male resident telling him she needed a hug and kiss. She stated I love you, you are my heart. Unable to determine if she thought she knew him? She was redirected and kept under supervision through the night. One to one tomorrow for safety until discharge. Care plan placed. Placed on alert for soliciting affection inappropriately. In a progress note dated 12/01/17 at 2200, No inappropriate behavior. Reiterated the meaning of consent and that many of our residents are incapable of consenting. Res. (resident) expressed understanding. In a progress note dated 12/04/17 at 10:00 remove 1:1 as resident states understanding of consent and inappropriate bxs (behaviors). Review of a progress note dated 01/03/18 day (day shift-no exact time) revealed This nurse witnessed resident holding hand with another resident. When asked to head back towards her room, they both stood up and she kissed him on the cheek. On 01/04/18 at 9:05 AM, Resident 9 was observed resting in her bed. A female staff member was seated in a chair outside her door. She confirmed she was doing one on ones for Resident 9. In an interview on 01/04/18 at 9:15 AM. Staff E, Licensed Practical Nurse, was asked why Resident 9 was receiving one on one supervision. Staff E stated he was familiar with Resident 9 then stated I am not sure I haven't read the chart but it is something about a resident on East and I believe sexual in nature. On 01/04/18 at 3:45 PM, The Director of Nursing Services confirmed Resident 9 did not have a detailed dementia care plan in place or interventions to assist the resident who had difficulty with personal interaction and socialization. The facility failed to ensure care plans addressed interventions and were re-evaluated as to their effectiveness. Placing both residents on short term 1:1 supervision allowed behaviors to re-occur. These failures resulted in harm of resident 6 having to seclude herself in her room so resident 5 would no longer enter uninvited. Refer to F656 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plans Refer to F657 CFR 483.21(b)(2)(i)-(iii) Care Plan Timimg and Revision Refer to F658 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards Refer to F725 CFR 483.(a)(1)(2) Sufficient Nurse Staffing Refer to F838 CFR 483.70(e)(1)-(3) Facility Assessment Reference (WAC) 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to provide thorough and comprehensive care and services for 1 of 4 (55) residents reviewed for Activities of Daily Living. Failure to provide adequate face washing, oral hygiene, and shaving would result harm to Resident 55 and a reasonable person of embarassment knowing they did not have good hygiene or their breathe had odor. Findings include: Resident 55 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident 55 was dependent upon staff for all hygiene needs. She had severe cognitive impairment and was unable to communicate her needs. Due to the resident's severe cognitive impairment, the Reasonable Person concept was applied. It was determined a reasonable person in a similar situation would expect his/her personal hygiene needs would be adequately met. The resident's quality of life, comfort, and dignity would be negatively impacted by inadequate face-washing, oral care and untrimmed facial hair (female). Review of Resident 55's medical record revealed the goal was for comfort. Review of the Monthly Note dated 03/09/17 revealed Resident 55's son / Power of Attorney communicated to the facility that he would like her mouth to be cleaned more often. In a family interview on 03/23/17 at 3:36 PM, Resident 55's family member stated she visits the facility 3-4 times a week. She stated the resident's lips look dry each time she visits and her tongue gets dry and brown. She stated the resident needs very frequent care to keep her mouth and lips moist and clean. She stated she recently supplied soft washcloths for staff to use to wash the residents mouth. Review of the facility 'Procedure for AM Care and Procedure for HS Care revealed if a residents teeth could not be cleaned with a toothbrush and toothpaste, full mouth care should be completed with toothettes, etc. to make sure the mouth was thoroughly cleaned. Review of the facility Standards of Care for Nursing Assistants revealed oral care was to be done twice daily and as needed, hands and faces to be washed twice daily and as needed, and shaving for women was to be done as needed. Review of the current care plan revealed the resident had halitosis and dry mouth. Interventions included [MEDICATION NAME] (oral moisturizing gel) swab each shift, brush teeth each shift, and provide and maintain good oral hygiene. Goals on her Oral / Dental Care Plan included Resident's oral mucosa will be moist and clean. In an observation on 03/23/17 at 3:23 PM, Resident 55's lips had patches of dry, crusty matter, especially on her lower lip. At 03:30 PM the resident's breath was observed to be foul. On 03/23/17, Resident 55's tongue was dry and her bottom lip was coated in crusty dried substance. At 2:25 PM her lips remained crusty and her breath was extremely foul from 4 feet away. At 2:57 PM her lips remained dry and crusty, her tongue was dry with areas of tan matter. On 03/24/17 at 8:51 AM, Resident 55's lips had chapped areas, especially on her lower lip. At 9:10 AM, the tip of her tongue was red and she had cream color coating on the back of her tongue. Her bottom lip was chapped. At 09:45 AM, her lips were chapped and irritated. Her tongue was dry and her breath foul. On 03/27/17 at 8:56 AM, Resident 55's lips and mouth were dry. At 10:01 AM, her lips appeared drier and her lower lip was crusty. At 10:44 AM her tongue was very dry. Her lower lip was crusty and her upper lip had dry chapped areas. At 1:33 PM her lips were dry with crusty debris on and around her bottom lip At 1:59 PM her lips and surrounding area were coated with a crusty substance. At 2:23 PM and 3:21 PM, her tongue was dry and had 2 reddened, raw areas at the tip of her tongue. Her lips and surrounding area were covered in crusty debris. On 03/28/20 at 8:51 AM Resident 55's lips were dry. . At 9:31 AM, her lips were dry and had patchy red and tan chapped areas. At 10:27 AM her tongue and lips were dry. Her upper lip was coated in crusty, fur-like substance and her lower lip had chapped raw areas. Her lips looked worse than when observed at 09:31 AM. At 11:19 AM, Resident 55 was observed rubbing her face with her right hand. She was looking around and making unintelligible verbalizations. She had debris on her lips which was covered by a clear substance. Her breath was very foul. At 1:26 PM and 1:48 PM, her lips were coated with dry fuzzy matter. At 3:11 PM and 4:01 PM, her tongue was dry, lips were dry and crusty, and there was debris around her mouth. In multiple observations on 03/23/17, 03/24/17 and 03/27/17 through 03/28/17, Resident 55 was observed to have facial hair above and to the sides of her lips. In an observation and interview on 03/28/17 at 5:17 PM, Resident 55 had a large amount of debris on her lips, tongue, and around her mouth. Her breath was very foul. Staff N, Resident Care Manager (RCM) stated oral care was not acceptable. She stated oral care had been a problem with Resident 55. She stated nurses were doing oral care, but apparently not often enough. Staff N, RCM also observed Resident 55's facial hair, and she stated she should be shaved. She said she would be in-servicing the staff about oral care and shaving. She stated she would ensure orders and the care plan were adjusted to meet Resident 55's needs for oral care as it was evident care was not being completed as frequently as needed. There was no evidence of oral care supplies at bedside or sink area during all observations throughout the survey. In an interview on 03/28/2017 at 11:25 AM, Staff P, Nursing Assistant (NA) stated the NA's do not do the oral care; the nurses do it. In an interview on 03/29/17 at 8:56 AM, the Director of Nursing Services stated she was aware Resident 55 needed more oral care. She stated they were going to watch her closely and determine how frequently oral care was needed. On 03/29/17 at 9:19 AM, Staff N, RCM stated she changed the order to have nurses clean Resident 55's face and mouth every shift and as needed. She stated both Licensed Nurses and NA's should be washing her face and doing oral care.

Based on observation, interview and record review the facility failed to provide services in accordance with accepted standards of medication administration practices for 2 of 5 (26 and 27) sampled residents. The failure of licensed staff to consistently transcribe and administer medications using professional nursing standards contributed to a medication overdose and a medication error. This placed other residents at risk for medication errors and potential negative health outcomes. Findings include: Nursing 2016 Drug Handbook 36th edition, describes the eight rights of medication administration as: 1. The Right drug 2. The Right patient 3. The Right dose 4. The Right time 5. The Right route In addition to the traditional five rights of individual practice, best-practice researchers have added three additional rights. 6. The Right reason 7. The Right response 8. The Right documentation American Nurses Association (ANA) Position Statement dated 3/12/09: To promote safe medication use in the older adult, the ANA supports: · Ongoing evaluation and monitoring of the older adult's medication profile to encourage safe medication use · Clear communication of medication information to patients, family members, caregivers, the next healthcare professional and/or organization providing care · Reconciliation of medications each time an older adult experiences a transition in care. · Research on clinical interventions to test the effects of specific interventions related to care of aging populations, medication prescribing and administration, clinical settings and staffing, and interdisciplinary approaches to safety and quality of care RESIDENT 26 On 01/25/16, the Resident returned to the facility from the hospital where she was being treated for [REDACTED]. During her stay at the hospital she received an order for [REDACTED].>[MEDICATION NAME] is a skeletal muscle relaxant to aide in the treatment of [REDACTED]. For elderly initially 5 mg 2 to 3 times a day then gradually increase. The side effects listed are agitation and drowsiness. The resident had just returned from the hospital and was on multiple medications for pain, most of which included the side effects of drowsiness. In an interview on 02/03/16 at 10:45 A.M., with a family member who questioned when does a nurse ever give 5 pills of the any medication and not question if that is the right thing to give a person? They literally had to give her 5 tablets, the doctor said she should have gotten 5 mg - a half tablet. She was in critical condition when I first saw her. On 02/10/16 at 9:20 A.M., with the Director of Nursing Services (DNS), verified the expectation is for licensed nurses was to verify new orders and record them in the medication administration record. These orders are checked by two nurses to verify accuracy. The orders are then sent to the Pharmacy. Prior to the resident going to the hospital the resident was receiving 40 mg of [MEDICATION NAME] per day as needed (per MAR from Dec and Jan). It was not a scheduled dose. The new order as written, was to give the resident a total of 100 mg a day as a scheduled dose. The new orders showed there was a change in the dosage amount which should have been noted by the nurses who checked the orders. According to standards the nurses who administered the medication, have the responsibility of knowing the action, the safest dose, the side effects of this medication and the interactions of all the medications they are administering to the resident. This lack of clarifying the order with the physician caused a medication overdose, [MEDICAL CONDITION] and an extended hospitalization . RESIDENT 27 Record review of resident records revealed [MEDICATION NAME] was not transcribed, clarified and not given to resident. The resident was readmitted to the facility 01/30/16 with an order to hold the [MEDICATION NAME] until 02/02/16. On 02/02/16 the anticoagulation clinic gave new [MEDICATION NAME] orders and to have the next INR (blood test) level drawn. This was not transcribed onto the MAR. Additionally, on 02/05/16 the physician ordered [MEDICATION NAME] for two days (to be given on 02/05 and 02/06) and to draw the next INR on 02/07/16. The resident lab was drawn, but the LN did not call the physician with the INR results to obtain a new [MEDICATION NAME]. On 02/08/16 the anticoagulation clinic ordered a new dosing of the [MEDICATION NAME] and when to have the next INR drawn. This order was not processed until 02/09/16. According to the MAR, the resident did not receive [MEDICATION NAME] on the 7th, 8th and 9th. This medication error was unknown to the facility and was brought to their attention during the investigation. The failure of the facility to maintain a functioning medication administration system as per facility policy and Nursing Standards of Practice left residents at risk for receiving incorrect/and or no medications.

Based on interview and record review the facility failed to ensure 2 of 3 Residents (26, 27) were free from significant medication errors. This failure resulted in harm for Resident 26 who was hospitalized related to a [MEDICATION NAME] overdose and required an extended hospitalization . In addition, it placed Resident 27 at risk for having blood clotting complications related to not receiving an anticoagulant medication as ordered. Findings Include: Resident 26 was admitted ,[DATE] with [DIAGNOSES REDACTED]. The Miminum Data Set ((MDS) dated [DATE] noted the resident was cognitively intact and had no behaviors. The resident experienced neuropathic leg pain and muscle spasms which caused her difficulty sleeping. The 2016 Nursing Drug Handbook stated that [MEDICATION NAME] is a skeletal muscle relaxant to aide in the treatment of [REDACTED]. Recommendations for the elderly initially was 5mg 2 to 3 times a day then gradually increase. A review of the progress notes dated 01/26/16 showed a late entry for timed 0900 Took in small glass of nectar think juice and pills in applesauce. No coughing noted. Seemed to tired with swallowing meds and spit a couple out. 11:30 A.M., she told RCC (Resident Care Cordinator) I'm too tired when asked to sign some papers. Observed by me to be very diaphoretic at 11:30 but was breathing regularly with 18 respirations a minute. The resident's vital signs were recorded as being: T 98.4, P 96, R18, BP 150/90 and Oxygen levels were 96% on room air. The resident's face was flushed and her blood sugar was 168. The LN documented at 12:50 pm the caregivers changed the resident's bed because she was wet from sweat and also incontinent of urine. The resident was lying with her eyes closed and not responsive to speech. Her vitals sign were: T 95, R18, BP 154/92 and oxygen 95%. The LN asked the ARNP (Nurse Practitioner) to evaluate the resident. Her pupils were not responsive and 911 was called. The ARNP who examined the resident documented The staff reported a noted decline in her cognition since 8:00 A.M. She is seen at noon, her linens are being changed due to profuse diaphoresis. Blood sugar was checked with a result. Vital signs are normal, afebrile (no fever). She was unresponsive to painful stimuli. her skin was very warm to touch and diaphoretic. Her pupils were 7mm, equal, non reactive to light. She is pale, no air movement noted, with shallow agonal breathing, frothy white sputum noted. Due to her presentation and code status of full code I alerted the nursing staff to ready the crash cart and call 911. Her pulses were diminished to her peripherals. no facial droop noted. left hand in cortical position, however she has left sided deficit from her prior [MEDICAL CONDITION]. Assessment and Plan: possibly having a new event of [MEDICAL CONDITIONS] high risk for blood clot, or acute [MEDICAL CONDITION] will send to ER. A physician summary note dated 02/02/16 noted the reason for the admission was Severe [MEDICAL CONDITION] (disease or disorder of the brain) without gag reflex and high risk [MEDICAL CONDITION]. The patient had toxic [MEDICAL CONDITION] secondary to [MEDICATION NAME] overdose. The patient unfortunately with this severe [MEDICAL CONDITION] and inability to protect airway had to be intubated. In an investigation from the facility dated 01/27/16 it was noted to be an allegation of a medication error. Documentation showed that on 01/26/16 the Resident was noted to have her eyes closed and she was unresponsive. The ARNP was in the facility and was told of the change in condition and ordered the resident to be sent to the hospital. On 01/27/16 the facility received a call from the doctor at the hospital and was asked about a medication order. The order from the hospital read [MEDICATION NAME] (a muscle relaxant) 10mg give 5 tablets po (by mouth) BID (twice a day). The Doctor explained to the nurse the order should have been 5mg po BID. The Doctor asked how many doses the resident received, the resident received 2 doses of 5 - 10mg tablets. The resident received 100mg of Bacolfen in approximately 8 hours. The investigation goes on to state the forms received from the hospital prior to the arrival of a new admission was the outpatient medication profile and copies of the hard prescriptions for medications. The purpose of receiving this paperwork is so the medications can checked, put into our system and the orders can be sent to the pharmacy. The investigation also included a note from the ARNP dated 01/29/16, where it noted current orders for Bacolfen 20mg three times a day when necessary for muscle spasms. A review of the Medication Administration Records (MAR) from December 2015 and January 2016 showed an order for [REDACTED]. The investigation did not include the names of the nurses who gave the resident the medication. In an interview on 02/10/16 at 12:00 P.M., with the Director of Nursing (DNS) and the Corportate Nurse were asked about paperwork from the hospital and access to the hospital's computer system. The facility had access to hospital records and dictation but it may not be available immediately. Two nurses check the orders before the resident arrives. The doctor or the ARNP come in the next day or the next scheduled visit day to review the orders. In an interview on 02/12/16 at 9:20 A.M., with the Director of Nursing in which clarification of the double check process was given. The nurses are to check old orders with the new orders and make changes as needed. The new orders are sent to the pharmacy where they review them and can call the physician for clarification. The DNS was not aware of any clarification performed by the pharmacy. Night shift also checked the charts and signed a sheet as a form of verification. Clarification on the medication error investigation was needed because it was incomplete. In the hospital Discharge Summary the Medications were decreased was [MEDICATION NAME] 5 mg by mouth twice a day. If the discharge summary had been reviewed and the proper dosing of the medication was known by the staff the order should have been questioned and verified with the physician. Two nurses and the pharmacy did not see the order was a high dose for an adult and even more concerning for an elderly resident. The previous order had the Resident receiving 40mg of [MEDICATION NAME] per day as needed, not a scheduled dose. The new order as written was to give the resident 100mg a day as a scheduled dose. There is a difference in these orders that should have been noted by the nurses who checked the orders and the pharmacy who filled the order. The nurse who gave the medication has a professional obligation to ensure the resident is getting the appropriate medication and the correct dose of the specific medicaiton. This medication error caused harm to the Resident of [MEDICAL CONDITION] and an extended hospitalization . RESIDENT 27 Resident 27 was re-admitted to the facility on [DATE]. Review of the physician orders [REDACTED]. Review of the hospital transfer orders directed staff to hold the [MEDICATION NAME] until the next scheduled lab draw on 02/02/16. Review of the lab draw on 02/02/16 indicated the resident's INR (an INR is a blood test to check how fast the blood clots. A normal INR is between 2-3) was 1.4. The resident's INR goal was between 2 and 3. The anticoagulation clinic ordered specific doses of [MEDICATION NAME] to be given on February 2, 3, 4th and to recheck the INR on 02/05/16. Review of the physician orders [REDACTED]. A telephone order was obtained on 02/05/16 with directions to give [MEDICATION NAME] on February 5th, 6th, and to have the INR level checked on 02/07/16. Review of the anticoagulation clinic orders on 02/08/16, indicated the residents INR was 1.3 on 02/7/16 and gave specific orders for the [MEDICATION NAME] dosing. This order was not processed until 02/09/16. Review of the nursing progress notes revealed the LN did not document the physician was notified on 02/07/16 after the INR level was drawn to obtain new orders. In fact, the resident missed an additional two doses of the [MEDICATION NAME] (which was on the 7th , 8th and 9th). There was no documentation in the resident medical record indicating a medication error occurred. Additionally, the resident was not placed on alert to monitor for possible side effects to the increase in [MEDICATION NAME] and/or assessed for possible [MEDICAL CONDITION]'s. This is the second medication error related to the [MEDICATION NAME] in the last 10 days. Review of the facility medication error report, dated 02/05/16, stated the resident had missed the [MEDICATION NAME] due to the order not being transcribed on February 2nd. The action taken to prevent reoccurrence was to educate the LN to ensure all INR orders are processed upon receipt. In an interview on 02/10/16 at 10:25 AM, Staff C, LN, stated the facility policy was when a resident was admitted the orders would be transcribed and double checked by two LN's. Both LN's would initial the orders. All telephone orders and faxes received were also doubled checked by two LN's to ensure accuracy. Staff C stated if she received an order that she questioned, due to possible large dosage or incorrect route, she would not give the medication and call the physician for clarification. In a telephone interview on 02/12/16 at 12:35 PM, the Director of Nursing Services (DNS) was made aware the resident missed [MEDICATION NAME] on the above dates. The DNS was not aware this error had occured.

Based on interview, observation and record review the facility failed to ensure a newly diagnosed parapalegic with a history of left ankle fracture was monitored for proper body alignment and secured in a wheel chair to ensure stability to prevent an accident for 1 of 1 residents reviewed for accidents (1). Failure to prevent an accident resulted in hospitalization and a [DIAGNOSES REDACTED]. Findings Include: RESIDENT 1 Resident 1 was admitted in October 2015 with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] noted the resident required 2 person physical assistance for bed mobility, transfers and toileting. The MDS noted an impairment for both lower extremities requiring use of a wheelchair with foot rests for stability and for mobility. The MDS noted the resident had no cognitive deficits. On 01/07/16 at 2:30 P.M., the resident was interviewed. Resident 1 was in a electric wheelchair with a large ace wrap and a splint on the left leg. The wheelchair had leg supports so the residents legs would not move off the wheelchair base. The resident had a brace on her right leg. The resident was asked about her injury to her left leg. The Resident stated, I had a back surgery and ended up with no use of my legs, I also have no feeling in them. I use to walk with a walker at home. In December, I had an incident when my leg fell off the chair and I didn't even feel it. I was dragging it behind me and I am not sure if the wheel hit it or not. The aide helped me and I told the therapist about it. I have had times when I noticed my leg fell off the bottom of the wheelchair and I tried to put my leg back up on the chair but it is hard to do by myself. I can use my arms, but this is all new to me. My leg swelled up and they didn't know why it was swollen, it took a long time to find out it was fractured and then I had to go to the hospital again. Since I have no feeling, I depended on them to watch and make sure I am ok. The Resident was asked if the leg supports were on at the time of the incident, No they did all this after they found the fracture. In an incident investigation dated 12/26/15 it stated on 12/08/15 at approximately 3:15 PM, Staff A reported to a Physical Therapy Assistant (PTA), that the resident's foot had slipped off her foot rest and that she was unable to place her foot back on the foot rest herself. Staff B, Nursing Assistant Certified (NAC) had seen the resident come out of her room and noticed her left foot had come off the foot rest. Staff B, NAC, reported it to the Licensed Nurse (LN). On 12/10/15 Staff C, LN documented during the evening shift the resident's left lower extremity was warm and red. Staff C, LN, notified the physician on call and was told to wait for the physician's visit the next day. On 12/11/15 Staff C, LN, asked Staff D, Physicial Therapist (PT), to come and evaluate the residents left lower leg. There was no significant increase on patient's Left ankle edema. The ARNP saw the resident as well and reported no deformities to the lower extremities, but no x-ray was ordered. On 12/26/15 Staff E, LN, noted the resident's left lower extremity had weeping edema. The physican was called and orders were received for dressing to the lower left extremity. At 6:30 P.M., Staff F, PTA, expressed concern related to the alignnment of the lower left extremity. The PTA told Staff G, LN, and the physician was called and an order for [REDACTED]. The resident had a [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] until her return on 12/30/15. The findings of the investigation was it was reasonably related to the condition/event listed was osteoporesis, [DIAGNOSES REDACTED], and history of fracture. Abuse and neglect were ruled out. In an interview on 01/06/16 at 3:10 P.M., with the resident's sister, she stated I told them staff to look at my sister's leg 2 weeks ago and they did not follow through. I still haven't heard back from them about the investigation. It was not until they moved her to another unit they noticed her leg looked strange. The Residents's sister verified the physician at the hospital said the fracture was at least 2 weeks old. It was not an acute fracture. On 01/07/16 at 10:30 A.M., an interview with Staff D, PT, stated because the resident's legs were flacid (limp) and had no muscle tone the legs would naturally invert. Staff D denied use of any devise to keep the resident's legs on the footrest prior to the fracture. Staff D also reported they tried an ankle support, but it was too big for the resident and offered no support. In an interview on 01/12/16 at 11:00 A.M., with Staff B, NAC, who witnessed the residents foot fall off the wheelchair. I saw the resident come out of her room in her electric wheelchair and she was driving along when I saw her left foot literally dragging behind her off the footrest. The top of her foot was bent down touching the floor and definately dragging. It was near the wheel of the wheelchair and since the resident cannot feel pain she did not seem to notice what was happening. I stopped her and repositioned the foot onto the foot rest. I told the nurse and I talked to the therapist about it. I wrote a statement about it after they found out she had a fracture, not before. It was hard to remember the details of dates, times and who I told about it since it was so long ago. In an interview on 01/12/16 at 11:30 A.M., with Staff A, PTA, she stated, I did see Staff B, NAC the day of the incident and he looked concerned enough that I went to see the resident. I checked to see her feet were on the foot rest. Before I left, I spoke to the nurse and the NAC about it so it was known to all of us. Staff A confirmed the resident used a leg lift to assist her in lifting her legs, but it is used only during therapy sessions. Staff A also confirmed the resident's sister said she had a brace/ankle support for her left foot to aide in stability, I kept asking the resident to tell her sister to bring it in so we could use it, but the resident was forgetful. She does wear a brace on the right leg. She also confirmed there were no devices used to maintain the resident's legs on the footplate of the wheelchair prior to the fracture. Staff A also confirmed she did not contact the family member about the ankle support/brace for the left leg. Staff A wrote a statment dated 01/08/16 about the incident on 12/08/15 stating the resident had always required total assist for foot placement and it appeared to be an isolated incident. A review of the record revealed there was no documented nursing assessment on 12/08/15 when the NAC witnessed the resident dragging her foot behind her. There was no documentation of the incident as described by Staff B, NAC. Nursing documentation on 12/10/15 stated Left leg appears increased swelling, redness and warmth, right leg is cool, normal color contacted on call doctor orders are to wait for doctor visit that occurs tomorrow. Left leg appears unsupported, ace wrap applied. 24 Hour Report -Alert Charting Log an entry dated for 12/11 right leg appears not right. Monitor for redness, s/s of infection. (This has the staff monitoring the incorrect leg) The documentation noted swelling and warmth to left leg documented until the 12/14/15. No further documentation noted assessment of the leg. On 12/26/15 at 4:00 P.M., the resident has left leg weeping edema, physician contacted, dressings ordered to be seen by physician on next visit. On 12/26/15 at 9:30 P.M., PTA reported to this Licensed Nurse (LN), no structure to the left lower extremity, redness, warmth and foot drop noted. Physician contacted, x-ray ordered. Complete fracture of left tibula and fibula. In an interview on 01/12/16 at 11:40 A.M., with the Nurse Practioner (ARNP), she confirmed I saw the resident only once for the reddened leg and I asked the staff what had happened and they could not tell me anything. I did not see the resident on the 26th, it was a telephone order. The History and Physical notes from the ARNP dated 12/11/15 stated, She does have lower leg edema and is currently wearing TEDS. The exam on the extremitites stated, no deformities, strength, tone and muscle mass are abnormal. The note also stated She is now not having any current issues. Yet, the nurses documented for several day the redness, edema and warmth of the left lower extremity continued. No new orders were written for the lower extremity on the ARNP's visit on 12/11/15. The Resident's care plan had interventions dated 12/28/15- velcro straps to feet and foot when up in chair. Binder around thighs to eliminate bowing of legs. Leg supports on wheelchair was dated 01/05/15. The Resident received PT daily in the month of December prior to her hospitalization . A review of Physical Therapy notes from 12/01/15 to 12/30/15 revealed: 12/08/15- Nursing reported the resident had an incident Sunday morning (12/06) where pt's foot slipped off foot rest and pt unable to place foot back on foot rest. Pt stated she was aware that her foot slipped off and that she pushed her call light for assistance. 12/09/15- total assist for foot placement. 12/11/15- called on PT to check on patients left ankle. No bruising, discoloration, no significant increase or change in edema observed. 12/13, 12/14, 12/15, 12/17, 12/25- total assist for bilateral foot placement during slide board transfer, or when using power wheelchair was noted in the documentation. 12/22/15- Trialed Left ankle soft brace for support during transfers, however, brace available was ill fitting. Instructed pt to ask sister to bring Left ankle brace in for added ankle support per consultation with PT for decreased laxity in ankle stability. A progress note from Staff G, Occupational Therapist (OT) dated 12/26/15 at 11:06 A.M., stated Pt noted Left ankle inversion in w/c and OT secured foot/ankle in alignment with a velcro strap. In an interview on 01/07/16 at 11:00 A.M., with Staff G, OT who stated the day 12/26/15, he secured the residents foot he just saw the ankle didn't look right and she had her teds on and he secured her ankle. It was something we were trying to stabalize her foot since her ankle inverted. The Orthopedic Surgeon's documentation dated 12/27/15 stated, She noticed something about her foot about 3 weeks ago, but did not notice any deformity. Her sister noticed about 10 days ago that there was some deformity developing in the ankle region and swelling. The documentation also stated The fibula is broken just above a previously placed plate and screws. There appears to be some calcification around fragments, rounding of the fracture edges suggesting it is not acute. The Hospital Discharge Documentation dated 12/30/15 stated, She had been run over by a wheelchair 3 weeks earlier and the family noted some swelling and malangulation of the left lower leg. On 12/29 she underwent a closed reduction with an application padded Jones type splint. On 01/12/16 at 10:20 A.M., the resident was seen in therapy driving her wheelchair in an obstacle coarse of cones and she had to drive in between without hitting them. The Resident would announce when she hit a cone. In an interview on 01/12/16 at 12:30 P.M., with the Interium Director of Nursing Services (DNS), she clarified it is the expectation of every nurse in the facility to immediately assess a resident who had been potentially injured, place them on alert, notify the DNS, family and physician, and write a statement. The DNS confirmed there was no documented assessment of the resident's foot and there was no documentation in the record to reflect an incident had taken place. The DNS also confirmed, there were also no preventative measures in place to keep the resident's foot on the foot rest of the wheelchair to prevent injury. Statements of the incident were started on 12/26/15, so staff could not remember important details. The staff failed to follow facility policy per the DNS. In addition, the facility provided information on 01/15/16, which changed the date of the incident to 12/06/15. There was also no documented nursing assessment of the resident's foot on this date and no mention of the incident in the record.

Based on observation, interview and record review the facility failed to prevent multiple falls for 1 of 2 sampled residents (2). Failure to prevent accidents for Resident 2 resulted in hospitalization , surgery and two fractures. The facility also failed to provide supervision to 1 of 2 sampled residents (3). This failure resulted in an elopement from the facility. These failures placed the residents at risk for injury, discomfort, and/or potential health complications. Resident 2 Resident 2 was admitted [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), an assessment, dated 6/30/15 noted the resident was a 2 person assist for care and was severely cognitively impaired. On 6/4/15 at 2:45 P.M., the resident attempted to ambulate to the bathroom and fell resulting in a 1.0 cm x 0.4 cm laceration on her forehead. Staff D, Licensed Nurse (LN), had the doctor look at the lacerations. The LN then asked Staff C, Cerified Nursing Assistant (CNA) to stay with the resident. At 3:10 P.M., the resident was found on the floor incontinent of bowel. Per the progress notes the resident was unable to straighen her right leg. Physician orders [REDACTED]. The resident was sent to the hospital. The Fall Risk Care Plan had an approach plan to remind the resident frequently to use the call light for assistance. Offer toileting frequently to assist with decreased falls dated 6/4/15. The resident returned on 6/9/15 to the facility with a dressing over the surgical site. The resident was non weight bearing. The progress notes dated 6/10/15 at 10:00 P.M., indicated the resident was found in bed with her legs dangling over the edge of the bed, the resident reported I am waiting for my ride to go home. Documented on a facility investigation dated 6/11/15 at 6:15 A.M., the LN heard a thump and Resident 2 was found on the floor. X-rays of right ankle revealed a displaced fracture of the right tibia requiring a second surgery for [REDACTED]. On 6/13/15 the resident returned to the facility with interventions documented in the nursing progress notes that the resident was moved closer to the nurse's station. A staff inservice dated 6/16/15 indicated the resident was to have a bed on the floor with a mat beside it. The care guide also dated 6/16/15 documented Resident 2 was to have a low bed and a mat on the floor. There were two different interventions and no assessment if either were going to prevent falls. In an interview on 7/7/15 at 1:10 P.M., Staff E, Residential Care Manager (RCM), stated during the first fall, Staff C, CNA, was instructed by the LN to stay with the resident. The aide did not follow directions and left the room to get the blood spill kit to clean up the blood on the floor. Staff C told the resident she would be right back and the resident fell again. After the second fall the bed was lowered, placed against the wall and a mat was on the floor. The RCM also verified there had been an inservice to educate the staff on checking the residents frequently and what that specifically meant. The resident was unable to be interviewed. The resident was observed to be resting in bed on all three days of observations. Resident 3 Resident 3 was admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment stated the resident was cognitively intact. In a statement dated 6/22/15 at 5:45 P.M., Staff F LN, a housekeeper reported to staff the resident was across the street from the facility. When staff went to the resident he reported he had removed his wanderguard and that he wanted something to eat so he was going into town. The facility investigation did not state how long the resident was gone from the facility. The analysis of information stated the resident was wheelchair dependent, could stand independently but was unable to walk independently. The resident would frequently exit seek, request to go home or to the MD, etc. The Care Plan for Wandering dated 5/8/15 indicated the resident was at risk of injury related to his wandering behavior, confusion, frustration, and was independent with his mobility when in his wheelchair. In addition the resident was unaware of safety. In an interview on 7/6/15 at 12:00 P.M., the resident reported he was in a world of hurt. He was being held prisoner here, can you believe this could happen in America? He admited to taking off his wanderguard and leaving because he had business to attend to and they were keeping me here. He wanted to go into town to have dinner. The resident moved in his wheelchair around the room without difficulty. The resident repeatedly made statements of wanting to leave the facility and had businness he needed to complete. In an interview on 7/8/15 at 11:00 A.M., the Director of Nursing Services (DNS), was shown the investigation and the lack of a timeframe for how long the resident was gone out of the facility. The DNS could not state how long the resident was out of the facility.

Based on interview, observation and record review the facility failed to ensure 5 of 5 sampled residents (Residents 1, 2, 3, 4 & 5) were free of significant medication errors. Failure to administer the correct medications as ordered by a physician resulted in harm to Resident 1 and required hospitalization . The facility also failed to transcribe new medication orders correctly for Residents 2, 3, 4 & 5 which resulted in medication errors and left residents at risk for health complications. Findings Include: The EmpRes Medication Administration Policy stated During Medication Pass the nurse completes the following: 1. The nurse reviews each resident's MAR (medication administration record) or TAR (treatment administration record) for ordered medications. 2. At no time is the nurse allowed to pre-pour or pre-chart the ordered medications. 3. At no time does the nurse borrow medications. 4. Medications are not left at the bedside for the resident to take later. 5. The nurse follows the 5 Rights of Medication Administration: Right person, Right medication, Right dose, Right time, Right route. Completion of new order-the nurse writes the medication order completely on the MAR indicated [REDACTED]. RESIDENT 1 Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 04/08/15 reported the resident was absent of spoken word and had moderately impaired vision. The resident had functional limitations of both upper and lower limbs requiring total dependence on staff to perform all activities of daily living. The resident was also fed through a feeding tube in her abdomen. On 5/17/15 at 8:00 P.M., Resident 1 was given her evening medications through the feeding tube. Staff A, Licensed Nurse (LN) gave the resident Risperidol (an antipsychotic) [MEDICATION NAME] (an antipsychotic), [MEDICATION NAME] (an antianxiety), [MEDICATION NAME] (an anti-ulcer), and [MEDICATION NAME] (an [MEDICATION NAME]). The Facility's Medication Error/Adverse Drug Reaction Report dated 05/17/15 stated Staff A, LN gave the resident medications through the feeding tube and realized immediately after giving the medications, she had given the resident the wrong medications. The nurse drew back on the syringe and removed the contents of the resident's stomach and then flushed with water. The nurse monitored the resident and at 8:30 P.M., the resident was noted to be unresponsive. The resident was sent to the hospital where she was admitted to Intensive Care Unit. The nurse admitted to pre-pouring medications and labeling them with initials of the two different residents. Staff A, LN, gave Resident 1 medications meant for another resident, who had a [DIAGNOSES REDACTED]. The summary from the hospital reports the resident was admitted unresponsive and hypotensive (low blood pressure) related to the accidental overdose. The resident was given IV fluids and was monitored closely for lethal cardiac arrhythmias (irregular heart beats). The resident spent two days in the hospital from the overdose. The resident returned to the facility on [DATE]. On 06/03/15 at 11:00 A.M., the resident was in bed and was able to answer to yes and no questions by nodding her head. The resident reported she was feeling well by nodding yes. The resident also nodded yes to the question about being in the hospital. Then she nodded yes to the question were you scared when it happened. The resident then closed her eyes and would no longer nod to questions. RESIDENT 2 Resident 2 had a [DIAGNOSES REDACTED]. The Medication Error/Adverse Drug Reaction Report dated 4/28/15 stated [MEDICATION NAME] increased to 10 units at bedtime but was transcribed on MAR indicated [REDACTED]. The resident received 2 doses of [MEDICATION NAME] on 04/27/15. In an interview on 6/3/15 at 12:00 P.M., the Director of Nursing Services (DNS) reported that the order did look like QID and it was transcribed and was not questioned by staff. RESIDENT 3 Resident 3 was receiving [MEDICATION NAME] (a blood thinner) for a [DIAGNOSES REDACTED]. In an interview on 6/3/15 at 12:00 P.M., the DNS verified the order was missed and noted by the Anticoagulation clinic which monitors the resident's blood levels for [MEDICATION NAME]. They noticed his levels were decreasing and the clinic called and asked if we were missing doses. RESIDENT 4 Resident 4 had a [DIAGNOSES REDACTED]. An order was given and the staff failed to follow up on any new orders. The Medication Error/Adverse Drug Reaction Report dated 5/6/15 stated the error was discovered when a paper was found in the resident's pocket with the new orders. The resident remained on [MEDICATION NAME] (an antiarrthymic), a medication the doctor had ordered discontinued. The resident received 27 doses of a discontinued medication. On 6/3/15 at 12:00 P.M., the DNS verified the order was missed because the staff did not follow up to see if any orders were sent with the resident nor did they call the physician's office to see if orders had changed. RESIDENT 5 Resident 5 had a [DIAGNOSES REDACTED]. The Medication Error/Adverse Drug Reaction Report dated 5/20/15 stated [MEDICATION NAME] (a diuretic) was given everyday 5/15 through 5/20 in error. The medication should have been given Monday, Wednesday and Friday, not everyday. The resident received 3 additional doses. The report stated the error did not have any effect on the residents weight loss. On 6/3/15 at 12:00 P.M., the DNS verified the resident was loosing weight as part of his treatment plan he had [MEDICAL CONDITION] and it decreased prior to the medication error. The DNS further verified that different nurses were involved in the medication errors and one error had caused a resident to be hospitalized and others to have medication errors that potentially could have resulted in injury to the residents. The licensed nurses named in the medication error reports received verbal counceling for the errors. Record review for Resident 2, 3, 4 and 5 were not found to have had any documented adverse effects from the medication errors but the potential for injury was present as a result of licensed nurses not following the facility's policy for medication administration.

Based on interview, observation and record review the facility failed to prevent an accident for 2 of 6 residents (Resident 1 & 2) reviewed for accidents. Failure to consistently follow facility policy for hot beverages resulted in harm of a second degree burn for Resident 1 and placed other resident's at risk for injury. The facility also failed to develop policies and educate staff on the correct use of Hoyer lifts for Resident 2. Failure to have a policy and education for use of a Hoyer lift resulted in harm of a fall with a subdural hematoma for Resident 2 and placed other residents at risk for injury. Findings Include: BURN The EmpRes Healthcare Hot Beverages Policy stated Dietary staff checks and documents on a temperature log the hot beverage temperature per meal just prior to the hot beverages leaving the kitchen. The Policy further stated, The temperature of the hot beverage at resident contact should NOT exceed 150 F. Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool, dated 04/10/15, revealed the Resident needed supervision when eating and required set up for meals. Supervision during eating was a change from previous assessments. The resident had moderate cognitive impairment. The resident was also noted to have functional impairments on both sides of both upper and lower extremities. The investigation stated on 04/29/15 at 8:00 P.M., the resident was in the hallway and yelled for help. The nurse on the opposite end of the hallway ran to the resident to find the resident had spilled a cup of tea on her chest. The resident reported, I spilt my tea on myself and it hurts. On 05/01/15 at 10:00 A.M., the area was observed with the Director of Nursing Services (DNS). The outer aspect of the resident's left breast was red and there was a fluid filled blister measuring 4 cm x 2 cm. The resident received a second degree burn from the incident. In an interview on 05/01/15 at 7:20 A.M., Resident 1 reported she spilled tea on herself but could not remember when, she stated it did hurt, but felt a bit better now. Observations on 05/01/15 of the resident at breakfast and lunch revealed the resident was left handed. Both of the residents hands were contracted by arthritis, the left more severely than the right. The resident leaned forward, used her left hand to put two fingers around the handle of a coffee cup and then used two fingers from her right hand underneath the cup to lift it to her mouth. Observations on 05/01/15 at 7:30 A.M., the facility served coffee and tea on three different hallways to be given to the residents at their request. Temperatures were taken of all hot water and coffee on the three units. The temperatures for hot water ranged from 160 to 176 degrees and the coffee ranged from 158 to 162 degrees. A review of the kitchen temperature logs from February 3 to April 30 revealed temperatures of hot beverages were to be taken at breakfast, lunch and dinner. Over an 87 day period there should be 261 temperatures recorded. The coffee was recorded 18 times and hot water was recorded 17 times. In an interview on 05/01/15 at 9:10 A.M., Staff A, Dietary manager, reviewed the log and reported the temperatures were to be taken prior to the hot beverages leaving the kitchen but it was not being done. Staff A was informed of the temperatures of the hot beverages on the unit and reported that is too hot. Staff A was aware the policy for hot beverage temperatures was 150 degrees. In an interview on 05/01/15 at 10:00 A.M., the DNS stated the coffee and tea was placed on the unit at 7:00 A.M. The DNS reported Resident 1 was moved to supervised dining room related to intermittent sickness, falling asleep at meals, and needing help cutting food. The DNS confirmed Resident 1 had not been assessed for safety with hot beverages despite being changed to a supervised dining. HOYER TRANSFER WITH FALL Resident 2 was admitted to the facility May 2014 with [DIAGNOSES REDACTED]. Resident 2 required using a Hoyer (mechanical device) lift for transfers. Review of the facility investigation, dated 04/18/15, revealed the Resident fell from the Hoyer sling while being transferred by Staff D and E, Certified Nursing Assistants (CNA). The right upper loop of the sling disconnected from the Hoyer hanger rod. Resident 2 fell out of the Hoyer sling hitting his head on the floor. The Resident was sent to the emergency department and was diagnosed with [REDACTED]. The facility concluded a possible explanation for the fall was the sling was not properly placed on the mechanical lift hook. In an interview at 10:00 AM, the Executive Director (ED) and DNS stated the facility did not have a Hoyer/mechanical lift transfer policy. The DNS was asked how the direct care staff knew what type of Hoyer sling resident's used. The DNS replied this information was not documented on the care plan or on the care directive. In addition they stated that staff was not educated on the appropriate size sling used for each individual resident. In an interview on 05/06/15 at 11:03 AM, Resident 2 stated they dropped me when asked how he fell . The resident was not able to state how the fall occurred but did remember hitting his head when he fell . Resident 2 stated he had suffered from occasional headaches after the fall. In an interview at 2:05 PM, the ED and DNS was asked how the facility ensured CNA's properly transferred residents using a Hoyer lift. The DNS stated CNA's were only observed performing a Hoyer transfer during their orientation (when hired). There was no annual skills check done at this time. Furthermore, the DNS confirmed there was no additional training done after Resident 2 fell to ensure CNA's were correctly using a Hoyer lift.

Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents (3) was free of significant medication errors. Failure to administer the correct physician-ordered frequency of medication for Resident 3 resulted in treatment and hospitalization for abnormalities in blood counts. Findings include: Resident 3 was admitted to the facility with [DIAGNOSES REDACTED]. On 6/17/14, the resident was seen by a specialist who noted the resident's complete blood count was normal, including the white blood cell count and platelets. The physician recommended Resident 3 be started on a new medication ([MEDICATION NAME]*) at very small doses and very regular lab monitoring. The 6/17/14 physician order [REDACTED]. 2 tabs po (oral) daily each week. Take in evening w/(with) small snack. The order was transcribed onto a physician order [REDACTED]. On 6/21/14, a nurse noted the order and transcribed the order onto the medication flow sheet as follows: [MEDICATION NAME] 2.5 mg 2 tabs PO (with) snack QHS (at bedtime). There was no documentation indicating any attempts on 6/17/14 or 6/21/14 by nursing to clarify the medication order's frequency (daily versus weekly) with the physician. During an interview with the Director of Nursing on 7/30/14 at 2:30 p.m., she stated the nurses who transcribed the order did not attempt to clarify the order prior to transcription. Review of the medication flow sheet indicated the resident received a dose of [MEDICATION NAME] on 6/21, 6/22, 6/23, and 6/24/14. (Per the original physician order, Resident 3 was to receive 5 mg of [MEDICATION NAME] once a week, but received 5 mg daily for 4 days.) On 6/27/14, a nurse re-wrote the [MEDICATION NAME] order onto the medication flow sheet to be given q(every) week(Tuesday) with a sticky note indicating the next dose was due on 7/1/14. A fax sent to the specialist, dated 6/27/14 at 11:30 p.m., indicated the resident had received [MEDICATION NAME] QHS until 6/24/14, the order was corrected, and the resident placed on alert for any adverse side effects. During an interview with the Director of Nursing on 7/30/14 at 2:30 p.m., she said the facility notified the physicians about the medication transcription error on 6/27/14, but she did not recall if there were responses received from the physicians related to the notification. On 7/1/14, the resident went to an infusion center for a routine treatment related to chronic [MEDICAL CONDITION] & kidney disease. The facility was notified by the center that Resident 3 had abnormal blood laboratory values indicating the white blood cell (cells that help fight infection), platelet, and [DIAGNOSES REDACTED] counts were at critical levels. The resident was evaluated by a medical practitioner who also discussed the lab results with the specialist, and then ordered a medication, Leucovorin. (According to a health information website (www.nlm.nih.gov/medlineplus/druginfo <http://www.nlm.nih.gov/medlineplus/druginfo>), Leucovorin is a medication used to prevent harmful effects of [MEDICATION NAME] and is also used to treat patients who have accidentally received an overdose of [MEDICATION NAME].) The resident received Leucovorin on 7/1/14 and 7/2/14, and was placed in reverse isolation (a protective measure to prevent transmitting infection to the patient). A medical practitioner note of 7/3/14 revealed , .followup of (severe [MEDICAL CONDITION]), rescue therapy with leucovorin recommended per (specialist) .in setting of [MEDICATION NAME] therapy. The note indicated Resident 3's white blood cell count had improved, however platelets were severely decreased and the resident also had a critically high blood level related to a lessened ability for blood clotting. The resident was then required a dose of Vitamin K to help with blood clotting/prevent excessive bleeding, and then was sent to the hospital for ongoing assessment and management of the abnormal platelet count and blood clotting level. Resident 3 was admitted to the hospital on [DATE] through 7/8/14. The hospital Discharge Summary indicated the medication [MEDICATION NAME] was discontinued due to toxicity. The final discharge [DIAGNOSES REDACTED]. *Per the American College of Rheumatology 2012 (www.rheumatology.org/practice/Patients/Medications), [MEDICATION NAME] is a commonly used medication for [MEDICAL CONDITION] arthritis, as well psoriasis and [MEDICAL CONDITION]. It is typically prescribed to be taken at one dose, once a week and it is important to take the medication exactly as directed. Side effects can include nausea, vomiting, mouth sores, and abnormalities in blood counts.