Every finding on record at Avamere at Pacific Ridge

Based on observation, interview, and record review, the facility failed to consistently maintain the medication refrigerator temperature logs in 2 of 2 medication rooms (The 100/200 hall and 300/400 hall medication rooms) reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medications. Findings included .Review of the facility's policy titled, Medication Storage, dated 2007, showed medications that required refrigeration, were to be kept in the refrigerator between 36 and 46 Fahrenheit (F, temperature scale) with a thermometer to allow temperature monitoring. It showed, A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. <100/200 Hall Medication Room>Observation on 04/22/2026 at 8:04 AM with Staff E, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), of the medication room refrigerator located in the 100/200 hall medication room showed various liquid medications including vaccines that were stored in the refrigerator. The thermometer showed a temperature of 28F (outside of parameters). Review of the April 2026 refrigerator temperature logs from 04/01/2026 - 04/22/2026 showed missing documentation and that temperatures were not consistently being monitored and documented twice a day. During an interview on 04/22/2026 at 8:04 AM, Staff E, RCM/LPN, stated the refrigerator temperature was 28F which was out of parameters. Staff E stated the April 2026 refrigerator and freezer temperature logs were missing documentation and were not being documented on twice a day and should have been because there were vaccines stored in the refrigerator. <300/400 Hall Medication Room>Observation on 04/22/2026 at 11:24 AM with Staff K, Registered Nurse (RN), of the medication room refrigerator located in the 300/400 hall medication room showed various liquid medications including vaccines that were stored in the refrigerator. Review of the April 2026 refrigerator temperature logs from 04/01/2026 - 04/22/2026 showed missing documentation and that temperatures were not consistently being monitored and documented twice a day. During an interview on 04/22/2026 at 11:24 AM, Staff K, RN, stated the April 2026 refrigerator temperature logs were not consistently being documented twice a day and should have been because there were vaccines stored in the refrigerator. During an interview on 04/22/2026 at 11:54 AM Staff A, Administrator, stated that the 100/200 hall April 2026 refrigerator temperature logs had missing documentation and were not being documented twice a day. Staff A stated the 300/400 hall April 2026 refrigerator temperature logs were not consistently documented twice a day. Staff A stated this did not meet their expectations. Reference WAC 388-97-2340

Based on interview and record review, the facility failed to consistently monitor potential adverse side effects (ASE) related to the use of psychoactive (affecting the mind) medications for 4 of 5 sampled residents (Residents 2, 11, 14, and 69) when reviewed for unnecessary medication use. Failure to have adequate indications or diagnosis for psychoactive medication use for Resident 2, consistent orthostatic blood pressure monitoring for Resident 11, and to conduct/obtain abnormal involuntary movement scale (AIMS) assessment for the use of an antipsychotic medication (a psychoactive medication that affects a person's mental status) for Residents 14 and 69, placed residents at risk of medical complications, unidentified presence and severity of AIM ASE, and a diminished quality of life. Findings included .Resident 2 Review of the electronic health record (EHR) showed Resident 2 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke caused by reduced blood flow in the brain), dementia (decline in cognitive function), and chronic obstructive pulmonary disease (restricted airflow that makes breathing difficult). Resident 2 was able to communicate needs. Review of the admission minimum data set (MDS, a required assessment) dated 02/19/2026 showed Resident 2 was receiving antipsychotic medication and did not have behaviors. Review of the provider order dated 02/13/2026 showed Resident 2 was ordered quetiapine 25 milligrams (mind altering medication) to be administered at bedtime without indication or diagnosis. During an interview on 04/22/2026 at 1:51 PM, Staff E, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated Resident 2 should have indication and diagnosis with an order of quetiapine. Resident 11 Review of the EHR showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include fracture of right arm, dementia, diabetes (high blood sugar) and heart failure. Resident 11 was not able to communicate needs. Review of the significant change MDS dated [DATE] showed Resident 11 was receiving antipsychotic medication. Review of a provider order dated 03/10/2026 showed Resident 11 was ordered Seroquel 25 mg (mind altering medication) twice a day for a diagnosis of vascular dementia without behaviors. Review of the EHR for the month of March 2026 showed Resident 11 did not have orthostatic (shows changes in blood pressure from laying sitting and standing, indicating side effects) blood pressure results. During an interview on 04/22/2026 at 1:56 PM, Staff E, RCM/LPN, stated Resident 11's diagnosis should have been updated and did not meet indication for use. Staff E stated the orthostatic blood pressure should have been completed. During an interview on 04/24/2026 at 11:36 AM, Staff C, Regional Director of Quality Assurance, stated lack of appropriate diagnosis for Resident 2 and 11's antipsychotic medications did not meet expectations. Resident 14 Review of the EHR showed that Resident 14 readmitted to the facility on [DATE] and had diagnoses to include schizoaffective disorder-depressive type (mental health condition combining primary schizophrenia symptoms such as hallucinations/false sensory perceptions or delusions/fixed false beliefs with major depressive episodes/persistent low mood), anxiety disorder, and post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or harmful event). Resident 14 was able to make needs known. Review of the quarterly MDS dated [DATE] and 03/03/2026 showed Resident 14 received an antipsychotic medications. Review of the EHR showed Resident 14's last AIMS assessment was conducted/obtained on 09/09/2026. Review of the medication administration records (MAR) from 10/01/2025 – 04/21/2026 showed Resident 14 had received an antipsychotic medication on a routine basis. During an interview on 04/22/2026 at 2:03 PM, Staff D, RCM/LPN, stated residents who received an antipsychotic medication were to have an AIMS conducted every six months. Staff D stated Resident 14 had an AIMS completed on 09/09/2025 and should have had another one performed in March 2026. During an interview on 04/22/2026 at 2:23 PM, Staff E, RCM/LPN, stated Resident 14's last AIMS was conducted on 09/09/2025 and was now late and needed to be conducted. Staff E stated AIMS were to be completed every six months for residents receiving antipsychotic medications. Resident 69 Review of the EHR showed that Resident 69 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (loss of cognitive function), congestive heart failure (when the heart is unable to pump blood efficiently) and depression. Resident 69 was unable to make needs known. Review of the providers' orders showed Resident 69 received antipsychotic medications used to treat/manage psychosis symptoms like hallucination, delusions, and severe agitation. Review of the EHR showed Resident 69 had an AIMS assessments conducted on 04/01/2025 and 01/06/2026. During an interview on 04/23/2026 at 1:08 PM, Staff D, RCM/LPN, stated residents who received an antipsychotic medication were to have an AIMS conducted every six months. Staff D stated Resident 69's 01/06/2026 AIMS was conducted late and did not meet expectations. Reference WAC-388-97- 0640(4)(9)

Based on observation and interview, the facility failed to ensure sharps containers (containers to safely store used sharp, medical equipment, e.g. used needles) were regularly emptied and sharps were inaccessible to residents for 2 of 4 sampled sharps containers (200 and 300 hall) reviewed for accident hazards. This failure placed residents at risk of access to used medical equipment, transmission of dangerous infections, and a diminished quality of life. Findings included.Observation on 04/24/2026 at 10:18 AM showed the 200 hall medication cart had a sharps container affixed to the side. Observation showed the sharps container contained used needles which were visible/assessable and were stacked flush to the rim. Observation showed the spinning part which allowed the needles to fall to the bottom of the container and be inaccessible was not visible due to the amount of needles stacked atop it. Observation on 04/24/2026 at 10:20 AM showed the 300 hall medication cart had a sharps container affixed to the side and a few needles were visible. Observation showed the spinning part did not turn when needles were inserted and needles were starting to be stacked atop. During an interview on 04/24/2026 at 10:22 AM, Staff A, Administrator, stated the sharp containers having visible/accessible needles did not meet expectations. During an interview on 04/24/2026 at 11:32 AM, Staff C, Regional Director of Quality Assurance, stated the facility ensured used sharps, such as needles, were not an accident risk to residents be regularly emptying the sharps containers and sharps were fully enclosed at the bottom of the container. Staff C stated the sharps containers which had visible/accessible needles did not meet expectations. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to consistently provide non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) for 2 of 5 sampled residents (Residents 11 and 14) when reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included.Resident 11 Review of the electronic health record (EHR) showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include fracture of right arm, dementia (decline in cognitive function), diabetes (high blood sugar) and heart failure. Resident 11 was not able to communicate needs. Review of April 2026 medication administration record (MAR) showed Resident 11 was administered acetaminophen (pain medicine) as needed seven times. Review of the acetaminophen order showed Resident 11 was to be offered nonpharmacological interventions prior to administering the pain medicine and was documented as not applicable. During an interview on 04/22/2026 at 1:57 PM, Staff E, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the nurses should have documented the interventions and not document not applicable. Resident 14 Review of the EHR showed that Resident 14 readmitted to the facility on [DATE] with diagnoses to include high blood pressure, anxiety disorder, and osteoporosis (a disease that weakens bones, making them fragile, thin, and brittle). Resident 14 was able to make needs known. Review of the April 2026 MAR from 04/01/2025 – 04/21/2025 showed Resident 14 had an order with a start date of 05/28/2024 for acetaminophen as needed for pain, document NPI attempted prior to providing the medication, and had listed NPI including a code for refusal. Documentation showed Resident 14 was provided acetaminophen on 04/07/2026 for pain; however, NA (not applicable) was documented for NPI interventions instead of a code from the listed NPIs. No NPIs were documented. Review of the April 2026 treatment administration records (TAR) from 04/01/2025 – 04/21/2025 showed Resident 14 had an order dated 04/21/2022, to document pain scale rating each shift and to record intervention and effectiveness every day and night shift. Documentation showed Resident 14 had a pain level of 0 each shift. During an interview on 04/22/2026 at 1:51 PM, Staff D, RCM/LPN, stated NPIs should be documented prior to giving an as needed pain medication. Staff D stated Resident 14 was provided as needed acetaminophen on 04/07/2026; however, NA was documented instead of NPIs and this did not meet expectations. During an interview on 04/22/2026 at 2:16 PM, Staff E, RCM/LPN, stated Resident 14 was given as needed acetaminophen on 04/07/2026 and the April 2026 MAR showed not applicable was documented and should have had an NPI and/or the code for refusal documented. Reference WAC-388-97- 1060(3)(k)(i)

Based on interview and record review, the facility failed to offer and educate for influenza and pneumococcal vaccines for 2 of 5 sampled residents (Residents 21 and 10) reviewed for influenza and pneumococcal immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death. Findings included .Review of Resident 21's electronic health record (EHR) showed an admission date of 07/02/2022. There was no documentation that the facility provided education of the risks and benefits of the influenza vaccine for the 2025/2026 season. Review of Resident 10's EHR showed an admission date of 01/10/2026. There was no documentation that the facility provided education of the risks and benefits of the influenza vaccine or the pneumovax vaccine in 2026. During an interview on 04/24/2026 at 11:39 AM, Staff C, Regional Director of Quality Assurance, stated it was their expectation that all residents be offered the pneumococcal vaccines on admission and influenza vaccine annually with education provided on risks and benefits and a consent/declination form completed. Staff C stated that this was not done for Residents 21 and 10, and should have been. Reference WAC 388-97-1340(1)(2)(3)

Based on interview and record review, the facility failed to ensure Covid-19 (a highly infectious respiratory illness caused by a virus) vaccinations had documented evidence in the medical record that education was provided regarding the benefits and potential side effects of the COVID-19 vaccine for 2 of 5 sampled residents (Residents 10 and 7) reviewed for Covid-19 vaccinations. There was no documented evidence that the resident/representative received education and accepted or refused the vaccine. These failures denied the resident/representative the right to make informed decisions and placed residents at risk for adverse health effects of a communicable disease. Findings included .Review of Resident 10's electronic health record (EHR) showed an admission date of 01/10/2026. There was no documentation that the facility provided education of the risks and benefits of the Covid-19 vaccine. Review of Resident 7's EHR showed an admission date of 02/11/2026. There was no documentation that the resident was provided education of the risks and benefits of the Covid-19 vaccine. During an interview on 04/24/2026 at 11:39 AM, Staff C, Regional Director of Quality Assurance, stated it was their expectation that all residents be offered the Covid-19 vaccines on admission with education provided on risks and benefits and a consent/declination form completed. Staff C stated that this was not done for Residents 7 and 10 and should have been. Reference WAC 388-97- 1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to inform residents of their right to formulate an advanced directive and failed to periodically review residents' decision to formulate an advanced directive for 2 of 3 sampled residents (Residents 57 and 63) reviewed for advanced directives. This failure placed residents at risk of lacking the ability to appoint someone to make decisions for them when incapacitated and a diminished quality of life. Findings included.Resident 57Review of the electronic health record (EHR) showed Resident 57 admitted to the facility on [DATE] with diagnoses to include pressure wound of the lower back, diabetes (too much sugar in the blood), and bipolar disorder (mental health condition characterized by manic highs and depressive lows). Resident 57 was able to make needs known. Review of the Profile page showed Resident 57 was their own responsible party and did not have a power of attorney (someone to make decisions for you when incapacitated) or guardian (someone appointed to make decisions for someone who is unable to make their own decisions). Review of a Care Conference Information evaluation, dated 04/14/2026, showed Resident 57 had an Advanced Directive (AD, a document stipulating who should make decisions for you if you are incapacitated, e.g. power of attorney or guardian). Resident 63Review of the EHR showed Resident 63 admitted to the facility on [DATE] with diagnoses to include chronic kidney disease, diabetes, and dementia (a group of symptoms that affects cognition). Resident 63 was able to make needs known. Review of the Profile page showed Resident 63 was their own responsible party and did not have a power of attorney or guardian. Review of a Care Conference Information evaluation, dated 01/25/2026, showed Resident 63 had an AD. During an interview on 04/22/2026 at 2:00 PM, Staff J, Social Services Director (SSD), stated the AD mentioned in the Care Conference Information evaluations referred to end-of-life care decisions. Staff J stated they were unsure how the facility was currently reviewing AD with residents and they would investigate. During an interview on 04/23/2026 at 10:31 AM, Staff J, SSD, stated AD should be reviewed with residents on admission, quarterly, and as needed. Staff J stated the facility was currently only reviewing end-of-life care decisions in the admission packet and Care Conference Information evaluation, and not resident AD. Staff J stated Residents 57 and 63 had not been informed of their right to formulate an AD and their AD decision was not reviewed, and this did not meet expectations. During an interview on 04/23/2026 at 10:47 AM, Staff A, Administrator, stated the facility reviewed AD through the admission packet and they should be reviewed at the quarterly care conference. Reference WAC 388-97-0280(3)(c)(i)(ii), -0300(1)(b)(3)(a)-(c)

Based on observation, interview, and record review, the facility failed to maintain a safe, homelike environment for 2 of 17 sampled residents (Residents 10 and 48) reviewed for safe/homelike environment. The facility's failure to ensure Resident 10's damaged wall was repaired and Resident 48's room contained cleanable surfaces placed residents at risk of decreased mood, infection, and a diminished quality of life. Findings included.Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include Wernicke's encephalopathy (vitamin B deficiency that leads to confusion and unsteady walking), dementia (a group of symptoms that affects cognition), and delusional disorder (a mental health condition characterized by the presence non-bizarre fixed, false beliefs). Resident 10 was unable to make needs known. Observation on 04/20/2026 at 12:57 PM showed a large, damaged area to the wall above Resident 10's bed which revealed the brown cardboard color beneath. Observation showed the damage was circular and approximately one foot in diameter. Observation on 04/24/2026 at 11:55 AM showed the damaged area above Resident 10's bed had not been repaired. During an interview on 04/24/2026 at 12:14 PM, Staff L, Maintenance Director, stated wall damage should be reported by staff through the electronic maintenance system to ensure repairs were completed and resident rooms remained homelike. Staff L stated there was a large, damaged area approximately one foot in diameter above Resident 10's bed and it had not been reported to them. Staff L stated the damaged wall was not homelike. During an interview on 04/24/2026 at 12:36 PM, Staff A, Administrator, stated facility staff reported needed repairs through an electronic maintenance system and one-foot diameter wall damage was not homelike. Resident 48 Review of the EHR showed that Resident 48 readmitted to the facility on [DATE] with diagnoses to include heart failure, depression, and was able to make needs known. Observation and interview on 04/20/2026 at 10:43 AM showed Resident 48's bed's footboard had a foam noodle/pool noodle taped to the top. Resident 48 stated that their family member had placed it there. During an interview on 04/23/2026 at 12:38 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the pool noodle attached with tape to Resident 48's footboard did not create a homelike environment; however, it was placed there by a family member. Staff D stated it was not a cleanable surface and the issue needed to be followed up on to see if there was a solution to having a device that would be a cleanable surface. During an interview on 04/23/2026 at 12:45 PM, Staff A, Administrator, stated Resident 48's pool noodle placed on the footboard was not a cleanable surface. Staff A stated that they needed to see if it could be replaced with a medical grade device to create a homelike environment and have a cleanable surface. Reference WAC 388-97-0880

Based on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 3 sampled residents (Resident 50) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed that Resident 50 readmitted to the facility on [DATE] with diagnoses to include high blood pressure, depression, anxiety disorder, and utilized a wheelchair for mobility. Resident 50 was able to make needs known. During an interview on 04/20/2026 at 12:37 PM, Resident 50 stated Resident 27 sped up and down the hallway in their wheelchair very fast all day. Resident 50 stated one time Resident 27's wheelchair wheel got caught in their wheelchair but was then able to go around. Resident 50 stated that staff were aware. Review of the facility's Grievance log from November 2025 - April 15, 2026, showed no grievance logged for Resident 50's safety concern regarding a resident that wheeled too fast up and down the hallway in their wheelchair. During an interview on 04/23/2026 at 2:54 PM, Staff A, Administrator, stated Resident 50 was evaluated on 04/16/2026 by physical therapy for wheelchair safety after Resident 50 had reported the concern to Staff B, Director of Nursing Services (DNS) on 04/15/2026; however, a grievance was not initiated and it should have been once Resident 50 reported the concern to the DNS. Staff A stated this did not meet their expectations. Reference WAC 388-97-0460

Based on interview and record review, the facility failed to ensure injuries of unknown sources were reported to the State Hotline for 1 of 2 sampled residents (Resident 42) when reviewed for abuse. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 42 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (loss of cognitive function), congestive heart failure (when the heart is unable to pump blood efficiently) and anxiety. Resident 42 was able to make needs known. Review of the February 2026 accident and incident log showed an entry dated 02/28/2026 for Resident 42 related to skin. The incident was logged as Small bruises occurring in places generally vulnerable to trauma. The action taken was no further action and was not reported to the State Agency according to the incident log. Review of a 02/28/2026 progress note showed Large bruise to right breast noted.Purple/maroon in color with yellowing to outside edges note. [Resident 42] unable to recall or explain cause of bruising due to cognitive impairment and baseline confusion. During an interview on 04/23/2026 at 1:12 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the resident was unable to explain the injury due to cognitive impairment and because of the location of the bruise it should have been reported to the State Hotline. Reference WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to thoroughly investigate the potential for abuse and/or neglect for 1 of 2 sampled residents (Resident 42) reviewed for abuse and neglect. This failure placed Resident 9 at risk for psychosocial harm and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 42 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (loss of cognitive function), congestive heart failure (when the heart is unable to pump blood efficiently) and anxiety. Resident 42 was able to make needs known. Review of the February 2026 accident and incident log showed an entry dated 02/28/2026 for Resident 42 related to skin. The incident was logged as Small bruises occurring in places generally vulnerable to trauma. The action taken was no further action and was not reported to the State Agency according to the incident log. Review of a 02/28/2026 progress note showed Large bruise to right breast noted. Purple/maroon in color with yellowing to outside edges note. [Resident 42] unable to recall or explain cause of bruising due to cognitive impairment and baseline confusion. During an interview on 04/23/2026 at 1:12 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated an incident report should have been completed but they were unable to locate the investigation. During an interview on 04/23/2026 at 2:30 PM, Staff A, Administrator, stated they were unable to locate any documentation related to Resident 42's 02/28/2026 incident. Staff A stated an investigation should have been completed. Reference WAC 388-97-0640 (6)(a-c)

Based on interview and record review, the facility failed to ensure residents received a transfer/discharge notice and/or offered a bed hold for 2 of 3 sampled residents (Residents 6 and 12) reviewed for discharge/hospitalization. This failure placed residents at risk of not understanding their reason for transfer, inability to return to their room, and a diminished quality of life. Findings included.Resident 6 Review of the electronic health record (EHR) showed Resident 6 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. During an interview on 04/23/2026 at 1:01 PM, Staff M, admission Director, stated the admission department would follow-up with the resident and/or representative after discharge to the hospital and offer a bed hold and fill out a nursing home transfer or discharge notice and send it to the ombudsman. Review of the nursing home transfer or discharge notice for Resident 6 showed that this notice was not given to Resident 6 or their representative; the area was left blank. During an interview on 04/24/2026 at 11:49 AM, Staff C, Regional Director of Quality Assurance, stated Resident 6's transfer or discharge notice to the hospital did not meet expectations. Resident 12 Review of the EHR showed that Resident 12 readmitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), heart failure, and an anxiety disorder. Resident 12 was able to make needs known. During an interview on 04/20/2026, Resident 12 stated they had gone to the hospital; however, they did not recall if the facility offered/provided a bed hold. Review of the Nursing Home Transfer or Discharge Notice, showed Resident 14 was notified of transfer to the hospital on [DATE]; however, the form was signed by a staff member on 04/14/2026 and had not been signed by Resident 12 or their representative. Review of the EHR showed Resident 12 had transferred/discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. It showed no documentation that Resident 12 was offered/provided a bed hold. During an interview on 04/23/2026 at 4:14 PM, Staff A, Administrator, stated it was their expectation that nursing home transfer/discharge forms and bed holds be provided to the resident and/or their representative. Staff A stated they were not aware that Resident 12 was not offered/provided a bed hold or had a singed Nursing Home Transfer or Discharge Notice, for their transfer to the hospital on [DATE]. Staff A stated this did not meet their expectations. Reference WAC-388-97-0120(1)(2)(a)-(d)(3)(a)(4)(b)(5), -0080, -0140(1)(a)-(c)(i)-(iii)

Based on observation, interview, and record review, the facility failed to ensure the comprehensive assessment was accurate for dental conditions or skin conditions for 2 of 17 sampled residents (Residents 35 and 3) reviewed for accuracy of the comprehensive assessment. These failures placed residents at risk of unidentified needs, risk of inadequate plan of care, and a diminished quality of life. Findings included.Resident 35 Review of the electronic health record (EHR) showed Resident 35 admitted to the facility on [DATE] with diagnoses to include spondylosis with myelopathy (compression of the bones in the spine), metabolic encephalopathy (brain dysfunction causing confusion and memory loss), and repeated falls. Resident 35 was able to make needs known. Observation on 04/20/2026 at 1:31 PM showed Resident 35 had damaged lower teeth and no upper teeth. Review of the 5-day minimum data set assessment (MDS), dated [DATE], showed Resident 35 was edentulous (lacked all teeth). During an interview on 04/23/2026 at 2:43 PM, Staff E, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated Resident 35 had lower teeth and the 02/18/2026 5-day MDS was inaccurate and needed correction. During an interview on 04/24/2026 at 11:28 AM, Staff C, Regional Director of Quality Assurance, stated Resident 35's 02/28/2026 5-day MDS was inaccurate for dental status, and this did not meet expectations. Resident 3 Review of the EHR showed Resident 3 readmitted to the facility on [DATE] with diagnoses to include heart failure, peripheral vascular disease (blood vessels usually in the legs and feet became narrowed, blocked, or damaged), non-pressure chronic ulcer (a long-lasting, slow-healing open sore caused by poor circulation) of the right calf, and inflammatory disorders of scrotum (swelling, pain, and redness in the testicles or surrounding structures). Resident 3 was able to make needs known. During an interview on 04/20/2026 at 10:25 AM, Resident 3 stated they had a wound along their right leg and that it was wrapped and treated by staff. Review of the care plan showed/included that Resident 3 had a non-pressure chronic ulcer of the right calf/ankle initiated on 04/16/2025 and lymphedema (swelling, thickened, bumpy, reddened skin) to the scrotum (the pouch of skin hanging behind the penis that holds and protects the testicles) initiated on 04/27/2023. Review of the treatment administration records (TAR), dated March and April 2026, showed Resident 3 received treatment for their wounds/impaired skin located on their right lower extremity and to the scrotum for wound healing/treatment. Review of Resident 3's quarterly MDS dated [DATE] showed no skin issues documented. During an interview on 04/24/2026 at 10:50 AM, Staff H, Minimum Data Set Coordinator/Registered Nurse (MDSC/RN), stated the March and April 2026 TARs showed Resident 3 had wound treatments conducted for the right lower extremity and scrotum. Staff H stated Resident 3's quarterly MDS dated [DATE] was not coded for their impaired skin integrity and should have been. During an interview on 04/24/2026 at 11:02 AM, after reviewing Resident 3's EHR, Staff C, Regional Director of Quality Assurance, stated the quarterly MDS dated [DATE] was not coded accurately and needed to be modified to reflect Resident 3's skin status. Reference WAC 388-97-1000(1)(a)(b)(4)(a)

Based on interview and record review, the facility failed to ensure resident care plans were comprehensively completed to include resident participation for 2 of 17 sampled residents (Residents 12 and 50) when reviewed for care plans. This failure placed residents at risk of not having their input considered in their plan of care, lack of treatments, a decline in clinical condition, and a diminished quality of life. Findings included.Resident 12 Review of the electronic health record (EHR) showed Resident 12 was re-admitted to the facility on [DATE] with diagnoses of urinary tract infection (UTI) with extended-spectrum B-lactamases (ESBL, enzymes produced by bacteria that are resistant to widely used anti-infective medications), diabetes (high blood sugar), and foot infection. Review of a provider orders dated 04/19/2026 showed Resident 12 was ordered antibiotics (anti-infective) medications for their ESBL and foot infection. Review of the care plan on 04/23/2025 showed Resident 12 did not have focus, goal and interventions regarding their ESBL infection and precautions that should be used. During an interview on 04/24/2026 at 10:57 AM, Staff D, Resident Care Manager/Licensed Practical Nurse, stated Resident 12 should have their ESBL/UTI infection and precautions on the care plan. During an interview on 04/24/2026 at 12:49 PM, Staff C, Regional Director of Quality Assurance, stated Resident 12 's care plan did not meet expectations about ESBL. Resident 50 Review of the EHR showed that Resident 50 readmitted to the facility on [DATE] with diagnoses to include high blood pressure, depression, and anxiety disorder. Resident 50 was able to make needs known. During an interview on 04/20/2026 at 12:16 PM, Resident 50 stated it had been a while since they participated in a care conference. Resident 50 stated they did not remember going to a care conference recently. Review of the EHR showed the last care conference Resident 50 participated in was held on 11/26/2025. During an interview on 04/23/2026 at 10:16 AM, Staff J, Social Services Director (SSD), stated care conferences were to be conducted initially within the first seven to ten days upon admit and then quarterly thereafter and/or as needed, and were to be documented in the resident's EHR. Staff J state Resident 50 had their quarterly care conference held on 11/26/2025 and should have had another one held in February 2026 and that did not happen. During an interview on 04/23/2026 at 11:02 AM, Staff A, Administrator, stated Resident 50 had a care conference on 11/26/2025 and should have had another care conference conducted in February 2026. Staff A stated they were unable to locate an invite for another care conference in Resident 50's EHR and there should have been. Reference WAC-388-97-1020(2)(c)(d), -1020(2)(e)(f)(4)(b)(d)-(f)

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for hearing needs, obtained needed hearing devices, and hearing devices used were included in plans of care for 1 of 2 sampled residents (Resident 35) reviewed for communication/sensory. This failure placed the residents at risk of inability to hear, reduced ability to participate in activities, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 35 admitted to the facility on [DATE] with diagnoses to include spondylosis with myelopathy (compression of the bones in the spine), metabolic encephalopathy (brain dysfunction causing confusion and memory loss), and repeated falls. Resident 35 was able to make needs known. During an interview and observation on 04/20/2026 at 1:31 PM, Resident 35 stated they used hearing aids at home, and they had left them there before coming to the facility. Observation showed Resident 35 was able to hear questions if the speaker raised their voice to a soft yell. Review of the plan of care, initiated on 02/12/2026, showed no focus area related to hearing or the use of hearing aids for Resident 35. Review of a provider's encounter note, dated 02/20/2026 showed, Behavior: Cooperative throughout the interview, though noted significant hearing impairment requiring repeated questions and clarification and Speech: Normal volume and rhythm, though patient frequently requested repetition due to hearing difficulties. During an interview on 04/23/2026 at 12:07 PM, Staff E, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the facility ensured residents with hearing difficulties were provided with assistive devices by reaching out to the admitting hospital to see if their hearing devices were left there and then asking the provider to make a referral to a hearing specialist. Staff E stated Resident 35 was hard of hearing and required a raised voice to communicate. Staff E stated Resident 35 would benefit from a device to increase their hearing, they were unaware Resident 35 had hearing aids at their home, and the facility should have reached out to obtain Resident 35's hearing aids. During a follow-up interview on 04/23/2026 at 2:46 PM, Staff E, RCM/LPN, stated Resident 35's hearing difficulties and hearing aid use should have been included in the plan of care. During an interview on 04/24/2026 at 11:28 AM, Staff C, Regional Director of Quality Assurance, stated the facility should have attempted to obtain Resident 35's hearing aids, and, if unsuccessful, should have referred Resident 35 to a hearing specialist to obtain new hearing aids. Staff C stated hearing difficulties and hearing aid use should be included in the plan of care. Staff C stated Resident 35's lack of care for their hearing difficulties did not meet expectations. Reference WAC 388-97-1060(2)(a)

Based on observation, interview, and record review, the facility failed to provide complete nail care to 1 of 3 sampled residents (Resident 1) reviewed for activities of daily living (ADL). This failure placed dependent residents at risk for unmet care needs, poor hygiene and diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses of diabetes (too much sugar in the blood), polyneuropathy (nerve damage to multiple nerves) and vascular dementia (reduced or blocked blood flow to the brain, leading to cognitive decline and impaired daily functioning). Resident 1 required extensive staff assistance for ADLs. Observation on 04/20/2026 at 11:59 AM showed Resident 1 laid in bed with their feet in pressure relieving boots. Resident 1's toenails on both feet were long, curved and discolored. Review of the provider's orders showed an order for diabetic nail care (nail care performed by a medical professional) weekly on Wednesdays. Observation on 04/22/2026 at 3:00 PM and 04/23/2026 at 10:00 AM showed Resident 1's toenails remained long, curved and discolored. Review of the April MAR showed Staff F, Licensed Practical Nurse (LPN), signed off on diabetic nail care on 04/22/2026. During an interview on 04/23/2026 at 11:07 AM, Staff F, LPN, stated diabetic nail care included both toenails and fingernails. Staff F stated if residents had thick toenails they were referred to podiatry (foot doctor). Staff F stated the nail care completed for Resident 1 was filing of their fingernails, but their toenails were not included. Staff F did not provide an explanation why Resident 1's toenails were not completed but said they would complete them when they had time. During an interview on 04/23/2026 at 11:30 AM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the expectation was for nursing staff to complete resident's fingernails and toenails with weekly diabetic nail care. Staff D stated a referral should only be completed if there was an order from the provider or if resident's had thick toenails. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview and record review, the facility failed to develop and implement an individualized activity plan for 1 of 3 sampled residents (Residents 61) reviewed for activities. The failure to develop and implement an activity plan of care, that incorporated residents stated interests, hobbies and preferences, placed the residents at risk for boredom, isolation, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 61 admitted to the facility on [DATE] with diagnoses of stroke, vascular dementia (group of symptoms that affect cognition) and kidney failure. Resident 61 was non-verbal and unable to make needs known. Observations on 04/20/2026 at 9:45 AM, 04/21/2026 at 11:41 AM and 04/22/2026 at 1:46 PM showed Resident 61 laid in bed awake looking at the ceiling or the wall. There was a television in the room, but it was not observed on during any of the observations. Review of Resident 61's care plan (CP) showed the activity focus, goals and invention areas were incomplete. Review of the March and April 2026 activity flow sheet showed Resident 61 was not offered and did not participate in any individual or group activities. During an interview on 04/22/2026 at 2:02 PM, Staff G, Activity Director, reviewed the EHR and stated they should have contacted Resident 61's resident representative to assist with the activity care plan. Staff G stated based on the activity flow sheet Resident 61 had not been offered any independent or group activities and that did not meet expectations. Reference WAC 388-97-0940 (1)

Based on interview and record review, the facility failed to ensure residents on a fluid restriction were not provided too much fluid for 1 of 4 sampled residents (Resident 78) reviewed for nutrition. This failure placed residents at risk of fluid overload, a decreased clinical status, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 78 admitted to the facility on [DATE] with diagnoses to include acute hypoxemic respiratory failure (the lungs cannot adequately transfer oxygen to the blood), chronic systolic congestive heart failure (reduced ability for the heart to contract and pump blood effectively), and end-stage renal disease (kidney function has dropped to less than 10-15% of normal). Resident 78 was able to make needs known. Review of the care plan, initiated 01/12/2026, showed Resident 78 had a fluid restriction of 1800 milliliters (ml, unit of volume), with nursing providing 480 ml twice a day for 965 ml total and dietary providing 835 ml total per tray card. Review of a provider's order, dated 04/18/2026, showed Resident 78 had a fluid restriction of 1800 ml, with nursing providing 540 ml twice a day for 1080 ml total and dietary providing 240 ml per meal tray for 720 ml total. Review of the January, February, March, and April 2026 medication administration record (MAR) showed how much fluid nursing provided Resident 78 but did not include fluids provided by dietary and did not include the total amounts of fluids consumed. Review of the March 2026 MAR showed nursing provided Resident 78 the following fluids: 04/19/2026 1080 ml, 04/20/2026 1080 ml, and 04/21/2026 1080 ml. Review of a tray card, dated, 04/23/2026, showed Resident 78 was provided the following liquids by dietary: Breakfast: 8 ounces (oz) milk and 8 oz coffee, for a total of 16 oz (473 ml), Lunch: 6 oz lemonade (177 ml), Dinner: 6 oz lemonade (177 ml), and Daily total: 827 ml (107 ml more than provider's order). Review of a fluid tracking form, printed 04/23/2026, showed nursing aids provided Resident 78 the following fluids: 04/19/2026 958 ml, 04/20/2026 840 ml, and 04/21/2026 640 ml. Review of the March 2026 MAR, tray card, and fluid tracking form from 04/19/2026 through 04/21/2026 showed Resident 78 consumed the following total fluids: 04/19/2026 2,865 ml, 04/20/2026 2,747 ml, and 04/21/2026 2,547 ml (respectively, 1,065 ml, 947 ml, and 747 ml over fluid restriction). During an interview on 04/23/2026 at 11:54 AM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the facility would ensure a resident on a fluid restriction would not overconsume liquids by nurses recording provided fluid in the MAR, nursing aids recording fluids provided in the fluid tracking form, and dietary providing the amount of fluid on the tray card. Staff D stated staff should total the fluid recorded to ensure the residents on a fluid restriction were not provided too much fluid. During an interview on 04/23/2026 at 3:00 PM, Staff C, Regional Director of Quality Assurance, stated residents on a fluid restriction were only provided fluids by nursing and dietary and should not receive fluids from nursing aids. Staff C stated nursing provided the fluids specified in the MAR and dietary provided fluids specified by the tray card. Staff C stated Resident 78 was provided fluids over their fluid restriction on some days and this did not meet expectations. Reference WAC 388-97-1060(3)(i)

Based on interview and record review, the facility failed to ensure recommendations from mental health consultations were followed up on for 1 of 5 sampled residents (Resident 11) reviewed for unnecessary antipsychotic (mind altering) medications. This failure placed the residents at risk for increased side effects, increased behaviors and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include fracture of right arm, dementia (decline in cognitive function), diabetes (high blood sugar) and heart failure. Resident 11 was not able to communicate needs. Review of the significant change minimum data set assessment (MDS) dated [DATE] showed Resident 11 was receiving antipsychotic medication and had experienced a fall with injury. Review of a provider order dated 03/10/2026 showed Resident 11 was ordered Seroquel 25 mg (mind altering medication) twice a day for a diagnosis of vascular dementia without behaviors. Review of EHR showed Resident 11 was seen by psychiatry (branch of medicine focused on diagnosis, treatment and prevention of mental, emotional and behavioral disorders) on 03/06/2026 and showed Resident 11 had recommendations to perform Keppra (medication for seizures) levels and to consider a neurology consultation. Review of the EHR showed Resident 11 was seen by psychiatry on 03/11/2026 with recommendations to discontinue Celexa (a medication for depression) for potential side effects of mania. Review of the EHR showed Resident 11 did not have blood levels for Keppra, and recommendations to discontinue Celexa were not followed. Review of the EHR showed Resident 11 had a fall with injury on the 19th of March and was sent to the hospital. During an interview on 04/22/2026 at 2:03 PM, Staff E, Resident Crae Manager/Licensed Practical Nurse (RCM/LPN), stated typically the process was to read the recommendations from specialist such as psychiatry and follow up on them. Staff E stated Resident 11's psychiatric recommendations should have been completed. Reference WAC 388-97-1000(2)(f)(g)

Based on interview and record review, the facility failed to ensure care plans were completed to address all aspects of care for 1 of 5 sampled residents (Resident 9) reviewed for dementia care. Failure to develop and implement care plans to address residents' dementia diagnoses and behaviors, placed the residents at risk for unmet care needs, avoidable decline, and diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses of Alzheimer's Dementia (effects memory), chronic pain, and diabetes (too much sugar in the blood). Resident 9 was rarely/never understood, had a short-term memory problem, made poor decisions and required extensive assistance with activities of daily living. Review of the EHR showed Resident 9 had no Care Plan (CP) specifically for Focus, Goals or Interventions related to Alzheimer's Dementia. Review of the April 2026 MAR showed no behavior monitoring in place related to Alzheimer's Dementia. During an interview on 04/22/2026 at 2:57 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated they were unable to locate a CP for Resident 9 related to Dementia care. Staff D stated the expectation was that residents were to have an individualized CP that addressed all areas of care. Reference WAC 388-97-1040 (1)(a-c)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered per physician orders for 1 of 3 residents (Resident 1) reviewed for medication management. Resident 1, who was newly placed on an anticoagulant (blood thinning) medication to treat multiple blood clots, experienced harm when the facility failed to administer the medication resulting in pain, increased swelling, and required inpatient treatment at the hospital. This failure placed residents at risk for medical complications, unintended health consequences, and a diminished quality of life. Findings included .The facility's policy entitled Medication and Treatment Orders, approved 11/2025, stated that orders for medications and treatments will be consistent with principles of safe and effective order writing, and that orders for anticoagulants will be prescribed only with appropriate clinical and laboratory monitoring, and that the attending physician must periodically record in the progress notes the results of the laboratory monitoring and review for potential complications. Resident 1 was admitted to the facility on [DATE] with multiple diagnoses to include heart disease, congestive heart failure, end stage renal disease, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia (low blood levels of oxygen), and required the use of supplemental oxygen, and had a blood clot in one lower leg diagnosed in February 2026, and a blood clot in one of their upper arms diagnosed in March 2026. Review of Resident 1's electronic health record showed the resident discharged from the hospital to the facility on [DATE] with orders for Coumadin (also known as warfarin, an anticoagulant for prevention and treatment of blood clots) to be given daily for treatment of a deep vein thrombosis (DVT (blood clot)) in their upper arm as well as their lower leg. Review of Resident 1's electronic health record at the facility showed that on 03/26/2026 the resident's Coumadin was discontinued. Review of the resident's record did not include a reason the medication was discontinued, or the substitution of a different medication to treat the resident's blood clots. On 03/30/2026 the provider documented they saw the resident for evaluation of missed warfarin doses, noted the resident had not received warfarin for 5 days, and that nursing had reported increased right foot swelling. The provider noted a change in the resident's condition in that they had worsened breathing and leg swelling, and documented a concern for recurrent blood clot formation and complications given the missed doses of warfarin for 5 days and Resident 1's history of large DVT/PE (pulmonary embolus, a blood clot that affects the lungs). The provider ordered the resident to be sent to the hospital for reevaluation, reinitiation of intravenous (IV) anticoagulation medication and transition back to the warfarin. Review of 03/30/2026 hospital documentation showed the resident was sent to the hospital emergency room for evaluation of worsening left arm pain and swelling. Hospital pharmacy staff contacted the facility and found out Resident 1 did not receive the Coumadin (warfarin) since they last discharged from the hospital on [DATE]. The resident was evaluated and admitted for treatment of the blood clot and restarted on the warfarin as well as the IV anticoagulant medication. Review of facility investigation documentation initiated on 03/30/2026, documented the facility identified a system breakdown when the medication was discontinued and not resumed, and also noted that no doses of the anticoagulant medication had been given since the resident was readmitted . The investigation noted that after the medication was discontinued, no replacement or revised anticoagulation order was entered following the discontinuation, resulting in an interruption of therapy. The investigation also noted that there was no documented follow-up or clarification after the discontinuation to ensure anticoagulation was resumed despite the resident having an active diagnosis of DVT that required ongoing treatment. On 04/23/2026 at 12:18 PM, Staff B, a Registered Nurse and the interim Director of Nursing Services, stated that residents who were on coumadin were to be discussed during clinical morning meetings. When asked about new orders, and particularly orders anticoagulant therapy, Staff B said either the providers could put them in or the nurses would put them in and the resident care managers (RCMs) would cross-verify the orders. Staff B said their expectation is for residents on anticoagulant therapy to receive medications as ordered and for their treatment to be monitored and follow-up provided. On 04/23/2026 at 12:54 PM, Staff A, the facility Administrator, acknowledged the facility had identified a breakdown in communication regarding Resident 1's medication therapy. Refer to WAC 388-97-1060(3)(k)(iii).

Based on observation, interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a tube feeding [TF] directly into the stomach or small intestine) was administered in accordance with physician's orders and professional standards of practice for 4 of 4 residents (Resident 1, 2, 3, & 4), reviewed for TF management. Resident 1 experienced harm when they were found positioned in bed at a 10 degree angle while actively receiving TF in respiratory distress and had tube feeding formula coming from their mouth requiring transfer to the hospital where they were diagnosed with aspiration pneumonia (a lung infection that occurs when you inhale liquid into your lungs). Failure of the facility to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive, accurately record the amount of enteral formula and water flushes administered, label/date and discard tube feeding syringes, and position residents correctly in bed when receiving TF placed residents that require enteral nutrition at risk for inadequate nutrition, dehydration, infection and other adverse outcomes. Findings included . Review of the facility November 2018, Enteral Tube Feeding via Continuous Pump policy and procedure, showed directives to review the resident's care plan and provide for any special needs of the residents: Position the head of the bed at 30 degrees - 45 degrees (semi-Fowler's position [elevated head of bed]) for feeding, unless medically contraindicated, and on the formula label document initials, date and time the formula was hung/administered. <RESIDENT 1> According to the 11/25/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 was dependent on staff for bed mobility, had diagnoses included dysphagia (swallowing disorder) following a cerebral infarction (stroke), and received more than 51% of their nutrition by a feeding tube. Review of Resident 1's Care Plan (CP), revised 10/23/2024, showed the resident was dependent on one staff for repositioning and turning in bed, received no fluids or nutrition by mouth (NPO), had a GJ tube (a feeding tube that has a gastric tube that goes into the stomach and a jejunal tube that goes into the small intestine). The CP did not direct staff to elevate the head of bed during feedings. Review of the January 2025 Treatment Administration Record (TAR) showed 10/23/2024 enteral feeding orders to run Fibersource HN (TF formula with fiber) via pump at 95 milliter (ml)/hour (hr) x 18 hours (from 3:00 PM to 9:00 AM) for a total volume to be delivered of 1710 ml. Staff were directed to document ml administered via pump at 9:00 AM when pump turned off. Review of a Nursing Care Note, dated 01/06/2025 at 7:04 AM, showed Resident 1's roommate turned on their call light at 6:20 AM, an Aide answered and the roommate reported that Resident 1 was struggling breathing. The Aide called the nurse into the room where Resident 1 was found positioned in bed at around a 10 degree angle, in respiratory distress, and had a moderate amount of tube feeding coming from their mouth and on their chest. Resident 1 was put on oxygen, suctioned and 911 was called and resident was transported to the hospital. During an interview on 01/14/2025 at 1:20 PM, Resident 1's roommate stated that it didn't sound like Resident 1 could breath, they were congested with a lot of phlegm, so I called. Resident 1's roommate stated staff came right away. Review of the Nursing Home to Hospital Transfer Form, dated 01/06/2025, showed the reason for the transfer was listed as, Possible aspiration. Review of hospital records showed on 01/06/2025 Resident 1 had acute respiratory failure with hypoxia (insufficient oxygen) related to aspiration related tube feeds; Reported that they were given 500 ml more formula then they were supposed to get and had been coughing up what looks like tube feeds. Resident was admitted to the hospital on 01/06/2025 and treated for aspiration pneumonia and discharged on hospice on 01/09/2025. During an interview on 01/14/2025 at 3:20 PM, Staff D, Corporate Nurse, stated during the investigation staff stated Resident 1 had a tendency to slide down in bed and the staff would reposition them. Staff D stated review of the care plan showed no identified interventions to address Resident 1's sliding. During an interview on 01/13/2025 at 4:49 PM, Collateral Contact for Resident 1 stated Resident 1 was discharged from the hospital to hospice. According to the collateral contact they were told the facility staff reported to the hospital that they had done an overfeed, and had administered an extra 500 ml of formula. Further review of documentation on the January 2025 TAR showed staff documented 55 ml were administered in total (rather than the 1710 ml ordered) when turned off at 9:00 AM on 01/01/2025, 01/02/2025, 01/04/2025 and 01/05/2025. No amount was documented on 01/06/2025 as staff documented resident was out of the facility. Further review of the January 2025 TAR showed no documentation of the Gastric Residual Volume (GRV), the amount of liquid in Resident 1's stomach following administration of enteral feed daily from 01/01/2025-01/06/2025. During an interview on 01/14/2025 at 2:01 PM, Staff B, Director of Nursing, stated staff did not document the correct amount of formula infused and should have documented the GRV as well. Review of the facility incident investigation, dated 01/16/2025, showed that the primary nurse stated upon arrival to Resident 1's room, the resident was found at a 10 degree angle. During an interview on 01/17/2025 at 11:55 AM, Staff B stated that on 01/06/2025, at 4:30 AM, prior to the incident, staff stated the head of the bed was elevated and the resident was fine. Staff B stated none of the staff that were on duty will admit to seeing the head of the bed down at any point in time prior to the nurse finding the resident at 10 degrees (almost flat). <RESIDENT 2> According to the 11/12/2024 Quarterly MDS Resident 2 was assessed as alert, oriented and cognitively intact. Resident 2 was dependent on staff for eating and bed mobility. The resident received nutrition by a feeding tube and a mechanically altered diet. Review of Resident 2's CP showed directives revised 08/20/2024 for Certified Nursing Assistant (CNA)/Nursing to offer oral fluids from bedside every two hours from 10:00 AM to 8:00 PM or whenever Resident 2 is up in wheelchair, in addition to meals. The diet as ordered was revised 06/17/2024 as regular diet, pureed texture, IDDSI Extremely Thick (cannot be sucked through a straw) consistency (diet noted to be recreational). Review of the January 2025 TAR showed 10/14/2022 orders for tube feeding syringes to be thoroughly rinsed after each use and replace every 24 hours, which was documented as completed daily as ordered. In addition, a 11/01/2023 order directed staff to offer oral fluids every two hours six times a day, Resident 2 wanted fluids offered every two hours; ensure cold water or fluids at bedside at all times, which was also documented as done. On 01/14/2025 at 11:23 AM, Resident 2's room was observed with a posted sign notifying staff of enteral feeding and that the head of the bed should be elevated to 30-45 degrees at all times. In addition, aspiration precautions signage was posted for pureed diet and extremely thick fluids information. Two syringes were observed, one dated 01/05/2025 and the other dated 01/09/2025. Resident 2 was not in the room. On 01/17/2025 at 9:27 AM, Resident 2 was observed in bed. The head of the bed was elevated as directed, but the resident had slid down in the bed, and was laying flat in a fetal position. The TF was observed running at 75 ml/hr, the water flush at 55 ml every 4 hours, with a total of 1160 ml fed. Neither the feeding tube formula label or the water bag label were documented with initials, date and time the formula was hung/administered as directed in policy. On 01/17/2025 at 9:27 AM, three open syringes were observed in the room; one undated, one dated 01/02/2025, and another dated 01/12/2025. On 01/17/2025 at 9:40 AM, Staff E Licensed Practical Nurse (LPN), was observed to flush Resident 2's feeding tube using the undated syringe. On 01/17/2025 at 9:37 AM, Staff E, entered the room, stated to Resident 2, You're sliding all the way down here, and assisted the resident up in the bed. Staff E was observed to give Resident 2 a sip of thin water through a straw. On 01/17/2025 at 9:40 AM, the posted aspiration precautions sign was dated 10/23/2024, with directives that residents prescribed thick liquids will have no thin liquids or a bedside water pitcher. A plastic glass with thin water and a straw was observed at Resident 2's bedside. In an interview on 01/17/2025 at 9:40 AM, Resident 2 stated they slid down and ended up being down in the bed, which was not good for their back, and it hurt. Resident 2 stated yes they received a sip of thin liquids, just a sip, it was not constant, it was because they had a dry mouth. In an interview on 01/17/2025 at 9:57 AM, Staff E stated that Resident 2 slides down in the bed and staff reposition frequently. Staff E stated the night shift staff were supposed to discard the old syringes when they put new ones in the room. Staff E stated they gave Resident 2 a sip of water because the resident's mouth gets dry and they can't talk so they give them just a little bit of water. Staff E stated there were orders for water every two hours throughout the day. During an interview on 01/17/2025 at 10:29 AM, Staff C, Resident Care Manager, stated that Resident 2 wanted fluids cold, with water at bedside at all times. Staff C stated there was a physician's order to offer fluids every two hours. Staff C stated Resident 2 was on thickened liquids and although the resident was fed a pureed diet for lunch and dinner, there were not orders for thin liquids. During an interview on 01/17/2025 at 11:55 AM, Staff B stated the staff should raise the foot of Resident 2's bed so they do not slide down. Staff B stated they were not aware Resident 2 was receiving thin liquids. Staff B said prior to receiving thin liquids they would expect physician notification, resident education, and staff to follow a process, which did not appear to have occurred. <RESIDENT 3> According to the 01/03/2025 Quarterly MDS, Resident 3 was dependent on staff for bed mobility, and received more than 51% of their nutrition by a feeding tube. Review of the Tube Feeding CP, initiated 02/17/2022, showed Head of Bead (HOB) positioning to be elevated to at least 30 degrees when in bed and receiving tube feeding. Review of the January 2025 TAR showed a 10/15/2024 order to change feeding administration set with each new bottle/bag. Label and date one time a day, which was scheduled for midnight, and documented as done. On 01/14/2025 at 3:04 PM, no enteral feeding sign was observed posted directing staff to keep HOB elevated. In an interview on 01/14/2025 at 3:10 PM Staff E stated there should be a sign on the wall. On 01/17/2025 at 9:33 AM, Resident 3 was observed in bed with TF running and the head of the bed elevated. There was no sign posted directing staff to elevate the HOB during feedings. The open syringe was dated 01/14/2025. <RESIDENT 4> According to the 01/15/2025 Discharge return anticipated MDS Resident 4 was independent with bed mobility, received nutrition by a Mechanically altered, therapeutic diet and a feeding tube. Review of the Feeding Tube Care Plan initiated on 11/02/2023 listed the intervention Elevate HOB 30-40 degrees during and one hour after feeding. Review of the January 2025 TAR showed 01/06/2025 orders to change feeding administration set with each new bottle/bag and scheduled for 9:00 PM. Label and date one time a day. Staff documented this was completed each evening 01/06/2025 through 01/14/2025. On 01/15/2025 staff documented that it was not completed as the resident was hospitalized . Further review of the January TAR showed 01/08/2025 orders for the feeding tube formula to run for 11 hours, from 8:00 PM to 7:00 AM, with a total volume delivered of 1100 ml. Staff documented the TF was started on 01/14/2025 at 8:00 PM, and ended on 01/15/2025 at 7:00 AM after 1100 ml had been infused. On 01/14/2025 at 11:18 AM, a tube feeding pump, but no TF or water bags were observed in the resident's room. In an interview at that time, Resident 4 stated the received tube feedings from 8:00 PM until 6:00 AM. On 01/17/2025 at 9:34 AM, Resident 4 was not in the room. There was a bag of TF and a bag of water both dated as hung 01/14/2025 at 8:00 PM. Resident 4's roommate stated at that time that Resident 4 went out for dialysis and didn't come back. There was a sign with posted aspiration precautions, but no enteral feeding sign posted directing staff to elevate the HOB during feedings. During an interview on 01/17/2025 at 10:03 AM, when asked how staff knew Resident 4 was on TF and what to do, Staff C stated the directives were in the care plan. Staff C stated the HOB should be elevated when the TF was running. Staff C stated the facility did not post signs to elevate the HOB. Reference WAC 388-97-1060 (3)(f)

Based on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 5 sample residents (Resident 1, 2 & 3) reviewed for two person assists with transfers. Resident 1 experienced harm when they received care without two staff assistance which resulted in a fall, hospitalization and diagnosis of a traumatic brain injury (TBI). This failure placed residents at risk for falls, injury and a diminished quality of life. Findings included . <Resident 1> According to the 07/22/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 1 required substantial to maximal assistance with standing, transfers, toileting hygiene, and was dependent for lower body dressing. Review of the Self-Care Performance Deficit Care Plan (CP), dated 07/16/2024, showed Resident 1 required extensive assistance of two staff to dress, for toileting and with transfers. Review of the Nursing Assistant documentation, dated 09/05/2024 through 09/24/2024, showed only one person assistance was provided on one to two shifts daily with toileting hygiene on 20 of 20 days, with toileting on 17 of 20 days, and with bed to chair transfers on 18 of 20 days. Review of a Nursing Care Note, dated 09/24/2024 at 7:56 PM, showed Resident 1 fell on to the floor and sustained a large laceration to their right eyebrow. 911 was called for transport to the Emergency Department. Review of the Fall Scene Investigation Report, dated 09/24/2024, showed Resident 1 was receiving care from Staff C, Certified Nursing Assistant (CNA) when they fell . There were no other staff present at the time of the fall. Resident 1 was being transferred by one staff. Review of the Incident Report, dated 09/24/2024, showed Staff C was transferring Resident 1 from their wheelchair into bed. Resident 1 stood up and as Staff C pulled up Resident 1's pants. Resident 1 slipped from Staff C's hold, fell forward and hit their head on the floor. The resident was assessed with a 3.5 centimeter (cm) laceration (cut or tear) to their right eyebrow. According to the facility investigation Staff C was interviewed on 09/27/2024 and prior to the incident, Staff C did not know Resident 1 required two person extensive assist with Activities of Daily Living (ADLs). During an interview on 10/04/2024 at 10:28 AM, Staff B, Interim Director of Nursing, stated Staff C should have but did not get assistance of another staff to provide care to Resident 1. Review of hospital records showed Resident 1 was in the hospital from 09/24/2024 until 09/27/2024, where the resident was diagnosed with a TBI as medical imaging showed subdural hematoma (SDH - blood pools between the brain and the skull) on the left and right side of the resident's head. Additionally, Resident 1 had bruising and swelling to their right eyelid and a 6 cm laceration over their right brow which required stitches. Review of the Nursing Assistant documentation, dated 09/27/2024 through 10/04/2024, after return from the hospital, showed only one person assist was provided on one to two shifts daily with toileting hygiene on 7 of 8 days, with toileting on 2 of 8 days, and with bed to chair transfers on 4 of 8 days. On 10/04/2024 at 12:30 PM, Resident 1 was observed up in a wheelchair, eating lunch. Resident 1 was unable to answer questions asked regarding the incident. During an interview on 10/04/2024 at 1:07 PM, Staff B, stated a peace sign posted on a resident's doorway indicated the resident required two person assist with transfers and/or ADLs. Staff B stated Resident 1 required two person assist for transfers, for care, and cleaning and should have a peace sign posted. On 10/04/2024 at 11:02 AM, 12:30 PM, 1:05 PM Resident 1's room was observed without a peace sign. <Resident 2> According to the 08/15/2024 Quarterly MDS Resident 2 was assessed as dependent on staff for toileting hygiene and required substantial/maximal assistance for chair to bed transfers. Review of the 02/26/2024 Self-Care Performance Deficit CP and Kardex showed Resident 2 required two person assist for stand pivot transfer with gait belt. On 10/04/2024 at 11:02 AM, Resident 2's room was observed with a peace sign posted. At 11:14 AM, Resident 2 was observed in bed. At 11:34 AM, Resident 2 was observed seated up in a wheelchair. In an interview at that time, Resident 2 stated one staff assisted them up. On 10/02/2024 at 11:36 AM, Staff D, CNA, stated that they were assisted by Staff E, CNA, to get Resident 2 out of bed. Review of the Nursing Assistant documentation showed Staff D documented transferring Resident 2 with one person assist on 10/03/2024, but two person assist on 10/04/2024. On 10/02/2024 at 11:41 AM, Staff E stated Staff D changed Resident 2 and then summoned Staff E who assisted Staff D to transfer Resident 2 into the wheelchair. Staff E stated the Kardex stated Resident 2 was a one person stand pivot transfer, but they tried to do two person assist to be safe. Further review of the Nursing Assistant documentation, dated 09/05/2024 through 10/04/2024, showed only one person assist was provided with bed to chair transfers on one to two shifts daily on 17 of 30 dates. <Resident 3> Resident 3 admitted to the facility on [DATE]. Review of the 10/02/2024 Self-Care Performance Deficit CP and Kardex showed Resident 3 required two person assist for bed mobility and transfers. Review of Nursing Care Notes, dated 10/02/2024 at 9:36 PM and 10/04/2024 at 1:16 AM, showed nursing staff documented Resident 3 needed one person assist with full ADLs, transfers and toileting. Review of Nursing Assistant documentation, dated 10/03/2024, showed only one staff person assisted with transfers. On 10/04/2024 at 11:02 AM, Resident 3's room was observed with a peace sign posted. During an interview on 10/04/2024 at 11:17 AM, Resident 3 stated they thought that two staff should assist them with mobility, but depending on the shift, sometimes there was only one assistant. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 5 residents (Resident 1, 2 and 3) reviewed for two person assists with transfers. Resident 1 experienced harm when they received care while in bed without two staff assistance which resulted in a fall and shoulder fracture. This failure placed residents at risk for falls, injury and and diminished quality of life. Findings included . <Resident 1> According to the 07/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 was alert and oriented, was dependent on staff to roll left and right in bed, dependent on staff for a chair to bed transfers and had one non injury fall since the previous MDS. Review of the Activities of Daily Living (ADL) Care Plan (CP), showed Resident 1 was totally dependent on staff for repositioning and turning in bed, two person maximum assist (initiated 12/13/2023). Review of the risk of falls CP revised showed Resident 1 had a non injury fall from the bed on 12/24/2023 and was a two person assist for cares in bed to prevent rolling out (initiated 01/02/2024). Review of the Nursing Assistant documentation for support provided to assist Resident 1 to roll left and right showed only one person assist was provided on one to two shifts daily from 06/16/2024 through 07/04/2024, and on 07/06/2024. Review of the facility 07/06/2024 incident investigation showed that at 11:15 AM the facility was notified of an incident involving Resident 1 and Staff D, Nursing Assistant Certified (NAC). Staff D was providing incontinence care alone. Resident 1 turned toward Staff D in an attempt to assist the staff providing the care, however rolled over too far and slid down the bed between the frame and Staff D. Staff D attempted to prevent Resident 1 from rolling off the bed by grabbing Resident 1's right arm, however could not stop the rolling and lowered Resident 1 to the floor. Review of the Emergency Department After Visit Summary dated 07/06/2024 showed Resident 1 was diagnosed with a closed fracture of the proximal end of the right humerous (the largest bone of the upper extremity, the upper arm bone). Review of progress notes dated 07/08/2024 showed Resident 1 had a sling on with bruises and swollen shoulder. Resident 1 was medicated for pain with some effectiveness. During an interview on 07/10/2024 at 11:33 AM, Resident 1 stated staff were changing me and I had to roll to the side and I rolled out of bed. They caught me with my arm so I got a fractured shoulder. During an interview on 07/10/2024 at 11:47 PM, Staff C, Interim Director of Nursing, stated that Staff D had been provided one on one training to read and follow the plan of care, and completed a skills competency prior to returning to work on the floor. During an interview on 07/19/2024 at 12:15 PM, Staff D stated prior to the incident, they were giving care while waiting for someone to assist them and Resident 1 rolled towards them and slipped out of bed. Staff D stated they instinctively grabbed Resident 1's arm to try to keep them from falling and then lowered Resident 1 to the floor. On 07/19/2024 at 12:21 PM Staff D and Staff E, NAC, were observed to provide care to Resident 1. Resident 1 was observed to lift their pelvis up and Staff D placed a clean incontinence product underneath the resident. When asked why they had rolled the resident during the incident, Staff D stated it was how they changed Resident 1. Resident 1 stated, I don't do that anymore. Staff E stated to Resident 1, I didn't know you could lift your hips. While applying a splint, Staff E started to roll Resident 1 who stated, I can't roll and I can't. Staff D stated Resident 1 gets very nervous now. Staff E reassured Resident 1 as they carefully turned the resident towards staff D. Resident 1 yelled out, Ouch, my shoulder ouch, it hurts real bad! The staff waited and let the resident take a break before transferring the resident into a wheelchair using a mechanical lift. The resident's bed was an alternating air mattress, which the staff did not adjust prior to moving or transferring the resident. During an interview on 07/19/2024 at 1:13 PM, Staff B, Director of Nursing, stated the level of assistance a resident requires was determined by assessments by the admitting nurse or by therapy. Staff B stated they expected the Nursing Assistant to check the care plan at the beginning of the shift, prior to providing care. Staff B stated prior to providing care, the staff were expected to set air mattresses to firm or transfer depending on the mattress. <Resident 2> According to the 05/24/2024 Significant Change MDS Resident 2 was assessed with moderate cognitive impairment, required substantial assistance to roll left and right, was dependent on staff for chair to bed transfers and had two non injury falls since the previous MDS. Review of the 02/26/2024 ADL CP showed Resident 2 required two person moderate assist for transfers. Review of the Nursing Assistant documentation for support provided to assist Resident 2 in a chair/bed to chair transfer, showed only one person assist was provided on one to two shifts on 06/25/2024, 06/26/024, 06/29/2024 through 07/03/2024, 07/05/2024 through 07/09/2024, 07/11/2024 through 07/19/2024. On 07/19/2024 at 10:47 AM Resident 2 was observed asleep in bed. On 07/19/2024 at 12:41 PM, Resident 2 was observed up in a wheelchair in the dining room eating lunch. On 07/19/2024 at 12:41 PM, Resident 2 did not know who had assisted them out of bed. When asked how many staff assisted them, Resident 2 replied, One as far as I know. On 07/19/2024 at 12:52 PM, Staff F, Nursing Assistant, stated they had assisted Resident 2 up for lunch, by themselves. Staff F stated they were not aware that Resident 2 was a two person assist for transfers. <Resident 3> According to the 04/17/2024 Quarterly MDS, Resident 3 was assessed as dependent on staff for rolling left and right. Review of the 02/08/2023 high risk for falls CP showed Resident 3 was a two person assist for cares in bed to prevent rolling out. The 04/22/2023 ADL CP showed the resident required a mechanical lift for transfers by two staff. Review of the Nursing Assistant documentation for support provided to assist Resident 3 to roll left and right showed only one person assist was provided on one to two shifts daily from 06/16/2024 through 07/02/2024, and on 07/04/2024 through 07/09/2024. On 07/19/2024 at 11:11 AM, Resident 3 was observed in bed with one Nursing Assistant present assisting the resident to wash their face and hands. During an interview Resident 3 stated that staff used two people to assist them with transfers using a mechanical lift, but only used one person, sometimes two, when they assisted the resident to change their briefs. REFERENCE: WAC 388-97-1060(3)(g).

Based on interview and record review the facility nursing staff failed to complete physical assessments, obtain vital signs and delayed carrying out physician orders. This failure affected 3 of 4 Residents reviewed for acute change of condition and identification [MEDICAL CONDITION]. This constituted actual harm to Resident # 1 and potentially contributed to avoidable hospitalization s for Resident # 2 and #3. Findings include: Sepsis is a life threatening complication of infection.[MEDICAL CONDITION] occurs when the body releases chemicals into the bloodstream in response to the infection resulting in damage to the organs. According to the Center for Disease [MEDICAL CONDITION] can be preventable when symptoms are known or identified early. Interviews were conducted with facility Staff, C, D, E, F, &H, Licensed Nurses, on 10/24/18 between 1:39 PM and 1:54 PM, and on 10/25/18 between 1:30 PM and 2:04 PM. During the interviews five out of seven nurses who provided direct care reported they did not have training [MEDICAL CONDITION]. RESIDENT #1 Resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/18/18 at 2:05 PM Resident #1 was found unresponsive. Resident was transferred to the hospital at 2:45 PM. Resident #1 was diagnosed with [REDACTED]. According to interviews with Staff A, Administrator and Staff B, Nurse Investigator on 10/24/18 at 11:23 AM, and record review there was a pattern of missed care and inaction by facility nursing staff. Between 10/01/18 and 10/18/18 Resident #1's had upper respiratory symptoms which became progressively worse. On 10/11/18 a blood sample was collected. On 10/15/18 the results became available and showed a high white blood cell count of 12.5 (normal range 4.0 -11.5). High levels are indicative of [MEDICAL CONDITION] process or the body trying to fight an infection. According to the progress notes, on 10/15/18 nursing staff was aware of abnormal whiteblood cell count and there was an order to repeat complete blood count (CBC) on 10/16/18. The blood draw did not occur on 10/16/18. According to facility's incident investigation, on 10/15/18 nursing staff placed Resident #1 on physician communication tool (cluster board) for ongoing cough and request to obtain a chest x-ray. There was no follow up on the communication until 10/17/18 when the physician approved requested chest x-ray. The order was not carried out until 10/18/18. Between 10/15/18 and 10/18/18 Resident #1 had an abnormal white blood cell count and a pending chest x-rays, the facility did not have evidence that nursing staff conducted physical assessment on each shift including auscultating lung sounds and documenting full set of vital signs (temperature, blood pressure, heart rate, oxygen saturation, & respiratory rate). A Medication Administration Record [REDACTED]. A thorough physical assessment would have allowed nursing staff to gather additional objective data for comparison and analysis of resident's condition. During acute change of condition on 10/18/18 at 11:55 AM Staff D, Licensed Nurse was informed of critically high white blood cells. A physician ordered IV (itntravenous) antibiotic and IV fluid at 12:45 PM. The antibiotic and IV fluids were not administered as nursing staff failed to obtain intravenous access. The resident coded approximately one hour and fifty minutes later. On 10/24/18 at 11:57 AM ,during an interview, Staff A and B explained the facility investigation identified opportunity for improvement related to obtaining vital signs, alert charting of nursing assessments and communication breakdown between nursing staff and physician(s). Staff A reported that clinical system(s) are being revised and training was completed with nurses. RESIDENT#2 Resident #2 admitted on [DATE] for rehabilitation following hospitalization for heart failure. According to a Nurse Practitioner note on 8/10/18 2:45 PM, Resident #2 was confused and a stat (urgent) laboratory tests were ordered (CBC, BMP, TSH, B12 & urine test) the same day. Review of NN nurses notes showed no evidence of a thorough physical assessment including a full set of vital signs between 08/10/18 and 08/12/18 when resident was exhibiting changes in mentation and pending stat lab results. NN on 8/12/18 at 11:25 AM showed therapy staff notified nursing that Resident #2 had difficulty in speaking in full sentences and was confused. The nursing staff did not assess the patient and instead of consulting with a physician left a voice mail. On 8/12/18 at 12:20 PM Resident #2 was sent to the hospital per family's request. Staff A on 10/25 at 2:38 PM was asked to review records and locate laboratory results ordered on [DATE]. Staff A was unable to find lab results. RESIDENT #3 Resident #3 was not thoroughly assessed/monitored for potential development [MEDICAL CONDITION] when she had an actual risk of dehydration and ongoing infectious process. Additionally, a complete set of vital signs was not documented as complete. On 9/23/18 a physician progress notes [REDACTED]. Resident had infection to bilateral great toes and a gangrene on both heels. The resident had decreased intake and worsening kidney function potentially related to dehydration. This finding indicates resident had a change of condition and was at risk for [MEDICAL CONDITION] given the presence of infection. Nursing notes reviewed between 9/23/18-9/26/18 did not evidence of nursing assessment specific to actual dehydration risk. On 09/26/18 and on 09/27/18 Resident's temperature was documented once according to the Vitals Summary report. On 09/27/18 at 2:29 PM nursing notes documented Resident #1 was sent out to the hospital for [MEDICAL CONDITION] and pneumonia. Facility's Alert Charting Protocol revised (MONTH) 2011 directed licensed nurses to place resident on alert and enter reason/problem that resident is on alert and document assessment and interventions every shift for 72 hours or until stable.

Based on observation, interview, and record review the facility failed to ensure staff provided the correct diet to 1 of 5 sampled residents (#1) to prevent avoidable choking hazards. Staff gave the resident a regular diet when a pureed diet was ordered by the medical provider. This failure resulted in the resident choking on the food. The resident died immediately after the choking episode. Findings include: Record review for Resident #1 revealed he admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (an assessment tool) dated [DATE] revealed the resident was on a mechanically altered diet and had not had any swallowing or choking during meals or when swallowing medications or any complaints of difficulty or pain with swallowing. Record review of progress notes dated [DATE] at 8:20 p.m. revealed Resident #1 was observed pocketing food in his mouth and started coughing at dinner. Licensed nurse intervened and removed food from resident's mouth. Resident was having difficulty eating solid food and a message was left to request the medical provider order a swallow evaluation. Review of medical provider orders revealed Regular diet, pureed texture, nectar thick consistency fluids was ordered on [DATE] at 11:50 a.m. Speech therapy to evaluate and treat was also ordered. Record review of Speech Therapy Evaluation and Plan of Treatment completed [DATE] revealed Resident # 1 had moderate dysphagia (difficulty swallowing as a symptom of disease) impaired by self-monitoring abilities, swallow delay, and poor bolus manipulations which placed him at increased risk for aspiration and aspiration pneumonia. Recommendations were for resident to continue on a Puree texture diet and nectar thick liquids. Further recommendations were to adhere to strict aspiration precautions with 1:1 staff supervision at meal times at the supervised table in the dining hall. Review of progress note dated [DATE] at 1:25 p.m., revealed Resident #1 continued on a pureed, nectar thick diet and no adverse side effects were noted. Record review of progress note dated [DATE] at 7:46 p.m. revealed Resident #1 was observed in respiratory distress in the dining room. Back blows and abdominal thrusts were initiated. Coughing continued with erratic breathing. Food particles were noted in resident's mouth and he was suctioned to clear the airway. Resident stopped breathing, 911 called and CPR initiated with resident on the floor. Emergency medical services (EMS) arrived and took over. During an interview on [DATE] at 11:00 a.m., Staff B, Director of Nursing (DON), stated Resident # 1 had a choking episode on Wednesday, [DATE] and been downgraded to a pureed diet. A speech evaluation had also been ordered. When the speech evaluation was completed the pureed diet had been kept in place. On Friday, [DATE] at dinner time, the resident had a choking episode, staff intervened with Heimlich maneuver, suctioning, then CPR when the resident became unresponsive and no pulse. 911 was called and EMS took over when they arrived. CPR was stopped by EMS when staff reported the resident had a no code, do not resuscitate status (DNR), and the resident was pronounced dead. Staff B, DON, stated it was immediately discovered that the food on the resident's tray was not what the diet slip indicated the resident should have or what was ordered. The resident had been given Jambalaya, with chunks of sausage in it. The dietary aide had looked at the dietary slip wrong and put regular food on the tray. Next an unknown aide gave the tray to Resident #1. During an interview on [DATE] at 11:10 a.m., Staff A, administrator (ADM), stated the coroner was notified at the time of death and responded to the facility. The coroner gave a verbal report that the resident died of natural causes. Staff A, ADM, further stated all six aides that were in the dining room at the time were suspended as no one admitted to giving the tray to the resident. Staff A, ADM, stated a new procedure for tray service was implemented at the next meal. The dietary manager validated trays when placed on a cart in the kitchen for correct diet and a nurse checked each tray before it could be given to a resident. All facility staff were being educated on correct diets and confirming diets given to each resident. During an interview on [DATE] at 11:45 a.m., Staff C, dietary manager (DM), stated the process for new diet orders was when the order slip came to the kitchen the chart was checked to confirm the diet and a diet slip was made. Tray line staff went through the diet slips, verified any changes and special diets were to be highlighted on the diet slip. The diet slip was put on the tray and the next dietary aide called the diet to the cook. The cook put the food on the plate and gave the food to the dietary aide. The dietary aide then should verify the correct food before a lid was put on the plate and tray placed on cart. Staff C, DM, stated the diet slip for Resident #1 was printed Regular, pureed and pureed should have been highlighted to draw attention to the staff but it was not. Observation on [DATE] at 11:50 a.m. of lunch tray line in the kitchen revealed diets placed on trays matched the diet on each diet slip. Observation on [DATE] at 12:05 p.m., revealed beverages being served to residents in the main dining room by multiple staff. During an interview on [DATE] at 12:06 p.m., Staff E, activity assistant (AA), stated there was a list of diets on the beverage cart to show what diets residents were on. If she had any questions about a diet she would check with Staff C, DM, or the speech therapist across the hall. Observation on [DATE] at 12:20 p.m., revealed tray carts delivered to the main dining room. As each aide removed a tray from the cart, Staff B, DON, lifted the lid on each plate on each tray and looked at the diet slip. The aide then delivered the tray to each resident. Multiple observations on [DATE] of meal trays during lunch confirmed each plate of food, side dishes, and beverages matched the diet listed on the diet slip. During an interview on [DATE] at 1:00 p.m., Staff D, licensed practical nurse (LPN), stated she was in her office on Friday evening when an aide come to report a resident had choked in the dining room. When Staff D, LPN, arrived to the dining room, paramedics were there and the resident was on the floor. The resident had already passed away. Staff D, LPN, stated the coroner, law enforcement, physician, guardian, state hotline, ADM, and DON were notified. All of the staff were still in the dining room and interviews began right away. Staff D, LPN, stated the food on Resident #1's tray was a regular diet with pieces of sausage in the main dish, and the diet slip said pureed. Staff D, LPN, was not aware of any issues with residents getting wrong diets previously. During an interview on [DATE] at 2:25 p.m., Staff F, speech therapist (ST), stated the speech therapists work closely with the dietary manager and nursing staff to communicate resident specific needs and educate staff. She further stated it had generally not been a problem for residents to get a wrong meal. If a problem had been seen it would be communicated directly to the Dietary Manager. During an interview on [DATE] at 2:23 p.m., Staff G, speech therapist (ST), stated an evaluation of Resident#1's swallowing had been completed on [DATE]. The resident required 1:1 supervision with meals and a mechanical soft finger food diet was downgraded to puree with nectar thick fluids. He had confirmed the diet was communicated to the kitchen and the resident received the correct diet that day. Record review of facility investigation dated [DATE] and revised [DATE] revealed Resident # 1 had an unexpected death during dinner service on [DATE] at 5:20 p.m. The meal tray and meal ticket for the resident confirmed he had Received a regular tray despite calling for a puree tray. Dietary Services staff confirmed the meal ticket was misread and did not see the ticket called for a puree meal. During interview on [DATE] at 11:00 a.m., Staff B, DON, stated there had been a system breakdown and not the fault of one individual. The system failure had been corrected with education of staff and monitoring of trays. During interview on [DATE] at 10:30 a.m., Staff A, ADM, stated the facility had not yet received a death certificate from the coroner and she would check on it. Record review of Certificate of Death dated [DATE] revealed Resident #1 died on [DATE] and cause of death was Parkinson's disease and condition contributing to death was [DIAGNOSES REDACTED]. Failure to provide the resident with ordered diet resulted in a choking hazard and an avoidable accident. Reference WAC [DATE] (3)(g)

Based on observation, interview and record review, the facility failed to ensure 1 of 3 Sampled Residents (#18) was free from restraints. The facility placed Resident #18 in a tilt in space wheelchair (a wheelchair that reclines back) with an alarming seatbelt which prevented rising and limited freedom of movement. This failure resulted in Resident #18 being unnecessarily restrained with subsequent psychological harm, decline in quality of life and potential decline in range of motion and physical mobility. Findings include; RESIDENT #18 Resident #18 had [DIAGNOSES REDACTED]. Resident #18 had falls on 6/28/16 and 8/12/16. Resident #18's prior life habits and a way of making a living included high level of physical activity on a daily basis. Observations on 8/22/16 around 12:00 p.m., revealed Resident #18 in a tilt in space wheelchair. Resident #18 rocked back and forth and attempted to move his body forward in the wheelchair. Resident #18 was attached to a wheelchair by a seatbelt. The wheelchair was tilted back at approximately 20 degrees. Resident #18 was asked about the seat belt and he placed his hands on the belt and tugged at it. The seatbelt did not release. Resident #18 appeared frustrated as he rocked back and forth in the wheelchair. On 8/22/16 at 2:15 p.m. Staff BB was asked to have Resident #18 attempt to self remove the seatbelt. Resident #18 was unable to follow instructions and did not demonstrate ability to self release the seatbelt over his waist. Staff BB stated if the resident tried to remove the seatbelt an alarm would sound. Staff BB said Resident #18 could not remove the seatbelt because of his cognitive impairment. When Staff BB was asked why Resident #18 had the seatbelt she stated to prevent him from getting out of the chair . so he does not fall. On 8/26/16 at 12:00 p.m., Resident #18 appeared with eyes closed while he sat in the wheelchair. A family member adjusted Resident #18's seatbelt when it alarmed and made loud noises startling the resident. Resident #18 jerked his body and woke up after the seatbelt alarmed. During an interview with Staff S on 8/22/16 around 2:27 p.m. related to Resident #18 using a seatbelt. Staff S stated Resident had the seatbelt it since February 2016. Record review with Staff S at the same time found Resident #18 did not have a quarterly seatbelt re-assessment in the medical record. The facility policy required quarterly reassessments of devices including alarmed seatbelts. The facility did not re-assess Resident #18 for using a seatbelt as a restraint and did not review risks versus benefits of the device use. During the same interview with Staff BB it was confirmed Resident #18 was not evaluated or participated in a walking program. A family member stated on 8/23/16 around 10:05 a.m., she visited Resident#18 daily and felt he would benefit from walking. The family member indicated sometimes she would stand him up, and with her support, Resident #18 walked from the doorway to the window, which was at least 10 feet. The family member indicated the resident's strength and ability to ambulate had decreased since initiation of the alarming seatbelt in a wheelchair. Record review of the annual Minimum Data Set (MDS- comprehensive assessment tool) dated 5/24/16, revealed Resident #18 was capable of ambulating in the room with supervision and cueing. Care staff did not ambulate Resident #18 and he was not placed on a restorative walking program, although he demonstrated ability to ambulate according to facility assessment and family interview. Not trying alternative interventions initially, and periodically, and not having a medical reason for use of an alarming seatbelt and a tilt in space wheelchair, constituted the devise as a restraint. The device(s) prevented Resident #18 from rising and voluntarily getting out of the chair constituting mental harm as evidenced by agitation and frustration in accordance with reasonable person concept. During the 8/26/16 interview with the Director of Nursing Services (DBS) between 2:40 p.m. and 4:00 p.m., the DNS was unable to verbalize medical justification for use of a seatbelt alarm for Resident #18. The DNS was unable to provide an answer as to why alternatives had not been attempted, in order to decrease fall risk.

Based on observation, interview and record review, the facility failed to provide care and services specific to assessing, monitoring, evaluating change in condition, and revising interventions in a time consistent with residents' changed needs, for 4 of 7 Sampled Residents (#s 10, 19, 21 & 4) reviewed for changes in medical condition and monitoring after falls. These failures resulted in clinical compromise and subsequent decline for Resident #10, and placed residents at risk for harm related to delay in treatment. Findings include; RESIDENT #10 Resident #10 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan initiated on [DATE] indicated the goal was for the resident to discharge to a retirement center. Resident #10 sustained 10 falls between [DATE] and [DATE] and died on [DATE]. On three occasions the resident hit his head. Therapy notes in [DATE] indicated the resident walked with a walker. Nursing notes in [DATE] indicated the resident self propelled in a wheelchair. Closed record review found Resident #10 showed signs of change in condition as documented repeatedly in the nursing notes on [DATE], [DATE], and [DATE]. On [DATE] nursing noted garbled speech. This finding by a nurse occurred after a number of falls. In interview on [DATE] at 1:07 p.m., Staff W said she did .not know about this. According to the nursing assessment documented in the progress notes on [DATE], Resident #10 was identified with onset of left neglect which is a neurological symptom and often occurs after brain damage. An interview was completed on [DATE] at 1:12 p.m. with nurse CC who documented this assessment to clarify the meaning of the documentation and whether this was a new symptom and a change for this resident. Staff CC confirmed it was a new symptom for Resident #10. When asked what actions were taken after identifying this change, Staff CC said I mentioned this in the medicare meeting that morning. There was no further nursing assessment of ongoing monitoring documented, specific to onset of left sided neglect after [DATE]. Therapy notes between [DATE] and [DATE] indicated the resident was able to maintain his trunk (upper body) upright as evidenced by walking 250 feet on [DATE]. On [DATE], nursing notes documented Resident #10 had poor trunk control and was too sleepy. According to assessment documentation in the facility investigation, two staff sat him on the bed and he fell to the left, striking his head on the foot board. On [DATE], Resident #10 fell at 12:30 p.m., according to facility investigation. The [DATE] Medication Administration Record [REDACTED]. Record review did not find evidence the resident was assessed for those changes that were common. On [DATE] between 4:00 p.m. and 6 p.m., the DNS said orthostatic blood pressures were not done after this fall. Nursing notes were reviewed between [DATE] and [DATE]. On [DATE] nursing documented therapy stated they have not been able to work with him yesterday and today related to being too sleepy.' On [DATE] resident refused breakfast and lunch . and had 3 loose stools and remained in bed all shift. On [DATE] resident was confused, very resistive to care, combative, had poor fluid intake and voided small amount of urine, had anxiety episodes, rapid breathing, red face, and refused medications. Interview with Staff W on [DATE] at 12:04 p.m. revealed, Resident #10 was placed on comfort measures on [DATE]. Staff W provided a document at this time showing that Resident #10 was prescribed [MEDICATION NAME] and [MEDICATION NAME] which are typically prescribed for people going through a dying process to decrease suffering. Staff W said there was no official physician order for comfort measures. Staff W was unable to locate a care plan specific to initiating comfort care or end of life measures. Changes of condition were not ruled out prior to placing Resident #10 on comfort care. Interview with DNS on [DATE] around 4:00 p.m. regarding above timeline of events specific to Resident #10's falls and change of condition was completed. The DNS was unable to explain what actions were done to rule out changes of condition after each fall. RESIDENT #21 Review of a facility policy entitled Assessing Falls and Their Causes dated [DATE], revealed if a resident is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities. Review of the facility incident investigation dated [DATE] revealed, Resident #21 had been in an altercation with another resident and was found sitting on the floor crying. The investigation indicated the altercation was not witnessed by staff and the process of Resident #21 ending up on the floor was not witnessed. During an interview on [DATE] at 12:40 p.m., Staff W reported staff completed neurological assessments on residents when the residents were found on the floor due to most of the resident population were not able to tell staff if they fell or if they had hit their heads during the fall. Staff W confirmed, neurological assessments were used to help identify injuries that effect neurological function. Review of Resident #21's medical record revealed staff initiated neurological assessments on [DATE] after the altercation. Review of the Neurological Flow Sheet revealed instructions to staff Neuro checks to be completed: q (every) 15 min (minutes) x 4; q 30 min x 4; q 1 hr (hour) x 4; q4hr x 4; q8hr x 6. Review of Resident #21's neurological flow sheet indicated the first four 15 minute checks were documented. The fifth assessment, 1 hour after the potential injury, did not include vital signs. The following four assessments, from 2:35 p.m. until 4:30 p.m., did not include assessments and had documentation asleep. There was no documentation to evidence Resident #21 had been assessed from 2:05 p.m. until 5:30 p.m., two and half hours later. Additionally, assessments timed at 3:30 a.m. and at 7:30 a.m. did not include vital signs, and had documentation asleep. There was no documented assessments between 11:30 p.m. on [DATE] until 11:30 a.m. on [DATE]. Twelve hours passed between neurological assessments. During an interview on [DATE] at 12:40 p.m., Staff W confirmed staff should have attempted to wake Resident #21 to check on her as drowsiness may have been a change in the resident's condition. Failure to adequately assess Resident #21 following a potential injury placed her at risk for delayed identification of the injury, and therefore a potential delay in treatment. RESIDENT #19 Resident #19 was no longer in the facility. Resident #19 was taking a blood thinning medication (causes longer time for blood to clot) which placed him at risk of bleeding easily and for not being able to stop the bleeding. Review of Resident #19's medical record revealed a nursing progress note dated [DATE] at 8:55 p.m., indicating the resident was found on the floor bleeding with head against drawer a laceration to back of his head and with a hematoma and swelling of his left eye. The note indicated the resident was awake but confused. Further progress notes indicated Resident #19 was sent to the hospital for evaluation at approximately 6:00 p.m. and returned to the facility at 10:00 p.m. During an interview on [DATE] at 12:00 noon, Staff B reported due to Resident #19 having an unwitnessed fall and a known head injury, staff should have completed the neurological flow sheet to assess the resident for neurological changes. Staff B reported she was unable to locate a neurological flow sheet related to Resident #19's fall on [DATE]. RESIDENT #4 Review of the facility incident log revealed there had been three resident to resident altercations where Resident #4 was the victim and Resident #5 was the aggressor within a 24 hour period. Review of facility incident investigations revealed on [DATE] at 7:15 a.m., Resident #4's roommate, Resident #5, slapped her. Further review revealed later the same day, Resident #5 grabbed Resident #4 by her hair. The next morning, on [DATE], Resident #5 again physically grabbed Resident #4. During an interview on [DATE] at approximately 12:30 p.m., Resident #4 stated she remembered the incidents, and was afraid of Resident #5. Review of Resident #4's record revealed a nursing progress noted dated [DATE] at 11:52 p.m., describing the resident as remains concerned and anxious regarding roommate's care and her own safety. There were no further notes regarding Resident #4 having potential psychological harm until two days later on [DATE] when a nurse documented Resident #4 was on alert charting related to a resident to resident altercation. During an interview on [DATE] at 11:00 a.m., Staff Y reported if a resident was being monitored through alert charting, staff should document the resident's status at least each shift for 72 hours. Staff Y reviewed the nursing progress notes in Resident #4's record and confirmed there was not documented evidence the resident was monitored for psychological harm.

Based on observations, interview and record review, the facility did not ensure the environment was free of hazards, did not provide supervision and protect residents from repeat injuries. The facility failed to identify root cause related to falls, resident to resident altercations, and elopements. These failures resulted in ineffective interventions/strategies to prevent re-occurrence of accidents/incidents for 9 out of 29 Sampled Residents (#'s 3, 10, 12, 15, 18, 19, 21, 23 & 29), and caused actual harm to Resident #'s 10, 18, 19. Findings include: SUPERVISION/ACCIDENT PREVENTION RESIDENT#3 Resident #3 had [DIAGNOSES REDACTED]. On [DATE] Resident #3 was found lying on the floor in the middle of the room bleeding from the back of her head after she lost her balance while ambulating without a walker, according to facility investigative notes. Resident #3 sustained serious injuries and was sent to the emergency room (ER) and received treatment for [REDACTED]. Resident #3 was observed intermittently on [DATE] and [DATE]. Resident #10 had a purple/blue colored bruise to the left eye area measuring 3x 1.8 cm, a large bruise to the neck in a shape of a rope measuring 16.5 cm long, and a bruise to the left arm, measuring 17 x 13 c.m. The observations were confirmed by staff S on [DATE] at 10:55 a.m. On [DATE] around 11:15 a.m., Staff S stated Resident #3's injuries resulted of a fall on [DATE]. On [DATE] between 10:55 a.m. and 11:15 a.m., observations revealed Resident #3 in bed with eyes closed, the call light was hanging over the headboard where the resident would not have been able to reach. Resident #3's walker was located approximately 2 feet away from the bed and there was an unlocked wheelchair approximately two feet away. The two items were on each side of the bed making the room cluttered. Additional observations on [DATE] at 2:15 p.m., 2:30 p.m. and 4:30 p.m. revealed, Resident #3 sat in a wheelchair alone in her room. The resident was approximately 3 feet away from the bed. The call light was on the bed and out of the resident's reach. The facility provided the resident with a call light when the Department Surveyor brought observations to staff S' attention at 2:30 p.m. Staff S said Resident #3 did not use the walker anymore as she was too weak to use it after the fall. Staff S did not have an explanation as to why the walker remained in the room and why the call light was not within reach. Repeat observations on [DATE] between 8:03 and 9:30 a.m. revealed, Resident #3 in a wheelchair in her room alone. The the call light was out of the resident's reach. RESIDENT #10 Resident #10 admitted on [DATE]. [DIAGNOSES REDACTED]. Therapy assessment notes on [DATE] indicated the resident had good rehabilitation potential as evidenced by his ability to follow one-step directions, was motivated to return to a lower level of care facility, and had strong family support. According to the resident's care plan, Resident #10 was identified at risk for dehydration, sleep problems related to sleep apnea, pain, and hyper/[DIAGNOSES REDACTED] related to diabetes. Resident #10 sustained 10 falls in June and [DATE] according to facility investigations, nursing notes and interview with Director of Nursing Services (DNS), on [DATE] around 4:00 p.m. Record review found during 3 out of 10 falls, the resident hit his head. On [DATE] at 12:20 p.m., the resident was found on the floor next to his bed. Resident #10 claimed he hit his head On [DATE] Resident #10 fell three times. At 5:30 a.m. from his bed, at 6:30 a.m., next to his bed, and at 6:00 p.m. the nurse saw him stand up and fall to the floor. Resident #10 hurt his elbow and had a laceration to the left eye. On [DATE] at 9:45 a.m., Resident #10 fell in the doorway of the activity room. On [DATE] at 10:15 a.m., Resident #10 was found on the floor next to his bed on the floor mat. On [DATE] at 6:10 p.m. Resident #10 got up, walked in the hallway and fell . The wheelchair alarm did not sound when the resident fell . On [DATE] at 6:15 p.m. Resident #10 was found on the floor bleeding from his head, and noted to have garbled speech according to the documented nursing assessment. On [DATE] Resident #10 fell striking his head, while two staff members were present in the room and were in the process of providing care. On [DATE] at 12:30 p.m. Resident #10 stood up and fell in the dining room. The wheelchair alarm did not sound when the resident fell because it was not turned on by staff. Although therapy noted on [DATE] Resident #10 would do well with walk to dine, there was no evidence in the record those services were provided. According to therapy notes, Resident#10 exhibited pain on [DATE] ,[DATE], [DATE] ,[DATE], [DATE] ,[DATE], [DATE] ,[DATE], on [DATE] demonstrated agitation due to pain, on [DATE] therapy indicated the resident had ,[DATE] pain, and on [DATE] patient demonstrates agitation due to pain. After Resident #10 had 3 falls within 24 hour period on [DATE], the facility failed to increase supervision and ensure Resident #10 remained safe as evidenced by continued repeat falls. There was no evidence of identifying contributing factors for each fall and implementing effective interventions. Resident #10 sustained 6 more falls and died on [DATE]. Therapy assessment summary for dates of service between [DATE] and [DATE] indicated patient's progress has been slower than initially anticipated . patient presents with new onset of left neglect Patient has had recent increase in agitation and more s/s (signs and symptoms) of pain. On [DATE] therapy noted significant change in mobility over the last few days Patient has diarrhea this afternoon. An interview was conducted with Staff W on [DATE] at approximately 1: 10 p.m. regarding Department Surveyor findings related to repeat falls within 12 hours on [DATE]. Staff W was asked what was done to protect and supervise Resident #10 from further repeat falls and injury. Staff W pointed to the care plan which read; low bed, bed against the wall and a perimeter mattress. Additional record review found the facility used a bed and wheelchair sensor alarm to predict movement. There was no evidence that increase in supervision was initiated as resident continued falling. There was no root cause analysis of what motivated Resident to move. The investigative documentation indicated the alarm did not sound on every fall incident. Resident #10 had a number of factors that could have contributed to repeat falls including: highly impaired vision requiring corrective lenses as indicated in Medical Data Set (MDS)(Comprehensive assessment tool) dated [DATE], pain issues as indicated in therapy notes, sleep apnea and intolerance of CPAP, changes of condition related to neurological system pertainin to progress note on [DATE] of new onset of left-sided neglect, loss of trunk control, and new onset of diarrhea on [DATE]. Additionally, Resident #10 was at risk for fluctuating blood sugars, increased agitation related to noise levels from bed and chair alarm use, and incontinence of bowel and bladder. Facility fall investigations were reviewed for each of the 10 falls with DNS and Administrator on [DATE] between 12:30 p.m. and 4:00 p.m. Facility investigations did not conclude or find root cause and specific contributing factors to the repeat falls. Without conducting root cause analysis for each fall, the facility did not identify appropriate interventions including identifying change of condition and did not decrease likelihood of repeat falls, resulting in recurring falls with injuries. Refer to F226 for failure to complete thorough investigations of falls. RESIDENT #18 Resident #18 had [DIAGNOSES REDACTED]. Resident #18 had history of fall with injury while residing at the facility. On [DATE] Resident #18 was found laying on the floor after a fall and had a deep laceration to the forehead and was sent to an emergency room (ER). On [DATE] staff found Resident #18 on the floor next to his dresser, bleeding from the left forehead and left eye. Resident #18 sustained a puncture wound above the eye and medics were summoned. Both incidents were recorded in the nursing notes and facility investigations. According to a comprehensive assessment ((MDS) dated [DATE] Resident #18's vision was highly impaired and required a two person assistance with transfers. On [DATE] between 10:18 a.m. and 10:30 a.m., observations revealed facility staff performing an unsafe transfer of Resident #18 from a shower chair to the wheel chair. Staff I and Staff AA transferred the resident without using a gait belt (a belt device that is applied to the resident to ensure a safe hold during a transfer, and is a standard of practice when transferring). The two employees picked Resident #18 up under the arms and transferred him into a wheelchair. The staff failed to use safe transfer technique including a use of an assistive device (gait belt) in order to decrease likelihood of an accident. After the transfer, staff were unable to locate the resident's glasses. Both staff verbalized they could not locate Resident #18's glasses after checking all of the drawers and the resident's closet. The two falls experienced by Resident #18 were investigated by the facility. Both investigations did not evaluate vision, physical restraint in use, and use of assistive devices as contributing factors to the falls. This placed the resident at risk for repeat injuries. UNSECURED DOORS AND ELOPEMENT RESIDENT #19 Resident #19 was no longer in the facility. Review of Resident #19's medical record revealed he had been assessed as being at risk for elopement (wandering away from the facility). Review of Resident #19's Brief Interview Mental Status (BIMS) score dated [DATE], revealed a score of 4 out of 15, indicating Resident #19 had severe cognitive impairment. On [DATE], Resident #19 was found in a therapy office seriously injured including bleeding from the back of his head and his left eye, according to the facility investigation. The investigation indicated Resident #19 had swelling to the left side of his face and redness to the left sclera (the white portion of the eye). The [DATE] investigation revealed, care staff were not able to locate Resident #19 in the facility. The investigation indicated care staff began looking for Resident #19 at 4:30 p.m., and did not locate the resident until over an hour later at 5:45 p.m., when he was found injured on the floor in a staff office located within the therapy gym. Care staff sent Resident #19 to the emergency room (ER). According to Resident #19's hospital discharge summary, the resident's final [DIAGNOSES REDACTED]. After the hospitalization , Resident #19 was admitted to a different facility. Observations on [DATE] at 2:30 p.m., at a different facility, revealed Resident #19 in bed with a metal, padded, eye cover over his left eye. Resident #19 was confused and unable to be interviewed. In interview on [DATE] at 12:30 p.m., Staff B said the incident occurred on a Sunday evening. Staff B confirmed the therapy gym was not scheduled to be used that day. Staff B explained the door leading from the hall (the only door inside the facility leading into the gym) was locked at the time of the incident. According to Staff B, the door leading from the gym to the outside courtyard was not locked, therefore, Resident #19 exited the facility to the courtyard and then entered the therapy gym and into the staff office within the gym. Staff B confirmed the facility staff had done a room to room check of the facility while looking for Resident #19 on [DATE], and were unable to locate the resident. Staff B said a staff member who had assisted residents with dinner went to the therapy room to return a piece of resident care equipment he/she had borrowed earlier, and discovered Resident #19 on the floor in the therapy room office. During an interview with the therapy staff on [DATE] at 12:30 p.m., Staff V reported the therapy staff did not have a key to lock the door that Resident #19 had entered through. Staff V said staff never locked the office that Resident #19 was found in. Staff V further stated, since Resident #19's fall, staff lock the door at night when leaving the building. Observations during the interview revealed the door that Resident #19 had entered the therapy gym through, was propped in an open position by a weighted dumbbell. Observations of the therapy room on [DATE] at 12:30 p.m., revealed various therapy equipment that were potential hazards; including barbells, stairs, an oven and a stove top with electric burners. The office that Resident #19 was found in had a metal desk with desk drawers. The drawers had square metal handles with corners on each side. During an interview on [DATE] at 12:35 p.m., Staff B said Resident #19 was found on the floor next to the metal desk. Resident #19 sustained a significant injury related to facility failure to ensure that areas with potential hazards was secured. Failure to ensure residents were not able to access a room with potentially hazardous items from an outside door, without supervision, resulted in actual harm to Resident #19. Review of the facility policy entitled Elopement Risk Guidelines - CODE PINK dated ,[DATE] indicated when staff were not able to find a resident they were to implement an elopement protocol, also known in the facility as Code Pink. Review of the Elopement Risk Guidelines revealed directives to staff when a resident could not be located, staff were to search the facility, then the grounds. If the resident still had not been located, staff were to call the director of nursing, the administrator, the physician and the police. During an interview on [DATE] at 1:08 p.m., Staff B rsaid when a resident could not be located, staff should implement the Code Pink Procedure. According to Staff B, staff were expected to search room to room throughout the facility looking for the missing resident. If the resident was not found in the facility, staff would then check the property around the facility including courtyards and that parking lots. Staff B said if staff still had not located the missing resident, they should notify the administrator, the director of nursing and local law enforcement and begin to search the neighborhood. RESIDENT #21 Resident #21 had [DIAGNOSES REDACTED]. Observations on [DATE] between 11:10 and 12:00 p.m. revealed, Resident #21 walked fast and was actively exit seeking. Resident #21 approached the Department Surveyor and said I want to go with you . where is the door? Resident #21 was walking back and forth in the hallway. Resident #21 had a wander guard in place (device triggers alarm when resident gets close to the door). Resident #21 had known elopement risks and wandering behaviors. According to record review, Resident #21 eloped from the facility on [DATE]. The resident was seen around 5:10 p.m. by a staff member, and around 5:30 p.m. the front door alarm sounded. A nurse looked outside and did not see any residents. The nurse went back inside and noticed Resident #21's dinner tray was untouched according to facility incident investigation. Care staff searched for the resident. At 6:00 p.m. a neighbor saw the resident walking down the sidewalk, became concerned, and made the facility aware of the resident wandering outside. The investigation indicated care staff searched the facility and the property and were not able to locate Resident #21. Care staff then began searching the neighborhood. The investigation indicated at 6:00 p.m. a neighbor saw the resident walking down the sidewalk, became concerned and made facility aware of the resident wandering outside. Resident #21 was in found off the facility property and at a nearby private residence. The investigation did not include documentation to show evidence local law enforcement had been notified. During an interview on [DATE] at 10:35 a.m., Staff B reviewed the facility investigation and confirmed law enforcement had not been notified when care staff were unable to locate Resident #21 on the facility property. Although the resident was missing for at least 50 minutes from the facility, the care staff did not initiate police involvement when the resident was not found inside and outside of the premises. Not activating emergency services when a resident was found missing, placed residents at risk of being lost for prolonged periods of time before taking action. RESIDENT #15 Observations on [DATE] at 8:45 a.m. revealed Resident #15 was near the front door of the facility while alarms were sounding and facility staff were attempting to convince him/her to walk away from the door. Review of Resident #15's most recent comprehensive assessment ((MDS) dated [DATE], indicated she had Moderately impaired cognitive function. Review of a facility investigation dated [DATE] indicated Resident #15 was at the fence door behind the facility stating she was going home, and fell while pushing on the door handle. Review of the facility policy entitled Elopements dated February 2014, revealed directives to staff that residents who had been assessed as being at risk for elopement should be included in the Code Pink protocol which included having a book at the nurse station that had information pertaining to each resident who was at risk. The protocol indicated the book should contain the following for each at risk resident a. Resident Face Sheet b. Photo of Resident c. Area mapped d. Missing resident Action Plan. Review of Resident #15's medical record revealed he/she had been identified as being at risk for elopement. Resident #15's care plan included interventions to prevent elopement, including, implementing the Code Pink procedures. Review of the Code Pink notebook located at the nurse station near Resident #15's room, revealed no documentation related to Resident #15. During an interview on [DATE] at 10:20 a.m., the primary nurse (PM) confirmed Resident #15 was at risk for eloping and should be included in the Code Pink book. PM reviewed the Code Pink book and confirmed Resident #15's information was not included in the book. PM reported she believed the Resident Care Manager (RCM) was responsible for updating and ensuring the Pink Book was up to date. During an interview on [DATE] at 10:30 a.m., the RCM in charge of the hall where Resident #15 resided, reported she was not responsible for updating the Code Pink Book, and it was the responsibility of the Director of Nursing (DNS). During an interview on [DATE] at 10:36 a.m., the DNS said the RCM was responsible for ensuring the Code Pink Book was up to date. Interviews with staff revealed a failed elopement system as nobody took ownership of reviewing the responsibility for ensuring the Code Pink Book was accurate and up to date. This failure placed residents at risk for a delay in staff response to a missing resident. FAILURE TO PREVENT RESIDENT ALTERCATIONS RESIDENT #12 Review of the facility policy entitled Abuse Prevention Policy and Procedures dated [DATE], indicated abuse included any physical injury to a resident, which has been caused by other than accidental means. This includes injuries that a reasonable and prudent person would have been able to prevent such as hitting, pinching or striking, or injury resulting from rough handling. The policy stated All staff members and agents of the facility are mandatory reporters of abuse. Observations on [DATE] at 2:15 p.m., revealed Resident #1 independently maneuvering throughout the facility in an electric wheelchair. During an interview, using pen and paper, on [DATE] at 1:45 p.m., Resident #12 answered questions and communicated appropriately. Review of Resident #12's medical record revealed his BIMS (Brief Interview for Mental Status) score dated [DATE], was 15 out of 15, meaning the resident was alert and oriented. Review of a facility incident investigation dated [DATE] revealed, in the dining room at approximately 8:00a.m., before breakfast, Resident #12 was witnessed using his electric wheelchair to block Resident #11's path, and to attempt to prevent Resident #11 from walking past. When Resident #11 continued to attempt to get past, Resident #12 was witnessed to raise his hand at Resident #11. Resident #12 was then seen to grab Resident #11's shirt and pull him to the floor, causing an injury to Resident #11's elbow. The investigation indicated to prevent further occurrences, the staff would implement every 15 minute checks to monitor Resident #12. Review of Resident #12's medical record revealed a progress note dated [DATE] at 1:44 p.m., indicated Resident #12 was witnessed by staff to ram his w/c (wheelchair) into the other pts (patient's) chair in attempt to move him. The note further indicated when the nurse attempted to intervene, Resident #12 speed forward running over the top of his toes. The note indicated the interventions in place, included frequent visual checks and 1 to 1 monitoring as needed, would continue. After Resident #12 showed aggression on the morning of [DATE], the staff identified the aggressive behavior and documented they would monitor Resident #12 to prevent further occurrences. There was no evidence to support staff were actually monitoring the resident. A few hours later Resident #12 caused injury to someone else by running over other resident's toes. The facility failed to prevent further incidents from occurring. In interview on [DATE] at 9:30 a.m., Staff B said Resident #12 had a history of [REDACTED]. Review of the facility state reporting log revealed no log entries related to Resident #12 being in an altercation with another resident in the hall on [DATE]. During an interview on [DATE] at 2:26 p.m., Staff B reviewed the progress notes and confirmed the incident was not on the state reporting log and had not been investigated to rule out abuse. Staff B reported this was the first time the incident had been reported to her and confirmed staff had not reported the incident. Staff B further stated she did not know who Resident #12 had run over in his chair or if s/he had been injured. Staff B was asked for evidence that Resident #12 was being monitored by frequent checks or determination of 1 to 1 monitoring. Staff B replied the staff did not document anywhere who was on frequent checks, or the checks themselves. Staff B confirmed staff who witnessed the second altercation on [DATE], failed to report the altercation involving an alert and oriented resident potentially purposefully injuring another resident. The incident was not investigated, the alleged unidentified, victim was not monitored for injury and/or psychological harm, and other residents were not protected for Resident #12. During an interview on [DATE] at 2:26 p.m., the Director of Nursing Services (DNS) reported the facility did not document every 15 minutes checks. According to the DNS, the facility did not have an every 15 minute protocol or form to show staff were monitoring residents every 15 minutes. The DNS was unable to provide evidence the planned every 15 minutes checks were done to provide supervision for Resident # 12. Failure to supervise Resident # 12 adequately, put other residents at risk for altercations and related psychological distress. RESIDENT CARE EQUIPMENT Observations on [DATE] at 10:00 a.m. revealed, the ,[DATE] hall dining room did not have an emergency crash cart with equipment to use in case a resident was choking during the meal. During an interview on [DATE] at 10:05 a.m., Staff X reported the closest crash cart was located in a storage room on the 100 hall. Staff X attempted to demonstrate the suction machine use. The machine did not have all necessary parts with it. Staff X took the machine from the top of the cart, and the necessary plastic canister was in a cupboard. The necessary tubing to connect the canister was in a drawer, and the suction tip for the tubing was in another drawer. It took Staff X several minutes to locate and assemble all of the necessary parts. Staff X confirmed this was too long if there was an emergent situation that required the suction machine. On [DATE] at 10:03 a.m., observations completed with Staff J revealed a crash cart located in the 300 hall storage room that did not have a backboard. Staff J confirmed the cart should have a backboard attached. Staff J reported if there was an emergency that required CPR she would get the backboard from the crash cart located in the main dining room. Staff J then walked the length of one hall to the dining room where the crash cart was stored in the corner. Staff J first move a dining room chair, a resident's wheelchair, and three folding chairs that were leaned against the cart to retrieve the crash cart and backboard. Once Staff J took the suction machine from the cart, the suction canister did not have a lid and did not have the necessary tubing attached to it. Record review of Code Cart Checklist that was completed daily by nurses to ensure all supplies were present in case of an emergency, revealed in June, July and August of 2016 section read back board had o documented indicating it was absent. Additionally, the suction on the crash cart was not set and connected and ready for use in case of emergency. There was no extension cord in the crash cart. ENVIRONMENT Observations on [DATE] at 9:30 a.m., in the outside courtyard, accessible to residents had uneven ground and broken cement pavement on a sidewalk. The observed environment hazard was reported to the Administrator on [DATE] between 12:00 p.m. and 4:00 p.m. The Administrator stated that area would be fixed. The Administrator agreed it was a hazard for residents attempting to walk that path, and could cause a resident to fall with subsequent injury.

Based on interview and record review, the facility failed to adequately assess and monitor 1 resident (#10) for a safe discharge back into the community. This failure placed the resident at risk for possible suicide attempt, severe deterioration in health status, and may have contributed to his subsequent death. Findings include: Review of 5/4/16 progress notes revealed Resident #10 was discharged from the facility on 5/4/16 to the homeless shelter at approximately 3:00 p.m. Suicide Ideations: Home and Community Services CARE assessment dated [DATE], identified [DIAGNOSES REDACTED]. Resident #10 had a history of [REDACTED]. Psychiatry progress note dated 2/18/16 at 9:08 a.m. indicated Resident #10 felt his Cymbalta was no longer effective. The Physician impression of Resident #10 was depression with chronic insomnia. A new order was received for Seroquel 25 mg at bedtime for his major depressive disorder; to use in conjunction with antidepressant. Review of the behavioral monitoring sheets for 4/16 and 5/16 revealed behaviors of self isolation and refusal of care and medications for Resident #10's Cymbalta, while the associated behaviors for his seroquel were for verbal and physical aggression. His/her mood was not monitored despite his/her [DIAGNOSES REDACTED].#10's sleep pattern was not documented despite his/her [DIAGNOSES REDACTED]. According to progress note dated 5/3/16 at 2:00 p.m., Resident #10 stated to the therapy staff member that it would be easier to kill himself than to discharge to a shelter. Staff A reported the suicide threat to the crisis line and requested a face to face with a counselor. Resident #10 was put on alert, his room was searched. Suicide precautions put in place. Review of progress note dated 5/3/16 at 2:57 p.m. revealed, Staff A gave Crisis Line phone number to Resident #10 and encouraged him to call and speak to a counselor. Resident #10 stated he didn't have a phone. Staff A informed him he could use a phone at the nurses station. No further documentation in progress notes with regards to his suicide ideation was found. In telephone conference on 7/1/16 at 2:30 p.m., Staff L was asked if the facility had a policy and procedure for suicide ideations. Staff L replied, no. Staff L was asked if the mental health community services counselor was aware of suicide ideation. Staff L replied, no. In interview on 6/30/16 at 11:30 a.m., Staff K was asked if she was aware of Resident #10's suicide ideation. Staff K stated, Yes, but he was upset so probably didn't mean it. In telephone interview on 7/6/16 at 1:50 p.m., Staff A was asked what the facility's protocol for suicide precautions were. Staff A stated the crisis center was called, Resident #10's room was searched and potential harmful items were removed from his/her room, and the resident was put on alert. Staff A was asked what alert meant. S/he stated it meant frequest checks. S/he was asked who performed the frequent checks and what time period was considered frequent. Staff A replied, I don't know. Although the resident verbalized idea of killing himself on 5/3/16 at 2:00 p.m. the facility discharged him to a shelter on 5/4/16 at 3:17 p.m. There was no alert charting and no evaluation or monitoring for suicidal ideation. Safe Medication Administration Review of Occupational Evaluation and Plan of Treatment dated 4/6/16 - 5/17/16 indicated Resident #10's self medication management = <25%. (This indicated that on initial assessment of the resident's ability to self administer medications, he was 25% accurate with managing his medications). Risk factors identified - Due to the documented physical impairments and associated functional deficits, the patient is at risk for falls, further decline in function and immobility. Precautions - Nonweight bearing RLE. Review of Occupational therapy evaluation of medication education dated 4/8/16 identified Resident #10 was able to open easy open cap small and large independently. S/he was unable to open side lever safety caps small and large, push down and turn safety cap, side squeeze safety cap, and safety caps by lining up arrows and pushing up. Review of progress note dated 4/15/16 at 11:48 a.m., revealed Staff T documented Resident #10 was unable to pop medications out of bingo cards. In interview on 6/30/16 at 8:45 a.m., Staff J presented this Department staff with the undated MedicineTracking Chart that was given to Resident #10 in order to keep track of his/her medications and the time of day in which the medications should be taken. Resident #10 was to approach his/her nurse when his medication was due and ask for the specific medication scheduled. In interview on 6/30/16 at 11:30 a.m., Staff K was asked where it was documented Resident #10's ability to self administer his medication. Staff K stated that information was probably not documented anywhere. In interview on 6/30/16 at 12:45 p.m., Staff M was asked what the process was for a resident to self administer his/her own medications. Staff M was not sure how to answer. S/he was then asked if Resident #10 was able to administer his own medications and where that information was documented. Staff M stated it changed day to day depending on Resident #10's mood; normally the nurse just administered his medications. Physician orders [REDACTED]. These changes were not reflected on the resident's Medicine Tracking Chart. Review of physician order [REDACTED]. This change was not reflected on the resident's Medicine Tracking Chart. Review of physician orders [REDACTED]. Instill 1 drop in right eye 4 times a day related to cataract extraction and Pred Forte 1% suspense instill 1 drop in right eye 4 times a day related to glaucoma surgery. These medications were not listed on Resident #10's Medicine Tracking Chart. Review of DAR (diabetic administration record) for 5/1/16 - 5/4/16 revealed Resident #10's blood sugars ranged from 167 to 500, indicating they were not stable, and that Resident #10 would need to self inject insulin at various doses, along the range scale. Review of DAR for 4/16 revealed his/her blood sugars ranged from 183 to 600, again indicating the need for various insulin doses. Review of Administrative Hearing document dated 4/12/16, revealed, section 5.6, Avamere at Pacific Ridge failed to meet the requirements of discharge based on a demonstration of the lack of a clinical need for Resident #10 to be at the facility. Although the facility identified Resident #10 was able to self administer medication, s/he was not assessed for self storage and administering. In addition, the facility did not indicate how the resident's medications were packaged to allow him to open them. Resisdent #10 was discharged with 2 different medications to treat heart disease and stroke, 4 different medications to treat high blood pressure, he needed insulin management, and medications for depression, with a history of suicidal ideation and attempt. Self Care Review of Occupational Evaluation and Plan of Treatment dated 4/6/16 - 5/17/16 identified Resident #10 required 50% hands on assist for his/her bathing. Risk factors identified - Due to the documented physical impairments and associated functional deficits, the patient is at risk for falls, further decline in function and immobility. Precautions - Nonweight bearing RLE. In interview on 6/30/16 at 8:45 a.m. Staff J stated the fit of his prosthesis was not finalized, as it did not fit properly, therefore, the prostetic leg was functional but not the final product. In interview on 6/30/16 at 1:05 p.m. Staff O stated Resident #10 needed assistance with his/her bathing because of his flacid left side and contracted left hand resulting from his prior CVA. Staff O said s/he allowed the resident to wash what he could and Staff O washed Resident #10's right side and back due to the resident's limitations on his left side. Review of Quarterly MDS (minimum data set) dated 4/19/16, revealed Resident #10 needed set up support from staff for his bed mobility, transfers, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. Range of motion indicated s/he had impairment to both lower extremities. Although Resident #10 needed assistance with medications, activities of daily living/self care, and mental health related to depression and suicidal ideation, the facility discharged the residen to a homeless shelter without assistance.

Based on observation, interview, and record review, the facility did not consistently address all factors that may have been precipitating causes for each fall for 5 of 10 residents (#'s 62, 80, 85, 118, 120) reviewed for accidents. Failure to attempt to identify a time pattern, assessing possible causes, developing new interventions and strategies, reevaluating for effectiveness, and implementing individualized care plans to attempt to prevent further falls, resulted in head injuries for Residents #62, #118, and #120, and recurring falls for Residents #62, #80, and #85. Findings include: Review of document titled, Facility Fall Clinical Protocol, dated October 2010 revealed the assessment of a fall included: 1. History of falls will be identified, including underlying causes 2. Nursing assessment to include vital signs, injuries, changes in physical function, cognitive status, pain, falls since last physician visit, precipitating factors on how fall occurred, current medications (especially those associated with dizziness or lethargy), and active [DIAGNOSES REDACTED]. All risk factors for subsequent falling 4. Physician input to identify medical conditions that affected the fall risk and complications 5. Staff will evaluate and document all falls that occurred in the facility including where, when, how, why, witnessed or unwitnessed 6. If the cause of the fall was unclear, the fall may have had a medical cause or adverse drug reaction. If the resident continues to fall, the physician will review the situation and help identify contributing causes. 7. Staff will try various relevant interventions based on assessment or the nature of the fall until the falling reduces, stops or reason was identified. 8. Staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling 9. The interventions will be re-evaluated if the resident continues to fall to consider other possible reasons of the falling (including the relevance of the current interventions). RESIDENT #80 Resident History Record review of the 3/18/16 quarterly Minimum Data Set (MDS), an assessment tool, revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had short and long term memory loss with periods of inattention and disorganized thoughts, required physical assistance of staff for bed mobility, transfers and activities of daily living (ADL's). Resident #80 had vision impairment, was incontinent of bowel and bladder and a history of falls. There was no history of attempts of a toileting program and staff anticipated the resident's needs. Prescribed medications included fluvoxamine (an antidepressant), Ativan (antianxiety), Lasix (diuretic) and antihypertensive (high blood pressure). According to Mosby's Nursing Drug Reference 2008, antidepressant and antianxiety medication side effects could include acute renal failure, high blood pressure, drop in blood pressure when standing, blurred vision, urinary retention, constipation, dizziness, drowsiness, increase in feelings of panic and should be used cautiously in the elderly. Potential side effects of Lasix included muscle weakness, muscle cramps, headache, blurred vision, and confusion especially in the geriatric population. Care plan dated 12/18/15 revealed the resident was a high risk for falls related to impaired cognitive and altered mental status, gait/balance problems and history of falls. The resident was started on a Restorative program (RA) for active range of motion, transfers and walking related to osteoarthritis and dizziness. Interventions included educating the resident, family and caregivers about safety reminders safety and what to do when a fall occurred, notify the physician, and obtain orthostatic blood pressure. No additional care plan interventions were revised or added since admission. The care plan also addressed Resident #80's unstable health condition to include edema to lower extremities, potential for pain, an ADL self-care performance deficit with limited mobility related to dementia, osteoarthritis and weakness. The resident required supervision to one person assistance with smoking, toileting, bathing, dressing, transfers and mobility. The care plan dated 12/18/15 revealed the resident demonstrated acts characterized by ineffective coping including anxious and yelling behaviors. Interventions included to establish a daily routine, encourage out of room activities establish root case and attempt to accommodate. Record review of Social Service notes dated 3/2/16 revealed the facility held a care conference where the family expressed concerns about the resident's anxiety levels. Recent medication changes included a change in dose of Ativan. In interview on 3/21/16 at 2:31 p.m., two aids, Staff BB and Staff CC, both identified Resident #80 as a high fall risk, to keep and eye on him/her and anticipate his/her needs. Incident 3/11/16 Record review of the incident report for fall on 3/11/16 at 9:15 a.m., revealed Resident #80 sustained an unwitnessed fall at bedside. The call light was in reach, and the resident did not use it. The resident said he was trying to get into bed. Vital signs were taken and discovered the resident had a fever. The report included the resident required supervision for cuing and safety. The incomplete investigation did not include interviews to include the resident's regular routine as per care plan intervention including meal times, nap time preferences, activity participation. The investigation did not identify when the resident was last seen, potential antecedents, if the staff anticipated the resident's needs including a fever identified earlier in the day, changes in status or appearance. Other potential factors were not addressed as potential contributing factors to the fall included changes in medications or potential side effects, the level of supervision required based on ADL performance and cognitive status, medical and physical status, or environmental hazards. In interview on 3/22/16 at 11:30 a.m., Staff B said an investigation for a fall included looking at the situation, circumstances, environment, interviews, staff assigned to him during that period of time, looking at that resident as a whole, cognition, mobility, care plan, was the care plan being followed at the time of the fall, last time the resident was seen, and root cause for the fall. Although the care plan indicated Resident #80 required assistance getting into bed with one caregiver, the caregiver did not assist the resident back to bed. There was no root cause analysis of the fall, the facility did not determine if the reisdent received the supervision s/he requried, and did not identify care staff oversight. The facility did update the care plan to prevent futher falls. Incident 3/14/16 Record review of the incident for the fall on 3/14/16 1:02 a.m. (night shift), revealed Resident #80 was found on the floor next to the bed in his/her room and sustained an abrasion to the nose. The resident stated s/he was attempting to get to the bathroom and fell . The resident presented confused and drowsy at the time s/he was found. Staff provided first aid, assisted the resident back to bed and educated to use the call light for assistance. The incident report identified the lighting was dim, the resident ambulated to the bathroom instead of using the wheelchair and complained of discomfort. The report did not include the resident ' s usual routine, when the resident was last seen and was toileted, if his/her medical conditions impacted the continence if the resident's needs were anticipated, an assessment of diagnoses, current medications and side effects that may have contributed to the fall. Record review of nursing progress notes attached to the 3/14/16 incident report, dated 3/15/16 and 3/16/16 revealed inconsistencies of the care provided for the resident: On 3/15/16 at 10:27 p.m. and 3/16/16 at 1:43p.m., a licensed nurse documented the resident was incontinent and required one person assist with most ADL's and transfers. On 3/16/16 at 4:44 a.m. (night shift), the licensed nurse documented Resident #80 was continent of bowel and bladder, used the bathroom independently and performed ADL's independently. The incident report did not identify discrepancies between caregivers, why the licensed nurse on 3/16/16 at 4:44 a.m. was not aware of the care plan and if s/he was the staff member on shift of the most recent fall. In interview on 3/22/16 at 11:30 a.m., Staff B stated when a fall was being investigated, the situation was evaluated including time, circumstances, environment, staff assigned to the resident during that period of time, the last time the resident was seen and care provided. In addition, the cognitive and physical abilities of the resident was identified, whether the care plan was being followed at the time of the fall, the purpose or intent of the resident when getting up. All factors would help identify the root cause of the fall. Staff B further stated Resident #80 did not always use his call light for assistance and staff were to anticipate his needs. Staff B said education was provided to the resident to use the call light, but said it was not always effective. Night shift was expected to perform rounds to check and change residents. Staff B confirmed the investigation did not include interviews, resident routine or time frame of care provided and whether toileting could have been anticipated to prevent the fall or rule out potential neglect. The investigation was incomplete, interventions to remind the resident to use the call light was ineffective for Resident #80's cognitive impairments. Although the staff were expected to check on the resident, it was not clear that the faciltiy monitored care staff. The facility failed to ensure the resident was free of accident hazards. RESIDENT #85 Resident History Record review of the Significant Change MDS dated [DATE] revealed Resident #85 was readmitted to the facility 11/27/15 with [DIAGNOSES REDACTED]. The resident exhibited short and long term memory loss, with impaired judgment and required assistance with mobility and activities of daily living (ADL's). The resident was incontinent of bowel and bladder, no toileting program had been attempted, and a high fall risk. Resident #85 was prescribed Klonopin (anticonvulsant), Perphenazine (antipsychotic), and Depakote (mood stabilizer) for schizophrenia and Trazodone (antidepressant) for insomnia. Record review of the MDS Care Area Assessment (CAA) dated 12/3/15 revealed Resident #85 triggered for falls related to history of multiple fall since his/her readmission. The resident had exhibited a functional decline and impulsive, unsteady on his/her feet and needs assistance with ADL's and mobility. The resident was on psychotropic medications that could increase his/her lethargy and increase the unsteadiness of his/her gait. The resident was referred to therapy. Review of Mosby's Nursing Drug Reference 2008 revealed side effects of klonopin and Depakote included confusion, behavioral changes, insomnia, drowsiness, dizziness, nausea, and constipation. Renal and liver function testing needed to be routinely monitored. Perphenazine side effects included blurred vision, urinary retention, dizziness, tardive dyskinesia (tremors), and sudden changes in blood pressure from lying to standing. Trazodone side effects included drowsiness, dizziness, blurred vision, suicidal tendencies, and urinary retention. Routine renal and liver function testing also was required for this medication. Record review of the care plan dated 11/27/15 revealed the resident was a fall risk and had ADL self-care performance deficit with limited mobility related to confusion, dementia, impaired balance and limited mobility. Resident #85 required one person assist with dressing, bed mobility for safety and weakness, and was a supervised smoker. Staff were to anticipate the resident's needs, was not to ambulate without assistance, provide frequent visual checks, ensure the resident was wearing non-skid footwear at all times, and assist with toileting every two hours or as needed. The resident had a history of [REDACTED]. Fall risk assessment dated [DATE] revealed Resident #85 was a high fall risk due to incontinence, cognitive impairment, jerking motions of extremities and unstable when ambulating and making turns. Record review of Physical Therapy discharge summary dated 2/22/16 revealed the resident required hands on assist for transfers, bed mobility and gait. Twenty-four (24) hour supervision and assistance was required. Record review of the Abnormal Involuntary Movement Scale dated 2/29/16 revealed the resident exhibited mild upper and lower extremity involuntary movements, even during sleep. Record review of the Bowel and Bladder assessment dated [DATE] revealed the resident was occasionally incontinent, but a good candidate for retraining. Observation on 3/16/16 at 2:34 p.m. revealed, Resident #85 was seen ambulating without assistance from staff or a wheelchair in the hall to the bathroom in his/her room. Moments later, staff arrived in the bathroom with the wheelchair. Observation on 3/18/16 at 8:53 a.m., Resident #85 was seen in the large dining room sitting at a table in a standard chair. A staff member brought over his/her wheelchair from the side of the room and parked it on the corner of the table on the opposite side where the resident sat, locked the wheelchair brakes and walked away. At 8:57 a.m., Resident #85 transferred him/herself without staff assistance or supervision, walked behind the wheelchair, leaned over and unlocked the brakes and exited the dining room to the outside to make the 9:00 a.m. smoke break, and pushed the wheelchair through the door with difficulty. Staff observed the resident having a difficult time and assisted him/her through the door to outside, where he waited without supervision. Observation on 3/21/16 at 12:54 p.m. revealed, Resident #85 was seen headed to the smoking area from the Day Room. Staff that entered from outside held the door held the door for the resident, where he exited propelling his wheelchair and remained outside without supervision until 1:00 p.m. for the scheduled smoke break waiting for staff. Observation at 2:34 p.m. revealed, Resident #85 was observed sitting in the day room alone, waiting for the scheduled 3:00 p.m. smoke break. Record review of the incident and accident log revealed Resident #85 sustained 9 unwitnessed falls between 1/12/16 and 2/29/16. Fall 1/12/16 Record review of incident dated 1/12/16 revealed, Resident #85 was found lying on the floor on his/her back in the resident's room at 7:41 a.m. right after the licensed nurse received report. The resident stated he fell out of bed and complained of pain everywhere. The resident was wearing socks (improper footwear) at the time of the fall and was identified as having a gait imbalance. The conclusion of the investigation included inconsistent information as compared to the initial report, to include footwear described as non-skid socks, identified that the resident continued to attempt to self-transfer, staff to continue to anticipate the resident ' s needs, but re-educate the resident to utilize staff when transferring, and the care plan was followed. The resident was active with skilled physical therapy at the time and the report did not review the recommendations at the time for safe transfers, ambulation or if the recommendations were followed by staff. Record review of the January 2016 Medication Administration Record (MAR) revealed that the resident scored a zero as a pain level, despite the resident had complained he hurt everywhere. It was not clear if the pain started before the fall or in result. Tylenol was not administered. Pain was not thoroughly assessed as a contributing factor. The investigation did not review other environmental factors including the condition of the bed, location of the call light, the reason the resident got up, when the resident was last seen and offered assistance. The report did not include interviews with staff on duty to verify footwear, why staff was not present when the resident attempted to transfer, or medical factors including [DIAGNOSES REDACTED]. The facility did not ensure a thorough investigation was conducted to identify the root cause of the fall to protect the resident and prevent recurrent falls. Fall 1/13/16 According to incident report on 1/13/16 at 11:12 a.m., the resident was discovered on the floor laying on his/her right side between the bed and the window and the clothing s/he had taken off and thrown on the floor. The resident was incontinent at the time of the fall. Resident #85 stated s/he was trying to change his/her clothes, due to wet clothing. Staff assisted the resident back to bed. The report identified the resident was confused, incontinent, had unsteady gait and attempted to ambulate without assistance. The resident was last seen and toileted by the CNA at 10:00 a.m. No witnesses were identified, and no further witness statements obtained. It was noted in the summary however that Resident #85 exhibited an increase in mental confusion since the hospital stay. The investigation was incomplete and the report did not identify the location of the call light, type of footwear the resident was wearing, if the immediate area the resident was found was cluttered and the current medication regime was reviewed, but did not address potential side effects or recommended changes. The report did not address other contributing factors including [DIAGNOSES REDACTED]. In addition, the resident was on therapy case load at that time, but the report did not identify the current level of assistance the resident required to include supervision for dressing, transferring and mobility. Though it stated the care plan was followed at the time of the fall, the resident did not have the supervision or assistance s/he required to ensure safety. Record review of the January 2016 MAR revealed the resident required a laxative the day before for complaint of constipation. The investigation did not address this potential concern that may have related to the fall. Interventions included re-educating the resident of the use of the call light for assistance, despite having been identified that the resident had a cognitive impairment and was impulsive. Interventions did not address the level of supervision required or that the resident's needs were not anticipated. The resdient was not adequately supervised and did not protect the resident from future falls. Fall 2/7/16 Record reivew of incident report revealed Resident #85 was found 2/7/16 at 2:45 p.m. on the floor on his/her back next to his/her bed with damp attends, shoe on left foot and a standard sock on the right foot. The resident stated s/he attempted to get up into the wheelchair and his/her shoe came off and his/her foot slipped. The report identified the resident had a gait imbalance, impaired memory, attempted to transfer and ambulate without assistance and was wearing improper footwear. No witnesses were identified, no staff interviews or statements were performed to include the last time the resident was seen and toileted, why the resident was wearing regular socks when the care plan stated to wear non-skid at all times. The incomplete report concluded the care plan was followed at the time of the fall and abuse and neglect were ruled out. A medication review was not performed to include side effects exhibited or if a medical condition played a role in the fall. The investigation stated the doctor was notified, but no orders or recommendations were noted. Record review of the Medication Administration Record for February 2016 revealed the resident was on a sleep aid for insomnia, and the licensed nurse did not document the number of hours slept the night before to address a potential change in sleep pattern or lack of sleep that may have contributed to the fall. An investigation did not indicate what type of shoes the resident was wearing, if they fit appropriately or were not tied. Though the shoe fell off and may have caused the fall, the footwear was not evaluated. Resident #85 was incontinent, attempted to change his/her wet clothing without assistance from staff. There was no evidence in the investigation to determine that staff anticipated the resident's needs. Fall 2/16/16 (12:57 p.m.) Record review of incident report revealed on 2/16/16 at 12:57 p.m., Resident #85 sustained an unwitnessed fall in the smoking area, laying on his/her right side. His/her shoes were on and the wheelchair was at his/her side. The resident stated he wanted to get up and walk to the smoking area and thought he missed his step and fell . The resident was reminded to use his wheelchair at all times and ask for assistance. All the areas including mental status, level of pain, predisposing environmental, physiological and situation factors were not answered and left blank on the form. It was not clear if there were any changes in cognition. No witnesses to the fall were identified; no staff or resident statements and interviews were completed to identify when the resident was last seen, any recent changes in status. Resident routine was not determined to include supervised smoking times (next at 1:00 p.m.). Care staff oversight was not addressed. Observations indicated staff did not attempt to anticipate his/her needs. Footwear and level of supervision were not evaluated to determine if they were appropriate or addressed earlier to potentially prevent recurrent falls. The conclusion reported the resident was continually impulsive and non-compliant with asking for assistance to ambulate safely. Staff continued to provide reminders to ask for assistance and anticipate the resident's needs. The investigation documented that the family was notified, but not the physician. The investigation did not thoroughly assess all risk factors to identify root cause of the fall to prevent future avoidable falls. Fall 2/16/16 (4:05 p.m.) Record reivew of incident report revealed at 4:05 p.m., Resident #85 sustained a fall in the 300 hall by the double doors while pushing his/her wheelchair. The fall was witnessed by a nursing assistant (CNA). When assisted up and assessed for injury, the resident became agitated and refused vital signs and information how the fall occurred. The report did not identify where the resident was heading, any recent changes in medication or medical status, physician input or interventions after having notified of the second fall that day. In addition, there were inconsistencies of the location of the wheelchair with the double doors and if the resident was attempting to open the door with the wheelchair. There were no additional interviews with staff to identify trends, routine, changes in behavior prior to the fall or if the care plan was followed. The investigation did not clarify why the resident was agitated; if signs and symptoms of pain were a contributing factor despite the report indicated s/he denied pain. Record review of the behavior monitor revealed no documentation of any behaviors exhibited that day or interventions attempted. It was not clear what type of footwear the resident wore, what interventions were attempted after the resident allegedly refused to sit in his/her wheelchair, and if staff anticipated his needs by walking with him/her. Record review of the incident report revealed the physician was notified 4:37 p.m Record review of nursing progress notes dated 2/17/16 at 7:50 p.m. revealed an order was received to obtain lab work and a urinalysis (UA) to rule out a medical cause for the falls. The note did not clarify the time that had elapsed from the time of the original call to the order received after the fall. Nursing progress notes also indicated that the resident refused the lab work and UA, agitated behaviors were present and not redirectable according to the February 2016 behavior monitor. The behavior monitor revealed no behaviors documented up until the time of the fall. The behaviors exhibited were not explored within the investigation to determine if there was a change in condition. Record review of the February 2016 MAR revealed a UA was obtained 2/18/16, however the nursing progress notes dated 2/22/16 revealed the results may have been contaminated. A new specimen was attempted 2/28/16, causing a potential for further delay in treatment and prevention. Fall 2/21/16 Record reivew of incident report dated 2/21/16 revealed Resident #85 was found lying on the floor, incontinent, next to his/her bed at 3:10 a.m. The resident stated s/he slid on the floor when attempting to go to the bathroom. Staff interview revealed the resident was last checked and changed at 12:12 a.m. and it was at the 2:00 a.m. rounds the resident was found at 3:10 a.m. on the right side of the bed on the floor. Floor was dry, bed in lowest position and the resident was barefoot. No additional interviews were included or performed. The investigation conclusion revealed the resident was last seen approximately one hour earlier on rounds, but inconsistent with the witness statement and the time the resident was discovered. The summary included the resident was able to use the call light for assistance but was non-compliant with the use. Intervention and conclusion stated safety education was repeated to the resident even though it was identified that the resident had a cognitive impairment and unaware of safety needs. Staff anticipated his/her needs even though the resident was incontinent and the time frame of care provided. Yet, the care plan was allegedly followed. The report noted the investigation was revised on 3/3/16, five days past the five day required time frame for the an investigation to have been completed. A root cause analysis was not identified to determine whether the staff anticipated Resident #85's needs based on the time frame, current medical status that was not obtained in a timely manner, potential medications taken at night may have impacted the fall, or the care plan was actually followed. Fall 2/26/16 Record review of incident report revealed on 2/26/16 at 11:14 a.m., Resident #85 was seen ambulating in his/her room with front wheeled walker (FWW) headed to the bathroom. The resident lost his/her footing and fell . Staff had walked by the resident's room at the time of the fall. The witness stated s/he asked if the resident needed anything approximately 20 minutes prior to the fall, but the resident declined assistance at the time. Incident report revealed immediate action was taken to educate the resident to not ambulate without assistance with staff. It was identified the resident continued to be impulsive and did not follow directions well. The investigation and witness statements did not include the last time the resident had toileted, daily routine and preferences, or clarified if the staff knew the resident needed to use the rest room and declined assistance or to confirm that the staff member had attempted to meet the resident's needs 20 minutes prior, and what additional interventions were initiated to ensure the resident's safety despite identification that the resident continues to ambulate and attempt to toilet self without assistance of staff. The report determined that the resident was wearing appropriate footwear, though it did not indicate what that was. Proper footwear was not evaluated for previous falls. The current medical status was not determined pending the results of the new UA. Record review of nutrition progress note dated 2/18/16 revealed the resident experienced a 9.5% weight loss over the last three (3) months and no recent labs were available to evaluate the current medical status, root cause or risk factors. This information was not included in the investigation. A root cause analysis was not identified, individualized interventions were not implemented, and level of oversight to protect the resident from further falls including level of supervision. Fall 2/27/16 Record reivew of incident report revealed on 2/27/16 at 4:30 p.m., a resident notified staff that Resident #85 fell in the large dining room. The resident was lying on his/her back during an activity, witnessed by multiple people (not specified if they were residents or staff). The resident stated s/he was getting up and his/her foot slipped. It was witnessed that the resident took a sock and shoe off during the activity, then attempted to stand and slid to the floor. The resident was not asked why s/he took off his/her sock and shoe, evaluated the shoes fit appropriately, if staff had witnessed increased agitation prior to him/her standing, if staff had supervised or was in the line of sight of the resident, the last time the resident was toileted, and if the resident exhibited signs and symptoms of pain and were consistent with his/her answer. The investigation did not include the medical status, results of recent labs obtained, and the UA was pending. The root cause analysis was not identified, the care plan interventions were not individualized, and the facility did not determine level of oversight was appropriate to prevent future falls. Fall 2/29/16 Record review of incident report revealed a resident informed staff that Resident #85 was on the floor at bedside at 6:50 p.m. with the wheelchair in front of him/her. The resident stated s/he was attempting to get in bed. Upon investigation, the resident was ambulatory with assistance, had a gait imbalance and had impaired memory. The investigation summary revealed the resident was attempting to go to the bathroom and lost his/her balance, inconsistant with the initial statement. The discrepancy was not explained in the investigation, or why the resident did not have sufficient oversight at the time of the fall. The resisdent's footwear was not assessed or noted in the investigation. The investigation did not identify the last time the resident was seen or toileted. Interventions included reminding the resident to call for staff for assistance, though identified as cognitively impaired. In addition, obtain orthostatic blood pressures were to be monitored for three (3) days. It was documented the resident was non-compliant with obtaining vital signs. The care plan was not individualized and did not address interventions as the resident demonstrated non-compliance. The facility did not identify the root cause of the fall and the care plan was not individualized to prevent future falls. Interview with Staff B In interview on 3/22/16 at 11:30 a.m., Staff B stated a resident with a cognitive impairment that was a high fall risk was expected to have frequent checks and the needs anticipated. Frequent checks did not have a time frame or require documentation, probably every 15-30 minutes. Staff B also stated falls are discussed as a team. When the interventions were reviewed, a staff member would say, I already tried that. When asked how the failed interventions were kept track, Staff B said s/he was not certain where they were recorded or if in the care plan that was being reivewed at the

Based on observation, interview, and record review, the administration failed to utilize its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure resulted in the potential risk of residents to receive substandard care and services related to quality of care, resulting in harm for Residents #62, #118, and #120, and recurring falls for Residents #62, #80, #85, and #124. Findings include: The information below is more detailed in the individual citations: 1. Refer to 42CFR 483.25(h), F323, for failure to prevent residents from injury related to falls, for Residents #62, #118, and #120, and recurring falls for Residents #62, #80, #85 and #124. The Administrator did not ensure residents received supervision as required, failed to ensure staff oversight was conducted to ensure the care staff implemented care directives, and failed to ensure residents were comprehensively assessed, and interventions individualized for each resident, in order to prevent recurring falls, and injury. 10. Refer to 42CFR 483.75(o)(1) F 520 QAA, for failure of the Administrator to ensure the quality deficiencies were identified, and an action plan was developed and implemented to track and trend resident outcome related to standards of practice and to prevent substandard practices in the delivery of care and services to the residents, for all the residents in the facility. In interview on 3/23/16 at 10:50 a.m., the Administrator said there were no concerns with falls and resident injuries in the facility. The Administrator said she met monthly with an interdisciplinary team to discuss number of incident reports, the nature of each incident, how staff responded, timeliness, thoroughness of investigations, critical thinking, and how to prevent recurring falls. The Administrator did not ensure systems were developed and implemented to prevent resident injury and recurring falls.

Based on observation interview and record review it was determined that the facility failed to take appropriate measures to reduce the risk of an accident when the resident's plan of care for 1 of 3 Sampled Residents (#2) was not followed. This failure caused Resident #2 to be sent to the emergency room to undergo a procedure he described as painful. Findings include: Resident #2 had a medical [DIAGNOSES REDACTED]. Resident #2 had one nephrostomy tube (a tube from the kidney through the skin to the outside of the body to drain urine) from each kidney. NEPHROSTOMY TUBE CARE PLAN Review of the facility's incident log revealed one of Resident #2's nephrostomy tubes was accidentally pulled and disconnected during a transfer on 10/6/13. Review of the facility investigation revealed that staff members were moving the resident from his wheelchair to his bed using a slide board technique. While staff slid the resident into bed the right sided tube became caught on either the bed or the wheelchair, pulling it and causing to disconnect. Review of Resident #2's care plan dated 11/11/12 for nephrostomy tubes revealed interventions listed to prevent dislodgement of the tubes. The interventions listed included directives for staff to place an abdominal binder for all transfers to promote tube safety, notify the nurse if the resident refuses the binder. During an interview on 11/21/13 at 3:00 p.m. Staff D reviewed Resident #2's care plan and confirmed the resident was to wear a binder whenever being transferred. Staff D confirmed the directives in the care plan were current at the time of the incident. Staff D reported she was not aware Resident #2 had a binder. During an interview on 11/21/13 at 3:05 p.m. Resident #2 reported he was not wearing a binder at the time of the incident. Resident #2 further reported he had not even seen the binder in several months. During an interview on 11/21/13 at 3:55 p.m. Staff E and Staff F who were both assigned to Resident #2 reported they were not aware he had a binder. During an interview on 11/21/13 at 4:05 p.m. Staff H, who was assigned to Resident #2's care, reported she was not aware he had a binder. During an interview on 11/21/13 at 4:00 p.m. Staff G reported she has been assigned to Resident #2's care and has not ever seen an abdominal binder. ACTIVITIES OF DAILY LIVING CARE PLAN Review of Resident #2's care plan for activities of daily living dated 10/10/12 revealed the resident was to be transferred by using a sliding board. Interventions listed included directives for staff to place the resident's nephrostomy tubes in front of him and between his legs prior to the transfer. Review of the facility's investigation of the nephrostomy tube dislodgement on 10/6/13 revealed a statement from the staff member who was assisting the resident in the transfer. In the written statement Staff J indicated he had placed the collection "bag on the bed beside him like we always do". During an interview on 11/21/13 at 2:27 p.m. Resident #2 reported staff usually put the tubes in front of him with the bag between his legs, but the day the tubes were dislodged they had put it beside him on the bed. During the same interview Residnet #2 confirmed he had been sent to the hospital to have new nephrostomy tubes placed. Resident #2 reported during the procedure the hospital staff had to place a "wire" onto his bladder which was painful for him. During an interview on 11/21/13 at 3:00 p.m. Staff D confirmed after the nephrostomy tubes were pulled during the transfer the resident had to be sent to the emergency room so new tubes could be placed. Staff D confirmed the placement of new tubes through the skin and into the kidneys placed Resident #2 at risk for pain and infection related to the procedure. Failure to follow the care plan during a transfer caused one of Resident #2's nephrostomy tubes to become dislodged. This avoidable accident resulted in Resident #2 being sent to the hospital where he underwent an invasive procedure to have the tube replaced.

Based on interview and record review the facility failed to protect Resident #2 from Resident #1 who exhibited verbal aggression that turned to resident to resident physical altercation.This failure resulted in potential for continued physical or psychological harm. Findings include: RESIDENT #2 Record review revealed Resident #2 admitted to facility on 01/19/12 with [DIAGNOSES REDACTED]. Interview with Resident #2 on 02/01/12 at 5:00 p.m. revealed during admission on 01/19/12 Resident #2 was taken to his room by staff. His roommate, Resident #1, was in the room and initiated conversation. Resident #2 informed him that he did not want to talk because he was tired. Resident #1 became verbally abusive and threw a cellular phone at Resident #2; the phone hit Resident #2 on his face. Resident #1 continued to yell obscenities at Resident #2 then threw a container of urine at Resident #2. Resident #1 then blocked the room door with his wheel chair preventing staff from entering the room. The staff entered the room through the adjoining bathroom and took Resident #2 to another room. Resident #2 stated feeling "terrified" and "scared to death". Interview with Staff C on 02/01/12 at 5:15 p.m. revealed when Resident #2 arrived he was to share a room with Resident #1. Staff C said she entered the room to assist Resident #2 with inventorying his personal belongings. Upon entering the room Resident #2 "looked frightened and said he was terrified". Resident #2 said Resident #1 threw a cellular phone at him. Staff C asked Resident #2 where the phone was, Resident #2 then moved slightly to expose the phone that was in the bed with him. Staff C then left to inform the nurse of what occurred. The nurse called Staff B and was instructed to move Resident #2 to another room. When Staff C attempted to reenter the resident's room she found the door was blocked by Resident #1. Staff C along with two additional staff entered through the connecting bathroom. Upon entering the room Resident #1 had moved away from the room door allowing access to the room and Resident #2 was wet on his face, clothes and bed. When Staff C approached Resident #2 she found he smelled of urine. Resident #2 informed Staff C that Resident #1 threw urine at him. Staff C gathered Resident #2's belongings moved him to another room. Review of incident reports dated 01/19/12 at 9:40 p.m. and 9:45 p.m. confirmed Resident #1 threw a cellular phone and urine at Resident #2. The report indicated the two residents were placed on 15 minute checks. Record review of chart for Resident #2 revealed the following day on 01/20/12 the resident was care planned for risk of psychological harm related to the incident. Interventions on the care plan included monitoring for signs and symptoms of psychological harm and alert charting x 72 hours. There was no evidence of any monitoring for potential psychological harm or any alert charting related to the incident. No new interventions were added to care plan for Resident #1. The incident report indicated "careplan already reflects behavior problems with other residents and staff." Record review indicated Resident #1 had a behavior contract for sexually inappropriate comments to staff dated 08/03/11 and a Mood/Behavior care plan instituted on 01/18/12, the day before the incident. Resident #2 endured abuse within minutes of entering the facility. After protecting the resident no follow-up was executed to ensure the resident did not suffer psychological trauma from the incident. No interventions were implemented to ensure Resident #1 did not assault or intimidate other residents. RESIDENT #3 Record review revealed Resident #3's [DIAGNOSES REDACTED]. Review of incident report revealed on 01/29/12 Resident #3 was yelling out the "N" word when Resident #1 threatened to hit Resident #3 and yelled vile language at him. Resident #1 also positioned his wheel chair in a manner preventing Resident #3 from leaving the area while Resident #1 yelled at him. Both residents were placed on 15 minute checks. Observation on 02/01/12 at 3:15 revealed Resident #3 ambulated to a chair at the entrance of the facility. The resident used a walker for mobility and ambulated with an unsteady gait. The resident was alert and oriented to self. Record review revealed Resident #3 had a history of [REDACTED]. The resident also had a history of [REDACTED]. Interview with Staff D on 02/02/12 at 11:15 a.m. revealed Resident #1 had verbal altercations with other residents but staff intervened and redirected. Record review revealed care plan for Resident #1 did not include any new interventions after the incident with Resident #3. The facility was aware of Resident #1's history of altercations with other residents and the impulsive behavior of Resident #3. No intervention was implemented to protect other vulnerable residents from Resident #1.

Based on interview and record review the facility failed to protect 1 of 14 Sampled Residents (#1) from physical and mental abuse. This failure resulted in the resident experiencing fear and despair and presented a potential for psychological harm. Findings include: Resident #1 was diagnosed with [REDACTED]. The [DIAGNOSES REDACTED]. Interview with Staff E on 01/03/12 at 4:40 p.m. revealed on 01/01/12 Resident #1 grabbed a bandage soiled with blood from her arm and threw it at Staff C. Staff C responded by picking up the soiled dressing and rubbing the side soiled with blood across the lips of Resident #1. Interview with Staff D on 01/04/12 at 6:00 p.m. revealed on 01/01/12 Resident #1 sustained a skin tear on both her hands. Staff C applied a dressing on the skin tear on the right hand. Resident #1 removed the dressing and threw it. Staff C picked up the dressing then rubbed the blood soiled side of the dressing on Resident #1's mouth. Resident #1 closed her mouth tightly and lied on the bed "with her eyes glassy as if she did not know what was going on" without responding to the incident. Interview with Staff C on 01/09/12 at 10:20 a.m. revealed on 01/01/12 Resident #1 was bleeding from a skin tear on her right arm. Staff C said she was applying a dressing to the right arm of Resident #1 when Staff D informed her of a skin tear on the left hand of Resident #1. Staff C admitted wiping the face and mouth of Resident #1 with the soiled dressing. Record review of facility incident report dated 01/02/12 revealed substantiation of Staff C wiping the soiled gauze across the mouth of Resident #1. .

Based on interview and record review the facility failed to provide medically related social services to 1 of 27 Sampled Residents (# 26).This failure resulted in harm due to the resident not receiving oxygen as needed, becoming non-responsive and the resident requiring emergency services to sustain life. Findings include: Interview with Interested Party 3 on 10/25/11 at 8:30 a.m. revealed Resident #26 was discharged from the facility on 10/12/11 to an AFH (adult family home). The facility indicated the resident required oxygen prn (as needed) but did not provide oxygen for the resident on the two to three hour ride to the AFH. Interested Party 3 reported speaking with the staff at the facility who admitted to "dropping the ball" and not arranging for oxygen for Resident during transport to the AFH. Interview with Interested Party 1 on 10/21/11 at 9:00 a.m. revealed Resident #26 arrived to the AFH (adult family home) on 10/12/11. The resident was so short of breath upon arriving that the resident could not speak. The resident asked to lay down, an hour later the Interested Party checked on the resident and found her to be unresponsive. Emergency Services was contacted and the resident was sent to the hospital. Interview with Interested Party 2 on 10/21/11 at 10:15 a.m. revealed Resident #26 arrived at the hospital on 8 liters of oxygen and she was responsive. The hospital found the resident with right lower lobe pneumonia. The resident was admitted and given intravenous antibiotics. Record review revealed Resident #26 received antibiotic treatment for [REDACTED]. She received the last dose of her antibiotics on 10/08/11, four days prior to discharge. Record review revealed the resident complained of "feeling ill" on 10/10/11, two days prior to discharge. No evidence of any assessment and no notification to the physician of the resident's self report. The records also indicted the resident used oxygen on the day of discharge, and almost daily during the week of discharge. The progress note dated 10/11/11 indicated the resident used oxygen while in bed. During interview on 10/21/11 Interested Party 1 said he was told by the facility social worker and the facility care manager that the resident did not require oxygen continuously. Interested Party indicated he was lead to believe the resident rarely used oxygen. Interested Party 1 said he visited the resident in the hospital on [DATE] and the resident informed him she used oxygen every night and frequently during the day. Interview with Staff R on 10/21/11 at 4:30 p.m. revealed Resident #26 used a concentrator in her room. Staff R said the resident would sometimes go outside and smoke then come inside and immediately grab her nasal cannula to get oxygen so she could breathe. Interview with Staff S on 10/21/11 at 4:40 p.m. revealed strict instructions were left to not turn off the resident's concentrator. Staff S said the concentrators were turned off for other residents once they were up and ambulating. However, Resident #26's concentrator was never to be turned off because of her oxygen needs. The resident would re-enter her room after ambulating and say, "Please put my oxygen on." Interview with Staff E on 10/20/11 at 3:05 p.m. revealed Resident #26 was given a hard script (paper prescription from physician prescription pad with physician signature) for oxygen when she was discharged ; oxygen was not sent with her. Staff E said the resident used oxygen prn (as needed) so she did not need to take oxygen with her. Review of facility discharge policy revealed social services coordinates DME (durable medical equipment), outpatient services, follow-up appointments and other arrangements. The oxygen was considered durable medical equipment. The facility's social services failed to make arrangements to obtain oxygen equipment needed by Resident #26 to maintain her already compromised respiratory status during transport and failed to verify that the receiving adult family home had oxygen available for the resident. This failure resulted in respiratory distress and hospitalization . .