Every finding on record at Aurora Valley Care

Based on observation, interview, and record review, the facility failed to ensure swallow interventions were developed and implemented for 1 of 3 residents (Resident 1). This failure placed residents at risk for inconsistent implementation of care and services from staff, poor oral intake, poor nutrition and potential harm.Findings included . Review of the facility census showed Resident 1's first admitted to the facility, from a local hospital, on 04/02/2026. Further review showed they were re-admitted to the same hospital on [DATE] and returned to the facility on [DATE] with new orders, dated 04/19/2026 at 4:34 PM, for aspiration precautions (measures taken to prevent inhalation of food, liquids, or other substances into the airway, which can lead to choking or aspiration pneumonia. Aspiration occurs when these substances enter the airway instead of the esophagus, potentially causing serious respiratory issues). Under the discharge instructions was written, establish care with gastroenterology, recommend esophageal manometry (a diagnostic procedure that measures how well the esophagus is functioning) to further work up dysphagia (difficulty swallowing, which can range from mild discomfort to an inability to swallow food or liquids).Record review of a facility medical provider note, written by Staff C, Nurse Practitioner, on 04/24/2026, showed the resident required dysphagia precautions, with dysphagia management (severe esophageal dysmotility (impairment of the esophagus's ability to move food and liquid from the mouth to the stomach through coordinated muscular contractions), aspiration risk). In the same note Staff C wrote under the diagnosis of disease of esophagus, unspecified, that the resident had experienced dysphagia for 1.5 months and on 04/19/2026 an esophagram (a live-action X-ray used to evaluate the function and structure of the esophagus) showed severe dysmotility with symptomatic retention of barium tablet (a contrast used in medical imaging to help visualize the esophagus and stomach) suggesting stenosis (narrowing). Staff C went on to write that the resident required aspiration precautions and must be upright for all oral intake.Record review of Resident 1's order summary for 04/01/2026 through 05/31/2026, did not show any orders related to aspiration, swallowing or dysphagia precautions.Record review of Resident 1's care plan, dated 04/02/2026, with updates on 04/22/2026, did not show any focus or interventions related to swallowing difficulty, dysphagia or aspiration precautions.Further review of Resident 1's facility medical record, on 05/27/2026 at 10:32 AM, showed diagnoses of chronic respiratory failure (long-term condition where the lungs cannot maintain adequate oxygen levels or remove enough carbon dioxide from the lungs), disease of esophagus, unspecified (a problem with the tube that connects the throat to the stomach ), and mild cognitive impairment (manifests through memory loss, difficulty concentrating and changes in behavior).In an observation and interview on 05/27/2026 at 12:40 PM, Resident 1 was observed lying in bed with the head of their bed at about 45 degrees. Their partially finished lunch tray was on the bedside table next to them and their family member, Collateral Contact 1 (CC1), was in the room with them. Resident 1 stated during this interview they had experienced increasing difficulty swallowing, had gone to the hospital after they had first admitted to the facility, and had returned on swallow precautions. They further stated not all the facility staff seemed to be aware of these precautions. They stated they had to take small bites and could only take 1-2 pills at a time. Resident 1 stated if they failed to do this, they would feel the food/pills stuck in their throat, it would cause discomfort and then whatever they had swallowed would come back up into their throat and mouth.During the same interview, on 05/27/2026 at 12:40 PM, CC1 stated Resident 1 had been having increasing trouble swallowing and had gone to the hospital on [DATE]. They stated during that stay the resident had been on aspiration precautions which included: not having the head of the bed flat, sitting all the way upright for all food and liquids, taking small bites and chewing thoroughly, having foods cut up into bite size pieces and staff being present when the resident swallowed their pills as this was especially difficult for Resident 1. They further stated they had told the medical providers that staff did not seem to know about the swallow precautions on at least two occasions and nothing had changed. During an interview on 05/27/2026 at 1:27 PM, Staff D, Registered Nurse, stated they had worked with Resident 1 during their stay at the facility and were aware the resident had swallowing difficulty and had to be upright when they ate or took pills. Staff D stated they knew this because Resident 1 was very aware and the Resident and their family members had told them. Upon review of Resident 1's orders, Staff D reported they could not find any orders for aspiration/swallow precautions and there should be orders in place. They further stated a resident with swallow difficulties could potentially swallow food or fluid into their airway if they were not sitting upright when they ate and drank and this could cause an emergency situation. During an interview with Staff B, Director of Nursing, on 05/27/2026 at 1:50 PM, they reviewed Resident 1's medical chart and stated the resident had readmitted with the need for aspiration precautions. Staff B stated they did not see orders, any care plan focus or interventions or a corresponding diagnosis. Staff B further stated a resident on aspiration precautions would typically have orders to include sitting upright for all food/fluid/pill intake, along with any other resident specific orders. Staff B stated the failure to do this could cause the resident to swallow fluid/food into their airway and potentially cause aspiration pneumonia (a lung infection that occurs when food, fluid or vomit is inhaled into the lungs).During an interview with Staff A, Administrator, on 05/27/2026 at 2:00 PM, they stated the regular staff who entered diagnoses and associated care plan updates had been on leave during the time period Resident 1 was admitted and then re-admitted and there had been another staff filling in for them. Reference WAC 388-97-1060 (3)(h)

Based on observation and interview, the facility failed to maintain a clean and sanitary environment for 3 of 4 residents (Resident 2, 3 and 4). This failure placed residents at risk of lack of dignity, unmet care needs, and diminished quality of life.Findings included. <Resident 2>Review of Resident 2's electronic medical record on 04/01/2026, showed they admitted to the facility on [DATE] after they suffered a fracture of their right upper leg. Other diagnoses included a developmental disability with disorders of speech and language.During an interview on 04/01/2026 at 10:42 AM, with Collateral Contact 1 (CC1), who had provided support for Resident 2 during their stay in the facility, they stated they had been in the facility almost daily to provide support to Resident 2 as they were nonverbal. They further stated that each day they had been there, Resident 2's floors had been sticky and dirty. They stated they had pointed this out to nursing staff but had seen little improve.During an observation on 04/01/2026 at 1:03 PM, the floor was sticky, had black scuff marks in various locations, had some sticky clear red liquid spilled in droplets on the floor and some small pieces of paper towel, hair and dust scattered about the room. <Resident 3>Review of Resident 3's electronic medical record on 03/10/2026, showed they were admitted to the facility on [DATE]. Further review of the same record showed the resident was cognitively intact.During an interview on 04/01/2026 at 1:25 PM, Resident 3 stated that their bathroom floor was often dirty with dried urine and dirt. They stated the floor in their room had a hole in it that had been repaired with duct tape that was starting to peel away and they felt it was becoming a tripping hazard.During an observation on 04/01/2026 at 1:25 PM, the Resident's bathroom, shared with the room next door, was visualized with a bariatric commode (a chair for larger individuals that covers the toilet to allow for stability and ease of self-transfer on and off the toilet ) covering the toilet and almost touching the walls of the bathroom on each side. Under the commode, at the base of the toilet and under the toilet dried yellow urine stained with dirt, hair and other debris was observed from wall to wall. A strong foul odor was also present. Duct tape, approximately 3 by 6 inches, was observed in the middle of the floor with peeling edges and dirt adhered to it. Scuff marks and general small debris were also visualized throughout the floor in the room. The smell from the bathroom was also present in the resident's room.<Resident 4>Review of Resident 4's electronic medical record on 04/01/2026, showed they were admitted to the facility on [DATE]. Further review of the same record showed the resident was cognitively intact.During an interview on 04/01/2026 at 1:10 PM, Resident 4 stated that they shared a bathroom with the room next door and it was often dirty with dried urine and smelled bad. They further stated the floor in their room was cracked and was often dirty.During an observation on 04/01/2026 at 1:10 PM, the Resident's bathroom, shared with the room next door, was visualized with a bariatric commode covering the toilet and almost touching the walls of the bathroom on each side. Under the commode, at the base of the toilet and under the toilet dried yellow urine stained with dirt, hair and other debris was observed from wall to wall. A strong foul odor was also present. Further observation of the resident's room showed cracked flooring, with the visible cracks embedded with dirt, scuff marks and general small debris were also visualized throughout the floor in the room. The smell from the bathroom was also present in the resident's room.During an interview with Staff C and Staff D, Nursing Assistants, on 04/01/2026 at 12:15 PM they stated the housekeeping supervisor had been sick and there seemed to be a language barrier with some of the housekeeping staff. They stated they thought there was a misunderstanding and housekeeping thought the nursing staff should be cleaning up urine spills in the bathrooms.During an Interview with Staff A, Administrator, on 04/01/2026 at 2:30 PM, they stated that their expectation was that resident bathrooms and rooms would be cleaned, at least daily, or as needed to maintain a sanitary environment.Reference WAC 388-97-0880

Based on interviews and record review the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 residents (Resident 1). The failure to ensure medications were acquired and administered as ordered placed residents at risk for adverse events related to missed medications.Findings included . <Resident 1>Review of Resident 1's electronic medical record, on 03/11/2026, showed they admitted to the facility on [DATE] and had diagnoses of surgical repair of a fracture in their mid-spine, ankylosing spondylitis (chronic, inflammatory, autoimmune disease that causes arthritis in the spine) and chronic respiratory failure (a prolonged, often progressive inability of the respiratory system to maintain proper gas exchange). The same record showed Resident 1 was cognitively intact.In a telephone interview, on 03/26/2026 at 10:15 AM, Resident 1 stated their medical provider ordered medications were not available for several days after they admitted on [DATE].Review of Resident 1's Medication Administration Record (MAR) for February 2026 showed the following missed medications:Enoxaparin (an anticoagulant used to prevent blood clots after surgery) -missed 02/08/2026 and 02/09/2026 at 7:00 PM.Mirtazapine (an antidepressant medication) -missed 02/08/2026 at 7:00 PM.Cyclobenzaprine (a muscle relaxer used to prevent muscle spasms) -missed 02/08/2026 at 7:00 PM and 02/09/2026 at 6:00 AM.Pregabalin (a medication used to treat pain) -missed 02/08/2026 at 7:00 PM and 02/09/2026 at 7:00 AM.Sildenafil (a medication used to treat high blood pressure) -missed 02/08/2026 at 3:00 PM and 11:00 PM, 02/09/2026 at 7:00 AM.Butrans patch (a patch used to help with pain control) -missed 02/20/2026 at 12:00 PM.In an interview on 04/01/2026 at 1:45 PM, Staff B, Director of Nursing, stated the facility had a new pharmacy, their services had been good, and they were not sure why Resident 1 had missed medications when they first admitted . They further stated the expectation was that resident specific medications, ordered by a medical provider, should be available to be administered the same day a resident admits to the facility. Reference: (WAC) 388-97-1300 (1)(a)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to provide an adequate supply of bed linens, gowns, towels and washcloths to ensure residents were maintained in a clean, comfortable, dignified manner for 15 of 15 sampled residents (Residents 4, 12, 63, 72, 77, 29, 48, 21, 31, 34, 38, 46, 19, 27, and 43 ) reviewed for safe, clean, homelike environment. In addition, the facility failure to ensure room temperatures for rooms 29 through 39 on the Southeast unit were at safe and comfortable levels. In addition, Resident 19 and 43's wheelchairs were not maintained in a clean manner. Those failures placed residents for potential decreased quality of life and care. <Resident Council> During a Resident Council meeting on 09/05/2025 at 10:58 AM to 12:08 PM when informed the previous three months of Resident Council minutes had been reviewed, attendees were asked if shortage of linen and/or missing clothing continued to be an issue, all residents (Resident 38, 21, 31, 34, and 46) replied in unison, “yes”. Resident 21 stated clothes don't come back from the laundry and Resident 46 stated there were afraid to sent a pillow and blanket to laundry for fear it would not be returned. Resident 38 stated it usually took a couple days for laundry to return, and they asked for linen when it first came back in order to have clean sheets. In an interview on 09/10/2025 at 9:20 AM, Staff AA, Nursing Assistant, stated there had been issues with linen running out and they did their best with what they had available. Staff AA stated the facility had changed to a new laundry service provider on 09/02/2025 and they were hoping it fixed the issues. When asked about missing personal clothing, Staff AA stated they were aware of this being an issue in the past, it was part of the problem with the other facility doing the laundry, but was not aware of any recent issues. In an observation and interview on 09/10/2025 at 3:59 PM, Staff J, Nursing Assistant, was observed at the linen supply cabinet on the Northwest Unit. Staff J stated there was no linen, nothing, and walked down the hall. <Resident 4> During an interview on 09/10/2025 at 9:29 AM, Resident 4 stated that the facility did not have enough bed linens. They reported at times they did not have a bottom sheet, or they had to use ones that were “slightly soiled”. Resident 4 stated that one time staff couldn't find a top sheet, so ended up using three pillowcases instead, one covering each leg and another across their front. They stated the facility started using a new laundry service, but they had not seen any improvement. <Resident 12> On 09/10/2025 at 9:28 AM, Resident 12 was observed lying in their bed, watching TV. Resident 12 stated they were still in bed because staff couldn't find a sling (fabric sling used with a mechanical lift) to get them up. Resident 12 further stated they liked being up in their wheelchair and were not happy about still being in bed. During an interview on 09/10/2025 at 10:33 AM, Staff Z, Nursing Assistant (NA) confirmed that the reason Resident 12 was still in bed was because they couldn't find a sling to get them up. Staff Z further reported that only few draw sheets and blankets were delivered, and low linen supply was an ongoing issue. Resident 12 was not observed out of their room on 09/10/2025 while the survey team was in the facility. <Resident 72> During a resident representative telephone interview on 09/09/2025 at 2:53 PM, Resident 72's representative stated that there were not enough linens. They stated that several days after the Resident's admission, Resident 72 went to the shower room to bathe. They requested towels so they could dry off and was given two hand towels. Resident 72's representative stated after that, they had to bring in bath-sized towels from their home for Resident 72 to use while they resided at the facility. <Resident 77> During an observation and interview on 09/03/2025 at 3:32 PM, Resident 77 was observed resting in their bed. They stated that for whatever reason, the facility frequently ran out of linens and gowns. Resident 77 stated the previous night at around midnight they accidentally spilled water on their bed and all there was to replace the fitted sheet was a flat sheet. The resident's mattress was observed to be uncovered from the waist up, and the flat sheet was loose, wrinkled and bunched up underneath them. Resident 77 stated that all the staff were able to find during the night and there were no sheets yet to replace the flat sheet. On 09/08/2025 at 11:37 AM, two men were observed distributing clean linens from a large rolling cart. The linen was wrapped in cellophane clear wrap in small bundles and included towels, washcloths, and bath blankets and sheets. They stated the facility just started laundry service with their company about one week prior and laundry was delivered to the facility twice weekly. They stated on their first delivery the par levels were too low and had to be increased for the next delivery. They noted that the supplier had been in discussions with the facility as it is estimated the facility needed three times the number of linens than they were currently allocated, which was part of why the facility ran out. They were unsure what services their company would be providing going forward. In an interview and observation on 09/08/2025 at 3:43 PM, Resident 77 was lying in bed. The resident stated they had no clothes and were told they were sent out to be washed. The resident stated they were kept in briefs because they had no gowns, no sheets and did not have a pillowcase for the pillow that was between their knees. In an observation and interview on 09/09/2025 at 11:44 AM, Resident 77 was lying in bed. Resident 77 stated they still did not have any clothes and were wearing a brief. In an interview and observation on 09/10/2025 at 9:35 AM, Resident 77 stated they still did not have any clothes and were wearing a brief. The resident stated they spoke to the nursing supervisor, and they were going to check on it, but they never heard back from them. In an interview on 09/11/2025 at 3:17 PM, Staff A, Administrator, stated they were aware there was a shortage of linens, and it had been a consistent issue. Staff A stated their sister facility had been doing their laundry for the past 25 years. Staff A stated they had complaint investigations due to lack of linen, and it had been subpar service. Staff A stated they have worked with corporate over the past two months to outsource their linen to alleviate concerns and stated it was a work in progress. Staff A stated the only way they would be sustainable was to bring laundry in house. When Staff A was asked how the lack of linens impacted the residents, they stated it posed a barrier for showers, a homelike environment and it was a dignity issue. On 09/04/2025, a review of the Resident Council minutes showed the following concerns were expressed: - on 07/28/2025, towels were dirty and other laundry that returned from being washed did not smell clean. Resident 34 reported missing her personal big towel, 3 washcloths and a white bandana. -on 08/25/2025, bedsheets were not changed for two weeks due to low linen supply and there were a lot of missing clothes. <Resident 38> In an interview on 09/04/2025 at 9:30 AM, when asked if they had any concerns about their cares, Resident 38 stated the facility run out of linen, you need to time your bathing, so you get clean sheets. Resident 38 further the laundry was done at their sister facility and that was why they often ran out of linen. In an observation of the activity room on 09/04/2025 at 2:01 PM, a bingo activity had just ended and Staff QQ, Life Enrichment Assistant, stated there was urine on the floor and they were trying to locate towels, they didn't have any. <Resident 29> On 09/05/2025 at 8:56 AM, Resident 29 was observed lying in bed eating breakfast. The top sheet covering the resident was observed to have several large brown stains surrounded by brown circles. Similar observations of the top sheet being soiled were made that same day at 9:59 AM and 10:53 AM. On 09/08/2025 at 9:05 AM and 11:15 AM, Resident 29 was observed sleeping in bed covered by a grey and white blanket, no top sheet was in place. <Resident 48> On 09/05/2025 at 8:54 AM, Resident 48 was observed lying in bed talking on the phone. The top sheet covering the resident was observed to have several brown stains. At 1:52 AM that same day, Resident 48 was observed sleeping in bed, the top sheet continued to have brown stains. On 09/08/2025 at 8:59 AM, Resident 48 was observed lying in bed covered only with a black and white blanket, no top sheet or facility blanket was present. When complimented on the blanket, Resident 48 stated, it isn't mine, they brought it because I was cold. When asked if there were sheets or blankets available, Resident 48 stated they didn't know, the staff just brought the blanket belonging to another resident after telling them it was cold. <Resident 63> During a resident representative telephone interview on 09/11/2025 at 9:58 AM, Resident 63's representative stated they informed the Administrator that staff had not been putting a sheet on their family member's bed and were informed they had a shortage of sheets. The resident representative stated the aides told them the linen was not sent out and all they had was pillowcases. They are putting something under my family member now but still do not have sheets all the time for their bed. <Safe and comfortable temperatures> During an observation of the Southeast unit on 09/03/2025 at 11:29, rooms [ROOM NUMBER] were observed to have the doors closed and the entryway blocked off with caution tape across the doors. In an interview on 09/03/2025 at 11:33 AM, Resident 48 stated the room was too hot at times and it made it difficult to sleep. A fan was present on the floor across from the bed. On 09/03/2025 at 11:57 AM, an outside pest control provider was observed standing by room [ROOM NUMBER]. When asked why the rooms were taped off, the pest control provider stated room [ROOM NUMBER] was found to have bed bugs and the adjacent rooms [ROOM NUMBERS] would be heat treated as preventive measures. When asked what the process was, the provider stated the rooms would be heated to 150 degrees from 9:45 AM until 2:45 PM and then a chemical treatment would be applied, and afterwards, residents could return to their rooms. Observation showed there were 13 residents residing on the unit from rooms 29 through 39 that would potentially be affected by the increased in room temperatures caused by the heat treatment. In a follow-up interaction with Resident 48 on 09/03/2025 at 2:18 PM, the room temperature was observed to be very warm and uncomfortable. Observation of the Southeast unit on 09/03/2025 at 2:19 PM showed multiple fans placed in the hallways, the hallway was very hot and uncomfortable. Review of the resident census roster on 09/03/2025 showed there were 19 empty rooms on the Northeast unit. On 09/03/2025 at 2:21 PM, Staff O, Maintenance Director, was informed the temperature in the hallway and resident rooms on the Southeast unit felt very hot. Staff O confirmed the rooms [ROOM NUMBER] were being heat treated due to bed bugs. Staff O walked down the hallway, acknowledged that temperature was hot, and at request of surveyor, temperatures were taken. Temperatures in Fahrenheit were as follows: - room [ROOM NUMBER] entry was 86.6 degrees - room [ROOM NUMBER] entry was 86.4 degrees - hallway by room [ROOM NUMBER] was 96 degrees, inside room [ROOM NUMBER] it was 94.2 degrees - hallway by room [ROOM NUMBER] was 85.7 degrees - room [ROOM NUMBER] entry was 85.6 degrees - hallway by room [ROOM NUMBER] was 89.4 degrees The temperature outside on 09/03/2025 was recorded at 103 degrees per the local weather station. In a follow-up interview at 2:56 PM, Staff O informed the survey team that the last heat treatment was completed, and the chemical treatment would start. Staff O stated the temperatures should start to decrease to more normal levels. In an observation of the Southeast unit hallway on 09/03/2025 at 3:44 PM, the temperature felt cooler and was more comfortable. In an interview on 09/12/2025 at 1:41 PM, Staff A, Administrator, was informed of the concern with the high temperatures on the Southeast unit during the heat treatment for the bed bugs and was asked if there were any discussions about moving residents to the Northeast unit. Staff A stated there was room on the Northeast unit to accommodate the residents, but there were no discussions about moving them since the treatment was short in duration and hydration rounds and fans were implemented. <Wheelchairs> <Resident 19> In an observation on 09/03/2025 at 10:22 AM, Resident 19 was sitting in their wheelchair, and it was unclean with food debris on the legs, foot pedals, and cushion. In an observation on 09/04/2024 at 11:27 AM, Resident 19 was sitting in their wheelchair across from the nurse's station. The wheelchair was unclean with food debris and there was blue foam affixed to the left wheelchair leg with cloth tape, not a cleanable surface. Similar observations of Resident 19's wheelchair being unclean with the blue foam padding were made on 09/05/2025 at 11:09 AM and 12:58 AM, 09/08/2025 at 8:43 AM, 10:21 AM and 3:39 PM, 09/09/2025 at 11:51 AM and 1:48 PM, and 09/10/2025 at 9:24 AM. <Resident 43> In an observation on 09/03/2025 at 12:05 PM, Resident 43 was sitting in their wheelchair, and it was unclean with debris on the legs and wheels. Similar observations of Resident 43's wheelchair with debris on the legs and wheels were made on 09/04/2025 at 11:21 AM, and on this day the cushion was unclean with white splatter, 09/11/2025 at 9:02 AM, 09/12/2025 at 9:00 AM and on this day there was brown matter on the cushion, and 09/15/2025 at 9:27 AM and the cushion remained with brown matter. In an interview on 09/11/2025 at 11:32 AM, Staff I, Nursing Assistant, stated the Nursing Assistants were in charge of cleaning the wheelchairs and thought they were cleaned after showers or on night shift. Staff I stated it was important to clean the wheelchairs for dignity. Staff I entered the room and observed Resident 19's wheelchair and stated it needed to be put in the shower and cleaned. In an interview on 09/11/2025 at 11:36 AM, Staff D, Registered Nurse, stated the Nursing Assistants were responsible for cleaning the wheelchairs. In an interview on 09/11/2025 at 11:56 AM, Staff A, Administrator, stated night shift cleaned the wheelchairs nightly and it was important to keep the wheelchairs clean for dignity and infection control. <Drywall> In an observation on 09/03/2025 at 10:52 AM, Resident 27 was lying in bed. There were multiple gauges out of the wall to the left of the resident's bed when you entered the room. Similar observations of Resident 27's drywall in disrepair were made on 09/03/2025 at 2:57 PM, 09/04/2025 at 11:18 AM, 09/08/2025 at 12:15 PM, 09/09/2025 at 1:44 PM, and 09/10/2025 at 9:26 AM. In an interview on 09/10/2025 at 3:08 PM, Staff O, Maintenance Director, stated they noticed when they came to the facility there were no bumpers on the walls to stop the beds from being pushed up against the walls and rubbing the paint. At 3:24 PM that same day, Staff O stated they were notified through the computer or verbally for the needed repairs and were not notified the room needed repaired. Staff O stated the room needed to be painted and it was important to maintain the rooms because this was the resident's home. In an interview on 09/11/2025 at 3:17 PM, Staff A stated a room that had peeling paint was not a homelike environment. Staff A stated their expectation was for the paint to remain intact on the walls and patch work completed in a timely manner. Staff A stated it was a potential dignity issue for the residents. <Malodorous Smell> On 08/28/2025 at 8:21 AM, the State Reporting Agency received an intake from a public complainant that the upkeep of the facility was not maintained as it smelled of urine. On 09/03/2025 at 8:30 AM, the facility was entered for the recertification survey. When going down the hall by resident room [ROOM NUMBER], 43, and 45, there was a faint smell of urine and a sour musty smell noted. During a telephone interview on 09/09/25 at 2:53 PM, a family representative for Resident 72 stated they smelled urine when they entered the facility to visit. The smells in the hall by rooms [ROOM NUMBER] were present during the entire recertification survey, more pronounced in the mornings. In an observation on 09/03/2025 at 10:52 AM, Resident 27 was lying in bed and their hair was greasy. In an observation on 09/08/2025 at 8:48 AM, Resident 27 was lying in bed and there was a strong body odor smell in the room. At 3:41 PM, the odor was notable from the hallway. Similar observations of the strong odor were made on 09/09/2025 at 1:44 PM, 09/10/2025 at 9:26 AM, and 09/11/2025 at 9:10 AM. In an interview on 09/10/2025 at 3:27 PM, Staff N, Housekeeping Director, stated the rooms were cleaned daily and if they noticed a foul odor in a room, they would inspect the room for feces or urine and would have the Nursing Assistants clean it. When asked how often the mattresses were changed out, Staff N stated maintenance oversaw that. Staff N stated they had not had any reports of Resident 27's room having a foul smell but sometimes the hall smelled, and they sprayed a deodorizer. In an interview on 09/10/2025 at 3:42 PM, Staff LL, Housekeeper, stated Resident 27's room had a smell and thought it was urine and the bedding. Staff LL stated they wiped the bed down when the resident was not in bed. In an interview on 09/10/2025 at 3:44 PM, Staff MM, Nursing Assistant, stated if they noticed a strong odor in a resident's room they would check to see if the resident needed care and if they could not figure out the odor, they notified housekeeping and maintenance. In an interview on 09/10/2025 at 3:48 PM, Staff B, Director of Nursing, stated mattresses could be changed out anytime and were not sure how often they were wiped down. Staff B stated they had not noticed an odor in Resident 27's room. Staff B added Resident 27 occasionally refused to be changed and showered. At 4:06 PM, Staff B stated anyone that saw the mattress unclean was responsible for wiping it down. Staff B stated the Resident Care Manager went into the room and sanitized the mattress and they were going to get the resident a new mattress. Reference: WAC 388-97-3220 (1)

Based on observation, interview and record review, the facility failed to ensure sufficient staff were available to meet the care needs for 7 of 9 sampled residents (Residents 17, 19, 29, 5, 43, 48, and 7) reviewed for activities of daily living (ADLS), and 3 of 3 sampled residents (Residents 44, 43, and 19) reviewed for restorative nursing (a personalized program that combined therapeutic techniques, exercises, and intervention to promote a resident's ability to maintain or improve their ADLS). These failures placed the residents at risk for unmet care needs, and diminished quality of life. Findings included.<Resident Observations and Interviews>In an interview on 09/03/2025 at 2:36 PM, Resident 27 stated they needed assistance with incontinence care and had to wait 30 minutes to be assisted.In an interview on 09/03/2025 at 10:42 AM, Resident 42 stated there was not enough staff and the facility was short staffed a lot. In an observation and interview on 09/03/2025 at 11:39 AM, Resident 48 stated there was not enough staff sometimes to assist with getting them out of bed. Resident 48's fingernails of both hands were observed to be long with brown matter underneath them. Subsequent observations of Resident 48 with long, dirty fingernails were made on 09/04/2025 at 10:36 AM, and 1:30 PM, 09/05/2025 at 8:54 AM and 10:51 AM, and 09/08/2025 at 8:59 AM.In an interview on 09/03/2025 at 11:45 AM, Resident 5 stated they needed assistance with incontinence care and had to wait an hour sometimes to be assisted. In an interview on 09/03/2025 at 2:27 PM, Resident 72 stated staff would come into their room, turn the call light off, and then leave without providing the care or return later. In an observation and interview on 09/03/2025 at 3:49 PM, Resident 29 stated there was not enough staff, and it sometime took awhile to be able to get assisted back to bed. Resident 29's fingernails of both hands were observed to be long with black debris underneath them. Additional observations of Resident 29 with long, dirty fingernails were made on 09/05/2025 at 8:56 AM, 10:53 AM, and 1:55 PM, 09/08/2025 at 9:05 AM and 11:15 AM, and 09/10/2025 at 9:25 AM. In an interview on 09/04/2025 at 8:58 AM, Resident 7 stated the facility had a problem with staff quitting and they had to wait to be assisted with cares. During a Resident Council meeting on 09/052025 at 10:58 AM to 12:08 PM, when attendees, (Residents 38, 21, 31, 34, and 46) were asked if there was enough staff to provide cares and assistance timely, Resident 46 replied there was not enough staff, and they had to wait 45 minutes to get their call light answered. All residents present nodded their heads in agreement. <Staffing Observations and Interviews> In an observation and interview on 09/05/2025 at 9:51 AM, the call light monitor at the South nurse's station showed the call light for room [ROOM NUMBER]-1 was on for 20 minutes. Resident 49 stated they were waiting for assistance to the bathroom, but it took too long, and they had to go in their incontinent brief. Continuous observations of the call light monitor and South hallways showed the following: - on 09/05/2025 at 10:26 AM, the call light for room [ROOM NUMBER]-2 was on for 15 minutes and 30 seconds prior to being answered.- on 09/09/2025 at 9:44 AM, the call light for room [ROOM NUMBER]-2 was on for 40 minutes, room [ROOM NUMBER]-2 was on for 39 minutes, and room [ROOM NUMBER]-1 was on for 19 minutes before being answered. At 1:42 PM, room [ROOM NUMBER]-2's call light was on for 30 minutes and the call light for room [ROOM NUMBER]-2 was on for 27 minutes before being answered.In an interview on 09/11/2025 at 10:41, Staff I, Nursing Assistant, stated there was not enough staff to provide care timely. Staff I stated there were usually two nursing assistants on each side and a float nursing assistant, but today, there were only three nursing assistants and that made it difficult to get cares done. In an interview on 09/11/2025 at 10:49 AM, Staff R, Licensed Practical Nurse, stated it was sometimes a challenge to get all tasks done when staffing was short.In an interview on 09/12/2025 at 11:32 AM, Staff B, Director of Nursing, stated there was a minimum staffing requirement, and the facility determined staffing based on the acuity of the residents and the care needed. Staff B stated staffing changed daily and every day was different, but the staffing should not be so bad that cares weren't provided. Please see F677 and F688 for additional informationReference (WAC): 388-97-1080 (1), 1090 (1)

Based on observation, interview and record review, the facility administration failed to effectively use its resources to maintain facility compliance with federal regulatory requirements, to provide clean bed and bath linens that were in good repair. Specifically, bed linens were often returned from the laundry provider soiled, stained, wet and malodorous. Additionally, there was an insufficient supply of linens for the resident needs, which resulted in the residents using slightly soiled linens or going without them. These failures caused residents to have a potential decreased quality of life and care.Findings included.During interviews on 09/03/2025, 09/04/2025, 09/08/2025, 09/09/2025, 09/10/2025, 09/12/2025 and 09/15/2025, as well as in the resident council meeting on 09/05/2025, multiple residents and staff members stated that not having enough bed linens and towels was a frequent issue at the facility.During an interview on 09/11/2025 at 3:17 PM, Staff A stated that their laundry had been done by a sister facility for the last 25 years, and they were aware of the poor service and lack of linen. It had been a consistent issue for the facility. Staff a further stated they had worked with the corporation for the last two months to change laundry vendors, and it was a work in progress. Staff A stated that their temporary fix was to triple their linen supply with the new vendor, which was delivered yesterday.During an interview on 09/12/2025 at 12:16 PM, Staff A stated they were not aware that the sister facility had a room with donated, unmarked clothes and items. During an interview on 09/15/2025 at 8:51 AM, Staff A stated that they had just gone to the sister facility and found an excess of linen. Staff A then stated they possibly were not getting their linens back, after they were laundered.During an interview on 09/15/2025 at 9:48 AM, Staff A stated that even before they became the administrator in 2023, the laundry had been done at another skilled nursing facility across town, and the poor quality of service had been an ongoing issue. Staff A further stated that the Quality Assurance and Performance Improvement (QAPI) committee did a performance improvement plan (PIP) about the laundry/linen issue in December of 2024, approximately nine months ago. Staff A reported that the problem was a pattern and not just a one-time event. Since December, Staff A stated they had been trying to improve and move control of as many aspects of the laundry service back to the facility. When asked what steps or interventions were taken when they ran out of linens, Staff A stated they reached out to administration of the sister facility last for additional linens and did receive some. Staff A did provide a copy of the email sent to them on 09/10/2025 to request more linens.Review of correspondence communication on 09/14/2024 (the first report of poor laundry service provided to the survey team) and 04/13/2025 through 09/03/2025, showed Staff A had notified the corporate office of issues with their current laundry service (clothing, tablecloths returned stained; resident clothing returned bagged, instead of hung up on provided hangers and rack; linens returned wet and clean towels smelled of feces.) The correspondence did not show any short-term interventions taken by the facility to address the immediate problem of lack of clean linens, before the survey started. No further documentation was provided.See F584 and F837 for further informationReference: WAC 388-97-1620(1)

Based on interview and record review the facility failed to have a written transfer agreement with one or more local hospitals as required. This failure placed all residents at risk of delay in emergency medical treatment, medical complications, and diminished quality of life. Findings included.Hospital transfer agreements were requested from Staff A, Administrator, on 09/15/2025 at 8:53 AM and 12:11 PM. No documentation was provided. In an interview on 09/15/2025 at 1:51 PM, Staff A, stated they expected the facility to have a transfer agreement with the local hospitals as required. Reference WAC 388-97-1620 (6)(a)

Based on observation, interview, and record review the facility failed to provide laundry services that included handling, storing, processing, and transporting linens in a manner to prevent the spread of infection. In addition, staff failed to perform hand hygiene when indicated during 2 of 3 medication administration observations. This failure placed residents at risk of potentially avoidable infections and diminished quality of life. Findings included. Review of the facility assessment updated August 2025 showed the facility's average daily census was 75 and provided complex medical care to residents with a variety of diagnoses and infectious diseases. No documentation was found to show how the facility provided laundry services. Review of an undated facility policy titled, Laundry and Linen Handling Policy showed staff were to wear tear-resistant reusable rubber gloves when handling and laundering soiled linens. Linens were to be washed using hot water ranging from 158-176 degrees Fahrenheit (F) for 10 minutes and dried completely in a commercial dryer. If hot water laundry services were not available staff were to reprocess soiled linens manually by immersion in detergent solution, use mechanical action to scrub and remove soil, disinfect by either 1) immersing the linen in boiling water or 2) immersing linen in disinfectant solution for the required contact time and rinsing, then fully drying, ideally in the sun. Each unit was to have a designated room for sorting clean linens and staff were to sort, package, transport, and store clean linens in a manner that prevented the risk of contamination by dust, debris, soiled linens or other soiled items. <LAUNDRY SERVICES> During observation and interview on 09/09/2025 at 11:53 AM, Staff L, Occupational Therapist, and Staff M, Physical Therapist Assistant, stated the facility implemented a new laundry process at the beginning of the month. Both Staff L and M stated they were unsure of the new process but were informed the facility would now be sharing the washer and dryer that was located in the therapy gym. Staff L and M explained occupational therapy (OT) utilized a washer and dryer to simulate a home environment and would ask residents who were working with OT to launder a load of their clothing in preparations for discharges back home. Observation of the therapy gym showed an alcove that contained a simulated home environment. A household top loading washer was observed in the left corner, to the right of the washer was a household front loading dryer that was heard to be running, to the right of the dryer was a kitchen environment that contained a counter, kitchen sink, stove, and refrigerator. There was no separation between clean and dirty, and protective gowns were not observed to be readily available for use when handling soiled linens. To the left of the alcove was a bathroom that contained a closet hanging rack to the left, upon entering. The closet had two handfuls of clean hanging clothing, with five walkers stored beneath the clean clothing. To the right of the walkers, within the same closet space, was a white rolling hamper that contained wet and soiled towels. There was no separation between clean and dirty, and protective gowns were not observed to be readily available for use when handling soiled linens. The dryer was heard stopping at the end of this observation. During observation and interview on 09/09/2025 at 1:11 PM, Staff N, Housekeeping Manager, stated the facility implemented a new laundry process at the beginning of the month. Staff N physically walked the surveyor through the new process while Staff N explained soiled linen was stored in large, covered barrels on each unit and nursing staff would transport the soiled barrels to the dirty linen room for sorting when full. Observation of the small dirty linen room showed a large, covered hanging rack surrounded by numerous larger sorting bins. Staff N stated the hanging rack was utilized to transport clean laundry to resident rooms. Staff N acknowledged the clean clothes transporting rack should not be stored in the same room as soiled linens. Staff N continued to explain staff were to wear gloves, a face shield, and a sleeveless plastic apron when sorting soiled linens. Once sorted, soiled linens were transported in a covered sorting bin to the therapy gym, located at the other end of the facility. Staff N stated they were unsure what temperature the washer reached. Staff N further explained clean linen was placed in a clean bag and transported to their office for sorting and folding. Observation of the office showed no designated sorting or folding area, the office contained a desk, chair, and shelving with stored chemicals. Stored under the desk, on the floor, was a pile of white blankets wrapped in plastic and a big black bag that contained soft pressure relieving boots was observed on the floor in the corner of the office. On the back of the office door was a hook with folded curtains and a few hangers with clothing. Staff N explained once clothes were sorted, it was folded and delivered to the resident or placed on the hanging rack, that was stored in the dirty room, to deliver. In an interview on 09/10/2025 at 1:02 PM, Staff O, Maintenance Director, stated they were unaware the facility began utilizing the household washer/dryer located in the therapy gym to wash all resident clothing and had not assessed or inspected the washer/dryer or water temperature prior to implementation of the new laundry process.The new laundry process was explained to Staff O. Staff O acknowledged the clean clothing rack should not be stored in the dirty area. In an interview on 09/12/2025 at 11:47 AM, Staff P, Infection Preventionist, stated they were not informed of the facility's newly implemented laundry process and was unsure if the facility utilized hot washing at 160 degrees F for 25 minutes or cold wash with the appropriately added chemicals. Staff P further stated dirty and clean areas should be kept separated, staff should wear gloves and sleeved gowns when handling and sorting soiled linen, including when loading the washer. Staff P stated they expect staff to store, handle, transport, and process laundry in a manner to prevent cross contamination and prevent the spread of germs. In an interview on 09/12/2025 at 12:43 PM, Staff A, Administrator, explained the facility implemented a new laundry system at the beginning of the month which included use of the household washer/dryer in the therapy gym area but recently realized the machines did not reach the required temperatures. Staff A stated they expected staff to store, handle, and process laundry in a manner to prevent cross contamination. <HAND HYGIENE> During observation on 09/11/2025 at 8:53 AM, Staff K, Licensed Practical Nurse (LPN), was observed dispensing medications for Resident 25. Staff K placed the pills in a medication cup, crushed them and mixed them with a small amount of pudding. Resident 25 was in their wheelchair near the nurses' station. Staff K gave them one spoonful of the medicine/pudding mixture, but for the next spoonful, Resident 25 turned their face away. Staff K then labeled the medication cup with the resident name using a marker, filled out a paper form at the medication cart, held a door open for another resident, in between attempts to get Resident 25 to take the rest of their medication. Staff K did not use alcohol-based hand sanitizer (ABHS) or perform hand hygiene, when changing from one task to another. A bottle of ABHS was not observed to be readily available for use, on the medication cart. During observation on 09/11/2025 at 10:03 AM, Staff K dispensed medications for Resident 34 at the medication cart. Staff K then brought the medications to Resident 34's room and put on a pair of gloves. Staff K did not use ABHS or perform hand hygiene before putting on the gloves. After they finished administering all of the medications, Staff K removed and discarded their gloves and used the wall mounted ABHS. During an interview on 09/11/2025 at 12:07 PM, the surveyor described the observations during the medication administration to Staff K. Staff K acknowledged they should have used ABHS after doing other tasks and before going back to Resident 25 to attempt to give them their medicine. Staff K stated they did not usually have bottles of ABHS on the medication carts, but hand hygiene was to be done between different residents' care, and before putting on and after taking off gloves. During an interview on 09/12/2025 at 2:28 PM, Staff B, Director of Nursing, acknowledged Staff K should have performed hand hygiene between different residents' care, and with glove changes. References: WAC 388-97-1320(1)(c)(3)

Based on observation, interview and record review, the facility failed to ensure residents and/or visitors were informed of the location of the State Recertification Survey results documents/binder, and that the binder location was known for 4 of 5 sampled residents (Residents 21, 34, 38, and 46). This failure placed residents and visitors at the risk of not being able to access the Survey results. Findings included .During a Resident Council meeting on 09/05/2025 at 11:55 AM, attendees were asked if they had access to the State Recertification Survey binder that contained the results from inspections completed by the State Agency. Residents 21, 34, 38, and 46 all stated they had never seen the binder and did not know where it was located. On 09/09/2025 at 8:05 AM, a binder that contained the State Recertification Survey results was observed in a plastic holder on the wall just underneath framed documents of the facility license at the area that previously was the lobby and main entrance into the facility. During an interview on 09/09/2025 at 10:12 AM, when informed that residents were not aware of the location of State Recertification Survey binder, Staff DD, Life Enrichment Director, stated the binder was discussed sometimes during Resident Council meetings, but they would follow up with the residents. During an interview on 09/12/2025 at 11:41, Staff A, Administrator, was informed that residents reported not knowing where the State Recertification Survey binder was located. Staff A stated there was a notice at the facility entrance that stated the survey binder was in the administrative lobby and they would follow up with the residents. No notice was seen during an observation of the lobby area after the interview. Reference (WAC): 388-97-0480

Based on interview and record review the facility failed to provide residents and/or their representatives a written notice that included the reason for transfer or discharge and failed to send a copy of the notice to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations), as required for 2 of 3 sampled residents (Residents 86 and 2) reviewed for discharges. This failure placed residents at risk of inappropriate transfers or discharges.Findings included.<Resident 2>The 09/05/2025 discharge assessment documented Resident 2 was discharged from the facility to the community on 09/01/2025 with a return not anticipated. Review of September 2025 nursing progress notes documented Resident 2 left the faciity on [DATE] against medical advice. There was no documentation the Ombudsman was notified of the discharge, as required. Ombudsman discharge notifications for the previous four months were requested from Staff A, Administrator, on 09/08/2025 at 2:11 PM. Review of the documentation received showed no documentation the Ombudsman was notified of Resident 2's discharge, as required. During an interview on 09/08/2025 at 2:48 PM, Staff C, Social Service Director, stated they notified the Ombudsman of each resident discharge by e-mail.During a follow-up interview on 09/09/2025 at 10:19 AM, Staff C acknowledged they were unable to find documentation the Ombudsman was notified of Resident 2's discharge. During an interview on 09/09/2025 at 10:22 AM, Staff A acknowledged they were unable to find documentation the Ombudsman was notified of Resident 2's discharge. Staff A further stated the Ombudsman should have been notified of the discharge, as required. <Resident 86>The 07/07/2025 admission assessment documented Resident 86 admitted to the facility on [DATE] and had diagnoses that included failure to thrive and end-stage kidney disease dependent on dialysis (medical treatment to remove fluid and waste from the blood when the kidneys no longer functioned). Resident 86 was cognitively intact. Review of July 2025 nursing progress notes documented Resident 86 was sent to the hospital emergency room on [DATE] from the dialysis provider related to low blood pressure. There was no documentation the Ombudsman was notified of the hospital transfer, as required. A list of hospitalizations and the corresponding Ombudsman notifications for the previous four months was requested from Staff A, Administrator, on 09/08/2025 at 2:11 PM and again on 09/09/2025 at 10:17 AM. Review of hospitalizations from 05/07/2025 through 09/09/2025 showed 43 resident transfers to the hospital occurred. No documentation was provided to show the Ombudsman was notified of the hospital transfers, as required. During an interview on 09/08/2025 at 2:48 PM, Staff C stated the floor nurse or the Resident Care Manager (RCM) notified the Ombudsman when a resident was transferred to the hospital. During an interview on 09/08/2025 at 2:59 PM, the LTC Ombudsman stated they were not notified of hospital transfers. The Ombudsman stated they typically learned of a resident transfer to the hospital when they visited the facility. During an interview on 09/09/2025 at 10:39 AM, Staff D, Registered Nurse, stated they had experience transporting residents to the hospital but had not notified the Ombudsman as part of the process. During an interview on 09/09/2025 at 11:04 AM, Staff H, RCM, stated they were unsure who was responsible for notifying the Ombudsman of hospital transfers. During an interview on 09/09/2025 at 11:07 AM, Staff B, Director of Nursing, stated Social Services notified the Ombudsman of hospital transfers. A 09/10/2025 at 11:53 AM e-mail correspondence from Staff A confirmed hospital transfer notices were not being sent to the Ombudsman, as required. No associated WAC

Based on interview and record review the facility failed to complete interdisciplinary team (IDT, at a minimum consisting of the resident's attending physician, nurse and nurse aide responsible for the resident, a member of food and nutrition services, the resident and/or the resident representative) care planning conference meetings to enable resident and/or the resident representative participation in development, review, and revision of the plan of care for 9 of 9 sampled residents (Resident 5, 7, 9, 27, 41, 43, 44, 48 and 63), reviewed for care conferences. This failure placed residents at risk of unmet care needs, and diminished quality of life. Findings included. Review of the facility policy titled, Care Conferences revised May 2023, showed the social worker would encourage the resident and/or their legal representative to attend care plan conferences. Care conferences would be scheduled based on identified needs and regulatory standards. The policy further showed care conferences would be scheduled upon admission, quarterly, with significant changes of condition, and as requested by the resident, family, or other team members. Staff were to notify the resident and resident representative of the next scheduled care conference and document method of notification in the medical record. After a care conference was held, a summary of the meeting's outcome was to be documented in a note. <Resident 9> According to a comprehensive assessment, dated 07/17/2025, Resident 9 had a diagnosis of dementia (a disorder that caused impaired memory and reasoning) with psychotic disturbance (hallucinations-sensing things that seemed real but actually are not and delusions-false beliefs that conflicted with reality). They made their basic needs known and had a guardian for medical decisions. During an interview on 09/04/2025 at 10:35 AM, Resident 9 stated staff did what they wanted and explained staff did not tell them anything about their plan of care. Review of a 07/19/2024, over 14 months prior, care conference progress note documented that the resident had not participated in the care conference, but their guardian did. Additional review of the medical record showed no documentation care conferences were held quarterly after 07/19/2024. Any care conference notes for Resident 9 were requested from Staff A, Administrator on 09/10/2025 at 10:20 AM. No documentation was provided. <Resident 27> According to a comprehensive assessment, dated 07/06/2025, Resident 27 had diagnoses which included diabetes and depression. They were alert, oriented and made their needs known. During an interview on 09/03/2025 at 2:38 PM, Resident 27 stated that they had never had a care conference. Review of a 07/09/2024,14 months prior, care conference evaluation note, documented the resident had attended the care conference. Additional review of the medical record showed no documentation care conferences were held quarterly after 07/09/2024. Any care conference notes for Resident 27 were requested from Staff A, Administrator on 09/10/2025 at 10:20 AM. No documentation was provided. <Resident 44> According to the 07/22/2025 quarterly assessment, Resident 44 admitted to the facility on [DATE] with diagnoses including medically complex conditions. The assessment further showed Resident 44 was cognitively intact and able to clearly verbalize their needs. Review of the 06/18/2024 care conference evaluation showed a quarterly care conference was held with the resident representative, social services, and nurse manager. No documentation was found to show a member of nutrition services attended the meeting. Further review of the record showed no documentation care conferences were held quarterly. Review of June 2024 through September 2025 social service progress notes showed no documentation care conferences were completed quarterly. <Resident 43> According to the 08/21/2025 quarterly assessment, Resident 43 admitted to the facility on [DATE] with diagnoses including dementia. The assessment further showed Resident 43 was cognitively intact and able to clearly verbalize their needs. Review of the 11/15/2024 care conference evaluation showed an initial care conference was held and a member of nutrition services was not present at care conference. Further review of the record showed no documentation care conferences were held quarterly. Review of November 2024 through September 2025 social service progress notes showed no documentation care conferences were completed quarterly. <Resident 41> The 06/27/2025 quarterly assessment documented Resident 41 admitted to the facility 09/17/2024 with diagnoses including anxiety and depression. Resident 41 had moderate cognitive impairment and was able to make their needs known. In an interview on 09/03/2025 at 10:44 AM, Resident 41 was asked if the facility kept them informed about their plan of care or had care conference meetings to inform them of any changes. Resident 41 stated they were not informed about changes with their medications, unless they asked. Review of a Care Conference Evaluation form documented a care conference occurred on 09/24/2024 and included Resident 41 and their representative. No other documentation of a care conference after 09/24/2024 was found. Review of the Social Services Quarterly Evaluation forms documented the evaluation was completed quarterly on 12/23/2024, 03/25/2025, and 06/26/2025, but all evaluations documented a care plan review was not completed and the text boxes for documenting the date and time the resident and/or representative were invited to participate in the care conference were blank. Review of the progress notes from 09/01/2024 through 09/10/2025 found no documentation that care conference or care planning meetings had occurred after 09/24/2024. <Resident 48> The 08/11/2025 quarterly assessment documented Resident 48 admitted to the facility on [DATE] with diagnoses including stroke and depression. Resident 48 was cognitively intact to make decisions regarding their care. In an interview on 09/03/2025 at 2:00 PM, Resident 48 was asked if the facility kept them informed about their plan of care or had meetings to discuss their care. Resident 48 stated no, they were not informed about changes, like with the medications, or their plan of care unless they asked. Review of the Care Conference Evaluation form documented a care conferences was held on 06/27/2024 which included Resident 48 and their representative. No other documentation of a care conference after 06/27/2024 was found. Review of the Social Services Quarterly Evaluation forms dated 08/08/2025 and 02/10/2025 documented Resident 48 was well adjusted to the facility, had not brought up wanting to discharge lately, and there were no concerns identified at the time of the evaluation. Both evaluation forms documented a care plan review was not completed and the text boxes for documenting the date and time of the invitation was made to resident and/or representative to participate in the care conference were blank. Review of the progress notes from 05/01/2025 through 09/10/2025 found no documentation that any care conference or care planning meetings had occurred. <Resident 5> According to the 08/16/2025 quarterly assessment, Resident 5 admitted to the facility on [DATE] and had diagnoses which included high blood pressure, diabetes and depression. The resident was able to make their needs known. In an interview on 09/03/2025 at 11:47 AM, Resident 5 stated they had not had a care conference meeting. A review of Resident 5's record showed no documentation a care conferences had occurred. <Resident 7> According to the 08/21/2025 quarterly assessment, Resident 43 admitted to the facility on [DATE] and had diagnoses which included Multiple Sclerosis (a disease that caused nerve damage and disrupted communication between the brain and body). The resident was able to make their needs known. In an interview on 09/04/2025 at 8:57 AM, Resident 7 stated they had never had a care conference and did not know what that was. Review of the care conference evaluation form showed an initial care conference was held on 12/20/2024. Additional record review showed no documentation care conferences were held quarterly thereafter. <Resident 63> According to the 08/08/2025 quarterly assessment, Resident 63 admitted to the facility on [DATE] and had diagnoses which included a stroke, diabetes and high blood pressure. The resident was able to make their needs known. In an interview on 09/03/2025 at 10:43 AM, Resident 63 stated they had never had a care conference. Review of the care conference evaluation form showed an initial care conference was held on 05/06/2025. Additional review of the record showed no documentation care conferences were held quarterly thereafter. In an interview on 09/11/2025 at 10:33 AM, Staff C, Social Service Director, stated care conferences were held within seven days of admission and quarterly thereafter. Staff C stated Social Services, nursing and therapy attended the care conference and the family and resident representative were invited to attend. Staff C acknowledged care conferences were not being held quarterly, and they recently hired an assistant. Staff C stated it was important to hold care conferences to keep the residents informed of their care and allow families to give input. In an interview on 09/11/2025 at 10:47 AM, Staff B, Director of Nursing, stated care conferences were held when requested and quarterly. Staff B acknowledged care conferences were not occurring quarterly and recently hired another Social Worker to assist with completing them. Reference: WAC 388-97-1020 (2)(f), (4)(b)

Based on observation, interview, and record review, the facility failed to consistently provide assistance with bathing, nail care, and eating for 7 of 9 sampled residents (Residents 5, 7, 17, 19, 29, 43 and 48) reviewed for activities of daily living (ADLs) for dependent residents. Those failures placed the residents at risk for diminished quality of life and unmet care needs. Findings included… <Resident 29> The 09/03/2025 quarterly assessment documented Resident 29 was cognitively intact to make decisions regarding their care, and had diagnoses which included stroke and diabetes. In addition, the assessment documented the resident needed assistance from nursing staff to complete ADLs for personal hygiene tasks such as nail care. On 09/03/2025 at 3:49 PM, Resident 29 was observed lying in bed watching television and eating a chocolate snack cake with their left hand. The fingernails of both hands were observed to be long with black debris underneath them. On 09/05/2025 at 8:56 AM, 10:53 AM, and 1:55 PM, Resident 29 was again observed with long fingernails with black debris underneath them. Additional observations of Resident 29 with long, dirty fingernails were made on 09/08/2025 at 9:05 AM and 11:15 AM. Review of the 03/05/2025 ADL care plan documented Resident 29 was dependent on staff to complete personal hygiene, and interventions informed nursing staff to the resident's nails were to be cleaned as needed on their bath day and trimmed by the nurse. In addition, the skin care plan had interventions implemented on 04/19/2024 that informed the nursing staff that Resident 29 had dry skin and to reduce the risk of injury from scratching, Resident 29's nails were to be kept clean and short. Review of the Treatment Administration Records (TARS) from June 2025 through September 2025 documented diabetic nail care was done weekly, and all nail care during the four-month period reviewed was documented as being refused by Resident 29. On 09/10/2025 at 9:25 AM, Resident 29 was observed lying in bed watching television, the fingernails of both hands were still long with black debris underneath. When asked about the condition of their fingernails being long and dirty, Resident 29 looked at the fingernails on their right hand and stated, “I like manicures, they are nice.” When asked if they ever refused to have their nails cleaned or trimmed, Resident 29 stated, they did not refuse, they liked their nails short, but long enough to be able to open their soda cans. Resident 29 then again stated manicures were nice. In an interview on 09/11/2025 at 10:55 AM, Staff R, Licensed Practical Nurse, stated Resident 29 consistently refused nail care. When asked if other interventions are done when resident refuses nail care, Staff R stated, they try and soak the resident's hands to get them clean, and they inform the provider of the refusals by writing in the communication book. Review of the provider communication books from 06/30/2025 through 09/11/2025 found entries related to Resident 29 refusal of nail care were made on 09/03/2025 and 09/10/2025, no other entries were made. <Resident 48> The 08/11/2025 quarterly assessment documented Resident 48 was cognitively intact to make decisions regarding their care, had diagnoses which included stroke, and needed moderate assistance from nursing staff to complete ADLS for personal hygiene. On 09/03/2025 at 11:47 AM, Resident 48 was observed lying in bed eating pie with their hands. The fingernails of both hands were observed to be long with brown matter underneath them. Subsequent observations of Resident 48 with long, dirty fingernails were made on 09/04/2025 at 10:36 AM, and 1:30 PM, 09/05/2025 at 8:54 AM and 10:51 AM, and 09/08/2025 at 8:59 AM. Review of the ADL care plan, last revised 08/22/2025, found interventions that informed nursing staff of Resident 48's personal hygiene care needs related to bathing, oral care and dressing, but no interventions or instructions related to nail care were included. Review of the nail care record from 08/12/2025 through 09/10/2025 documented no nail care was provided to Resident 48 and during the 30-day time frame, no documentation was found that showed Resident 48 had refused to have nail care done. In an interview on 09/11/2025 at 10:42 AM, Staff I, Nursing Assistant, stated nail care was done on a resident's bath day, or as needed, unless they were diabetic, and then the nurses did the nail care. In an interview on 09/11/2025 at 10:59 AM, Staff R, Licensed Practical Nurse, stated Resident 48 had recently transferred to the unit from the short stay unit, would refuse cares at times, and refusals should be documented when it occurred. In an interview on 09/11/2025 at 12:27 PM, when informed of the concern related to nail care not being provided consistently for Residents 29 and 48, Staff E, Resident Care Manager, stated they were not aware there was an issue. In an interview on 09/12/2025 at 11:21, Staff B, Director of Nursing, stated the facility expectation was that nail care was completed and documented and when a resident refused, then it was reoffered and followed up on. <Resident 17> The 08/25/2025 comprehensive assessment documented Resident 17 had diagnoses that included paralysis on one side of the body from a stroke and contractures (shortening or hardening of muscles that led to joint immobility). The resident was cognitively intact and required partial staff assistance for personal hygiene and substantial assistance for showering/bathing. The 08/19/2025 care plan documented Resident 17 had a self-care deficit; required extensive assistance of 1 staff for bathing twice weekly and set-up assistance for personal hygiene. The active KARDEX (Nursing Assistant, NAC, care instructions) documented Resident 17 was to be showered twice weekly. The care plan and the KARDEX did not have instructions or interventions for nail care for the resident. A provider progress note dated 08/20/2025 documented Resident 17 was slumped over in bed, was disheveled and withdrawn with minimal eye contact. The resident's left upper extremity was contracted with overgrown fingernails. They noted they were going to request nursing to trim. The resident was moderately uncooperative. A review of the NAC nail care task from 08/19/2025 through 09/04/2025 showed Resident 17 had no nail care. There were no refusals documented. The NAC shower task documentation showed Resident 17 was showered on 08/28/2025, and on 09/04/2025. The resident refused showers on 09/01/2025 and 09/08/2025. On 09/03/2025 at 9:50 AM, Resident 17 was observed in their room in their wheelchair. Their hair was uncombed, and their fingernails were long, jagged, and had dark brown/black material under them. Additional observations of the resident's jagged fingernails with dark matter under them were made on 09/05/2025 at 8:15 AM and 12:12 PM, 09/08/2025 at 9:10 AM, 09/10/2025 at 9:57 AM, and 09/11/2025 at 10:26 AM. On 09/05/2025 until the survey exit, Resident 17 was supervised by a NAC 1 to 1 for the resident's safety. On 09/11/2025 at 10:26, Staff T, NAC, stated they had not offered to clean Resident 17's nails on 09/10/2025 or 09/11/2025 when they sat with the resident 1 to 1. They stated they noticed the nails were dirty. Staff T stated they were going to give Resident 17 a shower and would provide nail care at that time. Resident 17 requested to have their beard shaved off during their shower as well; they stated they'd like it shaved once more before they grew it out for the winter. On 09/12/2025 at 1:10 PM, Resident 17 was observed; their fingernails had been clipped. There continued to be dark matter under the nails. They had been shaved as requested. On 09/12/2025 at 1:15 PM, Staff U, NAC, stated they were aware Resident 17 needed their nail care done since the resident first came to the facility. They stated nail care was done on shower days or if needed. They were unsure why the resident's nails had been clipped but not cleaned underneath. If a resident refused care, the refusal was documented in the NAC tasks. <Resident 5> The 08/16/2025 quarterly assessment documented Resident 5 had diagnoses that included a stroke, diabetes and seizures. The resident was able to make their needs known and required total assistance for bathing. In an interview on 09/03/2025 at 11:52 AM, Resident 5 stated they were not getting their showers twice a week. The 02/07/2024 care plan documented Resident 5 required extensive assistance for bathing twice weekly and as needed. The shower task documentation reviewed from 07/01/2025 through 09/04/2025 showed Resident 5 was showered on 07/02/2025, 07/05/2025, 07/12/2025, 07/16/2025, 07/26/2025, 07/30/2025, 08/02/2025, 08/09/2025, 08/24/2025, 08/27/2024 and 09/04/2025, not consistently twice weekly as care planned. <Resident 43> The 08/21/2025 quarterly assessment documented Resident 43 had diagnoses that included heart failure, dementia, and diabetes. The resident was able to make their needs known and required partial to moderate assistance for bathing and extensive assistance with nail care. In an observation 09/03/2025 at 12:05 PM, Resident 43 was sitting in their wheelchair in the doorway of their room. The resident's shirt was soiled and they only had a brief on. Resident 43's nails were very long. In an observation on 09/04/2025 at 11:21 AM, Resident 43 was sitting on the edge of their bed with a strong body odor. The resident's nails remained long, and they stated they did not like their nails that way. When Resident 43 was asked if they would allow staff to cut their nails, they stated they would. In an observation on 09/05/2025 at 9:38 AM, Resident 43 was sitting in their wheelchair. The resident was wearing the same shirt from the prior day, their nails were long, and their hair was unclean. Similar observations of Resident 43 with long nails were made on 09/08/2025 at 8:51 AM and 09/09/2025 at 9:33 AM. The 11/11/2024 care plan had a goal of the resident would be neat, clean and well groomed daily. The care plan instructed nursing staff to assist with bathing and personal hygiene. The shower task documentation reviewed from 07/01/2025 through 09/04/2025 showed Resident 43 was showered twice weekly in July with exception of 07/06/2025 to 07/13/2025, 07/16/2025 said refused and the next shower was given on 07/20/2025. In August the resident was showered on 08/02/2025, 08/09/2025, 08/13/2025, 08/20/2025 said non applicable, 08/24/2025, 08/27/2024 stated resident refused, and the next shower was on 09/04/2025, not consistently twice weekly as care planned. The nail care documentation in the Medication Administration Record showed Resident 43 had nail care completed weekly. In an observation on 09/12/2025 at 2:23 PM, Resident 43 held out their hands and showed their nails were trimmed and stated they were happy about it. <Resident 7> The 07/17/2025 quarterly assessment documented Resident 7 had diagnoses that included Multiple Sclerosis (a disease that damaged nerves and disrupted the communication between the brain and body) and anxiety. The resident was able to make their needs known and required substantial to maximum assistance for bathing. In an observation and interview on 09/11/2025 at 8:59 AM, Resident 7 was lying in bed and their hair was greasy. The resident stated it had been a while since they had a shower and said they had body odor and smelled. The resident stated they were told there were no towels or washcloths. The resident added they bathed themselves and all the staff had to do was supervise, so there was no reason they should not be able to shower. The 12/16/2025 care plan instructed nursing staff to assist the resident with bathing. The shower task documentation reviewed from 07/01/2025 through 09/04/2025 showed Resident 5 was showered on 07/02/2025, 07/05/2025, refused 07/09/2025, 07/16/2025 and 07/19/2025 stated non applicable, res was given a shower on 07/20/2025, 07/23/2025, 07/26/2025, 07/30/2025 stated resident refused, resident had a shower on 08/02/2025, refused on 08/06/2025, had a shower on 08/09/2025, 08/13/2025, shower on 08/16/2025 said refused, had a shower on 08/20/2025, 08/23/2025, refused on 08/27/2025, 08/30/2025 said non applicable and the next shower on 09/09/2025 said refused. In an interview on 09/08/2025 at 11:52 AM, Staff U, Nursing Assistant, stated they tried to complete nail care when they could and if the resident was diabetic they notified the nurse. Staff U stated ideally the residents got two showers per week, but showers did not happen near as often as they needed to be and this was related to inadequate staffing. Staff U stated occasionally they had a shower aide and would benefit from a permanent shower aide. Staff U stated it was important to provide nail care and showers for infection control, hygiene and dignity. In an interview on 09/08/2025 at 12:00 PM, Staff D [NAME], Registered Nurse, stated they thought showers were given three times per week and the nurse did diabetic nail care. In an interview on 09/08/2025 at 12:30 PM, Staff B, Director of Nursing, stated showers were given per the resident's preference, generally twice per week and nail care was done with weekly skin checks or during their shower. Staff B stated it was important to do routine bathing and nail care for cleanliness and dignity. Staff B added if the resident refused cares it was documented and a refusal sheet was filled out and placed in the medical record. <Resident 19> The 07/23/2025 quarterly assessment documented Resident 19 had diagnoses that included dementia and failure to thrive. The resident had severe cognitive impairments and required partial to moderate assistance for bathing and set up and clean up assistance with eating. In an observation on 09/03/2025 at 10:22 AM, Resident 19 was sitting in their wheelchair in their room with a glass of juice. The juice had spilled on the tray table, and the resident was wiping it with a paper towel and was confused. In an observation on 09/05/2025 at 12:08 PM, Resident 19 was sitting in the dining room with a bowl of soup in front of them. The resident held the spoon in the same position, was not moving their hand and no staff assisted them to eat. In an observation on 09/10/2025 at 8:45 AM, Resident 19 was sitting in the dining room eating breakfast. The resident used their fingers to feel around the plate for food and when they found food they placed it on their fork, no staff member was assisting the resident to eat. At 9:06 AM, Resident 19 sat at the table with another resident and Staff Z, Nursing Assistant. The resident had nasal drainage that hung approximately two inches out of their nose over their plate of food. Staff Z got up and assisted the other resident away from the table but did not assist Resident 19 with their nose. In an observation on 09/11/2025 at 8:35 AM to 8:42 AM, Resident 19 sat at a dining room table consuming breakfast. The resident's nose was dripping, and they continued eating and consuming fluids and the nasal drainage came in contact with their cup and spoon. The staff did not assist the resident until 8:43 AM with the nasal drainage. Resident 19 used their fingers to feel around their plate for food and placed the food into their mouth when they found it and was not assisted by staff. At 8:52 AM, the resident was trying to scoop food off the tablecloth. In an observation on 09/11/2025 at 12:52 PM, Resident 19 was sitting in the dining room and was taking small bites of food. The resident then tried to scoop some food and rubbed their butter knife against their fork and was unable to put the food onto the utensils. Resident 19 then lifted an empty spoon to their mouth, no staff assisted the resident. At 12:59 PM, Staff I, Nursing Assistant, walked over to the resident, looked at them and walked away. At 1:01 PM, Staff GG, Restorative Aide, asked Staff I to tell Resident 19 to take a bite because they were not getting anything on their spoon. Staff I told the resident not to use their hands and to use the spoon. In an interview on 09/11/2025 at 2:04 PM, Staff NN, Nursing Assistant, stated they looked at the care plan to know what care the residents needed. Staff NN stated if a resident was feeling around their plate with their fingers they should have been assisted to eat. Staff NN stated if they saw a resident with nasal drainage they would immediately assist them. In an interview on 09/11/2025 at 2:16 PM, Staff OO, Licensed Practical Nurse, stated residents required assistance with eating when they could not feed themselves, had poor coordination or problems with swallowing. Staff OO stated residents who feel around their plate for food may have vision problems and needed assistance with eating. Staff OO stated staff needed to intervene when a resident had nasal drainage during the meal service. In an interview on 09/11/2025 at 2:20 PM, Staff A, Administrator, stated residents required assistance with eating if they showed a change in their abilities. Staff A stated the staff needed to intervene when a resident put their fingers in their plate and felt around for food and had nasal drainage as they had assisted the resident multiple times with this and it was a dignity issue. Staff A added Resident 19 needed someone sitting with them or near them to assist them with meals. Reference: WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review the facility failed to implement and oversee a comprehensive restorative nursing program for 3 of 3 sampled residents (Resident 44, 43, and 19), reviewed for restorative services. This failure placed residents at risk for complications and diminished quality of life. Findings included. <Resident 44> According to the 07/22/2025 quarterly assessment, Resident 44 had diagnoses including stroke with weakness on one side of the body and a contracture of the left hand. The assessment further showed Resident 44 had functional limitations in range of motion to one arm and leg and received range of motion via a restorative nursing program. Review of the limited physical mobility care plan revised 01/31/2025 showed Resident 44 was to have gentle passive range of motion (PROM, joints moved by an outside source such as a staff, rather than independently) stretching performed to the joints in their left arm and leg, with participation documented. Review of the September 2024 through August 2025 PROM program documentation showed the following: - September 2024: response not required, not applicable, and/or 0 documented 19 times. - October 2024: response not required, not applicable, and/or 0 documented 11 times. - November 2024: response not required, not applicable, and/or 0 documented 17 times. - December 2024: response not required, not applicable, and/or 0 documented 10 times. - January 2025: response not required, not applicable, and/or 0 documented 14 times. - February 2025: response not required, not applicable, and/or 0 documented 13 times. - March 2025: response not required, not applicable, and/or 0 documented 14 times. - April 2025: response not required, not applicable, and/or 0 documented 18 times. - May 2025: response not required, not applicable, and/or 0 documented seven times. - July 2025: response not required, not applicable, and/or 0 documented six times. - August 2025: response not required, not applicable, and/or 0 documented 14 times. Review of September 2024 through August 2025 restorative program quarterly evaluations showed the following: -09/03/2024: Resident 44 PROM has been seldomly conducted due to restorative staffing. The PROM was reassigned to be performed by the nursing assistant working the floor. -12/03/2024: Resident 44 participated regularly in PROM to the left arm and leg. -03/14/2025: Resident 44 participated regularly in PROM to the left arm and leg. -06/12/2025: PROM was seldomly conducted and Resident 44 has had some recent functional decline with increased incidences of falls. A therapy screen was requested. -08/20/2025: Resident 44 completed physical therapy, and a restorative walking maintenance program was recommended and implemented. <Resident 43> According to the 08/21/2025 quarterly assessment, Resident 43 had diagnoses including non-traumatic brain injury (brain damage that occurred without an external physical force). The assessment further showed Resident 43 had no range of motion limitations and did not participate in a restorative nursing program. Resident 43 was cognitively intact and able to clearly verbalize their needs. Review of the 01/07/2025 limited physical mobility care plan showed Resident 43 was on a walking maintenance program. Resident 43 was to walk to and from the shower room, a distance of up to 150 feet, two to three times weekly, with participation documented. Review of the January 2025 through August 2025 walking maintenance program documentation showed the following: -January: response not required and/or not applicable documented 25 times. No documentation was found to show Resident 43 walked. -February: response not required and/or not applicable documented 23 times. Resident 43 walked once. -March: response not required and/or not applicable documented 29 times. Resident 43 walked twice. -April: response not required and/or not applicable documented 11 times. Resident 43 walked 19 times. -May: response not required and/or not applicable documented 26 times. Resident 43 walked eight times. -June: response not required and/or not applicable documented 16 times. Resident 43 walked 13 times. -July: response not required and/or not applicable documented 23 times. Resident 43 walked four times. -August: response not required and/or not applicable documented 26 times. Resident 43 walked five times. Review of January 2025 through August 2025 restorative program quarterly evaluations showed the following: -01/07/2025: Resident 43 was discharged from skilled therapy services with recommendations to participate in a walking program to maintain their current level of mobility. A care plan was initiated for Resident 43 to ambulate up to 150 feet, two to three times a week. -02/18/2025: Resident 43 participated fairly regularly with walking activity conducted three times during the previous 14 days. The care plan was to be continued to provide formal practice in walking. -05/19/2025: Resident 43 participated fairly regularly with walking activity conducted three times during the previous 14 days. The care plan was to be continued to provide formal practice in walking. -08/25/2025L Resident 43 participated regularly with walking. The care plan was to be continued to provide formal practice in walking. <Resident 19> The 07/23/2025 quarterly assessment documented Resident 19 had diagnoses which included dementia, failure to thrive and malnutrition. The assessment further showed Resident 19 had functional limitations in range of motion to bilateral upper and lower extremities and was not on a restorative nursing program. A review of the limited physical mobility care plan revised 01/31/2025 showed Resident 19 was to have gentle PROM stretching performed to the joints in their knees with each lower extremity dressing or toileting need, with participation documented. Review of the August 2025 through September 2025 PROM program documentation showed the following: - August: NO (did not occur), not applicable documented 40 times. - September: NO, not applicable documented 13 times. Review of August 2025 through September 2025 restorative program quarterly evaluations showed the following: -08/19/2025: Resident participating well without declines to ROM this quarter, continue program as recommended and monitor reviewed with restorative aids. -04/22/2025: Resident has participated regularly in PROM activities, tolerated it well, care plan continued. In an interview on 09/10/2025 at 10:18 AM, Staff EE, Nursing Assistant, stated they believed Resident 19 was on a restorative program for ROM that was completed by the Restorative Aids. In an interview on 09/10/2025 at 10:35 AM, Staff L, Occupational Therapist, stated Resident 19 was placed on a restorative program on 01/22/2025 for lower extremity ROM. Staff L stated they filled out a sheet with the program and gave it to the nurse to put it in the system. Staff L stated residents were placed on restorative programs for maintenance and they did quarterly assessments for changes in their baseline. In an interview on 09/10/2025 at 10:42 AM, Staff FF, Restorative Registered Nurse, stated Resident 19 was on a restorative program with the Nursing Assistants for ROM to their bilateral lower extremities. Staff FF stated Resident 19 refused the program once in the past 14 days. When asked if Resident 14 had a decline in their abilities, Staff FF stated not that they were aware of. Staff FF stated the Nurse Manager oversaw the programs, they only entered them and reviewed the programs quarterly or as needed. When asked who determined if the residents were maintaining their abilities, Staff FF stated they were not totally uninvolved, if they suspected a decline, they referred the residents to therapy. When asked who monitored to ensure Resident 19 maintained their ability to extend their knees 80 degrees, Staff FF stated the Restorative Aids if they were on a program with them and if it was completed by the Nursing Assistants it was by the Nurse Manager. Staff FF stated they completed the restorative evaluations and if they did not have a reason to suspect a change then they would enter a note that said the resident was tolerating the program well. Staff FF stated the programs should been conducted as written and the documentation should never say the program did not occur. Staff FF reviewed the restorative documentation and acknowledged it said the program did not occur, several times. In an interview on 09/10/2025 at 11:00 AM, Staff B, Director of Nursing, stated Staff FF, the Restorative Registered Nurse, monitored the therapy recommended programs and ensured residents maintained their abilities. In an interview on 09/11/2025 at 9:11 AM, Staff I, Nursing Assistant, stated they knew when a resident was on a restorative program by looking at their care plan. Staff I stated the Restorative Aids did the programs but if they did not have time to complete, then nursing assistant working the floor was to perform the program activities. Staff I stated the restorative aids had more skills than them. In an interview on 09/11/2025 at 9:15 AM, Staff GG, Restorative Aid, stated there were programs they did and programs the Nursing Assistant's did. Staff GG stated on the charting it showed who was supposed to do the program. When asked who was responsible for Resident 19's program, Staff GG stated the Nursing Assistants working the floor. In an interview and observation on 09/11/2025 at 11:42 AM, Staff M, Physical Assistant, entered Resident 19's room and performed ROM on their knees. Staff M stated the resident was probably ranging between 70-80 degrees. Staff M stated they needed their measuring tool. At 11:49 AM, Staff M and an assistant entered the resident's room with a goniometer (a measuring device to see how far a limb can extend). Resident 19's right knee extended to 78 degrees, not 80 degrees as care planned. In an interview on 09/11/2025 at 11:43 AM, Staff E, Resident Care Manager, stated Staff FF was in charge of maintaining the restorative programs. In an interview on 09/11/2025 at 12:07 PM, Staff A, Administrator, stated restorative programs were important to prevent declines in the resident's abilities. Staff A stated Staff FF oversaw the restorative programs for both the Restorative Aids and the Nursing Assistants working the floor, ensured residents' maintained their abilities, and care planned the programs for staff to reference. Staff A acknowledged they were aware there was a problem with the restorative nursing programs because the Nursing Assistants working the floor were providing the programs because the facility did not have a Restorative Aid for a long time. Reference: WAC 388-97-1060 (3)(d) (j)(ix) Refer to F725 for additional information

Based on interview and record review, the facility failed to administer medication according to provider orders for 3 of 5 residents (Resident 9, 43, and 63) reviewed for unnecessary medications. This failure placed residents at risk for medical complications and diminished quality of life. Findings included. <Resident 9> According to a comprehensive assessment, dated 07/17/2025, Resident 9 had diagnoses which included dementia (a disorder that caused impaired memory and reasoning), high blood pressure and heart failure (a condition where the heart muscle does not pump enough blood for the body's needs). They were alert and made their basic needs known. A review of the medical record documented a current order for Losartan (a medication to lower blood pressure) 100 milligrams (mg, a unit of measure) in the morning for high blood pressure. The order further showed the medication should not be given (held) if the systolic blood pressure (SBP, the top number of a blood pressure reading) was less than 110. A review of the Medication Administration Record (MAR) for August, 2025, documented the following instances when the medication was not administered according to the provider order: 1) On 08/09/2025 the blood pressure (BP) was 108/61 and Losartan was given. 2) On 08/21/2025 the BP was 116/79 and Losartan was held. 3) On 08/23/2025 the BP was 113/53 and Losartan was held. During an interview on 09/11/2025 at 12:23 PM, Staff K, Licensed Practical Nurse (LPN) stated that if an order for medication had parameters for when it should be given or held, those parameters showed up on the computer where the medication was documented on the MAR. They further stated that the medication should not be given if outside of the parameters, and those are set by the provider. During an interview on 09/11/2025 at 3:30 PM, Staff B, Director of Nursing, pulled Resident 9's August 2025 MAR up on their computer screen. After looking at the order and documentation, Staff B stated that the medication was not given on those days according to the provider order and staff needed to look closely at the parameters on the order and follow them. <Resident 43> The 08/21/2025 quarterly assessment documented Resident 43 had diagnoses that included heart failure and high blood pressure. The assessment further showed the resident was able to make their needs known. A review of the provider's orders documented Resident 43 received the following medications: -Amlodipine 5 mg twice daily for high blood pressure; hold medication if the SBP was below 110 and if the heart rate was less than 60. -Metoprolol Succinate 24 hour extended release 25 mg once daily for high blood pressure; hold medication if SBP was less than 110 and heart rate less than 60. The 08/2025 MAR showed Resident 43's blood pressure medication was given inappropriately on the following dates: Amlodipine: -08/01/2025 through 08/07/2025 the medication was given at night without a blood pressure and pulse being obtained prior to administration. -08/08/2025 the SBP in the morning was 103 and the medication was given; the medication was given at night without a blood pressure and pulse being obtained prior to administration. -08/09/2025 through 08/10/2025 the medication was given at night without a blood pressure and pulse being obtained prior to administration. -08/13/2025 the SBP was 109 and the medication was given. -08/15/2025 the SBP was 114 and the medication was not given. -08/26/2025 the SBP was 112 and the pulse was 76 and the medication was not given. -08/27/2025 the SBP was 101 and the pulse was 74 in the morning and the SBP was 105 and the pulse was 73 at night and the medication was given both times. -09/01/2025 the SBP at night was 101 and the pulse was 75 and the medication was given. -09/05/2025 there was an X in the box for the morning administration, and no vital signs were found. -09/08/2025 there was an X in the box for the night administration, and no vital signs were found. Metoprolol: -08/08/2025 the box said NA and the medication was given, no vital signs were found. -08/09/2025 the SBP was 103 and the pulse was 78, medication was given. -08/25/2025 the SBP was 112 and the pulse was 76, medication was not given. -08/26/2025 the SBP was 117 and the pulse was 71, medication was not given. -08/30/2025 there was an X in the box, and the medication was not given, and no vitals were found. -09/05/2025 the SBP was 117 and the pulse was 76, the medication was not given. -09/08/2025 the SBP was 103 and the medication was given. <Resident 63> The 08/08/2025 quarterly assessment documented Resident 63 had diagnoses that included a stroke and high blood pressure. The assessment further showed the resident was able to make their needs known. A review of the provider's orders documented Resident 63 received the following medications: -Amlodipine 10 mg once daily in the morning for high blood pressure; hold medication if the SBP was below 120 and if the heart rate was less than 60. -Hydralazine 50 mg three times daily for high blood pressure; hold medication if SBP was less than 120 and heart rate less than 60. -Lidocaine patches four percent, applied to the lower back in the morning for pain and was not to exceed three patches for up to 12 hours within a 24 hour period. The 08/2025 and 09/2025 MAR showed Resident 43's blood pressure medication was given inappropriately on the following dates: Amlodipine: -08/02/2025 the pulse was 54 and the medication was given. -08/02/2025 the SBP was 112 and the medication was given. -08/08/2025 there was an X in the box, and the medication was not given, and no vitals were found. -08/28/2025 there was an X in the box, and the medication was not given, and no vitals were found. -09/02/2025 the SBP was 117 and the medication was given. -09/09/2025 the SBP was 118 and the medication was given. -09/10/2025 the SBP was 101 and the medication was given. Hydralazine: -08/02/2025 the pulse in the morning was 54 and the medication was given. -08/04/2025 the SPB at night was 109 and the medication was given. -08/07/2025 the SBP in the morning was 112 and the medication was given, at noon there was an X in the box, and the medication was not given, and no vitals were found. -08/08/2025 there was an X in the box for noon, and the medication was not given, and no vitals were found. -08/12/2025 there was an X in the box for noon, and the medication was not given, and no vitals were found, the SBP at night was 118 and the medication was given. -08/14/2025 the SBP at noon was 136 and the pulse was 67, the medication was not given. -08/16/2025 the SBP at night was 114 and the medication was given. -08/17/2025 the SBP at night was 116 and the medication was given. -08/20/2025 the SBP at night was 119 and the medication was given. -08/25/2025 the SBP at night was 118 and the medication was given. -08/27/2025 the SBP at noon was 103 and the medication was given. -09/01/2025 the SBP at noon was 104 and the medication was given. -09/02/2025 there was an X in the box for noon, and the medication was not given, and no vitals were found. -09/06/2025 the SBP in the morning and night was 55 and the medication was given both times. -09/07/2025 the SBP at night was 111 and the pulse was 59, the medication was given. -09/08/2025 the SBP at noon was 104 and the medication was given. -09/09/2025 the SBP in the morning was 118, at noon it was 116 and the medication was given both times. -09/10/2025 the SBP in the morning was 101, at noon it was 101, and the medication was given both times. Lidocaine Patches: The August 2025 MARs showed the following: -08/02/2024 NA -08/07/2025 NA 100 -08/09/2025 NA -08/10/2025 NA 120 -08/27/2025 NA -09/07/2025 NA 100 -09/10/2025 NA 120 In an interview on 09/08/2025 at 12:00 PM, Staff D, Registered Nurse, stated when a blood pressure medication was given you needed to obtain a blood pressure, review the parameters and if the blood pressure and pulse were out of the parameters you were to hold the medication and notify the provider. Staff D was asked to read the blood pressure orders and how they understood them. Staff D stated that meant you were to hold the medication when both the pulse and blood pressure was out of the parameters. Staff D stated it was important to administer the medication as ordered to prevent complications of high blood pressure such as a stroke. Staff D was asked what NA meant in the MAR and they stated it meant non applicable. Staff D stated they had an emergency supply of medications in the PIXUS (a machine that held medications) and when a medication was not available they would check their overflow medications and call the pharmacy to have the medication sent as soon as possible. In an interview on 09/08/2025 at 12:30 PM, Staff B, Director of Nursing, stated they would hold the blood pressure medication if the SBP or the pulse were out of the parameters and notify the physician. Staff B reviewed the medications above and stated they should have been given as ordered. Staff B stated they were unaware of what NA meant on the MAR because they had never seen that before. Staff B stated medications were reordered just before they ran out, within three to five days. Staff B stated the nursing staff should have checked the emergency medication supply when they were out of a medication and called the pharmacy. Staff B stated they were able to request a stat delivery. Staff B stated their expectation was for nursing to reorder the medications in a timely manner and to notify them if they were not receiving the medications. In an interview on 09/09/2025 at 9:50 AM, Staff PP, Medical Director, stated their expectation was for nursing staff to hold the blood pressure medication if either the SBP or the pulse was out of the parameters. Staff PP stated they did not expect the nurses to notify them when the medications were held because the medical record was set up so that they were notified automatically. In an interview on 09/11/2025 at 10:51 AM, Staff B stated Resident 63 should have received their lidocaine patches as ordered and it was important for pain management. Reference: WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to provide evidence that the Medical Director received and reviewed the content of Quality Assurance & Performance Improvement (QAPI) meetings when they were not present, communicated with and participated in the QAPI process, as required. This failure minimized the effectiveness of the interdisciplinary Quality Assessment & Assurance (QAA) team's ability to identify potential quality of care deficiencies and develop and implement corrective action. This failure placed residents at risk for complications, unmet needs, and diminished quality of life.Findings included.An undated facility policy titled Aurora Valley Care QAA Committee, showed the purpose was to coordinate and evaluate activities under the QAPI program. The policy further showed the following data would be reviewed at the meetings: 3 months of QAPI minutes/data, risk managements incident reports, grievance log, survey results, staff turnover, staff and resident satisfaction, infection control and facility quality measure triggers.Review of the facility policy titled QAPI Plan policy revised May of 2023, showed responsibilities of QAA members included reviewing data, suggestions and input from residents, staff, family members and other stakeholders. Additionally, they would determine performance improvement plans (PIPS), how to correct issues or problems, monitor progress and provide input.During an interview on 09/12/2025 at 3:12 PM, Staff A, Administrator, explained the QAPI team included the QAA team as well as department heads of the facility included Staff PP, Medical Director and met quarterly (every three months). During a follow-up interview on 09/15/2025 at 9:48 AM, Staff A stated QAPI data has been uploaded into the cloud (platform utilized to save electronic data) since May 2025 and committee members had access to it. Staff A did not provide any evidence that showed the members read the uploaded QAPI meeting data. During a follow-up interview on 09/15/2025 at 10:14 AM, Staff A acknowledged the medical director did not attend QAA meetings in December 2024, February 2025, May 2025 or August 2025. Staff A further stated that it was important for the medical director to attend the meetings to provide input, be aware of failed practices and to ensure potential identified issues in the facility were being worked on.A review of a 09/15/2025 e-mail correspondence between Staff A and a survey team showed the surveyor requested copies of the QAPI/QAA meetings sign-in sheets from August 2024 through August 2025. Staff A provided sign-in sheets for 08/29/2024 and 12/04/2024. Review of the documentation provided showed it did not include a signature from the medical director to show their attendance or participation. Staff A reported they misplaced the sheets for February or March of 2025. Staff A was asked when the last time the medical director was involved with QAPI by physically attending, by phone, or other methods. Staff A acknowledged Staff PP attended the February 2025 meeting, approximately 7 months ago.No further documentation was provided.Reference: WAC 388-97-1760(1)(2)

Based on interview and record review the facility failed to ensure direct care staff received training on effective communication, as required. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included.Review of the staff list provided to the survey team on 09/03/2025 showed the facility employed 89 direct care staff. Effective communication training for all direct care staff was requested from Staff A, Administrator, on 09/15/2025 at 9:08 AM. Review of documentation provided showed only eight out of 89 direct care staff completed training on effective communication. In an interview on 09/15/2025 at 12:40 PM, Staff AA, Nursing Assistant, stated if they received training on effective communication, it would be documented in the electronic training records. In an interview on 09/15/2025 at 12:56 PM, Staff R, Licensed Practical Nurse, stated if they received training on effective communication, it would be documented in the electronic training records. In an interview on 09/15/2025 at 12:59 PM, Staff A, stated training on effective communication was new to the facility this year, and was scheduled to begin November 2025. Staff A acknowledged staff had not received training on effective communication. Staff A stated they expected staff to receive training on effective communication, as required. Reference WAC 388-97-1680

Based on interview and record review the facility failed to ensure all staff received training on the Quality Assurance and Performance Improvement (QAPI, a systemic interdisciplinary comprehensive data-driven approach to maintaining and improving safety and quality in nursing homes) program, as required. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included.Review of the staff list provided to the survey team on 09/03/2025 showed the facility employed 109 staff. QAPI training for all staff was requested from Staff A, Administrator, on 09/15/2025 at 9:08 AM. No documentation was provided. In an interview on 09/15/2025 at 12:40 PM, Staff AA, Nursing Assistant, stated if they received training on the facility's QAPI program, it would be documented in the electronic training records. In an interview on 09/15/2025 at 12:41 PM, Staff BB, Receptionist, stated I don't know what QAPI is. Should I know what that is? In an interview on 09/15/2025 at 12:47 PM, Staff CC, Maintenance Assistant, explained QAPI was a way for quality improvement through standardized metrics and achievable goals. Staff CC further stated they were unsure of the facility's QAPI process. In an interview on 09/15/2025 at 12:55 PM, Staff N, Housekeeping Manager, stated if they received training on the facility's QAPI program, it would be documented in the electronic training records. In an interview on 09/15/2025 at 12:56 PM, Staff R, Licensed Practical Nurse, stated if they received training on the facility's QAPI program, it would be documented in the electronic training records. In an interview on 09/15/2025 at 12:59 PM, Staff A, Administrator, acknowledged all staff had not received training on QAPI. Staff A stated they expected staff to receive training on QAPI, as required. No associated WAC

Based on observation, interview and record review, the facility failed to ensure contact information of all pertinent State regulatory and advocacy groups were provided and/or posted for 4 out of 5 residents interviewed (Residents 38, 21, 34, and 46) during Resident Council. Failure to ensure contact information was posted at levels that were readable and accessible to residents in wheelchairs, placed the residents at risk of not being fully informed of their rights, potential abuse and/or neglect, and a diminished quality of life.Findings included.During a Resident Council meeting on 09/05/2025 at 12:05 PM, attendees were asked if the facility informed them how to contact the State Agency if they had concerns regarding their care. Residents 21, 34, 38, and 46 all stated they had not been informed or remember being informed on how to report to the State Agency. On 09/05/2025 at 12:10 PM, a large green and white poster was observed on the wall next to the main dining room. The poster was titled, We Care about Your Concerns and included the contact information for the State regulatory agency and advocacy groups. The poster was situated high on the wall and not at a level that was readable or accessible for a resident who utilized a wheelchair for mobility. Residents 21, 38, and 46 all utilized wheelchairs. During an interview on 09/05/2025 at 2:17 PM, Residents 21 and 46 were informed of the poster on the wall next to the dining room and were given an information sheet that contained the contact information for the State regulatory agency and advocacy groups. Residents 38 and 34 were asleep in their respective rooms and the information sheet was left on their bedside tables. During an interview on 09/12/2025 at 11:41 AM, Staff A, Administrator, acknowledged the We Care about Your Concerns poster was not at eye level for residents who used wheelchairs and stated it would be moved. Reference: WAC 388-97-0300(7)(a-d)

Based on interview and record review, the facility failed to periodically review resident rights with residents during their stay at the facility for 4 of 5 sampled residents (Residents 21, 34, 38, and 46) interviewed during the Resident Council meeting. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life. Findings included.During a Resident Council meeting on 09/05/2025 at 11:47 PM, attendees were asked if the facility discussed their rights as residents and if they felt they were able to exercise their rights. Resident 38 stated residents were only given a copy of their rights if they asked for them. Residents 21 and 46 stated they did not remember ever being offered information on resident rights or having discussions about their rights. Resident 34 stated they were unable to exercise their rights if they did not know what their rights were. The residents confirmed they had not seen posted information related to resident rights. Review of the Resident Council minutes documented the following: - on 06/23/2025, nine residents attended the meeting. Copies of the Resident [NAME] of Rights were given to new residents, but the minutes did not document who those residents were. The minutes did not include documentation that the Resident [NAME] of Rights was discussed with all of the residents. - on 07/28/2025, five residents attended, and no documentation was found that showed resident rights were discussed or copies were provided.- on 08/25/2025, six residents attended. Three residents received a copy of the Resident [NAME] of Rights. There was no documentation that showed the Resident [NAME] of Rights was discussed or reviewed with all the residents.On 09/05/2025 at 12:10 PM, a poster titled, Know Your Rights and an attached binder and laminated sheets that contained information on the resident's rights was observed posted on the wall next to the dining room. The poster and binder were placed high on the wall and not at a level that was readable or accessible for a resident who utilized a wheelchair for mobility. Residents 21, 38, and 46 all utilized wheelchairs. During an interview on 09/09/2025 at 10:12 AM, Staff DD, Life Enrichment Director, stated residents were notified of their right when they were admitted to the facility, and usually only new residents received a copy of the resident rights, because most of the residents had lived at the facility a long time. During an interview on 09/12/2025 at 11:41, Staff A, Administrator, acknowledged the Know Your Rights poster and binder were not at eye level for residents who used wheelchairs, and stated resident rights should be reviewed/discussed periodically with all residents. Reference: WAC 388-97-0300(1)(a), (7)(b)

Based on interview and record review, the facility failed to ensure informed consents that explained the potential risks and benefits associated with the use of psychotropic medications (medications that affected mood or emotions) were obtained from the resident or their representative prior to their administration for 2 of 5 sampled residents (Residents 27 and 63) reviewed for unnecessary medications. This failure placed the residents and/or their representatives at risk of not being fully informed of the potential risks and benefits of receiving the medications. Findings included. <Resident 27> The 07/06/2025 quarterly assessment documented Resident 27 had diagnoses that included depression and received psychotropic medication to treat the symptoms of the depression. Review of the Medication Administration Records (MARs) for August and September 2025 documented the psychotropic medication, Escitalopram, was prescribed by the physician on 04/12/2025, and Resident 27 received the medication daily as ordered. Review of Resident 27's record from 04/12/2025 through 09/08/2025 found an informed consent for the Escitalopram was completed on 08/27/2025, 45 days after the medication had been prescribed and administered to Resident 27. During an interview on 09/08/2025 at 1:42 PM, Staff D, Registered Nurse, stated informed consents needed to be obtained when the medication was prescribed and prior to the medication being administered to the resident. During an interview on 09/08/2025 at 3:00 PM, Staff C, Social Services Director, stated informed consents for psychotropic medications needed to be obtained prior to a resident receiving the medication, and after review of Resident 27's record, confirmed the consent had not been obtained timely. <Resident 63> The 08/08/2025 quarterly assessment documented Resident 63 had diagnoses that included restlessness and agitation and received psychotropic medications daily. The Order Summary Report documented on 08/08/2025, Resident 63 was prescribed Duloxetine to treat depression, and on 05/30/2025 Seroquel to treat anxiety and restlessness. Review of the May and August 2025 MARs documented Resident 18 received the first dose of Duloxetine on 08/08/2025 and Seroquel on 05/30/2025. Review of the Psychoactive Medication Informed Consent documented Resident 63 signed the consent for Duloxetine on 08/20/2025, twelve days after the medication was first administered and Seroquel on 07/16/2025, forty-seven days after the medication was first administered. Further review of Resident 63's record did not show any additional documentation, either verbally or written, that the resident was educated regarding the reason the medications were prescribed and the risks/benefits expected from taking the medications had occurred. During an interview on 09/09/2025 at 11:38 AM, Staff D stated psychotropic medication informed consents were to be obtained prior to the first dose being given. During an interview on 09/11/2025 at 10:51 AM, Staff B, Director of Nursing, stated psychotropic informed consents were to be obtained prior to giving the first dose. This was important so residents were aware of the risks of the medications. Reference: WAC 388-97-1020(4)(a-b)

Based on interview, and record review, the facility failed to schedule a dental appointment for 1 of 1 sampled resident (Resident 59), reviewed for dental services. Resident experienced on-going mouth pain when there was a delay in coordination of a dental extractions appointment. This failed practice placed residents at risk of diminished quality of life. Findings included . Review of 03/20/2024 quarterly assessment, Resident 59 was cognitively intact, able to make decisions regarding their care, and had diagnoses which included cavities. Review of dental care plan, dated 01/02/2024, documented Resident 59 had broken teeth and instructed nursing staff to coordinate arrangements for dental care. Review of a dental visit note, dated 05/15/2024, documented Resident 59 requested to have all their teeth extracted because they experienced pain. In addition, the dentist documented the resident had several teeth extracted during that visit due to the pain and a referral was made to have the remaining teeth extracted. Further review of the resident's record found no documentation that the referral had been done, nor was there any documentation to show the resident's remaining teeth had been extracted. Review of a progress note, dated 06/05/2024 at 4:18 PM, documented Resident 59's bottom row of their teeth were breaking and causing pain. During an interview on 06/18/2024 at 2:15 PM, Resident 59 stated they had mentioned to Staff I, Resident Care Manager, and Staff J, Transportation Staff, about a month ago they needed a dental appointment set up to have their teeth extracted by a surgeon. During a follow up interview on 06/20/2024 at 9:41 AM, Resident 59 stated their teeth caused them constant pain. The resident rated their pain a 10 on a scale of 1-10 (1 being mild and 10 being severe pain). During an interview on 06/21/2024 at 9:48 AM, Resident 59 stated their pain was a 10 the night before and was currently a 6. In a subsequent interview at 1:53 PM, Resident 59 stated their pain remained a six and a dental appointment still had not been made. In an interview on 06/25/2024 at 2:20 PM, Staff J stated they were responsible to make appointments and arrange the transportation when a resident had an outside provider appointment. When asked if an appointment had been made for Resident 59 to have their teeth extracted, Staff J stated they had been notified by Staff I that the resident had dental pain and an appointment needed to be made, but it appeared to have been missed. In an interview on 06/25/2024 at 2:26 PM, Staff I stated if an appointment had been made for Resident 59 to have had their teeth extracted, they would not have had the mouth pain and Staff I acknowledged that Resident 59 the pain. During an interview on 06/25/2024 at 2:37 PM, Staff B, Director of Nursing, confirmed Resident 59 should have had a dental appointment made. Reference: WAC 388-97-1060 (3)(j)(vii)

Based on interview and record review the facility failed to act timely after altercations between Resident 1 with a roommate (Resident 2) for 1 of 4 sampled residents (Resident 1), reviewed for abuse. Resident 1 experienced verbal abuse and psychosocial harm evidenced by anxiety, tearfulness, lack of sleep, and expressed fear and not feeling safe in the facility because of their roommates' behaviors. This failure placed residents at risk of verbal and mental abuse, psychosocial harm, and diminished quality of life. Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse . dated 08/2022, defined verbal abuse as oral, written, or gestured language that included disparaging and derogatory terms to the resident or within their hearing distance that would demean or humiliate. Mental abuse could be verbal or non-verbal and included humiliation, harassment, and threats of punishment. Neglect was defined as disregard for resident care, comfort or safety that resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress. The policy further showed the facility would implement prevention techniques which included ongoing supervision of residents and staff, observation, and recognition of signs of resident-to-resident frustration or stress. Staff were to identify, intervene, and correct situations where abuse, neglect, and/or mistreatment were likely to occur such as resident with needs and behaviors that might lead to abuse. The policy instructed staff to provide for the immediate safety of the resident upon identification of potential abuse, neglect, or mistreatment by moving the resident to another room or unit. <Resident 1> Review of the admission assessment, dated 04/16/2024, showed Resident 1 admitted to the facility on [DATE] with diagnoses including liver cirrhosis with ascites (scarred and damaged liver that causes fluid to build up in the abdomen), and malnutrition (serious condition where the body has a nutrient deficit). Resident 1 was cognitively intact and able to make their needs known. Review of the 04/09/2024 hospital discharge summary showed Resident 1 had a complex medical history and was discharged to the facility for ongoing therapy and medical management. Review of Resident 1's May 2024 nursing progress notes showed Resident 1 had a room change on 05/06/2024. On 05/07/2024 Resident 1 reported to staff they got no sleep because of their new roommate (Resident 2) yelled all night. Resident 1 was noted to be anxious on 05/09/2024, and 05/10/2024. On 05/13/2024 at 4:44 AM, Resident 1 was distressed by Resident 2 and requested staff to take them out of the room to the nurses' station so they could be in peace. Resident 1 sat at the nurses' station silently and then slept for two hours. On 05/14/2024 at 10:49 PM, Resident 1 was upset and cried because Resident 2 screamed F**k you b***h, I will kill you! You devil. Resident 1 requested a different roommate. Resident 1 was moved to a different room on 05/15/2024, the following day. No documentation for monitoring potential psychological harm was found. Review of the May 2024 facility incident log showed a resident-to-resident altercation between Resident 1 and Resident 2 occurred on 05/14/2024 at 10 PM with the action taken listed as a room move. A second entry for a resident-to-resident altercation between Resident 1 and Resident 2 that occurred on 05/15/2024 at 12:27 PM with the action taken listed as a care plan revision. In an interview on 06/07/2024 at 2:54 PM, Resident 1's spouse stated Resident 2 yelled and was belligerent. Resident 2's behavior bothered their spouse, and they had to be moved out of the room. In an interview on 06/07/2024 at 2:59 PM, Resident 1 stated they feared Resident 2 because they yelled aggressively. Resident 2 called Resident 1 the devil then told Resident 1 they were going to kill them and everyone else. Resident 1 stated Resident 2 yelled like that every night, staff was aware of the situation, but it took staff a few days to move Resident 1 out of that room. Resident 1 further stated staff did not check on them after the incident occurred, they did not feel safe in the building, and decided to discharge the facility against medical advice (AMA). Resident 1 stated the incident still bothered them, but they felt safe at home with their spouse. Review of Resident 1's June nursing progress notes showed Resident 1 planned to discharge AMA on 06/04/2024 after they attended an appointment they had that day. The notes did not specify the details of why Resident 1 chose to discharge AMA. Resident 1 discharged the facility AMA on 06/04/2024 at 12:44 PM. Review of the 06/04/2024 AMA form showed Resident 1 was informed of the medical risks versus benefits of discharge from the facility AMA. The AMA form was signed by Resident 1 and their spouse. <Resident 2> Review of the quarterly assessment, dated 04/07/2024, showed Resident 2 had diagnoses that included stroke (blocked blood flow to the brain which can lead to permanent damage and cause confusion and problems with talking or understanding language), and dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities). Resident 2 had moderate cognitive impairment and exhibited no behaviors which were unchanged from the previous assessment. Review of Resident 2's April 2024 and May 2024 nursing progress notes showed Resident 2 yelled, and cursed when cares were provided, which had increased in frequency. Resident 2 experienced hallucinations (false perceptions of things that were not there but seem real to the person that experienced them), delusions (abnormal thought process with false beliefs that someone holds firmly even when presented with evidence to contrary), and verbal outbursts. On 05/14/2024 at 7 PM, Resident 2 began to yell F**k you, I will kill you! You devil when staff assisted them to bed with the mechanical lift. Resident 2 did not calm down until 9:10 PM, (2 hours and 10 minutes later). On 05/15/2024 at 7:06 AM, Resident 2 had an anger outburst, yelled out, called staff demons, and yelled at staff to get away from them, when staff provided AM cares. At 12:32 PM that same day, staff heard Resident 2 yell at their roommate (Resident 1). Review of the care plan initiated 04/18/2024 showed Resident 2 had a history of demonstrating verbally abusive behaviors of cursing at staff and/or other residents related to poor impulse control, pain, and cognitive impairment. The 04/18/2024 care plan showed Resident 2 became verbally aggressive towards staff when care was provided and would become verbally aggressive towards other residents when their spouse left. Resident 2 was unable to understand the effect of their cursing or give an explanation as to why they said certain things. Interventions dated 04/18/2024, instructed staff to document Resident 2's behaviors, assess and anticipate their needs for food, thirst, toileting, comfort, body positioning, and pain. Interventions dated 04/18/2024, instructed staff to intervene before agitation escalated, guide the resident away from the source of distress, engage calmly and if Resident 2 responded aggressively staff were to walk away calmly and approach later. No new interventions were added to Resident 2's care plan after the 05/14/2024 or 05/15/2024 incidents with Resident 1. Review of the 05/14/2024 and 05/15/2024 facility incident investigation showed Resident 2 had severe cognitive impairment and had been at the facility for two and a half years. Resident 2 had behaviors that were triggered when staff provided care or when Resident 2 saw others in their room. On 05/14/2024 around 7 PM staff assisted Resident 2 to bed which caused Resident 2 to yell and curse at staff. Resident 1 was upset, afraid, cried, and slept in the hall for a couple of hours related to hearing Resident 2 yell and curse because Resident 1 thought the yelling was directed towards them. The investigation summary showed Resident 1 was moved on 05/15/2024, Resident 2's care plan was revised to include potential for verbally aggressive behaviors and interventions to help manage and de-escalate behaviors, details of interventions added were not listed. The summary further showed staff were educated on the care plan revisions. Resident 1 had no long-lasting psychosocial harm related to the incident and abuse was unsubstantiated. In an interview on 06/12/2024 at 12:40 PM, Staff C, Lead Nursing Assistant, stated Resident 2 screamed a lot and would call staff offensive, derogatory, and vulgar names when care was provided. Resident 2 could be a sweet and nice person but could also quickly flip and become very mean and aggressive without warning. Resident 2 had verbal behaviors several times per week. Staff C further stated Resident 2 had issues with roommates because the roommates felt uncomfortable and threatened by Resident 2's verbal behaviors. Staff C acknowledged Resident 1 was distressed by Resident 2's behaviors and stayed up in their wheelchair all night one night because Resident 1 did not want to go back in the room with Resident 2. In an interview on 06/12/2024 at 1:11 PM, Staff D, Registered Nurse, stated Resident 2 has had behaviors for some time that included waking up at night screaming, shouting for people to get out of their room, and yelling profanities. Staff D acknowledged Resident 2 sounded aggressive when they yelled because they would yell lots of profanities and things like I am going to kill you! Staff D stated Resident 2's yelling upset Resident 1, and Resident 1 was moved out. In an interview on 06/12/2024 at 1:57 PM, Staff E, Resident Care Manager, stated Resident 2 had lots of verbal behaviors, almost daily. Staff E acknowledged Resident 2 would yell at their roommates and Resident 2's roommates would be afraid of the yelling because it was very verbally aggressive. In an interview on 06/12/2024 at 2:37 PM, Staff F, Social Services Director, stated Resident 2 had been at the facility for over years and frequently experienced verbally aggressive behaviors directed towards others. Staff F stated Resident 2's behaviors were unpredictable. Staff F reviewed Resident 2's medical record. Staff F stated Resident 2 required frequent redirection but was unable to state what behavioral interventions Resident 2 had in place. Staff F reviewed Resident 1's medical record. Staff F acknowledged Resident 1 was distressed on 05/13/2024 because their roommate (Resident 2) yelled out F**k you, I will kill you! Resident 1 requested to be taken to the nurses' station and slept in their wheelchair for two hours. Resident 1 was moved rooms on 05/15/2024. Staff F further stated Resident 1 discharged home AMA shortly after the incident with Resident 2. In an interview on 06/12/2024 at 3:19 PM, Staff H, Resident Care Manager, reviewed Resident 2's medical record. Staff H acknowledged Resident 2 liked to yell out and curse at others, almost daily. Resident 2 yelled out and said things like get the f**k out of my room and I am going to kill you! Staff H reviewed Resident 1's medical record. Staff F acknowledged Resident 2 yelled I am going to kill you! one night and Resident 1 was worried Resident 2 (their roommate) was talking to them and would do something to them. In a phone interview on 06/12/2024 at 4:14 PM, with Staff A, Administrator and Staff B, Director of Nursing, they acknowledged Resident 2 had verbal behaviors directed towards others for at least six months that were triggered when care was provided. Staff A stated interventions included guiding Resident 2 away from the source of agitation and try to figure out if they had any unmet needs such as thirst, pain, or hunger. Staff A stated Resident 2 had a history of issues with roommates because they did not understand the room was a shared space. Both Staff A and Staff B acknowledged Resident 1 was distressed by Resident 2 because Resident 2 yelled out and Resident 1 could not get sleep which ultimately resulted in Resident 1 being moved out of the shared room. Reference WAC: 388-97-0640 (1) See F744 for additional information.

Based on observation, interview, and record review, the facility failed to recognize and remove safety hazards prior to a burn injury occurring for 1 of 3 sample residents (Resident 1), reviewed for accidents. The facility was aware the resident was using a heating device that could potentially cause injuries yet did not address the issue until a burn occurred. This failure resulted in actual harm to Resident 1 who sustained a preventable burn injury. Findings included: A quarterly assessment, dated 01/02/2023, showed Resident 1 was cognitively intact and required extensive assistance of two people with bed mobility, setup assistance to eat meals, and had limited range of motion in both upper arms. Record review of the facility investigation showed that on 03/22/2023 at about 1:00 PM, Resident 1 requested facility staff to heat water in their personal electric hot pot to make soup. The hot soup was placed on the resident's bedside table after which the resident knocked it over and it spilled onto their right chest and abdomen. The investigation further showed that the spilled soup caused 2nd degree burns (involving the top and 2nd layer of skin, causing redness and blistering, swelling and pain) to the resident's right chest and abdomen. Facility interviews showed that the facility direct care staff were aware the resident had a hot pot or heating element that would boil water in a minute in their room, and staff were using it at the resident's request, to heat water to make the resident soup. During an interview on 03/27/2023 at 10:51 AM, Resident 1 confirmed that they sustained a burn to their right chest and abdomen when they knocked hot soup onto themselves while lying in bed. They further stated that staff had been making them soup using their electric hot pot for a while by heating water to boiling and pouring it over dry noodles in a bowl which staff then placed on the resident's bedside table. The resident stated that they had arthritis in their hands, and sometimes had tingling and numbness which made it hard to grab things. They further stated that they had spilled the soup before but had never been burned. Observation on 03/27/2023 at 10:51 AM of Resident 1's right hand showed a scab covering the tip of their right ring finger and redness at the tip of their right fifth finger. The resident confirmed this had happened when they spilled the soup. The resident refused to allow the burned area on their chest and abdomen to be visualized and stated that they did not want anyone to get in trouble. Record review of a skin assessment for Resident 1, completed on 03/22/2023 at 2:31 PM, showed a red area 13 centimeters (cm.) by 15 cm. on their right chest and abdomen, with blisters forming on the right chest area. Record review of a nurse progress note, dated 03/23/2023 at 1:26 PM, showed that Resident 1 had pain related to a burn on their chest, abdomen, and right fingertips. During an interview on 03/27/2023 at 11:01 AM, Staff D, Nursing Assistant (NA), stated that Resident 1 had a little tea pot in their room to warm up water that they would ask the staff to use to make hot water for soup. Per Staff D, they would put the noodles in a bowl, pour the hot water over the noodles, and then place the bowl on the resident's table for the resident to eat. They further stated that the resident had the tea pot for a while, and all the staff were aware of it because it was in plain sight. They further stated that they knew Resident 1 had trouble holding onto things and sometimes had trouble with being able to feel things they were holding. During an interview on 03/27/2023 at 11:19AM Staff E, NA, stated that Resident 1 liked hot soup and ate the soup sometimes two to three times a day. They further stated that staff prepared the soup by warming water up in a teapot that Resident 1 had in their room, and that usually the teapot was sitting right out on their table/shelf where the resident kept extra food. Staff E stated that they thought everyone knew about it because it was out in the open and that staff had been preparing the soup for the resident for months. During an interview on 03/27/2023 at 11:00 AM Staff B, Maintenance Director, stated that the maintenance staff complete monthly sweeps for fire hazards. They stated that would include an electric tea pot or coffee pot or any kind of heating device. They further stated that they started in the position about a month ago but had never seen the electric tea pot in Resident 1's room, but they knew that resident would purchase items and have them delivered to the facility. Staff B further stated that per facility policy, staff were supposed to notify maintenance when a resident had an electrical appliance so they could check it out, but that an electric tea pot or hot pot would not be okay for a resident to have in their room. Record review of an undated facility procedure titled Safety Inspection for Personal Electrical Articles, showed that staff should request maintenance staff to inspect and document all incoming electrical articles/appliances as quickly as possible but prior to use. During an interview on 03/27/2023 at 10:39 AM, Staff A, Corporate Nurse, stated that maintenance and social service staff had completed a sweep of the facility that morning and had removed one other similar heating device after a resident gave permission to do so. They also confirmed Resident 1 had sustained 2nd degree burns related to the soup having spilled onto their chest and abdomen. During an interview on 03/27/2023 at 11:28 AM, Staff C, Social Service Director, stated that they had spoken to Resident 1 that morning about the incident where they were burned by hot soup, and the resident had thrown the tea pot in the garbage. They stated that the facility staff were being educated on reporting electrical appliances to maintenance so they could check to make sure they met facility policy before they were used by residents, and they thought some staff may not have known to do this. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to monitor and intervene timely for 2 of 2 sample residents (9, 17), who experienced changes related to medication management. These failures caused actual harm to Resident 9, a resident with mental health diagnoses, who did not receive necessary medication secondary to required lab work not being completed and experienced anxiety, inadequately controlled insomnia, and a diminished quality of life, and placed Resident 17 at risk for worsening symptoms of heart failure. Findings included . Resident 9 Per the 12/08/2022 comprehensive assessment Resident 9 had diagnosis of anxiety, schizophrenia (a mental health condition in which people interpret reality abnormally), and Chronic Obstructive Pulmonary Disease (COPD - a lung disease that makes it difficult to breathe). Resident 9 was cognitively intact and able to make their needs known. Per the January 2023 Order Summary Report Resident 9 had medication orders to receive Clozaril (an antipsychotic requiring monthly lab draws prior to refills), to be given in the morning, and bedtime for schizophrenia (see above definition). Per the January 2023 Medication Administration Record (MAR), Resident 9 did not receive Clozaril on the evening of 01/06/2023, or on 01/07/2023, 01/08/2023, or 01/09/2023. The website PDR.net - in which PDR refers to Prescriber's Digital Reference - with regard to the medication Clozaril showed, Abrupt discontinuation of Clozapine [Clozaril] is not recommended (due to the rebound and recurrence of psychotic symptoms) . A nursing progress note on 01/07/2023 showed the medication was not available. There was no documentation related to an assessment of the resident's condition after not being able to obtain the medication. Per a 01/09/2023 1:06 AM progress note, Staff BB, Registered Nurse (RN), documented Resident 9 complained of 9/10 heart pain, and was transported to the hospital for further evaluation per resident request. Per interview on 01/09/2023 at 11:18 AM, Resident 9 acknowledged they went to the hospital the previous night, and stated they had not received Clozaril since 01/05/2023, and they should have received it twice daily. The resident's record was reviewed during the time the resident was not receiving the medication, and nursing staff were not monitoring the resident's reaction to having the medication stopped abruptly. Per interview on 01/09/2023 at 2:46 PM, Resident 9 reported they sustained two falls the previous night and one fall that morning, indicating two falls occurred outside in the smoking area. Resident 9 further stated they fell because they were too exhausted, as they couldn't sleep after not receiving the medication. There was no documentation of the falls. Per a 01/09/2023 note Staff U, Physician Assistant (PA), confirmed Resident 9 had not had a provider managing their lab work for the Clozaril since prior to admission. The PA note showed the previous night Resident 9 had some anxiety with chest pain, and was sent out to the hospital for further evaluation. Per a 01/09/2023 note Staff V, PA, wrote Resident 9 stopped receiving Clozaril on 01/5/2023. Staff V wrote in the note that Resident 9 reported increased anxiety and depression since stopping the Clozaril. The note also showed the resident told Staff V they had a decreased appetite, lack of energy, and poor sleep since stopping Clozaril. Resident 9 felt Clonazepam (another medication used to help reduce anxiety) was not sufficient for their anxiety. Staff V, PA, ordered immediate labs to restart the Clozaril. A provider note by Staff U, PA, on 01/10/2023 showed the medication (Clozaril) had still not been sent, and the resident was pacing the halls, reported increased anxiety, and was inquiring about the medication. A nursing progress note on 1/10/2023 showed the resident was not sleeping, and drinking coffee. Per interview on 01/11/2023 at 3:09 PM, Staff D, Social Services Director (SSD), confirmed the provider was aware the resident's Clozaril supply was running low the week prior, and the medication ran out on 01/09/2023. Staff D acknowledged the facility had previous experience managing this drug in the past, confirming Clozaril had strict guidelines requiring lab draws prior to sending refills. Per interview on 01/11/2023 at 3:31 PM, Staff C, Assistant Director of Nursing, stated they were unaware that Resident 9 did not have Clozaril for several days and was unsure of the refill process. Per interview on 01/12/2023 at 2:27 PM, Staff B, Director of Nursing Services (DNS), denied knowing why the resident ran out of Clozaril but confirmed that the medication was filled, with future follow up needed. Per observation and interview on 01/13/2023 11:47 AM, Resident 9 had disorganized thinking and was hyperverbal (talking excessively). Resident 9 spoke rapidly and changed subjects quickly, requiring the surveyor to redirect conversation numerous times. Resident 9 confirmed trouble sleeping stating that not having Clozaril is distressing causing their heart to beat really fast. Resident 9 stating they were self-medicating with marijuana to try to calm down when their heart pounded. Per inteview on 01/13/2023 at 1:04 PM Staff B, DNS, denied knowing about Resident 9's reported falls from 01/09/2023 but stated they would look into it. The DNS spoke to the resident on 01/17/2023 about the falls, and wrote a nursing communication note to therapy related the resident having had multiple unreported falls, with all but one being unwittnessed. Staff B also completed an incident report related to the falls. Further review of Resident 9 records showed the resident started receiving Clozaril again on 01/10/2023. Per interview on 01/13/2023 at 6:44 PM, Staff B, DNS, confirmed Resident 9 had not been on alert monitoring for a while, but would be placed on alert monitoring for marijuana use. 42802 Resident 17 According to a 12/07/2022 admission assessment, Resident 17 was cognitively intact and made their own decisions. The resident had diagnoses which included congestive heart failure (a condition where the heart weakens and doesn't pump blood as well as it should. Symptoms included shortness of breath, swelling of the legs/feet and weight gain from fluid buildup). A facility Weight Monitoring policy, dated 12/2019 and revised 11/14/2022, showed that the nursing assistant (NA) was to obtain the resident's weight at admission, weekly for four weeks, and monthly after that, and report results to the nurse. The policy also showed the licensed nurse was to monitor weights for any changes. A review of the resident's admission orders showed that they were on two different diuretics (medications to reduce swelling and manage heart failure), and the resident's weight was 190.4 pounds on 11/30/2022, the day of admission. A progress note from the admitting physician, dated 12/02/2022, showed that the resident had swelling of both their arms and legs. A 12/15/2022 provider progress note showed that the resident had swelling of both legs. TED hose (a type of compression stockings to treat leg swelling) were ordered on 12/20/2022. The order instructed staff to put them on in the morning and remove them at bedtime. A review of the December 2022 and January 2023 Medication Administration Record (MAR), showed the order for TED hose was signed off by the nurse as done twice daily (on in the morning and off at bedtime) from 12/22/2023 through 01/13/2023, except for one day (12/31/2022.) There were no notations that the resident had declined or refused. According to the resident record, their next weight was 201 pounds on 12/22/2022, an increase of 11 pounds. This second weight was done 3 weeks later, not one week later, as the policy directed. On 12/23/2022, Resident 17's Torsemide dose was doubled (one of the diuretics to treat swelling and heart failure.) A 12/27/2022 nutrition progress note showed that the interdisciplinary team had noted the weight gain, discussed the resident, ordered daily weights for 10 days, and planned to follow up the following week. A review of the December 2022 and January 2023 Treatment Administration Record (TAR) showed that daily weights were ordered from 12/28/2022 through 01/06/2023. The weight on 12/31/2022 and 01/01/2023 were both 201 pounds. The other 8 days were missing/blank. Neither the MAR or TAR showed any monitors for edema of the legs by nursing staff. A review of Resident 17's progress notes showed the following: - Provider notes that showed leg swelling were made on 12/2/2022, 12/15/2022, 12/27/2022, 12/28/2022, 01/03/2023, 01/04/2023, 01/05/2023, 01/06/2023, 01/09/2023, 01/10/2023, 01/12/2023, 01/13/2023 and 01/16/2023. - Provider notes that showed the resident was not wearing compression hose at the time of the assessment on 12/27/2022, 12/28/2022, 01/06/2023, 01/09/2023 and 01/10/2023. Per record review, there were no notes to show the resident was wearing the compression hose on any of the times the resident was seen by the provider (after they were ordered to be worn). - Provider notes that showed reminders to staff of compression stockings and/or to encourage their use were made on 12/28/2022, 01/05/2023, 01/06/2023 and 01/09/2023. - Nursing progress notes from the same time frame showed no assessments of the legs for swelling, or use/refusal of compression stockings. A 01/09/2023 provider progress note showed that a therapist questioned the provider about the compression stockings, as there were none in the room. The note also showed the provider then discussed the concern with the nurse, who was going to obtain a pair and have resident try them to see if it would manage the swelling they had. As noted above, the TED hose were ordered on 12/20/2023. During an observation on 01/19/2023 at 1:38 PM, the resident was not wearing compression stockings. During an interview on 01/18/2023 at 9:29 AM, Staff O, Nursing Assistant, stated that weights were routinely done on shower days, or at the request of the nurse or assistant director of nursing, and the nurse would document it. During an interview on 01/18/2023 at 9:30 AM, Staff K, NA, stated that the NA's filled out a sheet with resident weights, kept in a binder in the shower room. During an interview on 01/18/2023 at 2:12 PM, Staff G, RN (Registered Nurse), stated that the nurses let the NA's know who needed a weight. They further reported that they primarily monitored edema by monitoring the resident's weight. When shown Resident 17's TAR, with daily weights for ordered for 10 days, and weights for 8 of the 10 days were missing, they stated they were not sure how that would have been missed since the floor nurse and Staff B, Director of Nursing (DON), would both have gotten an alert about it. Staff G stated they weren't sure if Resident 17 was wearing their compression stockings, and they would have to check. During an interview on 01/18/2023 at 3:08 PM, Staff B, DON, stated that if ordered weights were not done, it showed up on the computer dashboard, and they would follow up with the floor nurse and NA's to ensure they were complete. When Staff B was notified of issues about Resident 17's edema monitoring and missing weights, they acknowledged that should have been caught, and it was not. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sample residents (1) reviewed for abuse, was free from sexual abuse. This failure resulted in actual psychosocial harm to Resident 1, who exhibited signs of fear and withdrawal after unwanted sexual contact from another facility resident (3). Findings included . Review of the 06/20/2022 quarterly assessment showed Resident 3 was cognitively intact and was independent with activities of daily living (ADLs). Per the 08/17/2022 quarterly assessment, Resident 1 was severely cognitively impaired and was dependent on staff for ADLs. Review of a 08/17/2022 facility investigation showed staff responded to Resident 1's room at approximately 5:30 PM that day, due to Resident 1 yelling and screaming. Per the report, Staff F, Nursing Assistant, found Resident 3 inside of Resident 1's room with their hands inside Resident 1's brief sexually assaulting them, and Resident 1 was yelling for Resident 3 to stop. Staff F immediately separated the residents and notified Staff D, Registered Nurse, and Staff A, Administrator, who then called local law enforcement. Per the report, the police interviewed both residents, and Resident 3 was arrested for sexually inappropriate behavior. In an interview on 08/19/2022 at 11:16 AM, Staff E, Registered Nurse, stated Resident 1 had been quiet that morning, which was unusual for them, and had been asking staff if Resident 3 was in the facility. Per Staff E, Resident 1 stated they were reassured Resident 3 was in jail. Observation on 08/19/2022 at 11:30 AM showed Resident 1 and Resident 3's rooms were across the hall from each other at the far end of the hall. Resident 1 was observed laying in bed in their room with a flat affect. When asked, the resident confirmed they went to the hospital and received treatment after the incident on 08/17/2022, but declined further interview. In an interview at 12:04 PM the same day, Staff A stated on the night of 08/17/2022, Staff F was working at the facility for first time, and responded to yelling and screaming from Resident 1's room. Per Staff A the incident was reported to the nurse on duty (Staff D), and themself; local law enforcement responded and interviewed both residents. Staff A stated Resident 3 initially denied their actions were inappropriate, but when Resident 3 was interviewed by police officers with Staff A present, the resident stated they had been petting Resident 1 for a week or two, fondling their breasts and putting hands down into their pants. Staff A stated they were also present when the police interviewed Resident 1, and Resident 1 also stated Resident 3 had come into their room on eight or nine previous occasions and touched their genitalia. Per Staff A, Resident 1 was upset and their demeanor was very different from their normal during the interview. In an interview on 08/19/2022 between 2:30 PM and 3:00 PM, Staff D, Registered Nurse, stated Resident 1 had been upset since the incident on 08/17/2022, and had required frequent assurance from the staff that Resident 3 was no longer in the facility. Per Staff D, Residents 1 and 3 resided on the same hallway for approximately a month prior to the incident, and Resident 3 was able to move quickly and independently. Staff D stated they were not aware of Resident 3 going into Resident 1's room prior to 08/17/2022, however they had observed bottles of Pepsi with markings that had been rubbed off in Resident 1's room, which the resident could not obtain independently. Staff D stated on 08/17/2022 there were new bottles of Pepsi in Resident 1's room which were clearly labeled with Resident 3's name. Additionally, Staff D stated in hindsight staff should have asked additional questions about the Pepsi in Resident 1's room. On 08/23/2022 at 11:35 AM Staff G, Nursing Assistant, stated Resident 3 usually did not come out of their room, but for the week and a half prior to the incident on 08/17/2022 they had been going everywhere, including going into other resident's rooms, trying to sell their Pepsi. Staff G stated they were shocked Resident 3 was going into other resident rooms, but no one indicated there was any concern with that behavior. Per Staff G, staff may not have been aware of Resident 3 entering Resident 1's room because it was at the end of the hallway, and it was typical for Resident 1 to yell from their bed (the resident could not get out of bed without staff assistance). At 3:05 PM the same day, Staff H, Nursing Assistant, stated they worked on another unit, down the hall from Resident 1 and 3's rooms, on the morning of 08/17/2022. Staff H stated Resident 3 had come down to the unit they were working on attempting to sell their Pepsi to staff, which was unusual. Additionally, Staff H stated Resident 3 had given some of their Pepsi bottles to Resident 1, which they thought was nice, until they learned the next day that the resident had an ulterior motive. In a follow-up interview with Staff A on 08/23/2022 at 4:30 PM, Staff A stated Resident 3 usually stayed in their room and the nurse's station, and had minimal to no contact with other residents. They stated they had not been notified of the resident leaving their room and going into other resident rooms, including Resident 1's room until the incident on 08/17/ . Reference: (WAC) 388-97-0640 (1)

Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (1), reviewed for medication administration, received care according to professional standards when receiving insulin. The facility failed to consistently monitor and document the blood sugar levels for one resident who was receiving insulin treatments. The facility also failed to administer injectable [MEDICATION(S)] when the resident's blood sugar was severely low. These failures resulted in the resident's hospitalization due loss of consciousness (unable to be awakened by painful stimulation) from critically low blood sugar, constituting harm. Findings included . Per the 05/10/2022 admission record, Resident 1 arrived at the facility on that day, following a hospital stay for a major surgery. The record also showed the resident required antibiotic therapy, was on [CONDITION(S)] for kidney failure, and had diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Resident 1 required injectable insulin to manage their diabetes. An interested party (D), was interviewed on 05/19/2022. They stated they found the resident in their room and unresponsive, on 05/13/2022. Additionally, they stated that Resident 1 was slumped over, and had food running down their side, and it looked like they had been trying to feed themselves. They stated that an unnamed registered nurse was unable to awaken the resident, and had not checked the resident's blood sugar at that time, and when the resident's blood sugar was checked it was critically low, and the resident had to be transported to the hospital. A review of the history and physical from the discharging hospital dated 04/29/2022, showed the resident had poorly controlled diabetes with a history of low blood sugars. According to the Centers for Disease Control (CDC.org/diabetes; 05/26/2021), blood sugar levels below 55 are considered severely low, and injectable [MEDICATION(S)] (a hormone that works with other hormones and bodily functions to control glucose levels in the blood) was the best treatment. Per the nursing progress notes dated 05/13/2022 at 12:28 PM, the resident, was found unresponsive not responding to sternal rub, BS (blood sugar) was checked and was 28. Nursing staff administered glucose gel; BS went up to 29. The resident remained unresponsive, and the medical provider gave orders to send the resident to the emergency room . Per a review of the provider note dated 05/13/2022, Staff C, Physician, documented nursing staff had attempted to administer [MEDICATION(S)] gel twice, but the resident was not alert enough to ingest either tube fully, and the facility did not have any other glucose-containing product on hand, so the decision was made to send the resident to the emergency room . Per review of the hospital records dated 05/13/2022, when Resident 1 arrived in the emergency room , they received intravenous medication for persistently low blood sugar. According to the record, the resident was admitted to the hospital where they remained until 05/16/2022, when they were discharged back to the facility. Review of the May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record showed no blood sugar levels were documented between 05/10/2022 when the resident admitted , and 05/13/2022, when the resident was sent out to the hospital. The nursing and provider progress notes were reviewed from 05/10/2022 through 05/13/2022. The first documented record of the resident's blood sugar being obtained was on 05/13/2022, when the resident became unresponsive and had to be sent to hospital. Additional review of the resident's electronic health , which included all nursing progress notes, also showed no documentation of the resident's blood sugar levels, until after they were readmitted from the hospital. In an interview on 06/29/2022 at 2:35 PM, Staff A, Director of Nursing, stated that the admitting nurse failed to follow up on a request to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In a follow-up interview on 06/29/2022 at 2:50 PM, Staff B, Corporate Nurse, stated that the facility discovered they did have an injectable form of [MEDICATION(S)] on hand that could have been administered to the resident (as the resident was not alert enough to swallow the gel) on the day they were sent to the hospital. Staff B further stated that the issue was nursing staff were unaware the medication was available, because the brand name had changed. Reference: (WAC) 388-97-1060(3)(k)(iii)(4)

Based on observation, interview, and record review, the facility failed to ensure one of one sample residents (2), reviewed for respiratory care and treatment, received appropriate services. This failure resulted in psychological harm to Resident 2, when their oxygen was not turned on for transport to an appointment, causing them to suffer shortness of breath and fear that they were dying. Findings included . According to the admission assessment dated [DATE], Resident 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment also showed the resident had some cognitive impairments and required extensive physical assistance with most activities of daily living. A physicians's progress note dated 01/25/2022 showed the resident required supplemental oxygen therapy 24 hours a day to maintain oxygen levels at an acceptable level, and to prevent total respiratory failure. According to the documentation, the resident required significant amounts of supplemental oxygen to enable them to breathe comfortably, and without having to gasp for air. On 02/17/2022, the resident had an appointment with a physician outside the facility who specialized in lung diseases. Per record review, the resident was sent to the appointment via a transport service. Per the physician's note, patient presented today without having [their] oxygen tank turned on. [They] were noted to be struggling with their breathing. Additionally, the documentation showed the resident was provided with one of the clinic's oxygen tanks, and was able to recover over several minutes. The physician also noted the resident was not provided with enough oxygen from the facility to complete the trip back from the clinic. Again, the clinic had to provide the oxygen for the resident's return trip back to the facility. In an observation and interview on 03/10/2022 at 2:00 PM, the resident was asked about the visit to the clinic. The resident stated that they didn't recall the specific appointment but remembered struggling to breathe. They said I panicked because when you don't breathe you die. I didn't want to die. In an interview on 03/10/2022 at 2:45 PM, Staff D, Director of Nursing, stated that the facility was in the process of providing in-service training to staff related to resident's receiving oxygen therapy. Reference: WAC 388-97-1060(3)(j)(vi)

Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (1), reviewed for medication administration, was free from a significant medication error. Failure to ensure medications were administered to the right resident resulted in harm to Resident 1, who required medical interventions, sustained a fall, and had mental status changes, due to receiving another resident's medications. Findings included . Per review of the admission assessment dated [DATE], Resident 1 admitted to the facility in June 2021, following below the knee amputation of both legs. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the assessment documented the resident was cognitively intact, and was not prescribed any mental health medications. According to a facility investigation dated 10/28/2021, Resident 1 received medications intended for another resident, including an antipsychotic medication (any of the powerful tranquilizers used especially to treat [CONDITION(S)] - a mental health problem that causes people to receive or interpret things differently from those around them), a medication to treat anxiety, and a medication to treat high blood pressure. Per the investigation report, the nurse who administered the medication had not used the correct identifiers (i.e., the right resident), prior to administering the medications. Review of Resident 1's October 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 10/28/2021 provider progress notes showed the resident was seen for acute [CONDITION(S)] (a functional alteration of mental status), related to the medication error. The provider documented the resident was very sedated, and required intravenous fluids and supplemental oxygen to bring their blood pressure and oxygen levels back to normal, following the medication error. According to a facility investigation dated 10/29/2021, Resident 1 had an unwitnessed fall out of bed at approximately 4:30 AM, due to . sedation/lethargy after receiving incorrect medications. The resident was assessed for physical injury, and none was identified. In an interview on 11/30/2021 at 2:30 PM, Resident 1 stated they remembered being on the floor stating, I felt cold and noticed I was on the floor. I never get on the floor because I have no legs. Other than that, I lost three days of my life. I don't remember anything else for about 3 days. In an interview on 11/20/2021 at 10:45 PM, Staff A, Registered Nurse, stated they were distracted at the time of the medication error, and realized the error had occurred within minutes. Per Staff A, the error was reported immediately to the resident and facility management. Staff A stated they attempted to induce vomiting in the resident immediately, and contacted the on-call medical provider about 20 minutes later, when that was unsuccessful. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to complete an admission elopement risk assessment (an assessment done to determine if a resident was safe to leave the facility independently and unsupervised), and to provide adequate supervision to prevent elopement for one of one sample resident (1), reviewed for accidents. This failure caused actual harm to Resident 1, who walked away from the facility and fell , resulting in multiple lacerations and a head injury, which required hospitalization . In addition, the facility failed to have a system in place to ensure Wander Guard devices were in place and functioning (devices that alarm when a resident tries to exit the building), for one of four sample residents (2). This failure placed residents who had a history of elopement at risk for elopement and possible harm. Findings included . ELOPEMENT Per the 06/17/2021 admission paperwork received by the facility, Resident 1 had a diagnosis of dementia, and needed rehabilitation therapy after suffering from a mild stroke. A review of the facility pre-admission packet for the resident showed the effects of the stroke were mild, and a good recovery was expected. The paperwork also showed Resident 1 most likely had chronic dementia with increased confusion in the evenings, and required a staff member (1:1) at the bedside, to maintain safety. Additional review of the 06/17/2021 facility admission paperwork found no documentation that an elopement risk assessment had been completed for Resident 1, and there was no documentation related to elopement risk, or the previous need for 1:1 supervision. A 06/18/2021 facility investigation showed the resident was found to be missing from the facility at 5:20 PM, when Staff L, Registered Nurse, went to give the resident evening medications. Per the investigation, the last time Resident 1 had been visually observed was at 5:05 PM, walking down the hallway. A facility search was initiated, and when the resident was not located by 7:00 PM (almost two hours later), Staff K, Assistant Director of Nursing, was notified. At 7:05 PM, Staff K notified Staff A, Administrator, and Staff B, Director of Nursing, that the resident was missing. The facility investigation further showed the police were then notified and a silver alert (a nation-wide public notification, enlisting the public's assistance in locating a vulnerable adult who was missing or at risk for harm) was initiated. The actual time the police were notified was not documented, but the investigation showed Resident 1 was found shortly after 9:15 PM, a mile away from the facility, and approximately 30 minutes after the silver alert was initiated. The investigation showed the resident was in distress with shortness of breath, weakness, and abrasions to the face and shoulder, and was taken to the hospital for evaluation. Review of the 06/19/2021 hospital records showed Resident 1 was diagnosed to have sustained a large subdural hematoma (brain bleed), and it was likely sustained while she eloped. The computer tomography scan (CT scan) determined the subdural hematoma was new, after comparing the scan with the previous scan done at the time of Resident 1's stroke. On 06/28/2021 at 2:40 PM, Staff A, Administrator, stated the facility was not aware that the resident required a 1:1 for safety while at the hospital, until the resident's representative was called to notify them the resident was missing. Per Staff A, the representative then told the facility the resident needed 1:1 supervision, and Staff A further stated they would not have admitted the resident if they had known that previously. In addition, Staff A stated Resident 1 had been wandering since admission, and required redirection from staff. When asked if an elopement risk assessment should have been completed, Staff A confirmed it should have been done at the time of admission. During an onsite visit to the facility on [DATE] at 1:00 PM, an observation was made that the room that belonged to Resident 1 was at the end of the south hallway, and next to a side exit door. At the same time, Staff A stated the facility was unable to determine what door the resident exited from, and further stated that exit door led to the back parking lot. WANDER GUARD Record review showed Resident 2 had diagnoses of dementia and anxiety. An elopement assessment completed on 06/04/2021 determined the resident was at high risk for elopement. On 06/06/2021, two days later, interventions were implemented, and a Wander Guard (see above definition) was placed on the resident's ankle. Review of progress notes from 06/04/2021 through 06/28/2021, showed the resident to be confused, and made multiple comments related to leaving the facility. On 06/26/2021, the resident was found to have cut the Wander Guard off. When asked, Resident 2 stated every time they went outside to smoke the door alarmed, and they didn't like it. In an interview on 06/28/2021 at 3:51 PM, Staff C, Registered Nurse, stated Resident 2 took the Wander Guard off, and it had been off for a couple of days. When asked how they would know if the resident left the building, Staff C stated, they watched her. When asked about the process for checking the functionality of the Wander Guards, Staff C stated the only way was to have a resident with a Wander Guard go by the door, so the alarm would go off. Staff C additionally stated placement of the Wander Guard was checked every shift, and documented on the treatment administration record (TAR). On 06/282/2021 at 4:00 PM, Resident 2 was observed in their bedroom. No Wander Guard was observed on the resident's ankles or wrist. When asked about the device, Resident 2 verified removing it two days ago because there was a little bug in it that kept biting the resident's ankle, and it caused a rash. Resident 2 stated it was left outside after being removed, and staff were told. Review of Resident 2's record showed the Wander Guard was not in place on 06/26/2021 through 06/28/2021. On 06/28/2021 at 4:05 PM, Staff B, Director of Nursing, stated the nursing staff were supposed to check placement and expiration dates of the Wander Guards daily, and Staff B wasn't aware if function was checked. When asked how they determined if the device was functioning properly, Staff B stated, that's a good question, and stated she had not been trained on that. Staff A, Administrator, stated staff were supposed to use the testing device located in the medication cart daily, to test the function. Staff B stated she was unaware of that, left the interview to check the function of all Wander Guards in the facility, and all devices were found to be working properly. Reference WAC: 388-97-1060 (3)(g)

Based on interview and record review, the governing body failed to ensure their admission placement process included the appropriate assessments, to determine if the facility could meet the care needs of a resident being considered for admission. In addition, the governing body failed to ensure the facility was fully informed in order to provide adequate supervision for one of one sample residents (1), reviewed for accidents. The governing body had information regarding Resident 1's need for 1:1 supervision, but did not notify the facility. These failures led to actual harm, when Resident 1 eloped from the building and sustained a terminal head injury. Findings included . Per the [DATE] admission paperwork received by the facility, Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility pre-admission packet for Resident 1, showed the effects of the stroke were mild, and a good recovery was expected. The paperwork also showed Resident 1 most likely had chronic dementia with increased confusion in the evenings, and required a staff member (1:1) at the bedside to maintain safety. Per the [DATE] admission paperwork, no documentation was found to show that an elopement risk assessment had been completed for Resident 1, or that the facility was aware of the need for 1:1 supervision for Resident 1. In an interview on [DATE] at 2:40 PM, Staff A, Administrator, stated the facility was not aware of the resident requiring 1:1 observation while at the hospital, stating they would not have accepted the resident had they known. Staff A further stated, the resident had been wandering since admission and had required frequent redirection. Staff A confirmed the resident had not been assessed for elopement on admission and should have been. A [DATE] facility investigation showed the resident was found to be missing from the facility at 5:20 PM, when Staff L, Registered Nurse, went to give the resident evening medications. The investigation showed Resident 1 was found shortly after 9:15 PM, a mile away from the facility, was in distress with shortness of breath, weakness, and abrasions to the face and shoulder, and was taken to the hospital for evaluation. The [DATE] hospital records showed Resident 1 was diagnosed to have sustained a large subdural hematoma (brain bleed), and it was likely sustained while she eloped. The computer tomography scan (CT scan) determined the subdural hematoma was new, after comparing the scan with the previous scan done at the time of Resident 1's stroke. The resident was placed on hospice after the incident and died . In an interview on [DATE] at 4:40 PM, Staff B, Director of Nursing, stated they no longer had an admission nurse on-site, and stated all admissions were processed through the central intake office in Gig Harbor, Washington. Staff B further stated they were not clinically-minded when reviewing for admission, and stated admissions were primarily based on bed capacity. In an interview on [DATE] at 3:50 PM, Staff D, Central Intake Admissions Coordinator in Gig Harbor, stated they reviewed insurance coverage and clinical notes, prior to accepting residents for placement. Staff D stated there were no red flags to indicate Resident 1 would not be a good candidate for admission. When asked if she was aware the resident was on 1:1 while at the hospital, and that the documentation was included in the pre-admission paperwork, Staff D stated, she was not aware, and had missed it when reviewing the paperwork. Staff D further stated Staff E, Central Intake Admission Director, reviewed the documents after the incident, and noted several red flags that should have been identified and reviewed prior to accepting the resident for admission. Those red flags included, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff D again stated she missed it. On [DATE] at 1:00 PM, Staff A provided a list containing names of seven members of the Governing Body, included on the list were; Staff A, Staff B, and Staff D. See F 689 for additional information. Reference WAC [DATE](1)(2)(c)

Based on interviews and record review, the facility failed to ensure staff provided adequate pain management for one of three sample residents (#1), reviewed for pain. This failure resulted in actual harm to Resident #1, who experienced uncontrolled pain requiring hospitalization and intravenous (directly into the vein, using a needle or tube) pain medications. Findings included . Review of Resident #1's record showed he was admitted to the facility from the hospital on 02/09/2021 at approximately 5:30 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the hospital records, the resident was alert, oriented, and able to make his needs known. Per hospital discharge orders, the resident was to receive [MEDICATION(S)] (a narcotic pain medication) ten milligrams (mg.), one to two tablets every four hours as needed for pain. [MEDICATION(S)] (a long-acting [MEDICATION(S)] narcotic pain medication) 30 mg. every 12 hours for pain; the next dose was ordered to be given at 9:00 PM. Review of progress notes on 02/10/21 showed Staff B, Registered Nurse, assumed care for Resident #1 at 6:30 PM, and the resident looked upset and angry, asking for pain pills. The note also showed the resident had arrived during day shift, at which time medication orders were faxed to the pharmacy, but had not arrived. Staff B attempted calls to the pharmacy and the on-call provider in order to get the medications, which were unsuccessful. Staff B could not access the emergency medication supply, which contained narcotic pain medications. Per interview on 02/16/2021 at 1:00 PM, Resident #1 remembered his admission to the facility in the late afternoon on 02/09/2021. He stated he was hurting so badly by 9:20 PM, and he did not know what to do. He went on to say he started calling family after pushing the call light several times and not getting help. He also remembered the nurse providing a couple of medications, but not pain pills. Per the resident, at 11:30 PM, the nurse told him she was trying to get his pain medications, but they had not arrived yet. Resident #1 stated by that time his pain was 10 out of 10 (a pain scale in which 0 is no pain, and 10 is excrutiating pain), so he called the hospital from where he had been discharged , and staff told him to called 911 and come back. He stated calling 911 seemed to be his only option since he was in so much pain, no one was helping him, and he did not feel safe. In a telephone interview with Staff B on 04/07/2021 at 11:35 AM, she stated she had not been given a report on Resident #1 and when she checked on him, he was already very agitated about not receiving pain medications. She thought his last dose of pain medication from the hospital was at 3:00 PM. She attempted to get the medications from the pharmacy, and was in contact with the after-hours provider, but was still not able to get the medications. She also stated she did not have a login/code to access the emergency medication, and no other nursing staff in the building had access at the time. She attempted but was unable to contact the director of nursing. When she returned to check on the resident, he had already call 911. Resident #1 was at the facility for approximately six and a half hours with no medications for pain. Per interview on 03/31/2021 at 12:00 PM Staff A, Director of Nursing, stated after the incident it was discovered some of the on-call staff did not have the login/code required to access emergency medications. According to the hospital emergency room record dated 02/10/2021, Resident #1 required [MEDICATION(S)] (a narcotic pain medication) 1.0 mg. intravenously every 30 minutes, for pain control. Reference (WAC) 388-97-1060(1)

Based on interview and record review, the facility failed to adequately monitor blood sugars for one of three diabetic sample residents (#1), reviewed for medication management. This failure caused actual harm to Resident #54, who was found unresponsive and hospitalized for [REDACTED]. Findings included . According to the 11/09/2020 admission assessment, Resident #1 had a [DIAGNOSES REDACTED]. Review of admission orders [REDACTED]. Review of an order written [REDACTED]. Per review of the resident's Medication Administration (MAR) record for November 2020, Resident #1 continued to receive long-acting insulin injections daily as ordered, however, blood sugar monitoring stopped on 11/11/2020. Resident #1's blood sugar was tested before meals and at bedtime from 11/09/2020 through 11/11/2020, then it was not tested again until he experienced a change in condition on 11/21/2020 (10 days later). Progress notes dated 11/21/2020 showed Resident #1 was difficult to arouse, and his blood glucose registered as high. He was sent to the hospital via ambulance. According to the hospital records dated 11/21/2020, Resident #1 required intubation (passing a tube into a person's airway to assist with breathing), prior to arrival. Resident #1's blood glucose/blood sugar was 944 (a normal level is between 100-140, depending on when a person has last eaten), when he arrived at the hospital. The resident required intravenous insulin to help bring the level down, and he was admitted to the Intensive Care Unit (ICU) at the hospital. In an interview on 12/17/2020 at 11:00 AM, Staff C, Registered Nurse, stated residents who are on any kind of insulin should have their blood sugar tested daily. During an interview on 12/17/2020 at 3:00 PM with Staff A, Director of Nursing, stated the expectation would be for residents to have blood sugars tested as ordered, but in the incident involving Resident # 1, confirmed it was not done. Reference: (WAC) 388-97-1060(3)(k)

Based on observation, interview, and record review, the facility failed to ensure that appropriate and timely services were provided to maintain, increase, and/or prevent decreases in range of motion for four of six sample residents (#58, 39, 64, 68), reviewed for range of motion. This failure resulted in harm for Resident #39, who required additional physical therapy treatments to regain lost mobility, and placed the other residents at risk for further decline in range of motion, and a decreased quality of life. Findings included . 1. According to the 07/23/19 quarterly assessment, Resident #39 had moderate cognitive impairment, required staff supervision for ambulating in her room, and limited assistance with ambulation in the hallway. In an interview on 09/18/19 at 11:33 AM, the resident stated when she finished physical therapy services, she was supposed to have exercises, but she was not receiving them. The resident stated the progress she made during physical therapy was gone, she could barely stand by herself, and could not walk. In an interview on 09/24/19 at 2:58 PM, Staff D, Acting Resident Care Manager, stated he and Staff F, Registered Nurse, were managing the facility's restorative services. When asked, he stated the resident was not receiving restorative services. Staff D then checked his electronic mail, and stated the physical therapy director had sent him a referral (he did not give date or time), but he had not followed up, and had not started the resident on a restorative program. In an interview on 09/25/19 at 8:30 AM, the surveyor informed Staff P, Rehab Director, that the resident's restorative services were not started timely. Staff P stated physical therapy would now screen the resident, to determine if physical therapy services were needed again. Record review of the physical therapy discharge summary, dated 08/28/19, showed, at discharge, the resident ambulated 125 feet 85% of the time. Record review of the document titled, Therapy Recommendation for Restorative Program, dated 08/28/19, showed therapy recommended a walking program consisting of two to three attempts at 75-125 feet for each attempt, with stand-by assistance each way. Record review of the physical therapy evaluation dated 09/25/19 showed the resident was referred to physical therapy following a decline in functional mobility with transfers and gait, secondary to a restorative program never being entered into the system, and thus never initiated. Review of the summary of previous treatment showed one month ago, the resident was ambulating 125-175 feet with a four-wheeled walker and stand-by assistance. Additionally, she was to tolerate three-five minutes standing. On 09/25/19, the resident stood with staff support for 30-60 seconds, and ambulated 20 feet, with contact guard assistance. Record review of the physical therapy treatment notes, dated 09/26/19, showed the resident could transfer with stand-by assistance, and walked 52 feet, 57 feet, and 58 feet, with prolonged and seated rest breaks. In an observation on 09/26/19 at 11:30 AM, the resident was in the hallway with the physical therapist. She had been walking a short distance, and was currently resting, with mild shortness of breath. She pointed to the surveyor and thanked her stating, You are the one responsible for this, and the reason I won't be in a wheelchair. The facility failed to timely initiate restorative services after completion of therapy, and failed to detect the omission, until informed by the surveyor on 09/24/19. As a result, the resident required physicial therapy treatment to regain lost mobility. 2. Per the 11/11/18 annual assesssment, Resident #58 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The assessment also showed the resident was severely impaired in cognition, and required extensive assistance with all activities of daily living. According to the assessment, the resident received restorative therapy (therapy to restore function when there is an expectation that the condition will improve) with passive range of motion (the therapist provides movement of the joints with no effort from the resident) and a splint/brace (rigid material used to support an extremity) assistance, three to four times per week According to the record, the resident was referred to the restorative program on 10/25/18, after meeting all of her planned goals with occupational therapy. Staff were to provide the resident with splint/brace assistance and passive range of motion. A limited mobility care plan showed the goal of the restorative program was to increase her range of motion and flexibility. Interventions, last revised on 03/20/19, included: floor staff were to perform passive range of motion to her right wrist/hand/fingers, and to apply the splint to her right hand, for three hours in the morning and three hours in the evening, six days per week. A Practitioner visit note, dated 04/02/19, showed the resident had a contracture to her right hand, and had sustained a non-healing skin tear, due to not having had her fingernails cut down. Per the note, the plan was for the staff continue to provide support to her right hand (by using the splint/brace), and to continue to monitor. The resident was to continue with occupational therapy until the splint fitted appropriately. A review of the (MONTH) 2019 restorative services documentation, from 09/11/19 to 09/25/19, showed that out of 12 opportunities to receive restorative therapy, she received therapy only nine times. In an interview on 09/25/19 at 3:54 PM, Staff C, Resident Care Manager, stated that there was no restorative aide to provide therapy to Resident #58 on Wednesdays, Thursdays, and Fridays. In an interview on 09/26/19 at 9:43 AM, Staff D, Restorative Nurse, stated there currently was not a good process for assessing range of motion progress. Staff D stated the facility used a periodic summary evaluation to track progress (to be done quarterly), however, the last time the evaluation was completed on Resident #58, was in (MONTH) 2019 (six months earlier). (For more information, refer to F-686: Treatment/services to prevent/heal pressure ulcers.) 3. According to a 08/18/19 significant change assessment, Resident #64 was severely cognitively impaired, had left sided paralysis due to a stroke, and required extensive assistance from one to two staff for most activities of daily living. According to a 07/25/19 occupational therapy initial assessment, the resident had been referred to therapy due to a decline in range of motion (ROM), and left hand contracture. Per the note, the resident was fitted with a left hand splint, and staff were instructed on its use, with the goal for the resident to wear it two hours off and two hours on, during the day. An 08/17/19 occupational therapy note showed the resident had been discharged from therapy, and a restorative nursing program was initiated for ROM exercises and splint application to preserve, and potentially increase, the resident's current level of function. Per the note, nursing staff were instructed on the resident's splint schedule. Review of the resident's physical mobility care plan, last revised on 08/26/19, showed no mention of a restorative program, ROM exercises, or the application of the resident's splint. No documentation of staff providing ROM exercises, or splint management, was found in the paper record or electronic record. Observations were made of the resident with a splint in place on her left hand during the survey, including 09/16/19 at 3:59 PM, 09/19/19 at 11:28 AM, and 09/23/19 at 3:06 PM. In an interview on 09/25/19 at 11:21 AM, Staff CC, Nursing Assistant, stated she had worked at the facility for three months, and usually was assigned to Resident #64's hall. Staff CC stated she had never seen the resident wear her splint, and thought the resident normally refused. Staff CC added that restorative staff was responsible for the splint. In an interview on 09/25/19 at 11:23 AM, Staff D, Resident Care Manager/Restorative Nurse, stated that the resident had recently been discharged from therapy, and did not have a restorative program in place. In an interview on 09/25/19 at 1:18 PM, Staff P, Rehab Director, confirmed the resident was to have been put on a restorative program for ROM exercises and splint management related to her left hand contracture, but that it had never been initiated. 4. Per the 08/20/19 quarterly assessment, Resident #68 had a [MEDICAL CONDITION] of the right leg, and needed assistance with activities of daily living such as transfers. On 09/17/19 at 9:03 AM, Resident #68 was observed sitting on the edge of his bed watching television. When asked about his care, the resident stated he was supposed to get therapy so he could walk with his right foot prosthesis (artificial limb). A review of the progress notes showed on 06/04/19 during a care conference, the resident had stated he wanted to start therapy again, so he could build up strength, and be able to use his walker and move around more. No documentation was found to show there was any follow up on the resident's request to have therapy. A nursing to therapy communication progress note, on 09/04/19 at 3:26 PM, requested the resident be re-screened for transfers. On 09/06/19 at 3:57 PM, therapy responded and instructed the nursing staff to get the resident up in his wheelchair as much as he allowed, and once the resident had consistently built up tolerance with sitting in the wheelchair, therapy would reassess. A review of the physical mobility care plan, did not show that it was revised to include getting the resident up in his wheelchair, as directed by therapy. On 09/19/19 at 8:51 AM, Resident #68 stated he had requested therapy last June, but it was only recently that it was mentioned again and he was still waiting, stating nothing had happened yet. In an interview on 09/23/19 at 2:43 PM, Staff D, Restorative Nurse, stated the communication from therapy to nursing on 09/06/19 should have triggered the care plan to be revised, to instruct staff to get the resident up in his wheelchair and once implemented, then it would be reviewed to determine how the resident tolerated it, and whether therapy should screen (to see if their services were needed), or if restorative services should be implemented. On 09/25/19 at 11:22 AM, Staff B, Director of Nursing, confirmed the resident's care plan should have been revised, and residents should be evaluated for restorative services when there was a suspected decline, or when services were requested by the resident or family. Staff B stated Resident #68 should have been evaluated for restorative services, as the restorative aide would be assessing the resident's tolerance for sitting in the wheelchair, and providing feedback to therapy. Reference (WAC) 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to timely evaluate and consistently monitor three of nine sample residents (#20, 89, 64), reviewed for nutrition. This failure resulted in actual harm to Resident #20, who experienced severe weight loss of 19.6 pounds (14.4% of his body weight) in approximately two months. Findings included . The Center for Medicare and Medicaid Services defines severe weight loss as losing more than 5% of body weight in one month, more that 7.5% of body weight over three months, and more than 10% of body weight over six months. Record review of the undated facility policy titled, Weight Monitoring, showed nursing assistants were directed to weigh each resident within 24 hours of admission, and readmission, then weekly for four weeks, and/or until the weight was determined to be stable by the interdisciplinary team (following admission and readmission). Each resident was then weighed monthly to monitor stability, and reviewed by the licensed nurse for accuracy. 1. According to the 09/18/19 quarterly assessment, Resident #20 had no cognitive impairment, clear speech, was able to make himself understood, and understood others. The resident had a [MEDICAL CONDITION] (a section of the large bowel diverted to an artificial opening in the abdominal wall), a right hip Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), and a left buttock surgical wound. Additionally, the resident had weight loss that was not due to a physician prescribed regimen (i.e. planned). The resident's record review showed he was admitted from the hospital on [DATE] after surgery, including a [MEDICAL CONDITION] for treatment of [REDACTED]. Per the recored, his [DIAGNOSES REDACTED]. No admission weight was documented, either in the electronic record, or the admission assessment dated [DATE]. Further hospitalization s, facility re-admissions, and weight history included: -On 01/29/19, he was readmitted to the hospital for treatment of [REDACTED]. His weight on 02/06/19 was 136.6 pounds (lbs.), which was the first documented facility weight. -Between 02/06/19 at 07/08/19, the resident was weighed periodically. His weight on 07/08/19 was 136 lbs. -Record review of a 07/08/19 note by Staff X, Registered Dietitian, showed she evaluated the resident. and that he stated he understood the need to include protein portions in meals, plus two cartons of milk with each meal. -On 07/10/19, the resident was admitted to the hospital with [REDACTED]. He was re-admitted on [DATE]. There was no documented re-admission weight, and no documented dietitian re-evaluation. -There were no recorded weights between 07/08/19 and 09/12/19, when the resident's weight was 116.4 lbs. The weight calculation included in the electronic record showed the weight loss between 136 lbs. and 116.4 lbs. as 19.6 lbs. (14.4% of his body weight) in two months. -Record review of Staff X's 09/19/19 note showed the resident's weight was down 20 lbs. to 116 lbs. Nutritional supplements were started on 09/19/19, to increase the resident's intake. Review of the resident's nutrition care plan, revised 07/22/19, showed goals including: not having weight loss or complications related to refusing food, and consuming at least 75% of meals and snacks. Interventions included allowing choice in meal time, menu selection, and dining location, monitoring and recording food intake at each meal, and monitoring weight per policy. In an interview on 09/17/19 at 2:51 PM, the resident stated he had lost weight. Additionally, the resident stated his pressure ulcer pain was bad, and he didn't eat when it hurt. Record review of the 09/17/19 nurse practitioner note showed the focus of the resident's care as palliative (to relieve the problem without addressing the underlying cause). Per the note, the pressure ulcer and surgical wound showed poor healing, he reported increased pain with high pain medication doses, and surgical intervention was not an option. Additionally, the resident stated he did not want to stop any treatments. On 09/19/19 at lunch, and on 09/23/19 at breakfast, the resident was observed eating double portion meals in his room. In an interview on 09/24/19 at 8:46 AM, Staff X was asked how the facility monitored weights. Staff X stated weight monitoring varied by unit. The north unit staff (where the resident resided) generally weighed residents monthly, or more often. Staff X stated every week she reviewed available weights for all residents. Regarding newly admitted and readmitted residents, she completed evaluations, and the dietary manager reviewed and documented food preferences. Additionally, Staff X was asked about the resident's re-admission on 07/17/19. She confirmed the resident should have been weighed, and she should have received a referral for re-evaluation. She stated she heard the resident was back, but she was waiting for a weight, which was not done. When asked, Staff X confirmed the resident's weight loss was significant and unplanned. Record review showed the resident's weight on 09/24/19 was 114.6 lbs., a loss of an additional 1.8 lbs. In a follow-up interview on 09/26/19 at 9:50 AM, Staff X stated the nurse practitioner documented the focus of care was palliative. Additionally, Staff X confirmed that even though the focus of care was palliative, more frequent weight monitoring would have possibly allowed her to intervene, before the severe weight loss occurred. 2. According to the 08/31/19 quarterly assessment, Resident #89 had moderate cognitive impairment, unclear speech, was sometimes able to make herself understood, sometimes understood others, and required extensive assistance of one staff with eating. Additionally, the resident had no swallowing problems, had weight loss, and was not on a physician-prescribed weight-loss regimen. Record review of the 02/28/19 nutritional risk care plan, revised on 09/19/19, showed goals of weight stability, and eating at least 50% of meals, two to three times daily. Interventions included monitoring weekly weights, and daily nutritional supplements. Weight monitoring record review showed a weight of 235.6 lbs. on 05/28/19, a weight gain of 19.6 lbs. The facility weighed the resident weekly until 06/26/19, when her weight was 234.6 lb. Record review of the nurse practitioner note dated 06/18/19 showed a recommendation for the resident to lose 5% of her baseline weight by 06/30/20, a time period of one year. Weight monitoring record review showed a weight of 192 lbs. on 07/22/19, a weight loss of 18.2 lbs. (a significant loss of 5% of total body weight), in approximately one month. The next recorded weight was 184.4 lbs. on 08/29/19, an additional weight loss of 7.2 lbs., and a significant weight loss of 10% since 02/19. Record review of the 08/29/19 quarterly nutritional evaluation by Staff X, Registered Dietitian, showed the resident had a slow weight loss, consumed 50% average at meals with snacks, and ate in her room. New care plan interventions included having the resident up in her chair for meals. A plan for more frequent weight monitoring was not documented. On 09/18/19 at breakfast, the resident was observed in bed with a breakfast tray on the table in front of her. She was served scrambled eggs, toast, and hot cereal, each in separate bowls. She had taken a bite of toast. She took a bite of hot cereal, and said she did not like it. On 09/23/19 at breakfast, the resident was observed in the dining room. She was served a plate of food, rather than each food item in a separate bowl. She stated loudly that it was not her food, and did not eat. Review of the resident's tray card showed her food should be served in bowls. In an interview on 09/24/19 at 8:46 AM, Staff X was asked about weight monitoring. She stated residents on the north hall (where the resident resided) were weighed once a month or more often. Additionally Staff X stated weights were the most important marker for how residents were doing nutritionally. When asked about the resident's weight loss, she stated it was unplanned, but the resident's overall nutritional status was stable. When asked about weight frequency, she stated the resident should be weighed more frequently. In an interview on 09/26/19 at 11:00 AM, Staff B, Director of Nursing, provided additional information related to the resident's Physician order [REDACTED]. In an interview on 09/26/19 at 2:37 PM with Staff A, Administrator, Staff B, Director of Nursing, Staff D, Acting Resident Care Manager, and Staff HH, Regional Director of Clinical Operation, additional information related to the facility policy for provision of Comfort Care was requested; none was provided. 3. According to the 08/18/19 significant change assessment, Resident #64 was cognitively impaired, required assistance from staff for eating, and had experienced weight loss. A nutrition care plan, initiated 08/31/17, instructed staff to monitor and record food intake at each meal. A 07/23/19 provider note showed the resident was experiencing a change in condition and decreased appetite. Per the note, weight loss related to advancing dementia was to be anticipated. Review of weights for (MONTH) 2019 - (MONTH) 2019 showed an 11% weight loss from 07/25/19 - 08/01/19, after which her weight stabilized. Review of physician orders [REDACTED]. Meal monitors for 08/23/19 - 09/23/19 showed intake for all three meals was documented only six of 32 days, and there were no entries for any meals on seven days. An assessment of the resident's weight loss, or any follow up by the dietician was not found in the record. In an interview on 09/24/19 at 8:46 AM, Staff X, Registered Dietician, confirmed there was no documentation of an assessment, or follow up related to the resident's recent weight loss, in the record. Staff X added that she had been aware of the loss, which was unplanned but unavoidable, and had recommended the supplement and enhanced diet. The resident's meal monitor was reviewed with Staff B, Director of Nursing, and Staff D, Resident Care Manager, on 09/26/19 at 2:06 PM. Staff D confirmed the meal monitor should be completed for each meal daily. Reference: WAC 388-97-1060 (3)(h)

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services for two of three sample residents (#1, 2) with urinary catheters (a flexible tube inserted into the bladder to drain urine). This failure resulted in actual harm to Resident #1, who developed severe penile erosion (a condition caused by a urinary catheter eroding the tip of the penis, penile skin, and nearly the entire urethra - the duct that drains urine from the bladder to the outside of the body), and as a result, significant pain. Findings included . Per review of the facility's Catheter Care policy and procedures, the facility referrenced the Lippincott Textbook (a book which provides information on general nursing care) as their procedure manual (undated). Per the policy, when caring for a person with a urinary catheter, staff were to secure the tubing loosely to the person's body, near the catheter insertion site, using a catheter strap or adhesive tape. In men, the tubing was attached to the thigh or lower abdomen. It was noted in the document a little slack was to be left, to prevent the catheter from pulling against the bladder outlet and urethral opening. Catheter care also involved thorough cleaning of the perineal area, especially the urethra, and the catheter tubing that extended outside of the body, to prevent infection. 1. Review of a facility assessment, dated 07/03/19, showed Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was able to make his needs known, and required a urinary catheter long-term. Review of the resident's care plan, dated 01/10/19, showed an alteration in urinary elimination related to having a catheter. The goal was to remain free of UTI's (urinary tract infection) and other catheter related complications. The staff were instructed to monitor/document/report to the physician any signs and symptoms of an infection. No interventions were found for catheter care or other treatments, such as securing the catheter to prevent pulling. On 07/30/19, a care plan was developed for severe ventral erosion of the penis, caused by the urinary catheter. Staff were to ensure the catheter bag was attached to the leg to help prevent pulling on the penis, ensure proper catheter care was done every shift, monitor for pain, and document the location, size, and treatment of [REDACTED]. During an interview on 08/08/19 at 9:30 AM, Resident #1 was sitting on the side of his bed. His catheter bag was laying on the floor next to his wheelchair. During the interview, a staff member came into the room to deliver medications to the resident, stepped over the catheter bag, and left the room, not placing the catheter near the bed. Resident #1 explained he had recently gone to the hospital because the catheter had caused his penis to split. He stated he let staff know when it first started to split, said no one looked at it, and it was now split down to the base of the penis. During the interview, Resident #1 went to lay down and when moving stated ow, ow. He went on to say he didn't receive any pain medication for the wound, and when he had gone to the hospital they ordered a numbing cream for him. Resident #1 stated he had not received it at the facility because people can't seem to find it. When asked about catheter care, he stated staff were not providing any. Review of the resident's Treatment Administration Record (TAR) for (MONTH) 2019 and (MONTH) 2019 showed catheter care was ordered to be done twice a day. Per the record, in (MONTH) 2019, the resident went five times without catheter care being completed, and six times in (MONTH) 2019. Catheter care was also to be documented in the nursing assistant tasks. Review of the tasks for the last 30 days revealed catheter care had not been done 28 times out of a possible 90. The resident had skin assessments ordered to be done weekly. In (MONTH) 2019, the resident had one assessment done, and it showed no new findings. In (MONTH) 2019, skin checks had been done with no new findings identified. Although catheter care and skin assessments had been documented as completed, there was no identification of the resident's penis beginning to tear. Per record review, a 07/10/19 progress note showed the resident was found on the floor. During the nursing assessment after the fall, the resident had a temperature of 101.6. An order was received from the physician to get stat (emergent) labs, which included a urinary sample, and a new urinary catheter was required to be inserted. It was documented upon removal of the old catheter it was noted that his head of his penis (in the back area) had a long tear. I was unable to reinsert the new cath at this time. The resident was then sent to the hospital for an evaluation, related to complaining of neck pain and having confusion. The next progress note which addressed the tear was on 08/04/19. The nurse documented the resident requested she look at his groin area, stating it is getting way worse and I don't know what to do, will you look at it? Per the note, the nurse assessed the area, and the resident was noted to have a chronic split that was now 4 inches long, located on the left side of penile urethra and shaft. The resident stated I think it's worse and I need to get it looked at. The resident was sent to the hospital for a urology consultation (a physician specializing in diseases/conditions of the urinary system). The resident returned to the facility the same day, and the progress notes had an order for [REDACTED]. Review of hospital notes, dated 08/04/19, showed an exam revealed a very large, extensive opening of the penis - spanning the entire length of the penile shaft - from the opening to the base. The note showed the catheter was exiting from the base of the penis. The findings were noted to be consistent with chronic acquired [DIAGNOSES REDACTED] (where the urethra is not at the tip of the penis), related to chronic use of a urinary catheter. Although the patient states this occurred last week, based on exam this appears more chronic, possibly just noticed recently related to increased local irritation. The resident was discharged with an order for [REDACTED]. Review of the record after the 08/04/19 hospital visit showed no documentation to indicate the wound was being assessed, monitored, or treated, after it had been identified as torn. In a follow-up interview with Resident #1 on 08/15/19 at 10:05 AM, he stated he still had not received the numbing cream stating, that is my problem now, pain. Resident #1 stated he had a strap on his leg prior that didn't hold the catheter tubing at all, and when he went to the hospital they gave him a strap with a locking device, that kept the tubing secure. Per review of the Medication Administration Record [REDACTED]. During an interview on 08/15/19 at 1:25 PM, Staff H, Nursing Assistant, stated the nursing assistants do perineal care, and clean around the catheters for the residents that have them. Per Staff H, the catheter tubing was usually secured to the leg with a velcro band. On 08/15/19 at 1:40 PM, Staff I, Nursing Assistant, stated the nursing assistants were the ones that did perineal care and catheter care. Staff I was not aware of an issue with Resident #1's penis splitting, until was told after the fact. On 08/15/19 at 2:30 PM, Staff A, Resident Care Manager, stated she was first aware of the tear in Resident #1's penis after he had fallen. An assessment was done at that time, and the tear was seen. Per Staff A, at that time, the split was about an inch long. She went on to say the information was placed on the transfer sheet for the hospital, in hopes they would do something about it, but they didn't. When asked for documentation of the facility evaluating or monitoring the area, none was provided. On 8/15/19 at 3:00 PM, Staff B, Director of Nursing, stated Resident #1 liked to self-transfer to his wheelchair, moved around a lot, and threw his catheter around. When asked about the [MEDICATION NAME], Staff B stated there wasn't an official prescription for the [MEDICATION NAME] so last week a message was left for the urologist. She confirmed she hadn't followed up since. 2. A 07/02/19 assessment showed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was alert, oriented, and able to make his needs known. The resident's care plan, dated 07/02/19, identified the resident had an alteration of urinary elimination related to a urinary catheter. The goal was to remain free of UTI's (urinary tract infections), and other catheter related complications. Staff were to monitor/document, and report signs and symptoms of a UTI. No further interventions were found, on how to care for the resident's catheter. On 08/01/19, a care plan was developed for slough (dead tissue usually cream or yellow in color), that had developed on the tip of the penis, related to the catheter tubing. Staff were to assess/record/monitor wound healing, and assess/document wound status weekly and as needed. Catheter care and treatment were to be provided as ordered, and staff were to ensure the catheter was secured to his leg appropriately, and not pulling on the penis. During an interview on 08/08/19 at 2:15 PM, Resident #2 stated he had a catheter because he was unable to urinate on his own. He stated he did not receive catheter care for the first month he had been there, and it was supposed to be done each shift. He went on to say, now they say my penis is infected. Per review of the (MONTH) 2019 Treatment Administration Record (TAR), the resident had catheter care ordered every shift. The resident had 11 shifts when catheter care was not documentated as being done, out of a possible 66. On 07/22/19, the TAR showed catheter care was discontinued. On 07/31/19 on evening shift, the catheter care was placed back on the TAR, to be done every shift. The resident went eight days with no documentation that the catheter had been cleaned, or the area evaluated. Review of the skin ssessments for (MONTH) 2019 showed no skin assessment was done until 07/30/19, and it was documented no new skin issues were identified. A 07/31/19 progress note showed the resident had slough on the tip of his penis. The (MONTH) 2019 TAR was reviewed. On 08/01/19, an order was received to clean the tip of the penis with [MEDICATION NAME] ointment (antiseptic for the topical treatment or prevention of minor infections), allow to air dry, loosely apply gauze at the catheter insertion site, and to ensure off-loading of the catheter tubing at the insertion site was done frequently. No treatment was documented as being done until the evening of 08/07/19, six days after the order. On 08/15/19 at 10:50 AM, Staff C, Registered Nurse, stated both the nursing assistants and the nurses do catheter care. She stated Resident #2 has not allowed catheter care this last week, a male nursing assistant had been brought from another unit to do the catheter care, and the resident was more receptive to allowing it to be done. Staff C stated she was aware the resident started to have breakdown on the tip of his penis. On 08/15/19 at 1:45 PM, Staff D, Wound Nurse, stated it had been brought to her attention Resident #2 had a split penis. Resident #2's wound was observed with Staff D present. There was a split at the tip of the penis from the urethra, and the area was reddened. Staff D stated the slough was no longer present. The resident was noted to have a loose velcro band across his thigh, to secure the catheter tubing. On 08/15/19 at 3:00 PM, Staff B, Director of Nursing, stated Resident #2 pulled on his catheter. Staff B stated there was one instance when staff were doing catheter care, that he pulled on it to the point it pulled apart. Per Staff B, at that time, the tubing had been secured to his leg. Reference: WAC: 388-97-1060(3)(c)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse. The facility failed to provide adequate supervision, or implement effective interventions, to prevent resident-to-resident abuse for one of seven sample residents ( #1), reviewed for abuse. This failure placed all vulnerable residents in the facility at risk for physical abuse, and caused actual harm to Resident #1, who was slapped across the face by Resident #2 causing pain, swelling, and redness. Findings included . Resident #2 was admitted with [DIAGNOSES REDACTED]. According to the facility assessment dated [DATE], she was alert and able to make her needs known. According to the resident's 02/22/19 care plan, an intervention for staff to follow when there was a conflict involving Resident #2, was to remove the resident to a calm safe environment, and allow her to vent and share her feelings. On 04/06/19, per facility investigation, Resident #2 stated to Staff B, Licensed Practical Nurse, the voices in my head are telling me to hit you. Staff B asked Resident #2 if she was feeling ok and she stated No, not really. The investigation showed Staff B left the area where Resident #2 was seated to alert another staff member. When she returned, residents and other staff were yelling that Resident #2 had slapped Resident #1 across the face, and knocked off her glasses. Staff C, Nursing Assistant, wrote a statement dated 04/06/19, showing she witnessed Resident #2 slap Resident #1 across the face and knock her glasses off. The statement also showed Staff C was down the hall from the both residents at the time of the incident, and was unable to intervene. Staff D, Nursing Assistant, who also witnessed the incident wrote a statement dated 04/06/19, which showed she was taking bins out when she witnessed Resident #2 stand up and slap Resident #1 across the face. According to the statement, Staff D was also unable to timely intervene. According to the investigation, the residents were then separated, and Resident #2 was taken to the hospital for a psychological evaluation. Resident #1 was assessed; her right cheek was slightly red and swollen, according to the skin assessment dated [DATE]. According to the resident observation form dated 04/06/19 through 04/07/19, Resident #2 was startled at the time of the incident, stated she was in pain, and was medicated with pain medication. Per the form, the resident also exhibited restless behavior including pained facial expressions, restless movements, and a distorted face. During an interview and observation on 04/18/19 at 1:55 PM, Resident #2 was in bed, and upon questioning, stated she had an incident with another resident. She stated Resident #2 came over and whacked me on the face; she knocked my glasses right off my face. The resident also stated her glasses were not broken, but stated, my face was red and it hurt; they (staff) gave me ice to put on it. The resident stated she feels safe now, because Resident #2 doesn't come around her anymore. On 04/17/19 at 3:00 PM, Staff A, Director of Nursing confirmed the conclusion of the facility investigation was resident-to-resident physical abuse. Per Staff A, after the incident, Staff B was given additional education, related to supervision of residents. WAC Reference: 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to consistently implement the planned intervention of using a cigarette extender, for one of three sample residents (#1), reviewed for smoking safety. This failure resulted in harm to the resident, who [MEDICAL CONDITION] two of her fingers. Findings included: Resident #1 was admitted with [DIAGNOSES REDACTED]. According to the facility assessment dated [DATE], she required extensive assistance with activities of daily living, and had limited range of motion in both of her upper extremities. The facility smoking policy, dated (MONTH) (YEAR) showed: Residents assessed as being dependent with smoking may only smoke under staff supervision and may be required to wear a smoking apron or other safety requirements at request of staff. According to the 05/21/18 smoking assessment, Resident #1 was determined to be a dependent smoker, requiring supervision and a smoking apron. Resident #1's initial care plan, dated 05/22/18, showed she was at risk for injury when smoking, related to hand contractures (stiffening of muscles or connective tissue, resulting in decreased movement and range of motion), and a history of unsafe smoking [MEDICAL CONDITION](present upon admission). Per a therapy-to-nurse communication note dated 05/23/18, Resident #1 required assistance from staff to hold a cigarette, and to flick ash due to ataxia (loss of muscle control), in both hands. On 05/25/18, Resident #1's care plan was updated, with interventions including the use of a cigarette holder for safety while smoking, and showed she remained a dependent smoker (requiring staff assistance and supervision while smoking). The care plan also showed all smoking supplies would be kept locked in the nurse's medication cart, and the supplies would only be provided to staff during established smoking times. Per a 07/02/18 progress note, a white-silvery blister, with a small opening, was found on Resident #1's left hand index finger. The note also showed the middle finger of the left hand had a circular open wound. Per record review, on 07/02/18, Staff A, Director of Nursing Services, interviewed Resident #1. The resident stated she had not used the smoking extender the day before, as per the care plan, and burned the inside of her fingers. According to the skin grid (a document used by the facility to track skin alterations) dated 07/02/18, the impairment on the left middle finger was described as a burn/blister with an open middle area. The grid described the left index finger as a blister/burn, which was silver in color. [MEDICAL CONDITION] monitored and measured on 07/09/18, but no further assessments or measurements were completed, per review of the record. The facility investigation, dated 07/06/18, showed [MEDICAL CONDITION] reasonably caused by Resident #1 not using the cigarette extender. On 07/27/18 at 1:30 p.m., Resident #1 was seated in her wheelchair waiting to go outside to smoke; she stated she needed staff assistance with smoking, pointing to the shiny skin on two fingers of her left hand. She stated she had burned herself while smoking a while ago. According to Staff C, Licensed Practice Nurse, during an interview on 07/27/18 at 1:35p.m., the expectation was for staff to go out to the designated smoking area with dependent smokers. Staff C stated once in the smoking area, they were to assist the residents with safety interventions, such as smoking aprons and cigarette extenders. She further stated some residents required assistance with lighting and extinguishing cigarettes, and if a resident refused to comply with safety and rules, they could not smoke. Resident #1 was observed smoking with Staff C shortly after the interview. All planned interventions were in place, including a smoking apron and cigarette extender, as per the care plan. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to meet the discharge requirements, related to a facility initiated discharge, for one of two sample residents (#1), when it issued a written discharge notice, identifying the discharge location was a homeless shelter or hotel. In addition, the facility failed to ensure the resident was informed of her appeal rights. This failure resulted in harm to the resident, who was discharged without a place to live, missed [MEDICAL TREATMENT] procedures (periodic outpatient procedures to remove toxins from the blood, associated with [MEDICAL CONDITION]), suffered a decline in health, and required a prolonged stay at a hospital, until safe and appropropriate placement could be arranged. Findings included: According to the facility assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The resident required limited assistance with bed mobility, transfers, and personal hygiene, and supervision to toilet. She had an ostomy with an appliance (a surgically created opening for bowel movements, with a collection bag), and had occasional urinary incontinence. Per the record, the discharge plan was for her to return to the community. Record review of a 03/31/18 progress note by Staff E, Registered Nurse, showed the resident was independent with all activities of daily living, which was different information from the facility assessment. Additionally, Staff E documented the resident performed ostomy care independently, and was able to manage medications. Record review of a 04/06/18 progress note by Staff A, Social Services Director, showed the out-patient [MEDICAL TREATMENT] unit called the facilty, to say the resident told [MEDICAL TREATMENT] staff she was being kicked out of the facility. Staff A explained to [MEDICAL TREATMENT] staff the facility issued a 30-day written discharge notice, informing the resident that 30 days was exhausted on 04/16/18, but the facility was assisting the resident to find housing. Additional record review showed there was no written discharge notice in the record, including a discharge location, reason for discharge, and appeal rights, as required. There was no information related to the facility educating the resident about her appeal rights. Record review of progress notes dated 04/16/18 at 2:30 p.m. and 5:30 p.m. showed the resident was discharged Against Medical Advice (meaning the resident stated she was leaving), prior to her [MEDICAL TREATMENT] appointment on 04/16/18, with medications, instructions for physician appointments, and home health services. The resident provided a discharge address, and gave the out-patient [MEDICAL TREATMENT] center telephone number as a message telephone number. According to emergency room and hospital records, the resident had emergency room admissions on 04/17/18, 04/18/18, and 04/24/18, related to homelessness, blood pressure problems, missed [MEDICAL TREATMENT] out-patient appointments, and inability to care for herself, due to lack of ostomy appliance supplies. Hospital staff arranged for an emergency shelter placement. From 04/29-05/05/18, the resident resided in the emergency room , due to an inability to care for herself in an emergency shelter situation, and was admitted to the hospital on [DATE], with an overall decline in condition. The resident was observed and interviewed in her hospital room on 06/01/18, day 34 of her hospitalization . The resident was alert and oriented, and sat in a wheelchair. She stated she was unable to transfer independently, and was participating in physical therapy. When asked about discharge from the facility, the resident stated the facility issued a written discharge notice, informing her she no longer needed services. She stated she wanted to find a place where she could live with her adult child, but could not find a place before the discharge date of [DATE]. She further stated staff informed her she had to have a discharge address, in order for her to take medication with her. As a result, she gave the facility the address of an apartment she used to live in, and used the [MEDICAL TREATMENT] center telephone number as a message phone. Per the resident, when she discharged Against Medical Advice on 04/16/18, she took the wrong size ostomy appliance supplies, and soon had problems with incontinence. She went to [MEDICAL TREATMENT] that afternoon, and spent the first night in a hospital emergency room waiting area, and on the street. When asked about her appeal rights for the written discharge notice, the resident stated the volunteer advocate who visited her at the facility informed her she probably had to be discharged , she didn't know what to do, and so she used the former address, and left the facility. During interview on 06/15/18 at 1:30 p.m., Staff A, Social Services, stated the resident was working with the facility and another state agency for placement. The resident had declined an assisted living facility, and had not been able to find an apartment, where she could have home services. When asked, Staff A stated Staff B, Administrator, and Staff C, Acting Director of Nursing Services, issued the discharge notice to the resident. During interview on 06/19/18 at 10:00 a.m., Staff B and Staff C confirmed they issued the written discharge notice to the resident. Additionally, they confirmed the facility did not have a copy of the discharge notice in the resident's record, and there was no documentation related to their discussion with the resident. Neither Staff B or Staff C could recall the reasons listed on the written notice. Staff B confirmed there was no discharge location on the notice, when issued, as required. Staff B stated she would contact the volunteer advocate for a copy of the written notice. When Staff B was informed the resident gave inaccurate information about her discharge location, and was homeless at discharge, Staff B stated the facility did not know that. She stated the volunteer advocate had just informed her the resident planned to appeal the written discharge notice, when the resident provided a discharge location, and was discharged from the facility. Review of a facsimile (fax) copy of the written discharge notice showed it was issued 03/16/18. The reason for discharge was listed as the resident's health had improved sufficiently, so she no longer needed the services provided by the facility, and the discharge location was to a homeless shelter or hotel on (MONTH) 16th, (YEAR). Reference (WAC) 388-97-0120(1)

Based on interview and record review, the facility failed to ensure one of three residents (#44), reviewed for anticoagulant (blood thinning) medication, received adequate monitoring to ensure appropriate administration of the high risk medication. This failure resulted in Immediate Jeopardy for Resident #44, who was placed at risk for blood clots and/or bleeding. The State Agency informed the facility on 01/11/18 at 3:29 p.m. of the Immediate Jeopardy situation. The facility provided education to nursing staff, and performed an audit of all residents receiving anticoagulant medications. They then ensured there were no additional outstanding laboratory results, or ongoing medication errors. On 01/12/18 at approximately 9:30 a.m., the facility was notified of the removal of the immediate jeopardy. Additionally, the facility failed to ensure two of eight residents (#44, 291), reviewed for unnecessary medications, received care and services to ensure the least required doses of sedating pain medications were utilized. This failure resulted in actual harm to Resident #291, who required hospitalization , due to an overdose of her medication. Findings included: 1. Per her quarterly assessment dated [DATE], Resident #44 admitted to the facility in August 2017, and had [DIAGNOSES REDACTED]. The assessment showed she used scheduled and as needed pain medication for occasional pain, and used anticoagulant (blood thinning) medication daily. Anticoagulant (Blood Thinner) Medications According to the Nursing 2016 Drug Handbook (Wolters Kluwer, 2016, p.1495) Black Box Warning, [MEDICATION NAME] (an anticoagulant medication to prevent blood clots) can cause major or fatal bleeding .Regularly monitor INR in all patients. Laboratory monitoring (INR) is used to determine if the anticoagulant medication is providing a therapeutic effect (evidenced by an INR within the goal range for the resident), and required to ensure the resident is not receiving excessive doses, which would increase the risk of bleeding. According to Resident #44's anticoagulant log, (which was for documenting each INR result, any dosage changes in the medication, and the schedule for the next laboratory draw), Resident #44's goal for [MEDICATION NAME] treatment was to keep her INR in the 2.5 to 3.5 range. The treatment was for a [DIAGNOSES REDACTED]. Resident #44's laboratory results, Medication Administration Records (MARs), progress notes and physician orders [REDACTED]. The INR was drawn on 10/11/17, with a result of 1.45 (significantly below the resident's goal therapeutic range). According to her MAR, she received the same dose of [MEDICATION NAME] on 10/12/17, although her INR was low. There was no evidence the provider was notified of the low result on 10/12/17, or that the nurse requested instructions for any dose adjustments. On 10/13/17, Resident #44's [MEDICATION NAME] dosage was increased. On 10/22/17, her INR was still below the therapeutic range at 1.8. The provider ordered an increase in her dose of [MEDICATION NAME], and upon recheck on 10/29/17, the INR had increased to 3.72, above the resident's therapeutic range (the dose was decreased at that time). Per progress notes, the resident experienced bleeding from her ear on 11/05/17, and was sent to the emergency department. Per the notes, her INR had increased to 7.1, a dangerously high value, in the week since her previous draw. This demonstrated how labile the resident's INRs were, and how necessary it was to monitor them closely. On 11/26/17 the INR was 1.32, significantly below her goal range. The same [MEDICATION NAME] dose was given on 11/27/17, although her INR was low, and the provider was not notified until 11/28/17, at which time the medication dosage was increased. On 11/29/17, Resident #44's laboratory report showed her INR was 1.48. Review of the records did not demonstrate that any staff addressed the low value. Meanwhile, the same dose of [MEDICATION NAME] was given to the resident. After reviewing the record on 01/11/18 at 10:35 a.m., Staff I, Registered Nurse, confirmed there was no documentation that the low value was addressed before the next draw, which was on 12/05/17. The INR on 12/05/17 showed a low level of 1.48. The anticoagulant log noted the next draw was due on 12/10/17, but there was no order detailing when the next draw should take place. Per the laboratory results, the lab was not drawn until 12/12/17, and the INR was still low at 1.4. There was no evidence the nurses administering [MEDICATION NAME] on 12/11/17 or 12/12/17 called the provider to obtain instructions for dosing the medication, while the laboratory result was not available. On 12/13/17, the medication dosage was increased. According to the laboratory results, Resident #44's INR was 2.07 on 12/29/17, which was below her therapeutic range. Per the note on the laboratory slip, the provider was not notified until 01/01/18. In an interview on 01/11/18 at 10:40 a.m., Staff I, Registered Nurse, explained that INR draws are done one day, and the results are received the following day, usually on evening shift. In an interview on 01/11/18 at 11:52 a.m., Staff D, Unit Manager, was asked what an evening shift nurse should do before administering [MEDICATION NAME], if the lab was drawn the day before. She stated the nurse should ensure the lab results are back, and make sure the provider is aware of the INR, to see if the dose is still appropriate or needs to be adjusted. In an interview on 01/11/18 at 12:14 p.m., when the above findings were discussed, Staff D stated she was not aware that the process was not being followed, and stated they would need to develop a plan to monitor it much better. Failure to ensure Resident #44's laboratory results were acknowledged, and new orders were obtained as necessary before the next dose of [MEDICATION NAME] was given, placed Resident #44 at risk for blood clots related to low INR values, or potentially dangerous bleeding, related to high values. Repeated occurrences of delay with monitoring reflected an ineffective system in place, to safely administer the medication. Sedating Medications Review of Resident #44's current medications as of 01/08/18 revealed she was on two opioid pain medications (extended release [MEDICATION NAME] 60 milligrams (mg) in the morning and 30mg in the evening, and [MEDICATION NAME] 5mg twice daily and every six hours as needed), which had the potential to cause oversedation as an adverse effect. A nursing note dated 10/24/17 indicated Resident #44 was complaining of pain that was not relieved by her routine pain medications due to tolerance to the medications. On 10/24/17, the provider ordered an increase in how often her as needed pain medication was available from every six hours to every four hours, and ordered that she have an appointment with the pain clinic ASAP (as soon as possible). Review of the record, including on 01/08/18, revealed no indication the resident was seen at a pain clinic. Observation of the resident during the survey time period revealed she exhibited signs of sedation. During an interview on 01/04/18 from 10:35-10:56 a.m., approximately every 30-45 seconds, the resident dozed off to sleep during conversation. She stated she did not know why she kept dozing. Observation on 01/08/18 at 3:36 p.m. and 01/09/18 at 12:00 p.m., revealed Resident #44 dozed off in her wheelchair while she was self-propelling it. In an interview on 01/16/18 at 9:18 a.m., Staff F, Medical Records Director, stated she began trying to identify a pain clinic Resident #44 could go to on 01/04/18 (over two months after the order to make an appointment for the resident as soon as possible). In an interview on 01/16/18 at 10:09 a.m., Staff D, Unit Manager, was asked about Resident #44's pain management. She stated it was a delicate balancing act because Resident #44 was on quite a bit of pain medications, and she did get oversedated easily. When asked whether Resident #44 had been seen by a pain clinic per the order to refer her ASAP in October 2017, Staff D stated she was not aware. 2. According to Resident #291's quarterly assessment dated [DATE], she was cognitively intact, had moderately severe depression, had functional impairment on one side, and required extensive assistance for most activities of daily living. The assessment showed she had [DIAGNOSES REDACTED]. Per the assessment, Resident #291 received scheduled and as needed pain medications, and had occasional pain that did not cause functional impairment. Review of Resident #291's physician orders [REDACTED]. Review of the medications Resident #291 received at that time, revealed the following medications, in addition to [MEDICATION NAME], that produce a central nervous system depressing effect (this can slow the breathing rate, and cause drowsiness): another opioid pain medication, an antianxiety medication (both scheduled and as needed), and two anticonvulsants. According to the Nursing 2016 Drug Handbook (Wolters Kluwer, p.978), a black box warning associated with [MEDICATION NAME] sulfate stated the extended release medication has a greater risk of overdose and death. Reserve their use for patients for whom alternative treatment options are ineffective . to provide adequate pain management. Another black box warning for the same drug stated, Monitor patients for respiratory depression (slowed respirations), especially during initiation of extended-release .[MEDICATION NAME] sulfate or after a dosage increase. Serious, life-threatening, or fatal respiratory depression may occur (p.979). Review of Resident #291's Medication Administration Record [REDACTED]. The progress notes leading up to 11/09/17 did not show any increased pain noted for Resident #291. No clear indication for the 11/09/17 increase in extended release [MEDICATION NAME] was noted in the record. Attempts to contact the provider who ordered the medication increase, to discuss the circumstances of the resident's pain management at the time, were unsuccessful. A nursing note, dated 11/18/17, showed Resident #291 was more lethargic that day. The note indicated the nurse practitioner had been notified, and the order for extended release [MEDICATION NAME] was changed back to three times per day. Another note shortly thereafter on 11/18/17 showed Resident #291 was not responding to verbal or painful stimuli, the provider was called, and ordered nursing staff to administer [MEDICATION NAME] (a medication to reverse the effects of opioid medications), and ultimately the resident was transferred to the hospital for further treatment. A provider note, dated 11/20/17, showed Resident #291 had overdosed on 11/18/17, and was found to have respirations of 9 per minute (below the normal range). The note showed [MEDICATION NAME] was administered, then the resident was transferred to the hospital. The note revealed she was admitted to the intensive care unit, given [MEDICATION NAME] intravenously, and when she returned to the facility on [DATE], her pain medications had been significantly decreased. The note stated apparently she is having significant family stressors and uses pain medications as a coping mechanism. In an interview on 01/09/18 at 2:15 p.m., Resident #291 stated she did not recall the details of why she was hospitalized in November 2017, and stated the surveyor could speak to her daughter, who might have more information. In a telephone interview on 01/10/18 at 10:18 a.m., when asked about the reason for her mother's hospitalization in November 2017, Resident #291's daughter stated her mother was hospitalized due to an overdose of sedating medications. She stated Resident #291 was experiencing emotional pain at the time when she had the increase in her pain medications, and she felt the provider did not identify underlying causes of the pain, or explore other options, before adding additional medication. Hospital records, dated 11/20/17, listed Resident #291's admission [DIAGNOSES REDACTED]. In an interview on 01/16/18 at 2:10 p.m. Staff G, Registered Nurse, and Staff I, Registered Nurse, were asked about Resident #291's use of opioid pain medications, and her November 2017 hospitalization . Staff I stated the increase in frequency of the long acting pain medication of 11/09/17 was due to the resident's request, when the Nurse Practitioner had seen her. When asked whether they were aware of additional stressors in place at the time the resident was requesting pain medication, Staff G stated they were not aware, until the daughter mentioned it when the resident returned from the hospital. Staff G stated Resident #291 had a history of [REDACTED]. This showed the facility was aware of the potential for Resident #291 to request pain medications, when they were not indicated for physical pain. Review of Resident #291's record on 01/12/18 at 10:57 a.m. revealed no notes related to formal psychological support for the resident, in light of the provider note from 11/20/17, that indicated she had family stressors that prompted her use of pain medication. In an interview on 01/12/18 at 2:56 p.m., Staff S, Social Services, was asked whether he was aware of any family stressors Resident #291 was experiencing. Staff S said there were episodes that occurred infrequently. When shown the note from the nurse practitioner indicating the resident had stressors in November 2017, and that she was utilizing pain medication for relief, Staff S said he was not made aware of that situation. In an interview on 01/16/18 at 10:20 a.m. Staff D, Unit Manager, stated she looked back at the doses of pain medication the resident was on before she was hospitalized for [REDACTED]. She stated Resident #291 was tolerating the dose for a while, but then it caught up with her. When the surveyor told Staff D that there was not a clear indication in the record that the resident was experiencing increased pain prior to the increase in medication, Staff D stated staff needed to work on documentation. Reference: (WAC) 388-97-1060(3)(k)(i)

Based on interview and record review, the facility failed to ensure 3 of 3 residents (#44, 60, 56) reviewed for anticoagulation (blood thinner) therapy received medications appropriately, in accordance with a valid physician's orders [REDACTED]. The State Agency informed the facility on 01/11/18 at 3:30 p.m. of the Immediate Jeopardy situation. The facility provided education to nursing staff, and performed an audit of all residents receiving anticoagulant medications. They then ensured there were no outstanding laboratory results or ongoing medication errors. On 01/12/18 at approximately 9:30 a.m., the facility was notified of the removal of the immediate jeopardy. Additionally, the facility failed to ensure one resident was free from a significant medication error, when Resident #6 received medications intended for another resident. This failure placed the resident at risk for adverse effects from excessive medications, which were not prescribed to her. Findings included: 1. Per her quarterly assessment dated [DATE], Resident #44 admitted to the facility in August 2017, and had [DIAGNOSES REDACTED]. The assessment showed she used anticoagulant (blood thinning) medication daily. Anticoagulant Medications According to the Nursing 2016 Drug Handbook (Wolters Kluwer, 2016, p.1495) Black Box Warning, [MEDICATION NAME] (an anticoagulant medication to prevent blood clots) can cause major or fatal bleeding .Regularly monitor INR in all patients. Laboratory monitoring (INR) is used to determine if the anticoagulant medication is providing a therapeutic effect (evidenced by an INR within the goal range for the resident), and required to ensure the resident is not receiving excessive doses, which would increase the risk of bleeding. According to Resident #44's anticoagulant logs for the time period covering October 2017 through review date of 01/11/18 (which was for documenting each INR result, any dosage changes in the medication, and the schedule for the next laboratory draw) Resident #44's goal for [MEDICATION NAME] treatment was to keep her INR in the 2.5 to 3.5 range. The treatment was for a [DIAGNOSES REDACTED]. Resident #44's laboratory results, Medication Administration Records (MARs), progress notes and physician orders [REDACTED]. The INR was drawn on 10/11/17, with a result of 1.45 (significantly below the resident's goal therapeutic range). According to her MAR, she received the same dose of [MEDICATION NAME] on 10/12/17, although her INR was low. There was no evidence the provider was notified of the low result on 10/12/17, or that the nurse requested instructions for the dose on 10/12/17. Administering the medication on 10/12/17 without obtaining new instructions constituted a significant medication error. On 11/26/17 Resident #44's INR was 1.32, significantly below her goal range. The same [MEDICATION NAME] dose was given on 11/27/17, although her INR was low, and the provider was not notified until 11/28/17, at which time the medication dosage was increased. This constituted another significant medication error. On 11/29/17, Resident #44's laboratory report showed her INR was 1.48. Review of the records did not demonstrate that any staff addressed the low value. Meanwhile, the same dose of [MEDICATION NAME] was given to the resident on 11/30/17, 12/01/17, 12/02/17, 12/03/17 and 12/04/17, before the provider was notified of a new laboratory value on 12/05/17 of 1.42, and an order was received to keep the dose the same. Each of the above dates represented significant medication errors. After reviewing the record on 01/11/18 at 10:35 a.m., Staff I, Registered Nurse, confirmed there was no documentation that the low INR value on 11/29/17 was addressed timely. The anticoagulant log noted the next draw was due on 12/10/17 but per the laboratory results, was not drawn until 12/12/17. There was no evidence the nurses administering [MEDICATION NAME] on 12/11/17 or 12/12/17 called the provider to obtain instructions for dosing the medication while the laboratory result was not available, which constituted medication errors related to the [MEDICATION NAME] they administered on those dates. On 12/13/17, the medication dosage was increased. According to the laboratory results, Resident #44's INR was 2.07 on 12/29/17, which was below her therapeutic range. Per the note on the laboratory slip, the provider was not notified until 01/01/18, constituting significant medication errors on 12/30/17 and 12/31/17, when the nurses administered the medication in the absence of new dosing instructions. In an interview on 01/11/18 at 10:40 a.m., Staff I, Registered Nurse, explained that INR draws are done one day, and the results are received the following day, usually on evening shift. In an interview on 01/11/18 at 11:52 a.m., Staff D, Unit Manager, was asked what an evening shift nurse should do before administering [MEDICATION NAME] if the lab was drawn the day before. She stated the nurse should ensure the lab results are back, and make sure the provider is aware of the INR, to see if the dose is still appropriate or needs to be adjusted. In an interview on 01/11/18 at 12:14 p.m., when the above findings were discussed, Staff D stated she was not aware that the process was not being followed, and stated they will need to develop a plan to monitor that much better. For Resident #44, who was at increased risk for clots due to [MEDICAL CONDITION] with a mechanical heart valve, and had a history of [REDACTED]. 2. Per the quarterly assessment dated [DATE], Resident #56 admitted with [DIAGNOSES REDACTED]. During an interview on 1/12/18 at 11:00 a.m., Staff C, Unit Manager, stated on 01/11/18, the facility completed an audit of all residents who received anticoagulant medications. Staff C stated the results of the audit determined Staff R, Registered Nurse, held the resident's anticoagulant/blood thinning medication ([MEDICATION NAME]) every time there was a lab draw (INR), and the results were not available. Per Staff C, Staff R should have notified the physician that the INR result was not back, to receive orders to administer the medication, and a dosage. Staff C stated the facility was not aware the resident's anticoagulant medication was held until the audit was completed. A review of Resident #56's medication administration records (MAR), physician orders, and progress notes, from October 2017 through 01/07/18, revealed several doses of [MEDICATION NAME] had been held without a physician's orders [REDACTED]. The October 2017 MAR indicated [REDACTED]. Holding the medication without a physician's orders [REDACTED].#56 at risk for developing a blood clot. A review of the November and December 2017 MARs revealed similar results, with the [MEDICATION NAME] having been held without a physician's orders [REDACTED]. Each of these occurrences represented a significant medication error, and placed Resident #56 at increased risk of developing a blood clot. The progress notes from 10/01/17 through 01/07/18 did not show why the [MEDICATION NAME] had been held, and did not show any communication with the resident's physician, on the dates the medication was held. A review of a facility investigation dated 01/12/18 revealed Resident #56's [MEDICATION NAME] had been held on Sundays for the past 30 days, and the physician had not been notified when the doses were held, or to request clarification of the [MEDICATION NAME] orders. In an interview on 01/16/18 at 10:19, Staff B, Director of Nursing, acknowledged Resident #56's [MEDICATION NAME] was held on the above dates without a physician's orders [REDACTED]. 3. According to the record, Resident #60 had [DIAGNOSES REDACTED]. During an interview on 01/12/18 at 11:00 a.m., Staff C, Unit Manager, stated on 01/11/18, the facility completed an audit of all residents who received anticoagulant medications. Staff C stated the results of the audit determined Staff R, Registered Nurse, held the resident's anticoagulant every time there was a lab draw (INR), and lab did not arrive to do the blood draw until late in the evening, after the time the medication was scheduled to be given. Per Staff C, Staff R should have notified the physician that the INR result was not back, for orders to administer the medication, and at what dosage. Staff C stated the facility was not aware the resident's anticoagulant medication was held, until the audit was completed. The resident's December 2017 Medication Administration Record [REDACTED]. Each of these occurrences represented a significant medication error, and placed the resident at risk for developing a blood clot. According to the laboratory results, the resident's INR on 12/18/17 was 1.16 (range should be 2-3), on 12/24/17 was 1.20, and on 01/01/18 was 1.42. Record review showed Staff R held the resident's anticoagulant on 01/07/18. On 01/08/18, the INR was 4.22, which was elevated, placing the resident at increased risk for bleeding. The anticoagulant medication was held on 01/08/17. Additional record review showed on 01/09/18, the anticoagulant order was 10 milligrams(mg), and Staff R administered 15 milligrams (mg). On 01/10/18, the anticoagulant order was 15 mg, and Staff R administered 10 mg. Each of these occurrences represented a significant medication error, and placed the resident at risk for developing a blood clot or bleeding. A review of a facility investigation, dated 01/12/18, revealed Resident 60's anticoagulant dose had been held on Sundays, due to the lab not arriving to do the blood draw for the INR until late in the evening, after the time the medication was scheduled to be given. The investigation also documented the physician was not notified. In an interview on 01/16/18 at 10:19 a.m., Staff B, Director of Nursing, acknowledged Resident 60's anticoagulation medication had been held without a physician's orders [REDACTED]. 4. Review of the progress notes for 11/17/17 revealed Resident #6 erroneously received medications intended for another resident on that date. The facility incident report follow up, dated 11/21/17, showed Staff BB, Registered Nurse, administered medications to Resident #6 which were prescribed to her roommate. The medications included two muscle relaxants, two opioid pain medications, and one anti-anxiety medication. Each of the medications had the potential adverse reactions of lowering blood pressure, and causing sedation. Review of the blood pressures documented on 11/17/17, from 4:45 a.m. to 5:45 a.m., showed Resident #6's systolic blood pressure (the upper number, for which a normal range for the resident was 100-120), was as low as the 70s. In an interview on 01/10/18 at 2:51 p.m., the surveyor notified Staff B, Director of Nursing, of concerns with the medication error and the low blood pressures. He stated the low blood pressures were concerning, and the nurse would have been instructed to call the provider, to notify him of the values. On 01/10/18, Staff Z, Licensed Practical Nurse, provided documentation the physician was notified of the blood pressures by Staff BB on 11/17/17, and that although the blood pressures were low, the resident was not experiencing an adverse symptoms, and therefore was not harmed by the medication error. Reference: (WAC) 388-97-1060(3)9k)(iii)

Based on interview and record review, the facility failed to ensure quality deficiencies, related to repeated failures to comply with the federal regulations for nursing homes, were analyzed and corrected, based on an effective improvement plan. These failures caused actual harm to Resident #291 and Resident #81, and placed other residents at risk for deficiencies in quality of care. Findings included: On 01/17/18 from 9:37 a.m. to 10:02 a.m., the surveyor conducted an interview with Staff A, Administrator, and Staff B, Director of Nursing, regarding the facility's quality assurance and performance improvement (QAPI) activities. On 01/17/18 at 9:37 a.m., Staff A stated the monthly and quarterly QAPI reviews were a weak area, because they required daily QAPI in the building. She stated a regional staff member was assisting her to develop a program in which they can analyze the forest rather than the trees. There was no evidence a higher level analysis of the facility's quality deficiency patterns, and tracking their progress toward improvement, had been implemented. The following areas of repeated deficiency were identified, which were not identified and corrected through the QAPI process before the survey: -Unnecessary High Risk Medications and Medication Errors See F757, F759 and F760 for additional information. Similar deficiencies were cited during the annual recertification surveys dated 11/08/17 and 01/14/16 at F329, F332, and F333 -Accidents and Supervision See F689 for additional information. Similar deficiencies were cited during the annual recertification surveys dated 11/08/16 and 01/14/16 at F323 -Dental Services See F791 for additional information. Similar deficiencies were cited during the annual recertification surveys dated 11/08/16 and 01/14/16 at F412. -Sufficient Staffing See F 725 for additional information. Similar deficiencies were cited during the annual recertification surveys dated 11/08/16, 01/14/16, and 11/12/14 at F 353. -Pressure Ulcers See F686 for additional information. A citation on an abbreviated survey dated 08/21/17 revealed deficiencies related to pressure ulcers, which resulted in harm to Resident #76. Corrections were not maintained, and pressure ulcers were again cited for this annual survey. -Preadmission Screening and Resident Review See F644 for additional information. Similar deficiencies were cited during the annual recertification surveys dated 11/08/16, 01/14/16, 11/12/14, and 12/13/13, at F285. When asked about tracking medication errors on 01/17/18 at 9:54 a.m., Staff B stated he believed there was a way to look at trends with the numbers of incidents in their risk management system, but they had not yet been trained on that. He said in the future they could use that program to present information, and determine how the facility was doing, during QAPI meetings. As an example, on 01/17/18 at 9:59 a.m., when asked about whether dental issues had been identified by QAPI as a focus for improvement, Staff A said it had not. Staff B added they had identified a problem with dental assessments, so they did a house-wide sweep to ensure assessments were done. When asked about follow through with ensuring the residents received the services they were assessed to require, there was no evidence presented the facility followed up, to ensure their identified quality deficiency related to dental care was resolved. On 01/17/18 at 10:00 a.m., Staff A emphasized the facility had undergone significant changes in recent months with new management, and stated what they need to incorporate into their meetings is a system of summarizing the status of the issues they were reviewing. Patterns of repeated deficiencies showed the facility's failure to monitor its own processes to ensure ongoing compliance with the federal regulations, and ensure quality care and safety for their residents. Reference: (WAC) 388-97-1760(1)(2)

Based on observation, interview, and record review, the facility failed to ensure staff obtained accurate and timely weights for two of two residents (#81, 65), reviewed for nutrition. Failure to obtain a baseline admission weight, and weekly weights for the first four weeks per policy, resulted in harm to Resident #81, who had a significant, unplanned weight loss, and experienced frustration with being connected to a tube feeding (a tube inserted directly into the stomach for nutrition, fluids, and medication). Findings included: A review of the facility's procedure titled, Weight Monitoring, dated July 2015, showed each resident is weighed within 24 hours of admission/readmission, weekly for four weeks (or until the weight is determined to be stable), then monthly to monitor stability. 1. According to the facility's admission assessment dated [DATE], Resident #81 had [DIAGNOSES REDACTED]. The resident had memory problems, required limited to extensive assistance of 1-2 staff for mobility, and total assistance to eat (related to unsafe swallow). All nutrition, fluids, and medications were delivered via a tube feeding. Review of a 12/21/17 nutritional assesssment by Staff X, Dietician, showed the resident was receiving tube feeding and water continuously (24 hours per day), via a pump, which was meeting 100% of his estimated nutrition/hydration needs. The resident's weight of 215 pounds (lb) was above the resident's ideal weight range. Nutritional goals included maintaining weight, and monitoring the resident's weight. According to the record, the resident's admission weight on 12/13/17 was 215 lb. The next documented weight on 01/02/18, 30 days after admission, was 203.7 lbs., which showed a 5% unplanned, significant weight loss. Per review of a 01/14/18 nutrition progress note, Staff X had received a referral from nursing services, to evaluate the resident for changing the tube feeding rate. Staff X noted the resident had experienced a weight loss, and changes to the tube feeding rate were not appropriate at that time. Staff X requested the resident be weighed weekly for the next four weeks. Review of a 01/06/18 progress note by Staff HH, Licensed Practical Nurse, showed the resident was restless, self-transferring multiple times, and disconnecting his tube feeding multiple times. A 01/08/18 note by Staff II, Registered Nurse, showed the resident was verbalizing frustration that the tube feeding limited his freedom. During observation on 01/09/18 at 11:50 a.m., the resident was propelling the wheelchair independently in his room and hallway, with the tube feeding running continuously, and a pump and bags suspended on a pole, attached to the wheelchair. During interview on 1/11/18 at 10:25 a.m., Staff X was asked about the resident's weight change. Staff X stated the resident's admit weight was the same as the hospital weight, and she could not determine if the resident was weighed by facility staff upon admission. Staff X confirmed the resident had a 5% weight change in 30 days, which was an unplanned, significant weight loss. Upon questioning regarding the referral from nursing services to change the tube feeding rate, Staff X stated nursing staff wanted to increase the tube feeding rate, and reduce the number of hours the resident needed to be connected to the tube feeding. When asked, Staff X confirmed that because the resident was not weighed weekly as required, and had a weight loss, there would be a delay in being able to recommend changes to the tube feeding schedule. The facility failed to consistently monitor the weight of a resident receiving all nutrition through a tube feeding, which resulted in a 5% weight loss. 2. Per the admission assessment dated [DATE], Resident #65 had [DIAGNOSES REDACTED]. The assessment indicated the resident was independent with eating, had no natural teeth, and received a therapeutic diet. Per record review, Resident #65's weight on admission was 125 pounds. The next recorded weight was 12 days after admission, and documented the resident weighed 120 pounds. From 12/11/17 until 01/08/18, no documentation of the resident's weight was found. She was not weighed for 28 days, despite the fact weekly weights were to be done. On 01/08/18, Resident #65 weighed 125 pounds. In an interview on 01/11/18 at 2:46 p.m. Staff X, Dietician, stated she recommended during the last nutritional review meeting (on 01/08/17) Resident #65 should be placed on weekly weights, to ensure faciity staff were consistent in obtaining weights. On 01/16/18 at 10:48 a.m., after discussion and review of Resident #65's weights, Staff B, Director of Nursing, stated the expectation and facility policy was that weights were to obtained weekly for all residents upon admission, and then monthly, if stable. After a review of Resident #65's weight record, Staff B acknowledged weights were not done weekly. Reference (WAC) 388-97-1060 (3)(h)

Based on observation, interview, and record review, the facility failed to ensure one of five residents (#1), was free from abuse. The facility failed to take immediate action to identify the resident's report of abuse, and failed to take immediate steps to protect the resident. This failure resulted in an additional resident-to-resident incident between Resident #1 and Resident #2, which caused actual harm to Resident #1, who voiced fear, and exhibited signs and symptoms of mental anguish. Findings included: Resident #1 was admitted in October 2017, for rehabilitation after a total knee replacement. According to the most recent assessment dated [DATE], she was alert and able to make her needs known. The resident required assistance for transfers and turning in bed. Resident #2 was admitted in August 2017, with [DIAGNOSES REDACTED]. According to her most recent assessment dated [DATE], she was cognitively impaired, but able to make her needs known. She required supervision only for transfers and ambulation. Per interview with Resident #1 on 12/06/17 at 11:40 a.m., she stated she had been at the facility to recover after knee surgery. Resident #1 stated she thought she and her roommate (Resident #2) were friends. Per the resident, on the morning of 11/26/17, Resident #2 came over to her bed, looking for the television remote. When she told her it wasn't there, Resident #2 got mad, and hit her twice on the bad knee. Resident #1 stated she told staff after the incident, but nobody did anything. Resident #1 said her roommate went back to her side of the room, so she went back to sleep. The next thing I knew Resident #2 had my arm held down with her knee, and she was wiping something on me that smelled so bad; I tried to scream, and she tried to put it in my mouth so I couldn't yell, and I had an IV in my arm, so I couldn't move either. I was in shock. At the conclusion of the interview, Resident #1 stated she still has bad dreams and bad memories of the incident. At first she stated she was afraid to open the curtain that divided the room, because of fear the roommate was still there. Per observation, Resident #1 had no roommate, and the curtain was partially closed. Per facility investigation dated 11/27/17, on 11/26/17, Resident #1 was heard screaming for help. When staff arrived, Resident #2 was observed standing over the top of Resident #1, spreading feces all over her face. The investigation also revealed prior to the screams for help (a short time prior to the incident), Resident #1 had informed Staff C, Nursing Assistant, that Resident #2 had hit her twice on her operative knee. According to Staff C's statement, she arrived at work at 6:00 a.m. on 11/26/17. Resident #1 had informed her she had been physically assaulted by her roommate ( Resident #2). Staff C stated she informed the night nurse of Resident #1's concern. She did not see Resident #1 again until shortly after breakfast, when she heard screaming, and found Resident #2 smearing feces all over Resident #1. According to the facility investigation, the night nurse who received the report from Staff C, did not follow up, as she did not recognize it as a resident-to-resident altercation. She was later provided additional education, and received disciplinary action. After the second incident, the residents were separated, the police were called, and Resident #2 was discharged for a psychological evaluation. Per interview with Staff B, Social Services, on 12/11/17 at 10:10 a.m., he stated Resident #1 was doing well now, but stated immediately after the incident, noises would bother her, and she had to work thorough her fear and anger. Facility staff had knowledge of an earlier incident involving Residents' #1 and #2, but took no action to prevent a second incident, which was physical abuse, resulting in psychological harm to Resident #1. .

Based on observation, interview, and record review, the facility failed to provide necessary care and services related to pressure ulcers, for one of two sample residents reviewed (#7). The facility failed to monitor, assess, and intervene in a timely manner, which led to the redevelopment of a coccyx pressure ulcer for Resident #7. Findings included: Resident #7 was admitted to the facility in June 2017 for rehabilitation, following a motor vehicle accident which left him a tetraplegic (paralysis caused by injury, resulting in partial or total loss of the use of all four limbs and torso). A review of the admission comprehensive assessment, dated 06/14/17, showed Resident #7 was cognitively intact for daily decision-making. He required extensive assistance of two staff for bed mobility, transfers, and toilet use. The skin section of the assessment identifed the resident had a stage II pressure ulcer (partial thickness loss, which presents as a shallow open ulcer) on the coccyx, was at risk for further pressure ulcer development/skin breakdown, and was on an air mattress and had a pressure relieving device on his bed. A review of the care plan for pressure ulcers, undated, did not show a problem, goal, or interventions, as it related to the resident's ongoing pressure ulcers and skin issues. (See-279). Per review of the progress notes, a stage II pressure ulcer was documented as healed on 07/12/17. Per record review from 07/12/17 to 07/29/17, there was no documentation of the status of the wound. On 08/09/17 a PUSH (pressure ulcer scale for healing) documented the wound had redeveloped, and measured measured 4.6 cm. (centimeters) x 4.9 cm. x 2.7cm. A corresponding nursing progress note written by Staff C, Registered Nurse Unit Supervisor, documented the coccyx wound was healing. A skin/wound assessment, dated 08/10/17, indicated the wound was unstageable (where the depth of an ulcer was undetermined), and contained 100% eschar/slough (dead tissue which is dark or black in color). The record did not contain documentation the medical provider or wound specialist were notified of the redevelopement of the coccyx wound on 08/09/17 until 08/13/17, when an order for [REDACTED].>In an interview and observation of the pressure ulcer, on 08/15/17 at 9:52 a.m., the wound was observed to be approximately 3.0-4.0 cm. in length and approximately 2.0 cm. in width. The depth of the wound was approximatly 2.0 cm. The edges of the wound were black, and the wound bed had slough (dead tissue). Upon observation of the wound, Resident #7 was asked what happened that caused it to reopen. He stated sometime around the beginning of August 2017, staff had removed the occlusive dressing from his coccyx, to give him a shower. Resident #7 stated staff told him afterwards they would tell the wound nurse (to place a new dressing), but they put a brief on without a dressing, and put him into a wheelchair. The resident went on to say that during the time he was up in the wheelchair, he was incontinent of bowel, and told the two nursing assistants, who then told him he would have to wait for care. Resident #7 stated he started asking to get changed at approximately 5:00 p.m., and care was not provided until approximately 8:30 p.m. He further stated the wound care nurse did not come to put the dressing on or treat the wound, until 1:00 a.m. A skin/wound assessment, dated 08/16/17, indicated the wound was a stage II pressure ulcer, which measured 4.7 cm. x 3.7 cm. x 2.2 cm. deep, was 100% covered in slough in the wound bed, with no changes to the interventions. There was no documentation the physician or provider was updated. In an interview on 08/21/17 at 11:19 a.m., Staff B, Director of Nursing, was asked how the wound could have gone from an unstageable wound, essentially a stage III (full thickness tissue loss), to a lesser stage II. He stated a wound should be staged at the worst stage, and not at a lesser stage, even when it shows healing. Staff B further stated since the resident had necrosis/slough, and a deep open wound, it could not be categorized as a stage II ulcer. Staff B was further asked if there had been any monitoring of the wound between 07/12/17 and 08/09/17. He stated there should have been, but he could not find documenation of an assessment and/or monitoring. Staff B further stated the facility had hired a wound care specialist in June 2017, who comes once per week, assessing and providing treatments for pressure ulcers throughout the building. After his wound healed in July 2017, Resident #7 was no longer being seen. Staff B stated Resident #7 was not placed back on the list for the specialist to begin seeing him again, and could not fnd documentation the wound specialist was notified when the pressure ulcer redeveloped. In an interview on 08/21/17 at 11:46 a.m., Staff D, Resident Care Manager, was asked what her expectation was of staff, to meet the incontinent needs of the residents in a timely manner, to decrease skin issues. She stated resident requests for brief changes should occur as soon as possible, and should never take longer than 45 minutes. WAC: 399-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to provide necessary care and services for 1 of 3 residents (#1), related to pain management. This failure resulted in actual harm to Resident #1, who suffered from unrelieved pain for a prolonged period of time. Findings included: Per record review, Resident #1 had [DIAGNOSES REDACTED]. Per review of an assessment dated [DATE], the resident was alert, oriented, and able to make his needs known. The assessment documented the resident as having frequent pain, and received narcotic pain medication every 3 hours as needed. On 06/29/17 at 12:25 p.m., Resident #1 was sitting in a wheelchair in his room. He stated there was a day when he ran out of pain medication, and didn't receive any all day until 9:00 p.m. It was a rough day .it maybe took me a day to get back under control. Per review of the most recent care plan, dated 06/16/17, staff were to monitor the resident's pain every shift and document on the Medication Administration Record [REDACTED]. Non-medication interventions included relaxation and position changes. The resident also had an as needed order for Tylenol. Per review of the MAR for June 2017, Resident #1's pain had not been monitored from the evening shift of 06/16/17, through day shift of 06/18/17. The June 2017 MAR indicated [REDACTED]. On average, the resident was receiving the narcotic pain medication 4 - 5 times per day. A progress note, dated 06/17/17 at 11:05 p.m., documented the resident had run out of narcotic pain medication the morning of 06/17/17. The pharmacy was contacted that morning, and told the nurse a new prescription was needed; the physician was made aware. Per the record, the pharmacy was then contacted at 5:00 p.m., and the nurse was told there was a billing issue, and medication would arrive when it was resolved (the medication arrived at 8:30 p.m.). By the time the resident was given the narcotic pain medication, he rated his pain greater than 10 (on a scale of 0-10, 10 being the highest level). There was no documentation to indicate the physician was aware of the resident's pain, or how long the resident was out of medication. Documentation on 06/17/17 indicated the resident did not receive any narcotic pain medication from 06/17/17 at 2:00 a.m., until 06/17/17 at 9:10 p.m. (almost 20 hours later). There was no documentation indicating non-medical interventions had been attempted, or Tylenol given. During an interview on 06/29/17 at 1:35 p.m., Staff A, licensed nurse, said if a resident ran out of pain medication, and a new prescription was needed, the physician should have been called for an order to use pain medication from the emergency kit. On 06/29/17 at 3:05 p.m., Staff B, Director of Nursing, confirmed Resident #1 had run out of medication, and the nurse on shift tried to get the medication from pharmacy. He confirmed the nurse should have monitored the resident's pain, and should have attempted other interventions until the medication arrived.

Based on observation, interview, and record review, the facility failed to ensure 5 of 15 residents reviewed for smoking (#141, 66, 168, 96, 68), in a sample of 56, did so safely. Failure to complete timely assessments, develop care plans, and/or provide adequate supervision to residents, who continued to smoke after being determined by the facility to be unsafe to do so, put them at risk for injury, related to unsafe smoking. An immediate jeopardy was called, related to Resident #141, on 10/28/16 at 3:00 p.m. Findings include: 1. An admission assessment, dated 09/22/16, revealed Resident #141 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was able to make her needs known, and required minimal assistance with locomotion off the unit. Resident #141 was not included on the list of resident smokers, provided to the survey team by the facility, on 10/25/16. Review of Resident #141's physician's orders [REDACTED]. The side effects of these medications include fatigue, dizziness, drowsiness, and tremors. The facility's smoking policy, dated April 2016 included the following: No smoking materials will be given to another resident. Residents who fail to adhere to these requirements after counseling will be required to have all their smoking materials stored in a secure area at the nurse's station All residents who smoke will be screened using the Smoking Safety Data Collection and Assessment form, to assess their ability to smoke independently. Residents who meet the criteria to smoke independently may smoke in the center's designated smoking areas without staff supervision .Residents who fail to comply with the center's Smoking Policy may be subject to discharge, consistent with applicable regulatory requirements governing discharge of residents. The policy also included procedures used if the facility provided supervised smoking. Whether or not the facility did in fact provide supervised smoking was not indicated on the policy. A copy of the facility's smoking policy was signed by Resident #141on 09/16/16, indicating she had read, and agreed to follow it. A smoking assessment was completed on 09/16/16, which indicated the resident was an independent smoker, and goals and interventions related to smoking would be addressed in the resident's care plan. A care plan dated 09/28/16, addressing the resident's injury risk related to smoking, included the goal: will demonstrate safe smoking daily, and the following interventions: Smoking will be supervised by staff. Monitor compliance to smoking policy. No additional interventions related to how and when staff would supervise the resident smoking were included. A facility investigation, dated 10/06/16, revealed a burn had been discovered on Resident #141's abdomen by the shower aide. A statement from the shower aide, included in the investigation, revealed the resident reported she had fallen asleep outside while smoking, and the cigarette fell , and burned through her shirt and pants. The burn on the resident's skin measured 1.2 by 1.5 centimeters. The burn was treated, and a dressing was applied. Per the investigation, the resident's care plan was updated, to indicate the resident was no longer allowed to smoke cigarettes, and an order for [REDACTED]. The resident expressed interest in using an electronic cigarette, and was waiting for family members to bring one in. An electronic cigarette was determined to be an acceptable alternative to cigarettes as there was no lighted ember. A 10/06/16 progress note by Staff B, Social Services, documented she spoke with the resident about her smoking. The note indicated the resident was unable to smoke independently, and had been educated by social services and the Resident Care Manager. The note further documented Social Services would continue to monitor as needed. A nursing note dated 10/06/16 at 9:00 p.m. documented Resident #141 was non compliant (with) education to not smoke or to going outside. Resident observed outside smoking stating 'someone left me with one cigarette'. Resident brought back into facility by staff. Will continue to monitor where abouts of resident while out of bed. Per (nursing assistant) resident kept going outside when told by her not to go. A second smoking assessment was completed on 10/07/16, one day after the facility discovered the resident's burn. It documented the resident was unable to make her own decisions in relation to daily activities, hold a cigarette safely, maintain control of a cigarette if physically distracted, and to let go off and/or retrieve a cigarette appropriately. The assessment further documented the resident was not allowed to smoke, and was not compliant with the smoking policy. The non-compliance was not explained, but was to be addressed in the resident's plan of care. The resident's care plan related to smoking, had a line drawn across it with the statement, Resident no longer to smoke in facility 10/7/16. A care plan addressing the resident's noncompliance with regard to smoking, including disposition of her smoking materials, and directions for staff related to keeping the resident safe as she continued to smoke, was not found in her record. A nursing note dated 10/07/16 revealed the facility called the resident's family member to notify them of a fall the resident had experienced that afternoon. The facility informed the family member it had confiscated cigarettes from the resident. The family member indicated the resident still had smoking materials in her possession. The resident was found outside smoking at approx. 4:30 p.m. the same day, and was taken to Staff A, Resident Care Manager. A second note dated 10/07/16 documented the resident continued to be noncompliant with smoking, was going outside to smoke, and was difficult to redirect. Several more packs of cigarettes were found in the resident's room and on her person. A care plan addressing the resident's noncompliance, and continued access to smoking materials, was not initiated. A nursing note dated 10/09/16 revealed the resident was observed outside smoking a cigarette. Staff redirected her back into the facility, and reeducated the resident about not smoking. A lighter and cigarettes were taken from the resident. The lighter was given back to rightful owner . The note did not identify who the owner was. A care plan addressing the resident's noncompliance, and continued access to smoking materials, was not initiated. Further review of nursing progress notes documented Resident #141 was noted to be lethargic or difficult to arouse on 10/12/16, 10/13/16, 10/14/16, and 10/15/16. A nursing note dated 10/21/16 at 10:45 a.m. revealed the resident was caught smoking again, and her nicotine patch was discontinued. Per the note, the patch would be revisited if and when resident quits smoking. A care plan addressing the resident's noncompliance, and continued access to smoking materials, was not initiated. A nursing note dated 10/23/16 at 8:00 p.m. documented resident smoking outside. Was reported to this writer by roommate that she gave resident a cigarette but stated 'she looks spacey.' Resident denies smoking but does appear slightly lethargic. (Bedtime) medications held. Resident asleep within the hour. A care plan addressing the resident's noncompliance, and continued access to smoking materials, was not initiated. Observations of the facility smoking area were made on 10/26/16 at 9:05 a.m. The smoking area is located on the building's north side, covered and not viewable from a common area in the facility. Staff I, nurse aide, in an interview on 10/27/16 at 4:15 p.m., said residents were to be independent if they smoked, and Staff I was aware Resident #141 took herself out to smoke. In an interview on 10/27/16 at 4:18 p.m., Staff J, Licensed Nurse (LN) said Resident #141 had fallen asleep with her cigarette, and burned her abdomen. She said the resident continued to smoke, got cigarettes from other residents, was impulsive, and noncompliant with her smoking. Staff A, Resident Care Manager (RCM), in an interview on 10/27/16 at 5:00 p.m., said when Resident #141 is observed smoking, staff are to intervene and take the cigarette away from her. Additionally, he confirmed Resident #141's care plan had not been updated, with specific interventions related to her smoking, and only stated the resident could not smoke. In an interview on 10/28/16 at 1:43 p.m., Staff B, Social Services, stated she did talk to Resident #141 about not smoking after she burned herself, but stated the resident continued to smoke. Staff B was asked what, if any, measures were taken, to protect Resident #141, as she continued to smoke. On 10/28/16 at 2:33 p.m., in response to the surveyor's question, Staff B provided documentation of a mood and behavior program initiated on 10/27/16 (21 days after the resident burned herself) which instructed staff to remind her that she is not safe to smoke and continue to redirect as needed. The program did not address how staff should prevent the resident from continuing to get outside without their notice, or obtaining smoking materials. The program also did not address how the facility could supervise or support her to allow safer smoking. In an interview on 10/28/16 at 1:24 p.m., Staff G, Administrative Nurse, was asked what smoking will be supervised by staff entailed as referenced on the 09/28/16 care plan. Staff G stated Resident #141 was stealing other residents' cigarettes. She stated the care plan was not intended to instruct staff to physically supervise her while she was smoking (which was not allowed at the facility), rather to oversee her actions, to determine if she was following the smoking policies. Although staff had knowledge that Resident #141 was not complying with the facility policy, which prohibited acquisition of smoking materials from other residents, per record review, that issue was not addressed in the care plan, or elsewhere in the record. In an interview on 10/28/16 at 2:15 p.m., Staff E, nursing assistant, stated Resident #141 was not supposed to go to the smoking area, but did. When asked, she stated she knew this because when the resident could not be found in her room or the hallway, they looked in the smoking area and frequently (approximately one to two times per day) found her there. In an interview on 10/28/16 at 2:26 p.m., Staff H, nursing assistant, stated she was aware Resident #141 was not safe to smoke, but the resident would forget and go outside to smoke anyway. When asked whether Resident #141 had access to cigarettes, Staff H stated she heard there were cigarettes in the resident's room during the past weekend, and she was unaware of what nursing staff did to follow up after it was reported to them. In an interview on 10/28/16 at 3:05 p.m., Staff F, Director of Operations, stated the facility needed a more involved approach for Resident #141's safety than a casual conversation with the resident, as consequences could be severe, and include falls and burns. He stated the staff needed to be educated about the smoking policies, and the resident needed to receive increased supervision. 2. Resident #66 was admitted [DATE] for rehabilitation and monitoring. Per the facility assessment dated [DATE], the resident had no recent falls at the facility, required extensive assistance of 2 staff for transfers, and extensive assistance of one staff for mobility on/off the unit. In addition, the resident was a tobacco user. According to the Smoking Safety Data Collection and Assessment form, dated 08/15/16, 13 days after admission, the resident did not demonstrate appropriate use of an ashtray, and did not demonstrate the ability to let go of a cigarette, and then retrieve it. The assessment determined the resident was a dependent smoker, and required supervision to smoke. Resident #66 was included on the list of resident smokers provided to the survey team, by the facility, on 10/25/16. According to a Progress Note dated 10/25/16 at 3:00 p.m., the resident expressed anger over suspension of smoking privileges in the facility, due to a history of falls while entering and exiting the smoking area (by the North Hall exit door). There were no care plan interventions, and/or other information in the resident's clinical record, to show the facility's efforts to monitor the resident's safety if she entered or exited the facility by the North hall exit door. According to a progress note dated 10/28/16 at 10:30 a.m., the resident fell exiting the North Hall exit door, leading to the smoking area. The resident fell on the exit ramp, and hit her head. Facility staff and Emergency Medical Staff (summoned by the facility) evaluated the resident, who refused to go to the hospital for a thorough evaluation. On 10/28/16 at 12:25 p.m., the resident was not in her room. A lighter was on the bedside table, visible from the doorway. On 10/28/16 at 2:10 p.m., Staff B and D were interviewed regarding the resident's smoking. Staff D confirmed the lighter should be secured. When asked if the resident was continuing to smoke, Staff D stated the resident was a dependent smoker, and staff helped her if she was on the North Hall (which was not the hall where the resident resided). Staff B then stated staff did not help residents who were dependent smokers, and they were not supposed to smoke in the facility. When the surveyor asked about resident supervision for smoking, Staff B stated staff could remind and encourage the resident, but could not remove a resident from the smoking area if they decided to smoke. Upon additional interview, Staff D confirmed the resident was able to self-propel in her wheelchair the length of the facility to the North exit door, and fell on the exit ramp. 3. Resident #168 was readmitted [DATE], and had recent problems with low blood pressure, and fainting. During observation and interview on 10/28/16 at 1:15 p.m., the resident self-propelled into the designated outdoor smoking area, borrowed a cigarette from another resident, and smoked. The resident stated this was her last cigarette before she started a smoking cessation program. In an interview on 10/28/16 at 1:40 p.m., Staff A stated he spoke to the resident 2 days earlier about smoking. At that time, she did not tell him about smoking. Staff A confirmed the facility completed a smoking assessment when the resident was originally admitted [DATE], which documented the resident was not safe to smoke, due to inability to safely use the exit door ramp. Staff A confirmed an updated smoking assessment had not been completed. During interview on 10/28/16 at 3:00 p.m., Staff F, Director of Operations, confirmed staff and residents needed to be educated about the smoking policies. #4. Resident #96's smoking assessment dated [DATE] identified she was an independent smoker. The resident's care plan for fall and injury, dated 05/10/16, documented the resident was unsafe to smoke independently, and that her son takes her out. A progress note dated 05/17/16 documented, Resident deemed as unsafe smoker, unable to self propel to smoking area without almost hitting other residents. Failed smoking assessment . This LN (Licensed Nurse) confiscated ½ carton of smokes from resident and given to RCM (Resident Care Manager) . The second smoking assessment, dated 05/20/16, identified she was no longer an independent smoker (because she was not willing to follow the safety procedure on the smoking assessment). The assessment documented the resident threw ashes on the ground instead of using the ashtray, and disposed of the cigarette on the ground, while still lit, without first extinguishing them. Progress notes dated 06/06, 06/07, 06/09, and 06/12/16 documented the resident went out to smoke as her usual. The resident's original care plan for fall and injury was updated on 08/22/16, documenting the resident was reassessed and found safe. There were no other smoking assessments in the resident ' s record. During an observation on 10/28/16 at 12:31 p.m., the resident was observed in bed asleep; on her nightstand was a gray lighter. Later that day at 1:05 p.m., Staff K confirmed the resident was an independent smoker, but her smoking materials should be locked up and/or be on her person when not in use. Staff K said this had been a problem with the resident - keeping smoking materials out - and staff would now take them and lock them up. 5. Per the facility's admission assessment, dated 09/30/16, Resident #68 required assistance with activities of daily living. On 10/31/16, the resident had been assessed as safe to smoke independently. Per facility policy, updated 10/31/16, residents who were assessed as able to smoke independently had to go off the property to smoke if they wished to smoke outside designated facility smoking times. On 11/02/16 at 2:25 p.m., the resident was observed struggling to roll herself up onto the sidewalk, off the property, to smoke. After struggling for several minutes (which included the wheelchair rolling backwards a few times), another resident reached out a hand, and pulled Resident #68 the rest of the way onto the sidewalk. During an observation on 11/03/16 at 7:52 a.m., the resident was at the bottom of a ramp beside the building, on the property, smoking. On 11/03/16 at 12:08 p.m., the resident was observed in the parking lot smoking, in the driveway, on facility property. On 11/03/2016 12:15 p.m., the surveyor requested Staff L, Administrator, observe the resident in front of the building smoking. At that time, Staff L acknowledged the resident was still smoking on facility property, was in the driveway, and said it was a safety concern. The Administrator was made aware, at this time, of the above observations of the resident smoking. During this observation, the resident turned around, and rolled back down the driveway toward the building, at which time Staff L stated, oh - that was way too fast! The Administrator stated that although the resident had been assessed as safe to smoke independently, she would request the resident be re-assessed for smoking safety, based on recent observations. In addition, Staff L said the facility would re-evaluate the safety of the current smoking policy, because residents who were assessed as independent, were now smoking on the narrow sidewalk in front of a very busy main road, which was also a safety concern.

Based on observation, interview, and record review, the facility failed to ensure sufficient qualified staff was available, to provide and supervise care, for 14 of 56 sampled residents (#8, 20, 66, 68, 90, 95, 96, 117, 118, 125, 126, 137, 141, 152, 165, 168, 181, 182, 183, 187, 191). Observations, interviews with residents, family members and staff, combined with record review, revealed inadequate supervision of residents, to ensure the care needs of these residents were met by licensed staff or certified nursing assistants, in accordance with established clinical standards and their care plans. This failure placed all residents at risk of harm from lack of qualified staff, and resulted in actual harm for Residents #125, #183, and an Immediate Jeopardy related to Accidents and Supervision for Resident #141. In addition, the facility failed to designate a charge nurse for the evening shift, as required. Findings include: Refer to CFR 483.15(a), F-241, Dignity for failure to ensure care was provided in a manner that promoted residents' dignity. Refer to CFR 483.15(e)(1), F-246, Accomodation of Needs for failure to ensure resident needs related to toileting were addressed. Refer to CFR 483.25, F-309, Provision of Care and Services for failure to provide adequate pain management, bowel management, and/or monitoring/treatment of [REDACTED]. Refer to CFR 483.25(h)(2), F-323, Free of Accident Hazards/Supervision for facility failure to provide adequate supervision and timely assessments related to smoking. Refer to CFR 483.25(i)(1), F-325, Maintain Nutrtional Status for faliure to consistently montior weights. Refer to CFR 483.25(k)(2), F-328, Treatment/Care for Special Needs for failure to provide appropriate care and services related to intravenous access sites and subcutaneous fluid administration. Refer to CFR 483.25(l)(1)&(2)(ii), F-329, Free From Unnecessary Medications for failure to monitor indicators, side effects, and lab values, and/or ensure gradual dose reductions were completed. Refer to CFR 483.25(m)(2), F-333, Significant Medication Error for facility failure to administer blood thinning medications appropriately. Refer to CFR 483.65(a)(1)-(3), F-441, Infection Control for failure to maintain and infection control program. In an interview on 11/03/16 at 2:58 p.m., Staff HH, nursing assistant, reported she normally worked night shift, but was picking up an extra evening shift that day. She stated evening shift was understaffed 2-3 times a week. The hall she worked was supposed to have 4 nursing assistants during evening shift, but usually only had 3. Staff HH added the lack of adequate staffing affected call light response time. In an interview on 11/03/16 at 3:02 p.m., Staff II, licensed nurse, stated there was supposed to be 4 nursing assistants on the unit she worked, but there was frequently only 3. Staff II further stated the amount of time it took for staff to respond to resident call lights was affected. In an interview on 11/04/16 at 10:44 a.m., Staff JJ, nursing assistant, stated that staffing was poor and staff worked short a couple of times a week, which affected care. Additionally, 12 of 25 residents, and 3 of 3 family members interviewed during Stage 1, reported there was not enough staff available to get the care and assistance they needed, without having to wait a long time. Residents reported wait times of 30-60 minutes. In an interview on 11/04/16 at 1:22 p.m., Staff LL, confirmed the staffing sheets provided to the surveyor by the facility for 10/06/16-11/02/16 documented the staff that actually worked each shift. When questioned about multiple shifts that did not appear to be fully staffed, Staff LL stated sometimes a staff member stayed over to work an extra shift, or staff was called in. Any additional documentation regarding actual staffing for the period was requested. In a follow-up interview at 3:11 p.m. the same day, Staff LL stated she had cross checked payroll records, and filled in some of the missing shifts. Staff LL confirmed the staff members who were filled in did work the entire shift, but added there were still some holes in the staffing. Review of daily staffing records for 10/06/16-11/02/16 revealed the facility was short a licensed nurse for 2 shifts. The facility was short nursing assistants one shift on 4 days, and short nursing assistants for at least 2 shifts on 7 days. This represented 30% of the facility's shifts being understaffed. In an interview on 11/07/16 at 2:59 p.m., Staff F, Director of Operations, acknowledged sufficient staffing was a concern. CHARGE NURSE In an interview on 11/04/16 at 10:44 a.m., Staff D, Administrative Nurse, stated she was not aware of any staff member being designated by the facility as charge nurse. In an interview on 11/04/16 at 10:38 a.m., Staff A, Administrative Nurse, confirmed there was not a charge nurse designated for evening shift.

Based on deficient practices identified throughout the Annual and Extended Survey process, the facility's administration failed to effectively use its resources to ensure residents attained or maintained their highest practicable level of well-being. The administration failed to ensure the facility was in compliance with the following regulatory requirements. This failure resulted in harm to Resident #183 referenced in F-309, and Resident #125 referenced in F-328, and represented Immediate Jeopardy for Resident # 141 referenced in F-323. Findings include: Refer to CFR 483.20(k)(3)(i), F-281, Services Meet Professional Standards. The administration failed to ensure facility staff provided care and services according to professional standards in relation to medication administration, documentation, and/or monitoring of labs. Refer to CFR 483.25, F-309, Provision of Care and Services. The administration failed to ensure staff provided care and services related to pain management, bowel management, and monitoring/treatment of [REDACTED]. Refer to CFR 483.25(h)(2), F-323, Accidents and Supervision. The facility administration failed to ensure residents who smoked were assessed for safety timely. Additionally facility administration failed to ensure effective interventions were implemented to ensure the safety of residents who were identified as being unsafe to smoke, but continued to do so. Refer to CFR 483.25(i0(1), F-325, Maintain Nutritional Status. The administration failed to ensure staff consistently monitored weights for who were determined to be high risk for weight loss and other nutritional concerns. Refer to CFR 483.25(k)(2), F-328, Treatment/Care for Special Needs. The administration failed to ensure proper care and treatment for [REDACTED]. Refer to CFR 483.25(m)(1), F-332, Medication Error Rate >5%. The administration failed to ensure staff administered medications timely, and as ordered. Refer to CFR 483.25(m)(2), F-333, Significant Medication Errors. The administration failed to ensure staff administered blood thinning medications appropriately. Refer to CFR 483.30(a)(1)&(2), F-353, Sufficient Staffing. The administration failed to ensure sufficient, qualified staff to perform nursing services to provide resident care according to professional standards. Refer to CFR 483.75(o)(3), F-520, QAA Committee. The administration failed to ensure a Quality Assessment and Assurance Program (QA&A) self-identified deficiencies and developed/implemented effective plans of action to correct identified concerns.

Based on observation, interview, and record review, the facility failed to ensure the Medical Director provided coordination of care for residents in the facility, and helped identify, evaluate and resolve/address medical and clinical concerns affecting resident care, medical care, and quality of life for residents in the facility. This failure afftected the quality of care delivered to all residents, and caused harm to Resident's #125, #141, and #183. In addition, this created an unsafe environment, which resulted in a determination of Immediate Jeopardy for Resident #141. Findings include: During an extended survey on 11/08/16, the Medical Director Agreement was reviewed, and noted to be signed by the previous Medical Director, not the current one. The Administrator stated this was the only Medical Director Agreement she had, and she did not have one signed by the current Medical Director. In an interview on 11/16/16 at 2:50 p.m., Staff OO, Medical Director, confirmed he did not have a signed contract with the facility, and was unaware of what his contractual agreement and responsibilities were to the facility as Medical Director. He stated he had not formally reviewed facility policies related to skin conditions, smoking, intravenous medications, subcutaneous fluids for hydration, or medication error management. In addition, he stated he had not attended any Quality Assurance meetings at the facility, and was unaware of the frequency of the meetings, or his requirement to attend said meetings. He reported he believed the turnover of key personnel had been a hinderence to the facility. Refer to F125, F141, F182, F183, and F323 for additional details.

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance Program (QA&A) that self-identified deficient practice, and implemented appropriate, effective, corrective actions. The facility failed to recognize deficient care and services that resulted in actual resident harm, immediate jeopardy, substandard care, and put all residents at risk of unmet care needs, related to quality of life and quality of care. In addition, the facility failed to ensure a designated key member, a physician, particiapted at least quarterly in the QA&A meetings. Findings include: Throughout the survey the following deficiencies were identified: Refer to CFR 483.15(b), F-242, Choices. The facility failed to identify deficiencies related to honoring residents' bathing and morning routine preferences. This is a repeat deficiency from an Annual Survey conducted on 01/14/16. Refer to CFR 483.15(h)(6), F-257, Comfortable Room Temperatures. The facility failed to identify deficiencies related to room temperatures below 71 degrees. Refer to CFR 483.20(k)(3)(i), F-281, Services Meet Profession Standards. The facility failed to identify deficiencies related to medication administration, documentation, and monitoring of labs. This is a repeat deficiency from an Annual Survey conducted on 01/14/16. Refer to CFR 483.20(m), F-285, PASRR Requirements. The facility failed to identify deficiencies related to obtaining PASRR Level 2 evaluations timely. This is a repeat deficiency from an Annual Survey conducted on 01/14/16. Refer to CFR 483.25, F-309, Provision of Care and Services. The facility failed to identify deficiencies related to skin monitoring and treatment, pain management, and bowel management. This is a repeat deficiency from an Abbreviated Survey conducted on 07/15/16, and the Annual Survey conducted on 01/14/16. Refer to CFR 483.25(h)(2), F-323, Accidents and Supervision. The facility failed to identify deficiencies related to smoking hazards and falls. This failure led to an Immediate Jeopardy related to safe smoking. This is a repeat deficiency from an Annual Survey conducted on 01/14/16. Refer to CFR 483.25(i)(1), F-325, Maintain Nutritional Status. The facility failed to identify deficiencies related to consistently monitoring weights for at risk residents. This is a repeat deficiency from an Annual Survey conducted on 01/14/16. Refer to CFR 483.25(k)(2), F-328, Treatment/Care for Special Needs. The facility failed to identify deficiencies related to administration of IV and subcutaenous fluids and maintenance of IV sites. Refer to CFR 483.25(m)(1), F-332, Medication Error Rate >5%. The facility failed to identify deficiencies related to the administration of medication in a timely manner. This is a repeat deficiency from an Annual Survey conducted on 01/14/16. Refer to CFR 483.25(m)(2), F-333, Significant Medication Errors. The facility failed to identify deficiencies related to the administration of blood thinning medication. This is a repeat deficiency from an Annual Survey conducted on 01/14/16. Refer to CFR 483.30(a)(1)&(2), F-353, Sufficient Staffing. The facility failed to ensure sufficient, qualified staff to perform nursing services to provide resident care. This is a repeat deficiency from an Abbreviated Survey conducted on 08/05/16, and the Annual Survey conducted on 01/14/16. Refer to CFR 483.65(a)(1)-(3), F-441, Infection Control. The facility failed to identify deficiencies related to the lack of analysis of infection control data. This is a repeat deficiency from an Abbreviated Survey conducted on 04/13/16, and the Annual Survey conducted on 01/14/16. In an interview on 11/03/15 at 9:23 a.m., Staff P, Registered Dietician, was asked whether she was involved in any quality assurance meetings, or activities in the facility, to ensure weights were tracked and nutritional interventions were effective. She stated there used to be regular weight meetings in the facility, which she attended, but they stopped approximately two months prior, related to leadership changes in the facility. In an interview on 11/07/16 at 2:35 p.m., Staff L, Administrator, stated she had been at the facility for 2 months, and had attended the QA&A Committee's last meeting in September 2016. At that meeting, the committee discussed staff turnover, shower frequency, worker compensation issues, the restorative therapy program, as well as the facility's electronic education system, and documentation system for nursing assistants. When asked by what process the committee identified quality issues and concerns, Staff L responded the state surveyors had been alerting the committee to concerns during recent complaint investigations. Staff could fill out concern reports as well. Staff L was unable to identify any indicators or areas that were routinely looked at by the QA&A committee, with the exception of staffing. Staff L was unaware of any work the committee had done with regard to pain control, monitoring of anti-coagulation levels, smoking safety, IV therapy, or professional standards of care. With regard to medication errors, Staff L referred to a group the facility put in place to look at errors, and analyze for trends, in response to a previous citation. When asked how the committee monitored the effectiveness of such actions, in light of the multiple errors the surveyors had observed, Staff L stated she would have to consult other staff members. No further information was provided. In an interview on 11/16/16 at 2:50 p.m., Staff OO, Medical Director, (who had been in the position since May 2016) stated he had not attended any QA&A meetings at the facility, and was unaware of the frequency of the meeting, or his requirement to attend.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for 3 of 15 residents (#90,137,183) reviewed for skin conditions, pain management, and/or bowel management, in a sample of 56. This failure resulted in harm to Resident #183, who experienced unrelieved pain, and placed other residents at risk for worsening of skin conditions, and/or complications related to constipation. Findings include: 1. Review of Resident #183's admission assessment, dated 10/15/16, indicated the resident admitted to the facility after foot surgery. She was cognitively intact, and able to make her needs known. The assessment also documented the resident was in almost constant pain, rated as an 8 (on a 1-10 scale - with 10 being the highest/worst pain), which made it hard for her to sleep, and limited her daily activity. A care plan for pain management, dated 10/10/16, directed staff to administer pain medication as ordered, and provide alternate comfort measures, including position change and relaxation techniques. Review of nursing progress notes, from 10/15/16 - 11/01/16, revealed multiple entries documenting the resident requesting pain medication every four hours. Per review of the physician orders, the resident had a muscle relaxant for pain, which could be given every 8 hours as needed, Tylenol, every 6 hours as needed, and [MEDICATION NAME] (a narcotic pain medication), which on 10/26/16, was to be given at scheduled intervals (every 4 hours). In an interview on 10/26/16 at 2:21 p.m., when asked about her pain, Resident #183 tearfully stated she had had a problem with her pain that morning. The resident explained she had taken pain pills ([MEDICATION NAME]) at 10:00 p.m. the night before, and then woke up at 3:30 a.m., and requested another dose. She was told by the nurse on duty she had missed her 2:00 a.m. dose, so would have to wait until 6:00 a.m. before she could get any more narcotic pain medication. The resident said because of that, she had to go 8 hours between doses of the pain medicine, which made the pain much worse. In a follow-up interview on 10/27/16 at 12:42 p.m., Resident #183 reported her pain level was generally about a 6, but she would like it to be a 4 or 5. After going 8 hours without pain medication on 10/26/16, her pain level had reached 9. She stated the night nurse did not offer any other medications, or non-medication interventions for her pain, when she refused to give the [MEDICATION NAME]. Later that morning, the day shift nurse had offered her the muscle relaxants that were available. The resident stated, I took those and they really helped. If they would have given me those at night, that would have helped. The resident was again tearful during the interview. Further review of Resident #183's record revealed a nursing noted dated 10/26/16 at 5:05 a.m., indicating the resident had been asleep at 2:00 a.m., but had later requested a pain pill. The nurse informed her the next scheduled pain pill ([MEDICATION NAME]) could not be given until 6:00 a.m The progress notes and Medication Administration Record [REDACTED]. 2. Resident #137 was admitted [DATE] for rehabilitation. According to the admission assessment dated [DATE], the resident had no skin problems, and required extensive assistance for most activities of daily living. A nurse practitioner note, dated 09/21/16, documented the right tibia (leg) had an abscess (infection), with redness. Treatment was ordered to lance (a minor surgical procedure to pierce/open a wound, to drain pus) the abscess, and start a topical antibiotic. According to the clinical record, on 09/24/16, the right leg abscess was red and painful, and an oral antibiotic was ordered for 7 days. On 09/27/16, the resident complained of increased pain at the site of the abscess, and routine, and as needed narcotic pain pills were ordered. Additional clinical record review revealed the resident received 2 additional courses of oral antibiotics on 10/03 and 10/24/16, and topical treatments. Review of the October 2016 Treatment Administration Record (TAR) revealed the treatment was to be administered daily, between 10/11/16 and 10/25/16; it was not done on 5 of 14 days. During observation and interview on 10/26/16 at 9:27 a.m., the resident's right pant leg was rolled up to the knee. The right lower leg was swollen and slightly red, with a superficial open area in the center. She stated her pant leg rubbed the area, and it had bled in therapy earlier in the morning. During interview on 10/26/16 after the resident observation, Staff BB, a licensed nurse, stated the abscess had improved overall since it first developed. Staff BB stated she would obtain an order for [REDACTED].>According to the record, there was no consistent nursing evaluation to describe the appearance of the right leg abscess, and/or effectiveness of the ordered treatments. In an interview on 11/03/16 at 9:05 a.m., Staff A stated the resident's skin condition should have been evaluated and documented weekly. In addition, he had no additional information to offer, related to the lack of daily wound treatment as ordered, between 10/11/16 and 10/25/16. During additional record review on 11/04/16, the surveyor identified a progress note dated 09/21/16 at 2:30 p.m., by Staff Z, a licensed nurse, who documented she received a telephone order to lance the boil, and apply an antibiotic ointment and dressing. On 11/04/16, additional information was requested regarding the facility policy for licensed nurses to perform the procedure. Review of facility record revealed Staff L, the Administrator, identified the procedure to lance the resident's leg wound was not within the licensed nurse's scope of practice at the facility. There was no additional investigation related to the procedure used by the licensed nurse, and whether the procedure contributed to the worsening of the right leg abscess. Refer to F279 and F281 for additional findings. 3. Resident #90's comprehensive assessment, dated 08/18/16, identified she was continent of bowel, but needs extensive assistance with toileting. This resident also had [DIAGNOSES REDACTED]. The facility's policy titled Bowel and Bladder Program dated July 2015 documented standardized bowel care to relieve constipation, which included: 1. Milk of Magnesia after eight shifts of no BM (bowel movement); 2. [MEDICATION NAME] suppository rectally if no results from the Milk of Magnesia; and 3. Fleets enema rectally if no results from the [MEDICATION NAME] suppository. Resident #90 had orders for these medications. On 10/28/16 at 2:37 p.m., the resident's spouse said the resident was constipated this morning, and said this happened approximately every 4 days. Review of the resident's bowel record for September 2016 revealed one incident where staff documented the resident had no bowel movements for 17 shifts. During October 2016, there were two instances where staff documented the resident went for 18 shifts and 22 shifts without a bowel movement. In addition, on 10/02, 10/03,10/04, and 10/22/16, staff did not document whether or not the resident had a bowel movement, for 1 of 3 shifts during those days. Review of the September and October 2016 Medication Administration Record [REDACTED]. On 11/04/2016 at 10:14 a.m., Staff G, Administrative Nurse, stated direct care staff needed additional education about the accuracy of documenting bowel movements in the electronic system. Staff G also recalled notifying the medication/treatment nurses on a couple occasions, related to the resident needing interventions for bowel management, and was unable to explain why medications were not given as ordered.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and care of specialized intravenous access devices (IV), for the purpose of administration of [MEDICATION NAME] nutrition (through the venous system) and medications, were provided. The facility did not ensure clear physician orders were in place, concerning the flushing of catheter lines based on the type of catheter used for 1 of 2 residents (#125), in a sample of 56. This failure resulted in harm to Resident #125, who experienced a delay in recognition of an infection requiring 3 IV antibiotics, and transfer to the hospital for evaluation of her overall condition. In addition the facility failed to ensure appropriate treatment and care for 2 of 2 sample residents (#8, 20), in a sample of 56, related to subcutaneous administration of fluids (giving fluids into the space under the skin). As a result, the residents were placed at risk for poor absorption of fluids. Findings include: Intravenous Access Device Resident #125 had [DIAGNOSES REDACTED]. According to the most recent facility assessment, dated 09/09/16, the resident could voice her own needs, and required supervision with most activities of daily living. According to the clinical record, the resident had the IV line for daily nutrition. In September 2016, the resident was hospitalized [MEDICAL CONDITION] (an infection present in the blood and/or tissues), due to the IV line. Additional clinical record review revealed the resident was hospitalized again in October 2016. The resident was readmitted [DATE], with physician orders to resume the daily IV nutrition. There were no physician orders for IV flushes (to ensure the line stayed open) or IV line dressing changes (to maintain sterility, and decrease the risk of infection). Review of the October 2016 Medication Administration Record [REDACTED]. Review of the October 2016 Treatment Administration Record (TAR) directed staff to monitor and change the dressing at the IV line insertion site weekly, on 10/18 and 10/25/16. According to the October MAR, and October 2016 progress notes, the IV line dressing change was not performed until 10/31/16, 14 days after admission. Additional review of the progress notes revealed no documentation, between 10/25/16 at 8:00 p.m., and 10/31/16 at 8:45 a.m., when a licensed nurse documented the resident had [MEDICAL CONDITION] (observable swelling) to the right upper arm, and a fever of 99.9 degrees Fahrenheit (F). There was no information to indicate when the right arm swelling started. According to a Nurse Practitioner note dated 10/31/16, blood cultures were drawn, and 3 different IV antibiotics were ordered to treat possible IV line infection. Observation of medication pass, on 11/01/16 at 12:13 p.m., revealed Staff D flushed Resident #125's IV line in her right arm with 10 ccs (cubic centimeters) of normal saline (NS), then administered the IV antibiotic. Additional clinical record and hospital record review revealed on 11/01/16, the resident continued to feel very weak, and was transferred to the hospital for weakness and [MEDICAL CONDITION], where the IV antibiotics were continued. During interview on 11/02/2016 at 11:49 a.m., Staff K stated on the days he worked, he flushed the resident's IV line after the IV nutrition infused. He described the IV line as having 2 ports. He stated the IV nutrition infused in the purple port, and IV medications in the red port. When asked, he stated he flushed the purple port after use with [MEDICATION NAME], and he flushed the red port with NS, after medication infusion. Staff K reviewed the resident's November 2016 MAR indicated [REDACTED]. Staff K inspected the resident's pharmacy supply of flushes, stored in the south medication room. There was a box of pre-drawn 10 cc NS flushes, with labeled directions from pharmacy to use as directed. There was also a bag of pre-drawn [MEDICATION NAME] flushes, with labeled directions from pharmacy to use as directed. During an interview on 11/02/16 at 12:20 p.m., Staff D stated after the antibiotic infused on 11/01/16, she flushed the IV line with NS, then [MEDICATION NAME]. She confirmed there were no physician orders for the flushes, and she did not document the flushes on the November 2016 MAR. When asked, she stated she knew which flushes to use from policy, and her nursing experience. She stated she was the Administrative Nurse on another unit, and did not often give medications to residents in the south unit. According to the facility policy, licensed nurses were directed to use only NS for valved IV lines, and NS followed by [MEDICATION NAME] for non-valved IV lines. Sterile dressing change guidelines varied, according to the type of dressing used, and ranged from every 2 days to weekly. In addition, the facility policy recommended assessment of the IV site be performed routinely for signs and symptoms of infusion related complications, at a frequency based on resident condition, age, type of medication, and rate of flow. During interview on 11/03/16 at 9:05 a.m., Staff A had no additional information to offer related to the type of IV line, the lack of physician orders for care and flushing, the lack of licensed nurse documentation of flushes administered, and lack of consistent monitoring of the resident's IV site. Staff A stated he was going to be the Acting Director of Nursing, showed the surveyor a copy of the current facility policy, and stated the facility would follow the policy. Refer to F279 and F281 for additional findings. Subcutaneous Administration of Fluids (Hypodermoclysis) 1. Resident #8 had [DIAGNOSES REDACTED]. Review of the clinical record revealed In October 2016, the resident developed a urinary infection, then pneumonia. On 10/23/16, the Nurse Practitioner ordered subcutaneous administration of 2 liters of fluid, because the resident was not drinking sufficient oral fluids. Each liter (1000 milliliters) was ordered to run at 80 milliliters (ml.) per hour (i.e., 1000 ml. would infuse in approximately 12 hours). According to the facility policy, licensed nurses were directed to ensure the fluids infused at the prescribed rate, and to observe the infusion site every 2 hours. Review of the resident's progress notes revealed licensed nurses started the first liter during the day shift on 10/23/16. During the evening shift of 10/24/16, licensed nurses referred to the 2nd liter infusing. The 2nd liter finished infusing sometime during the day shift on 10/25/16. Additional review of the progress notes revealed licensed nurses documented the rate of infusion as 80 ml. per hour, and did not evaluate the reason the fluids actually infused at a slower rate. 2. According to the record, Resident #20 had an acute decline in condition, and was unable to drink sufficient oral fluids. On 10/24/16, subcutaneous administration of 2 liters of fluid was ordered. Each liter (1000 milliliters) was ordered to run at 80 milliliters (ml.) per hour (i.e., 1000 ml. would infuse in approximately 12 hours). Review of the resident's progress notes revealed staff started the infusion of the first liter during the day shift on 10/24/16. The 2nd liter was started on 10/25/16 at 8:30 a.m., and was completed during the day shift on 10/26/16. During interview on 11/03/16 at 9:05 a.m., Staff A stated a reason to infuse the fluids at a slower rate would be to allow the subcutaneous tissues to absorb the fluids. However, Staff A had no additional information to show why the physician orders were not followed. Refer to F281 for additional findings.

Based on observation, interview, and record review, the facility failed to ensure residents maintained adequate nutritional status, for 4 of 4 residents reviewed for nutrition (#145, 58, 40,185), in a sample of 51. Failure to monitor weights per physician order, and follow-up on large weight discrepancies, placed residents at risk for unidentified, unintended weight changes. This failure caused harm to 1 resident (#145), who experienced a significant weight loss. Findings include: 1. Resident #145 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff.) - a contagious intestinal infection - malnutrition, and depression. A review of the facility's comprehensive assessment dated [DATE], documented the resident was cognitively impaired, and required extensive assistance with all activities of daily living. The resident's weight was documented as 127 pounds (lbs.) at the time of his admission to the facility. A review of the resident's medical record documented the resident had a 3rd recurrence of [DIAGNOSES REDACTED]. on 10/22/15. On 11/04/15, the resident's weight was documented as 117 lbs., which was 11 pounds less than at admission, or an 8.6% loss. A dietary consult was requested on 12/03/15. Physician orders [REDACTED]. Staff were directed to document that the nutritional supplements were given, and the amount consumed. The physician also ordered a lab test be completed for [DIAGNOSES REDACTED]., which, if still present, could be one causal factor for weight loss. A review of the resident's Medication Administration Records (MARs) for December 2015 and January 2016, revealed nursing staff inconsistently documented whether/not the health shake and additional nutritional supplement were offered, and/or the amount consumed. When the record indicated the resident refused, there was no indication that other food/fluids were offered. A review of the resident's weight report documented the resident was only weighed one time in December 2016, rather than weekly, as ordered by the physician on 12/04/15. His weight on 12/09/15 was 117 pounds. In addition, the January 2016 MAR indicated [REDACTED]. In an interview on 01/13/16 at 3:32 p.m., Staff L, Resident Care Manager, reported the lab test for [DIAGNOSES REDACTED]., ordered by the physician on 12/04/15, was never completed. The lab test was re-ordered on [DATE], following questioning by the surveyor. In an interview on 01/14/16 at 10:16 a.m., Staff L confirmed the missing weight documentation, and stated no additional weights were available for the resident. On 01/18/16, laboratory results were reported to the facility, and provided to the surveyor. The resident was positive for [DIAGNOSES REDACTED]. An order in the resident's record to resume contact precautions was dated 01/18/16, and the resident was restarted on antibiotics to treat the infection. In a follow-up interview on 01/26/16 at 8:37 a.m., Staff L, reported Resident #145 had been weighed on 01/25/16. She reported the resident's weight was 105 lbs. - an additional loss of 12 lbs. since 12/09/15, and a total loss of 22 lbs. 2. Resident #58 admitted to the facility in 2012. Per his care plan dated 12/09/15, Resident #58 had nutritional risks related to [MEDICAL CONDITION]. Although weight loss was not identified on the care plan, interventions included weighing the resident per the facility policy. The nutrition goal was for no significant weight change. Per the facility weight policy dated July 2015, if a resident had a 3% change in weight, they were put on a 24-hour report for further review, and staff notified the dietitian. The policy also indicated the licensed nurse (LN) had the responsibility to Verify accuracy of the weight, by comparing the weight with the most recently recorded weight. Further, LNs were to Supervise the (Nursing Assistant) while re-weighing the resident to assure that correct process is followed, if the weight has changed with a gain or loss of 3% or greater. Review of the weights for Resident #58 revealed the following: On 06/16/15 his recorded weight was 168.6 lbs.; on 06/23/15 it was recorded as 208 (over 23% change in weight). From 06/23/15 to 09/02/15, weights were recorded as ranging from 207.8 to 211.6 lbs. The next weight, recorded on 09/30/15, was 170 pounds (about a 20% decrease). In an interview on 01/12/16 at 2:45 p.m., Staff I, a nursing assistant, stated when she weighed residents, she did not have a way to compare weights from the previous one. Instead, she gave the weights directly to the RCM. She stated for residents in wheelchairs, staff should weigh the wheelchair separately, and substract that amount, to determine the resident's weight. In an interview on 01/08/16 at 10:16 a.m., Staff T, Registered Dietitian, stated she was aware of weight errors for Resident #58, and said they were attributed to possible inconsistent methods for measuring his weight. She stated residents were discussed in the weekly weight meetings, if there was a weight change of 3%, and they normally wrote chart notes related to residents they discussed. Review of the record revealed no nutrition notes in June 2015 or July 2015, related to the increased weight documented on 06/23/15. An 08/28/15 nutrition note stated (Weight) seems stable (with) some errors. Additionally, there were no notes related to the 09/30/15 decrease in documented weight. In an interview on 01/12/16 at 3:20 p.m., Staff B, Director of Nursing, stated Resident #58's weight discrepancies were due to some weights being recorded without subtracting the weight of the wheelchair. She stated the weight differences were not caught until September 2015, due to a change in the computer system prior to that time. Staff B stated there was a period of time they were not holding weekly weight/nutrition meetings. She stated staff were instructed to weigh the wheelchair every time, for residents that are wheelchair bound, and subtract the weight of the wheelchair before entering the weight in the system. In an interview on 01/12/16 at 4:02 p.m., Staff B confirmed she did not find any additional information regarding the weight discrepancies. 3. Resident #40 admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The resident required extensive assistance with most activities of daily living, and had no memory problems. Per the facility weight monitoring policy, a resident on [MEDICAL TREATMENT] should be weighed by the [MEDICAL TREATMENT] unit after each treatment; the facility was then to record it in their electronic record. The facility policy was for weights to be taken within 24 hours of admission, then weekly for four weeks, or until the resident's weight was determined to be stable. The initial nutritional assessment dated [DATE] determined the resident's usual weight was 164 lbs., but there was no actual weight recorded by the facility from 10/8 (the date of admission) to 10/14/15. The Dietician recommended a weight increase, as the resident was noted to have severe protein calorie malnutrition, and foot wounds. On 10/16/15, the Dietician noted the resident had recent weight loss, and an increased need for protein and micronutrients related to healing and [MEDICAL TREATMENT]. She recommended Nepro 1 can every day (a protein supplement). The Dietician also documented she still needed a facility weight (post [MEDICAL TREATMENT]). There were no recorded weights in the electronic record at this time for the resident. Per review of the electronic record, the first recorded weight for the resident was 162 lbs. on 12/09/15 (over 2 months since his admission). Other weights recorded were as follows: 172 lbs on 12/15/15, 165 lbs on 01/06/16, and 174lbs on 01/07/16. The resident's post [MEDICAL TREATMENT] weight was not being consistently recorded by the facility, in order to assess and monitor his nutritional status. Review of the October, November and December 2015 MAR (Medication Administration Record) revealed Nepro supplement (1 can per day) was often refused by the resident. On 01/05/16 the resident's order for Nepro was increased to three times per day. In an interview on 01/07/16 at 11:00 a.m., the resident said they were supposed to get Nepro when I first came in here; they told me they were going to order it, and never ordered it. He went on to say he used to drink the supplement with every meal at home, to keep his protein levels up. The resident reported the nursing staff said it was in his chart (that he was supposed to be getting it) but it was circled, which meant he usually refused it. The resident said he told the nurse he never refused it, and if it was offered he would always drink it. In an interview on 01/12/16 at 10:46 a.m., Staff KK, the nurse, said the resident did not have Nepro ordered per the January 2016 MAR. However, review of the physician orders [REDACTED]. On 01/12/16 at 2:50 p.m., Staff L, the RCM, said she didn't know of the facility ever getting that supplement for the resident, but remembered it was brought up in several of the morning meetings with staff. In an interview on 01/13/16 at 11:18 a.m., Staff A, the Administrator, said the facility ordered the supplement for the resident last week. The Administrator was informed the resident said he hadn't been receiving the supplement at all until a few days ago (initially ordered 10/16/15 - nearly 3 months earlier). On 01/14/16 at approximately 10:00 a.m., the Administrator confirmed the facility hadn't ordered the supplement for the resident until the previous week, when he was re-admitted on [DATE], after an overnight procedure. The Administrator said it didn't look like the resident was receiving the supplement, though it was written on the October, November and December 2015 MARs as being offered. . 4. Resident #185. Per record review the resident was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. Per the 01/01/16 facility assessment, the resident was identified as having functional limitations to both upper arms, and required staff assistance with setting up meals. This resident's nutrition assessment dated [DATE] documented that due to pain, the resident had a decreased appetite, and was consuming about 72% of her meals. It also documented there was no height or weight yet recorded for the resident (approximately a week after admission to the facility). On 01/12/16 at 1:58 p.m., Staff NN, a nursing assistant, stated after weighing residents, the information was given to Staff L, the RCM, who would then enter the weights in the electronic record. On 01/12/16 at 2:03 p.m., Staff L, RCM, stated residents are weighed within 3 days of admission, and then weekly. Staff L was able to find only one weight entry in the electronic system for Resident #185, dated 01/06/16. Failure to ensure weights were obtained and monitored consistently placed the resident at risk for an unidentified weight decline.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services, for 1 of 5 residents reviewed for pain (#76), 2 of 4 residents reviewed for skin conditions (#72, 36), and 1 of 1 residents reviewed for [MEDICAL TREATMENT] (#40), in a sample of 51. This failure placed residents at risk for worsening skin conditions, complications related to [MEDICAL TREATMENT], and caused actual harm to Resident #76, who had unrelieved pain, and Resident #72, who developed a secondary eye infection as a result of a poorly monitored skin condition. Findings include: 1. Resident #76 had [DIAGNOSES REDACTED]. Per record review, the resident was able to self-propel in his wheelchair, and transfer independently, but required some supervision and assistance with other activities of daily living. The resident was able to make his needs known, and had no memory problems. Per the admission pain assessment dated [DATE], the resident had frequent back pain, and rated it a 4 out of 10 (0 being no pain/10 being the most intense pain). The most recent facility assessment of 01/07/16 documented the resident reported frequent pain, which affected his day-to-day activities. The most recent plan of care identified the resident as having persistent chronic pain and directed staff to administer pain medications as ordered, monitor for effectiveness, and report signs/symptoms of distress. Per the January 2016 Medication Administration Record [REDACTED]. The resident also had an order for [REDACTED]. In an interview on 01/04/16 at 2:50 p.m., the resident stated he was not having a good day, and was having pain in his right hip. He said he got pain medication for it, but it only helped for a little while. On 01/05/16 at 9:05 a.m., the resident was outside in the smoking area in his wheelchair; he told the surveyor he was having continuing problems with pain in his right hip. The resident explained he was supposed to have something put on it that morning (a pain patch) but didn't get it. The same day at 10:14 a.m., Staff R, a nursing assistant, informed Staff S, a nurse, that the resident was having hip pain, and need his pain patch (which was to have been applied at 7:00 a.m. per physician order). In an interview at 10:45 a.m., the resident way lying in bed, said he still didn't have the pain patch, and said he was still having a lot of hip pain. At 11:10 a.m., the resident said the nurse had gotten him the patch - over 4 hours since it was to have been applied. He stated he was starting to have some relief of the hip pain. On 01/06/16 at 8:30 a.m., the resident was observed in his room in bed. The resident said he didn't have his pain patch yet, and went on to say it takes forever. The resident said he was hurting, and was observed wincing in pain, and motioning toward his right hip. At 9:05 a.m., the resident was observed in the same position in his bed, wincing, and with labored breathing. He said he hadn't gotten the pain patch from the nurse yet, and rated his pain level at between 8-9 out of 10 (severe pain). At 9:10 a.m. the same day the surveyor informed Staff S, the nurse, the resident was complaining of severe pain in his right hip, and described the above signs and symptoms (i.e. wincing, labored breathing, rating of 8-9). Staff S said she was new to that area of the facility, and was still getting used to the medication pass routine. She confirmed the [MEDICATION NAME] was supposed to be on at 7:00 a.m. and off at 7:00 p.m., verified the physician order [REDACTED]. Per review of the MAR for 01/06/16, Resident #76 also required 2 tablets of as needed narcotic pain medication (for breakthrough pain) at 9:15 a.m., in addition to the [MEDICATION NAME]. The effectiveness of the pain medication was not documented. The facility failed to place a physician ordered pain patch in a timely manner on 2 separate days, causing the resident emotional upset and increased pain. 2. Resident #72 re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Per the facility's comprehensive assessment dated [DATE], the resident was cognitively impaired, had difficulty communicating, and required assistance with all activities of daily living. On multiple occasions during the survey, from 01/04/16 through 01/07/16, the resident' s left ear appeared red, swollen and scaly. A review of the resident's Treatment Administration Records (TARs) revealed a skin assessment was to be completed once a week. Further review of the TAR revealed during the month of December 2015, a skin assessment was only completed twice (12/15/15 and 12/24/15). Both skin assessments documented a (-), meaning the resident had no skin alterations. In addition, a review of the January 2016 TAR noted skin assessments had been completed on 01/06/16 and 01/13/16, with no areas of skin impairment identified. The nursing notes, and alert charting documents for that time period were also reviewed. No area of skin impairment on the resident's left ear was identified. A 01/12/16 progress note by the Advanced Practice Registered Nurse (ARNP) documented the resident was found to have [MEDICAL CONDITION] (inflammation) of left external ear secondary to unstageable pressure ulcer likely from glasses and/or oxygen tubing. In addition, the ARNP identified the resident had conjuctivitis (infection/inflammation) of the left eye, with green drainage, a red lower lid, and matted material in his eyelashes and on his face. The note indicated the resident had likely contaminated the eye when he rubbed his ear. Antibiotic treatment was started for both eye and ear, and dressing changes ordered. The facility's failure to complete skin assessments as ordered by the physician, and to recognize a new area of skin impairment in a timely manner, likely caused the resident to contract [MEDICAL CONDITION] of the ear, and a secondary infection of the left eye, both which required antibiotic treatment 3. Resident #36 had [DIAGNOSES REDACTED]. Per record review, the resident had recently declined, and required total assistance with activities of daily living. The resident had increased confusion, and difficulty making her needs known. Per the Care Area Assessment (CAA) dated 12/04/15, the resident was identified as having multiple medical issues, which placed her at increased risk for infections, falls, skin issues and pain. During an interview on 01/05/16 at 9:30 a.m., the resident was observed to have multiple bruises on both of her arms and hands. Review of the skin assessments in the treatment record on 01/06/16, showed there was no identification or monitoring of the bruising. In an interview on 01/07/16 at 8:50 a.m., Staff L, Resident Care Manager, said she was not aware of the bruising on both arms/hands of Resident #36, and confirmed any skin issues (including bruising) needed to be identified and placed on a skin sheet to be monitored. Per review of the facility investigation into the bruising, an interview was completed with the resident's family member on 01/08/16. The family member said she noticed the bruising on the resident's arms the weekend prior when she visited (01/02 and 01/03/16), but at that time they were much darker. 4. Resident #40 had [DIAGNOSES REDACTED]. Per record review, the resident had no memory impairment, and required extensive assistance with most activities of daily living. The resident also required [MEDICAL TREATMENT] (the process of filtering blood to maintain kidney function) three days per week, at an outside facility. Per review of the most recent care plan, licensed staff were directed to monitor the functioning of the [MEDICAL TREATMENT] site, by checking for bruit and thrill (sound and feel). Interventions also included monitoring for signs/symptoms of infection, bleeding and fatigue after [MEDICAL TREATMENT] treatments. In an interview on 01/13/16 at 1:45 p.m., Staff L, the Resident Care Manager, stated the facility was supposed to use the [MEDICAL TREATMENT] communication form each time the resident went to [MEDICAL TREATMENT], to ensure he was monitored before and after. The form also had a section for the [MEDICAL TREATMENT] nurse to communicate any pertinent information, or any change in condition. Staff L also said the resident's bruit and thrill should be checked and initialed every shift (on the Medication Administration Record). Review of the resident record on 01/13/16 revealed there were 9 [MEDICAL TREATMENT] communication forms completed, and maintained in the record, though the resident had been going to [MEDICAL TREATMENT] three times per week since admission on 10/8/15 (13 weeks or approximately 39 trips to the [MEDICAL TREATMENT] center). The progress notes were also reviewed during this time period - nursing staff did not consistently assess and/or monitor the resident's condition after returning from [MEDICAL TREATMENT]. In addition, the January 2016 MAR indicated [REDACTED].

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 residents (#1) reviewed for respiratory care received necessary care, treatment and services. Failure to implement planned interventions for this resident resulted in harm to Resident #1. Findings include: Resident #1 was alert and oriented and able to make her needs known. She had a lung disease in which she retained carbon [MEDICATION NAME] (when too little carbon [MEDICATION NAME] is removed by the lungs the overall level of consciousness and the respiratory effort decreases which could then result in [MEDICAL CONDITION]). The resident required the use of a bi-level positive airway pressure ([MEDICAL CONDITION]) device when she slept. This is a medical device that uses pressure to allow more air to reach the lungs with normal breathing. The resident had used this [MEDICAL CONDITION] machine for years. Per record review, the physician ordered the resident to have a [MEDICAL CONDITION] machine on at bedtime and off in the morning. Staff was to assit her to place the [MEDICAL CONDITION] and ensure the mask stayed in place. If the resident's oxygen level dropped below 88% (normal is 90% or greater) during waking hours then she was to be assisted in wearing the [MEDICAL CONDITION] during the day. Per record review, on 8/21/13 the resident was found in bed and her [MEDICAL CONDITION] mask had slipped off of her face, she was unresponsive and was admitted to the hospital. On 8/28/13, a care conference was held with the resident, family and facility to try and ensure the incident did not reoccur. The staff was to check the resident's [MEDICAL CONDITION] placement every 30 minutes to 1 hour any time the resident was napping or in bed. If the resident refused to wear the [MEDICAL CONDITION] then the staff was to contact the resident's daughter any time during the day or the night. Per record review, it was documented on 10/6/13 at about 6:15 a.m. a lab technician came and told Staff #A that the resident was unresponsive. Staff #C stated "oh she is fine, her saturations are 95%. She has been like that all night.... go ahead and draw her blood." Staff #A asked another nurse to check on the resident and it was reported that Staff #A needed to go to the resident's room right away. When Staff #A entered she found the resident "lying on her left side, with teeth hanging out of her mouth and foamy saliva below and on her mouth...O2 sats checked and read 86% on 2 liters (of oxygen) via nc (nasal cannula), resident did not and had not had her [MEDICAL CONDITION] on all noc. Resident was completely unresponsive with labored type breathing, unable to arouse with painful stimuli..." It was further documented that the ambulance was called and the resident was transported to the hospital. Per record review of the hospital notes dated 10/6/13, the resident was found to be hypoxic (lack of oxygen to the brain) and suspected to be hypercapnic (too much carbon [MEDICATION NAME] in the blood). The resident had to be intubated (a tube placed in the airway to assist in breathing) and placed on a ventilator (breathing machine). The hospital record also indicated the resident didn't have her [MEDICAL CONDITION] placed last night at the facility "which is probably the precipitating event". On 10/10/13 at 12:15 p.m., Resident #1 was interviewed. She stated that she would fall asleep sometimes without her [MEDICAL CONDITION] on and "I suck in carbon [MEDICATION NAME]." She explained the importance of wearing the [MEDICAL CONDITION] and staff was supposed to make sure it was on when she was sleeping. She stated that when she doesn't have it on she gets confused. If she ever refuses to wear it that means she needs it because she is not thinking clearly. She said that was why the staff were to call her daughter if she refused. In a follow up interview at 2:45 p.m., the resident stated "I am afraid to go to sleep at night. I have woken up to many times in the hospital. I didn't sleep at all last night." On 10/10/13 at 4:40 p.m., the a family member was contacted. She stated that the facility had been told to contact the resident's daughter anytime day or night when the resident refused to wear the [MEDICAL CONDITION] machine. She stated she was very frustrated and felt the staff needed to be educated on a person that retained carbon [MEDICATION NAME]. "The [MEDICAL CONDITION] can't be left off when she is sleeping and some staff think it is fine to not put on the [MEDICAL CONDITION] if her oxygen levels are high enough." She said the facility had never contacted the daughter because the resident refused to wear the device. Per review of an investigation on 10/10/13, Staff #C stated the resident had been sleeping with her oxygen on via nc and her saturation levels were above parameters, therefore, the [MEDICAL CONDITION] was not placed on the resident all night. Per interview on 10/10/13 at 5:35 p.m., Staff #A stated when she came on shift the morning of 10/6/13 at about 6:15 a.m., it was reported to her that the resident was unresponsive. She stated that the resident was to be monitored when her [MEDICAL CONDITION] was on because sometimes the resident would remove it or it would fall off when the resident was sleeping. She confirmed the night nurse had told her that the resident did not have the [MEDICAL CONDITION] on during the night because her oxygen levels were fine. "The resident needs the [MEDICAL CONDITION] on when sleeping at all times.....she keeps it on so her carbon [MEDICATION NAME] levels will go down". Per interview on 10/10/13 at 6:00 p.m., Staff #B confirmed the resident was to have the [MEDICAL CONDITION] on when napping or during the night. The staff was to assist the resident in wearing it and if there was a problem, they were to call the daughter. In a follow up interview on 10/11/13 at 11:45 a.m., Staff #B stated after the care conference with the resident's daughter in August, the staff was educated on checking [MEDICAL CONDITION] placement for the resident every 30 minutes to 1 hour but stated no education was given on care and services related to resident that used a [MEDICAL CONDITION]. Staff #B stated "the nurses here have had years of experience, I would think with all those years of knowledge they would know what a CO2 retainer was. I thought we were all on the same page." The facility's failure to implement planned interventions for [MEDICAL CONDITION] administration while the resident was sleeping resulted in harm. The resident developed [MEDICAL CONDITION] and required hospitalization and the use of a ventilator. On 10/10/13 the investigator requested the faciliy implement an immediate safety plan. All staff involved in the resident's care were provided education by a Respiratory Therapist regarding the proper use of the [MEDICAL CONDITION], Staff # C was no longer working with the resident, and night time supervision of the resident was increased. In an interview with the resident's family member on 10/15/13, she stated since the safety plan was implemented the resident now feels safe going to sleep.

Based on interview and record review the facility failed to take immediate action, timely notify the physician and follow through when there was no reponse from the physician for changes in condition for 1 of 3 residents (#2) in a sample of 17 related to changes in her bowel status, a lump in her neck, and an increased temperature that did not resolve with medication. This failure caused Resident #2, a resident with known history of having rapid temperature spikes, to not receive immediate treatment options. Findings include: 1) Resident #2, per the facility assessment dated [DATE] she was usually alert and oriented. Per record review, she had chronic mental health conditions, [MEDICAL CONDITION], chronic pain, and past history of going septic (a severe infection caused by pathogenic organisms, especially bacteria in the blood or tissues) within 12 hours. Per review of the facility investigation dated 4/3/13, the resident was sent to the hospital on [DATE] and 11/12/12 when she rapidly spiked a fever and required hospitalization related [MEDICAL CONDITION]. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She had a history of [REDACTED]. The nurse gave her a medication for fever and pain. One hour later at 11:00 p.m., the nurse rechecked her temperature and it was still elevated at 102.6 degrees. The doctor was not notified until 2/26/13 at 2:00 a.m. (3 hours later) despite the resident's history of going septic when experiencing an elevated temperature. Per telephone interview with the resident's doctor on 4/8/13 at 1:32 p.m., she reported the resident tended to go septic quickly, as soon as 12 hours. She said she was not notified of her increased temperature until 2/26/13 at 2:00 a.m. At that time she gave orders to transport the resident to the hospital. Per review of the hospital emergency room admission report dated 2/26/13, it stated the facility told them the resident had been in bed, not responding to getting out of bed or anything for the last 3 days. She was diagnosed with [REDACTED]. The facility failed to ensure that staff took immediate action to notify the physican with a resident who had a known recent history [MEDICAL CONDITION]. This failure delayed treatment options for Resident #2. 2) On 2/14/13, per record review, results of laboratory tests for Resident #2 came back and noted her white blood cell (WBC) count was elevated and her serum iron level was low. The resident's physician was interviewed on 4/8/13 at 1:32pm and she stated she was aware of the resident's low iron level and had faxed the facility to check if the resident was receiving any iron. She stated she did not get a response back from the facility. 3 ) On 2/20/13 in the morning, Staff #H documented in the nursing notes that the resident had a hard 3 inch lump on the right side of her neck. She faxed the physician and put the area on the treatment sheet for staff to check it three times a day. There was no acknowledgement the physician received the faxed information informing her of the lump, nor follow up by the facility with her when they did not hear back from the physician. Per interview with the resident's physician on 4/8/13, she said she was not aware of the lump on the resident's neck. On 4/25/13 with Staff #B, the facility's policy for notifying residents' doctors was if the concern was serious they would call the doctor right away, and if it was less serious they could fax the doctor, but needed to follow up the next day if they didn't hear back from the doctor.

Based on record review and interview, it was determined that the facility failed to ensure safety interventions were implemented for 1 of 4 residents (#1), related to transfers. Resident #1 experienced actual harm as a result of a fall during transfer. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident was alert and oriented and able to make her needs known. She was extensive assist with transfers. Per record review, on 12/27/11 the resident was assessed as a 2 person assist with mechanical lift for transfers. The resident's care plan on 7/11/12 identified the resident at risk for falls/injuries related to pain and poor weight bearing. The care plan directed staff to use a Hoyer lift with 2 person assist when transferring. During an interview on 8/8/12 at 1:50 p.m., the resident was observed in bed with a brace on her right leg. The resident stated she stays in bed most of the time. When asked about the brace, the resident stated she broke her leg when being transferred. The resident did not want to talk about the incident and had tears in her eyes. Per review of the incident investigation, the resident had an assisted fall on 7/12/12. The resident was asked to get out of bed so her room could be deep cleaned. The resident agreed but refused to have the Hoyer lift because it made her feel like "cargo". The nurse assessed the resident and determined she could be a 2 person transfer. Upon transfer back to her bed from the wheel chair, the resident's knees buckled and she was lowered to the floor on her knees. The resident complained of knee pain while on the floor so staff layed her on her side. The resident was then transferred back to bed with the Hoyer lift. The incident did not get reported to the nurse and the resident was not assessed prior to transferring her back into bed. Per record review, on 7/14/12 the resident complained of increased pain in her right knee. An assessment was completed and a fair amount of swelling was noted. An x-ray was ordered that revealed a fracture of her right femur and dislocation of her right tibia and fibula. The resident was transferred to the hospital. Per record review, the resident infrequently got out of bed per her request. There was no documentation to indicate that the resident was given other options to clean her room other than being asked to get out of bed and leave the room. During an interview on 8/9/12 at 10:50 a.m., Staff #A stated the resident agreed to get out of bed so her room could be deep cleaned. Staff #A stated she was very excited because the resident rarely agreed to get out of bed. The resident refused to use the lift so the nurse assessed her and determined she could be a 2 person assist. While assisting the resident to a sitting position, she fell back onto the bed and yelled "your dropping me, your dropping me." The staff calmed the resident down and proceeded with the transfer. No gait belt was used. Staff #A stated she was not present when the resident was transferred back to bed. On 8/9/12 at 11:25 a.m., Staff # B stated she helped transfer the resident back to bed. She stated the resident was lifted to a standing position and then became "dead weight." Staff was unable to hold the resident up and assisted her to the floor on her knees. The resident became upset and frightened and started hitting the other staff member saying her knees were hurting. She was then assisted to a laying position on the floor and was returned to bed with the Hoyer lift. On 8/9/12 at 12:25 p.m., Staff #C stated she assisted the resident being transferred out and in bed. On the transfer from the wheel chair to the bed, the resident's knees buckled and they lowered her to the floor on her knees. When on her knees, the resident complained of pain so she was assisted to her side on the floor. Staff #C stated they didn't have the nurse come in and assess the resident before lifting her with the Hoyer back into bed. On 8/9/12 at 12:45 p.m., Staff #D stated that she would expect the nurse to do an assessment before determining a resident's transfer status. When asked if she would expect the nurse to determine if a resident's status changed from a lift to a 2 person, she stated that she would have therapy and IDT involved as well before making that decision. The facility failed to safely transfer the resident which resulted in actual harm due to the resident sustaining a leg fracture.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for 4 of 40 sample residents (#31, 110, 191, 251) related to [MEDICAL CONDITION] and pain management. Resident #31 experienced harm related to poor pain management. Findings include: [MEDICAL CONDITION] MANAGEMENT: 1. Resident #251 was admitted to the facility with a skin infection to the left and right lower extremities. The resident was lethargic, confused and dependent on staff for daily decision making. According to the nursing admission assessment completed 11/12/10, the resident had 2+ [MEDICAL CONDITION] (swelling) to both lower extremities including ankles/feet. Planned interventions directed the licensed staff to treat the left and right skin infection, monitor scattered bruising to her bilateral upper extremities including forearms and to treat a skin tear to the resident's right forearm. The resident's care plan was revised to include long sleeves/pants to protect resident's fragile skin related to chronic steroid therapy. There was no plan in place for the the licensed nurse staff to monitor the resident's swelling to her lower extremities and/or were interventions put in place to help decrease the swelling. The resident was observed on 11/16,17,18,19,22,23/10. During rounds on 11/16/10, the resident was observed sitting in bed visiting with visitors, very confused, but pleasant. On 11/17/10 from 8 a.m. to 10:30 a.m., the resident was observed asleep in bed. According to the resident's roommate, she was awake most of the night, confused and finally was asleep. The resident appeared comfortable and was sleeping soundly. On 11/18/10 at 3:10 p.m., the resident was sitting in her wheelchair, legs and feet positioned dependently, asleep at the bedside. The resident aroused easily when spoken to, but remained sleepy. The resident was dressed in a long sleeved sweatshirt, long pants and non-skid socks. The swelling in the resident's ankles/feet had increased to 3+, and when the resident's right foot was touched (with permission from resident) she complained that it hurt and the resident grimaced. At 3:55 p.m., the resident remained up in wheelchair, at bedside, asleep with lower extremities positioned dependently. [MEDICAL CONDITION] remained at 3+. On 11/19/10 following breakfast, the resident remained in the dining room dozing. The resident awakened easily. The resident was dressed in a long sleeve sweatshirt and long pants. The resident was positioned in her wheel chair with both lower extremities in the dependent position with [MEDICAL CONDITION] of 2-3+ to both feet and ankles. At 11:00 a.m., the resident was observed in her room, up in wheelchair, at the bedside receiving Speech Therapy services. The resident's lower extremities remained in a dependent position with [MEDICAL CONDITION] 2-3+ to both feet/ankles. At 12:50 p.m., the resident was sitting in the dining room taking bites of her lunch and visiting with a tablemate. The resident's lower extremities remained in the dependent position with 3+ [MEDICAL CONDITION] to both feet and ankles. On 11/22/10 at 8:20 a.m., the resident was observed in the dining room asleep with the breakfast tray in front of her. An Occupational Therapist (O.T.) awakened the resident and encouraged her to eat. The resident remained very sleepy and was accepting of food and fluids. Following the meal, the resident was removed from the dining room and placed in the hall by the nurses station. The resident was in her wheel chair with both lower extremities positioned dependently. The resident's ankles and feet were very swollen, with an increase to 3-4+. The resident commented that her feet and legs hurt. On 11/22/10, licensed staff #M observed the resident's lower extremities with the surveyor and confirmed the resident had 3-4+ [MEDICAL CONDITION] in both feet and ankles. The licensed nurse commented that she was aware of the skin infection but was not aware of the [MEDICAL CONDITION] issues. On 11/19,22/10, the resident's record was reviewed. Per review of the licensed progress notes, treatment records and skin sheets since admission on 11/12/10, there was no documented LN evaluation which described the condition of the resident's bilateral lower extremity feet and ankle [MEDICAL CONDITION] (11 days) even though the swelling had increased. On 11/22/10 at 1:20 p.m., the resident's physician evaluated her bilateral lower extremity skin infection and [MEDICAL CONDITION]. The physician verified the resident had "significant" 3-4+ [MEDICAL CONDITION], and orders were written. The resident experienced harm related to the facility's failure to thoroughly evaluate, monitor and implement interventions to provide needed medical treatment for [REDACTED]. 2. Resident #191 had [DIAGNOSES REDACTED]. Per record review, the resident was alert, oriented and involved in daily decision making. Per review of the nurses notes and treatment records, staff were monitoring the resident for signs/symptoms of [MEDICAL CONDITION] and bilateral lower extremity (BLE) [MEDICAL CONDITION]. Per the documentation on the October 2010 treatment sheet, the licensed nurses documented weekly [MEDICAL CONDITION] as 1-2+. For 11/1,9,16/10, the licensed nurses documented the resident had 1+ BLE [MEDICAL CONDITION]. The resident's care plan directed staff to do weekly [MEDICAL CONDITION] monitoring, elevate the resident's legs as needed to decrease [MEDICAL CONDITION] and notify the physician if [MEDICAL CONDITION] >2+. On 11/19/10 at 8:55 a.m., the resident was sitting in her wheelchair in the hallway after breakfast. The resident's lower extremities were positioned dependently with 2+ [MEDICAL CONDITION] to both feet and ankles. At 10:50 a.m., the resident was sitting in her wheelchair in the hallway following activities. The resident's legs and feet were positioned dependently with 3+ [MEDICAL CONDITION] to both feet and ankles. On 11/19/10 at 11:00 a.m., licensed staff #M observed the resident's lower extremities with the surveyor and confirmed the resident had 3+ [MEDICAL CONDITION] in both feet and ankles. The licensed nurse (LN) requested staff to lay the resident down. The LN commented that "she's on diuretic therapy and does much better when she lays down but she has a few activities that she likes to attend. [MEDICAL CONDITION] goes up and down." On 11/19/10 at 12:45 p.m., following a nap in bed, the resident was sitting in the dining room having lunch. The resident's BLE [MEDICAL CONDITION] had decreased to 2+. On 11/22/10 at 7:50 a.m., the resident was sitting in her wheel chair by the nurses station waiting for breakfast. The resident's ankles and feet had 3+ [MEDICAL CONDITION]. The resident's lower extremities and feet were positioned dependently. The resident commented that her feet and legs felt better when they elevated them. "They puff up bad sometimes and hurt." At 9:40 a.m., following breakfast the resident attended an exercise class. Following the activity, the resident was assisted back to the unit and remained up in her wheel chair throughout the morning with her lower extremities positioned dependently with 3+ [MEDICAL CONDITION] to both feet and ankles. On 11/19,22,23/10, the resident's record was reviewed. According to the 11/10/10 weight committee notes, the resident had a weight loss of 12% in last 3 months. The resident was treated for [REDACTED]. The resident was on diuretic therapy and weight variance was expected. Weekly weights would no longer be monitored as the resident's weight was stable. Per interview with licensed staff #M, because the resident's weight was stable, they went back to monthly weights. The chair scale was broken and it was hard on the resident to stand or use the Hoyer lift. Per review of the licensed progress notes, treatment records and skin sheets since 11/1/10, there was no documented LN evaluation which described the condition of the resident's bilateral lower extremity feet and ankle [MEDICAL CONDITION] even though the swelling had increased. There was no weight available after 11/3/10 to determine whether the resident was experiencing signs/symptoms of [MEDICAL CONDITION]. The facility failed to thoroughly evaluate, monitor and implement interventions to provide needed medical treatment for [REDACTED]. PAIN MANAGEMENT: 3. Resident #31, per record review, had [DIAGNOSES REDACTED]. He had no memory problems or difficulty with making daily decisions. The resident required extensive assistance with activities of daily living (ADL's). The care plan directed staff to administer pain medications as needed, monitor effectiveness, and provide alternative measures for comfort, such as massage. Per the last quarterly assessment dated [DATE], the resident was noted to have no pain currently or in the past several months. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The previous full pain assessment was last reviewed on 8/25/10 and indicated that the resident had no pain. On 11/16/2010 at 3:09 p.m., the resident was sitting up in his wheel chair and reported that he had pain that he rated "8 out of 10" to his bottom. He reported that he spent a lot of time up in his wheel chair. On 11/19/10 at 8:55 a.m., Staff #Q finished working with the resident. The resident was up in his wheel chair in the hall and reported that he had pain to his bottom and rated the pain "7 out of 10." Staff Q was observed talking with the nurse after the resident reported his pain. On 11/19/10 at 10:10 a.m., the resident received medications from Staff #J. He was up in his wheel chair in the hall and reported that his pain was still "7 out of 10." He reported that he did not ask the nurse for any medications. On 11/19/10 at 10:20 a.m., the MAR indicated [REDACTED]. On 11/19/10 at 11:20 a.m., Staff #J reported that the resident did not tell her he was in pain. She reported that sometimes he reported his pain, but today he did not tell he that he was in pain. On 11/19/10 at 11:30 a.m., the resident was up in his wheel chair outside. Staff #J asked the resident about his pain. The resident reported the pain was "8 out of 10" to his bottom. He complained that his chair hurt him. The nurse told the resident she would bring him 2 pain pills and apologized. On 11/19/10 at 11:40 a.m., the resident came in from the outside. He again reported that his wheel chair cushion was uncomfortable. He reported that he was told that the facility did not have another type of cushion. On 11/19/10 at 11:44 a.m., Staff #J brought the resident 2 narcotic pain medications. She again apologized to him for not giving him his pain medications sooner. On 11/19/10 at 12:50 p.m., the resident reported his pain had subsided and was now a "3 out of 10." Staff#J reported that she would have therapy re-evaluate his wheel chair cushion and update his care plan to have the licensed nurses evaluate his pain twice per shift. On 11/19/10 at 1:40 p.m., Staff #Q reported that earlier when she wheeled the resident to the nurse, she did not report the resident's pain to the nurse because she thought he got routine pain medications. On 11/22/10 at 8:50 a.m., the resident was in his wheel chair in his room with his wheel chair tilted back. He reported that his pain was "8 out of 10" all weekend and received no pain medications. He reported that they had not asked him about his pain today. Review of the record showed that no narcotic pain medications were given over the weekend. Review of the nursing notes had nothing documented since evening shift on 11/19/10. On 11/22/10 at 9:15 a.m., following discussion regarding the resident's pain, Staff #J went to the resident's room and stated, "I just asked you how you were doing and you told me you were pretty good!" He reported that his pain was "8 out of 10." She told the resident to let her know when his pain was a 2 so that they could address it sooner. She told the resident she would let the doctor know and request routine narcotic pain medications. The nurse left the room and the resident reported that they don't ask him if he's in pain, but how he is doing. He stated, "I always say I'm good." On 11/22/10 at 10:30 a.m., the resident reported that his pain was now a "6 out of 10." He stated that as long as he did not move his pain was fine. On 11/22/10 at 1:50 p.m., MAR indicated [REDACTED]. On 11/22/10 at 1:50 p.m., the resident was up in the hall in his wheel chair. He stated that his pain was an "8 out of 10." He stated that he hurt so bad that he wasn't able to eat. On 11/22/10 at 2:05 p.m., Staff #J contacted the doctor and received orders for routine pain medications. On 11/22/10 at 3:55 p.m., Staff #J confirmed that she didn't update the alert charting or the 24 hour report. She stated that she passed the information along to the evening nurse, but there wasn't a paper trail to alert the weekend staff person of the change in his condition and the need to monitor his pain more frequently. Per review of the MAR, the resident received an as needed medication 12 times. There was no indication of what the resident's pain level was noted to be at the time prior to administration of the narcotic pain medication or measurement of effectiveness of the medication. On 11/23/10 at 11:20 a.m., Staff #I confirmed the effectiveness of the medication should be evaluated. The facility failed to evaluate the resident's change in pain, ensure that the resident's change in pain was communicated to the interdisciplinary team, or re-evaluate the effectiveness of the pain medication. This resulted in harm for the resident. 4. Per record review, Resident #110 had symptoms of weakness and pain related to a chronic medical condition. The resident had problems with short-term memory, daily decision-making, anxiety, and required extensive assistance of 1-2 staff with most activities of daily living. Per record review, the resident had physician orders [REDACTED]. The dosage for the routine narcotic pain medication was increased on 10/15/10. The most recent pain assessment dated [DATE] documented the resident had chronic pain in the neck, right arm and lower back and hips. During assessment, the resident reported her pain level (scale of 1-10) as 6-7 in the neck, 4 in the right arm, and 6 in the lower back and hips. The resident's Pain Management Plan of Care included a goal to decrease persistent pain to a tolerated level so the resident could function in daily life. There was no goal information to indicate what was a tolerable level of pain for the resident. The care plan directed staff to administer pain medication as ordered, monitor and record medication effectiveness, and provide alternative comfort measures including repositioning and mobility. In an interview on 11/17/10 at 11:21 a.m., the resident reported her pain level as 7. She stated she was supposed to report her pain level to staff and that staff did not ask her about her pain level every day. She stated she would like her pain level to be less but did not know if she could tolerate more pain medication because her confusion increased. In an interview with Staff #I and #N on 11/20/10 at 11:20 a.m., the resident again reported her pain level as 6-7. Staff #I stated the resident could report concerns about pain to the nursing assistants, who would document the resident's concerns and report them to the licensed nurses. The resident could report her pain level to the licensed nurses as well. Per record review, there was no information about the resident's pain relief with routine narcotic pain medication. Per the November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's pain level before the medication was administered and medication effectiveness was not documented. The medication dosage (1-2 tablets) was inconsistently documented. In an interview on 11/23/10 at 1:15 p.m. Staff #A had no additional information to offer regarding monitoring the resident's pain level. The lack of consistent monitoring placed the resident at risk for unrelieved pain.