Every finding on record at Beacon Hill Rehabilitation

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident 43) was free from physical restraints. This failure placed residents at risk of injury and a decreased quality of life.Findings included.Resident 43 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set (an assessment tool), dated 03/02/2026, indicated Resident 43 was alert and oriented.During an observation and interview on 05/19/2026 at 9:02 AM, Resident 43's bed was observed against the wall on the window side of the room. Resident 43 said the bed had always been like that.During an observation on 05/20/2025 at 2:36 PM, Resident 43's bed was still against the wall.Record review of Resident 43's electronic health record did not have an an assessment, consent, care plan or a physician's order regarding Resident 43's bed against the wall.During an observation and interview on 05/20/2026 at 2:45 PM, Staff H, Resident Care Manager/Licensed Practical Nurse, said before a bed was placed against a wall the facility would do a safety assessment, get consent, get an order, and update the care plan. When asked about Resident 43's bed against the wall, Staff H said Resident 43 did not have an intervention for his bed to be against the wall. When we went to the room Staff H said the nursing assistant could have accidentally pushed the bed against the wall. Staff H said the bed should not be there.Reference WAC 388-97-0620 (1)(B)

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 1 of 8 sampled residents (Resident 7) reviewed for physical restraints and unnecessary medications. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.Findings included. Resident 7 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 7 was severely cognitively impaired, did not use a wander/elopement alarm (Wander Guard, a security system that uses a wearable tag and/or sensor designed to prevent people with cognitive impairments from leaving secure areas to ensure their safety, by triggering alerts to caregivers), was taking anticoagulant medication (blood thinner medications that slow down or prevent blood clots), and was not taking antiplatelet medication (medications that stop blood cells from sticking together). Record review of Resident 7's physician orders, dated 11/19/2025, documented, LN [licensed nurse] to monitor wander guard placement to left ankle every shift. Record review of Resident 7's physician orders, dated 12/02/2025, documented, Check wander guard placement Qshift [every shift] Left ankle . Record review of Resident 7's care plan, dated 11/22/2025, documented, [Resident 7] Utilizes enabling devices.Wander guard.Check wander guard placement Qshift. In an observation on 05/20/2026 at 9:23 AM, Resident 7 was observed sitting in a chair in the third-floor lobby with a Wander Guard alarm bracelet attached to her left ankle. Record review of Resident 7's physician orders, dated 11/12/2025, showed Resident 7 was prescribed Clopidogrel, an antiplatelet medication. Further review of Resident 7's physician orders did not show Resident 7 was prescribed anticoagulant medications. Record review of Resident 7's May 2026 Electronic Medication Administration Record, showed Resident 7 was taking Clopidogrel daily. In an interview on 05/21/2026 at 9:05 AM, Staff D, Resident Care Manager/Licensed Practical Nurse, said the Wander Guard was not captured on Resident 7's MDS and it should have been, stating, I missed that. When asked about Resident 7's MDS coded for anticoagulant medication use and no antiplatelet medication use, Staff D said he thought the Clopidogrel medication was an anticoagulant, not an antiplatelet. In an interview on 05/21/2026 9:43 AM, Staff B, Director of Nursing/Registered Nurse, indicated Resident 7's Wander Guard should have been captured on the MDS. Staff B said Clopidogrel was not an anticoagulant and should not have been coded as one. Reference WAC 388-97-1000 (1)(b)(n)

Based on observation, interview, and record review, the facility failed to ensure physician orders and/or care plans were followed for 1 of 5 sampled residents (Resident 30) reviewed for unnecessary medications, 1 of 4 sampled residents (Resident 2) reviewed for accidents, and 1 of 1 sampled resident (Resident 4) reviewed for antibiotic use. This failure placed residents at risk of injury, unmet care needs, and a diminished quality of life.Findings included . Resident 30 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 04/16/2026, indicated Resident 30 was alert and oriented. Record review of Resident 30's physician's order, dated 04/10/2026, showed Resident 30 was prescribed Oxycodone (a narcotic pain medication) tablet, Give 1 tablet by mouth every 6 hours as needed for PAIN (LEVEL 6-10) NOT RELIEVED BY NON-OPIOD [sp] TX [treatment]. Record review of Resident 30's electronic Medication Administration Record (eMAR), dated 04/14/2026, documented Resident 30 was given an Oxycodone tablet for a pain level of 4. Record review of Resident 30's eMAR, dated 05/08/2026, documented Resident 30 was given an Oxycodone tablet for a pain level of 5. Record review of Resident 30's eMAR, dated 05/18/2026, documented Resident 30 was given an Oxycodone tablet for a pain level of 3. During an interview on 05/21/2026 at 9:52 AM, Staff I, Licensed Practical Nurse, said if a resident complained of pain, they would try non-pharmacological interventions first if that did not provide relief then they would give the resident pain medication as prescribed. Staff I said she would follow the parameters as set forth by the physician. During an interview on 05/21/2026 at 10:20 AM, Staff B, Director of Nursing/Registered Nurse (RN), said nurses should assess the pain level, attempt non-pharmacological interventions, and then follow the parameters for pain medication if needed. Staff B said Resident 30 should not have been given Oxycodone for a pain level of 3 to 5. Staff B said the nurse should have contacted the provider to get a new order if Oxycodone was needed. Resident 2 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 2 was moderately cognitively impaired. Record review of Resident 2's physician orders, dated 11/18/2025, documented, .FALL MATS TO RIGHT AND LEFT SIDES OF BED. Record Review of Resident 2's enabling devices care plan, dated 11/18/2025, documented, .fall mats to right and left sides of bed. In an observation on 05/18/2026 at 12:45 PM, Resident 2 was observed lying in bed with a fall mat on the floor to the left side of the bed. No fall mat was observed on the floor to the right side of the bed. In an observation on 05/18/2026 at 3:48 PM, Resident 2 was observed lying in bed with a fall mat on the floor to the left side of the bed. No fall mat was observed on the floor to the right side of the bed. In an observation on 05/19/2026 at 8:58 AM, Resident 2 was observed lying in bed with a fall mat on the floor to the left side of bed. A second fall mat was observed to the right side of the bed leaning up on its edge against the open closet. In a joint observation and interview on 05/19/2026 at 12:45 PM, Staff F, RN, went to Resident 2's room and observed a fall mat on the floor to the left side of the bed, and a mat to the right side of the bed leaning up on its edge against the open closet. Staff F pointed to the fall mat on the right side of the bed leaning on its edge and said she did not know why that fall mat was there. Staff F left the room and looked at Resident 2's Electronic Health Record, stating, It does definitely say fall mats to the right and left side of the bed. In an interview on 05/19/2026 at 1:40 PM, Staff B said she expected both fall mats to be down on the floor if that's what was ordered. Resident 4 was re-admitted to the facility on [DATE]. The Admission/Medicare – 5-day MDS, dated [DATE], documented Resident 4 was severely cognitively impaired and was on IV (intravenous, a method to administer fluids, medications, or nutrients directly into the bloodstream through a vein) medications. Record review of Resident 4's physician orders, dated 04/24/2026, documented, PICC [Peripherally Inserted Central Catheter, a type of long-term IV in the upper arm] Dressing change weekly every day shift every 7day(s) for PICC line w/ [with] IV ABO [antibiotic]. In an observation on 05/18/2026 at 3:02 PM, Resident 4 was observed lying in bed. An IV site with a dressing was observed on Resident 4's upper left arm that was dated 5/9, nine days ago. In an interview and observation on 05/18/2026 at 3:10 PM, Staff G, RN, said PICC dressings were changed every seven days. Staff G went to Resident 4's room and looked at the PICC dressing on Resident 4's upper left arm, stating, It does say 5/9 as the date on the dressing. Staff G said she would need to ask Staff J, Infection Preventionist /RN if a PICC dressing change should be done every seven or 10 days. In a joint interview on 05/18/2026 at 3:18 PM, Staff J and Staff B said PICC line dressings should be changed every seven days. In an interview on 05/19/2026 at 1:44 PM, Staff B said the dressing change for Resident 4's PICC was a missed treatment. Reference WAC 388-97-1060(1)(3)(g)(k)(i)

Based on observation, record review, and interview, the facility failed to ensure food items were properly stored in 2 of 5 walk-in facility refrigeration devices. This failure placed residents at risk for food borne illness, and a diminished quality of life. Findings included . Record review of the facility policy, titled, Policy/Procedure-Food Storage, revision date February 2025, documented, Food Rules As Follows:Please label and date all items you place in the refrigerator with a 'UB' or Use By Date.The Used By label is good for 2 days after date it is placed. Total 3 days.All items in the refrigerator past the UB Date will be discarded.Any perishable, non-sealed, no-marked item will be discarded for prevention of food borne illness. During an observation on 05/18/2026 at 9:54 AM, the kitchen walk-in refrigerator was observed with the following undated, opened items: Two plates containing two tuna salad sandwiches each, wrapped in plastic wrap, labeled with UB date of 05/17/2026.Six lbs (pounds) plastic container of salsa, opened and unlabeled.Five lbs plastic resealable bag of pepperoni, opened and unlabeledBlock of sliced American cheese, opened, undated and stored with plastic wrapping coming undone, exposing the cheese.16 oz (ounces) of Whipped Topping, opened and cut on bottom corner, unlabeled and stored with plastic wrapping coming undone, exposing the topping. During an observation on 05/18/2026 at 10:01 AM, the outside walk-in freezer, was observed with the following undated, opened items: Plastic bag of meatless chicken bites, opened and unlabeled In an interview on 05/18/2026 at 10:07 AM, Staff E, Dietary Manager, said the items going into the food storage areas should be labeled with a use by date, and should be discarded by that date. Staff E proceeded to discard all unlabeled items, and stated, Yes, all that should be tossed. In an interview on 05/21/2026 at 9:52 AM, Staff A, Administrator, said he expected food items in the refrigerators to be labeled accurately and discarded by the use by date. Reference WAC 388-97-1100 (3) & 2980

Based on interview and record review, the facility failed to ensure ongoing physician notifications were made when the resident experienced a change of condition in conjunction with a medication discontinuation and the need for a significant change in treatment for 1 of 7 sampled residents (162) reviewed for notification of change. Resident 162 experienced harm when the resident had ongoing increasing visual hallucinations (mice, snakes, does not feel safe, lost appetite due to snakes in the resident's room, people in the resident's room, tadpoles, river rats that can bite you, being held hostage, and stated, This is terrible.) and the physician was not consulted about the ongoing increasing hallucinations and a significant need for treatment. This failure placed residents at risk for untreated medical conditions and a diminished quality of life. Findings included . Resident 162 was admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS) assessment, dated 12/05/2024, indicated Resident 16 was moderately cognitively impaired. Physician orders showed Resident 162 was started on Seroquel (an antipsychotic medication used to treat psychosis and other major psychological mood disorders) 50 mg orally at bedtime for hallucinations during the resident's most recent hospitalization and when readmitted to the facility on [DATE]. A pharmacist recommendation, signed by the physician on 01/09/2025, reduced Resident 162's Seroquel dose to 25 mg orally for 1 week, and then to stop the Seroquel medication. A nursing note, dated 01/12/2025 at 10:10 AM, documented, Res [Resident 162] on alert for decreased Seroquel order. Res vital signs stable; when asked how [the resident] slept, res stated . restless 'because of the mice.' LN [Licensed Nurse] asked [the resident] to clarify if . hearing or seeing the mice. Res stated . was 'watching them run across the ceiling.' Res was matter of fact when reporting and was not in distress related to the 'mice.' The electronic health record (EHR) showed Resident 162's Seroquel ended on 01/15/2025 per pharmacy recommendations. A nursing note, dated 01/17/2025 at 12:26 AM, documented, Res c/o [complained of] having some cannabis missing from [the resident's] room, as well as seeing mice and snakes coming out of the vents in the walls.Assured [the resident] is safe and no mice or snakes are in [the resident's] room. A nursing note, dated 01/18/2025 at 1:02 AM, documented, Res is received in bed awake. Res talking about people in [the] room looking at [the resident]. Res states . doesn't feel safe. Res is assured no one was in [the] room. A nursing note, dated 01/19/2025 at 3:40 PM, documented, On alert for c/o seeing 'snakes' in [the] room. Res declined eating lunch, indicating [a lost appetite] after seeing 'snakes.' [Resident 162] indicated [knowing] it is in [the resident's] head, but it is bothersome. A nursing note, dated 01/20/2025 at 4:21 AM, documented, Res cont [continues] with hallucinations. Res stated [knowing] the 'snakes,' 'tadpoles,' and 'mice' are not real, but . can still see them. Upon giving scheduled medication, res stated . wasn't sure if this LN was real. Reassured and reoriented res. An eMAR-Medication Administration Note, dated 01/27/2025 at 5:53 AM, documented, Res cont with hallucinations. Res hollering for help when awake this shift. Res adamant that there's a river rat in [the] room. Tried to reassured res, but res was insistent it was there and had this LN put [the resident's] shoes on while in bed so that the river rat would not be able to bite [the resident's] feet. NAC [Nursing Assistant Certified] reported to this LN that res thinks we're keeping [the resident] hostage. Had to reorient and reassured res multiple times as res thinks this LN also in danger. A eMAR-Medication Administration Note, dated 01/29/2025 at 12:07 PM, documented, This shift LN went into [Resident 162's] room [ROOM NUMBER] times to provide care. Each time resident was experiencing hallucinations. 'This is terrible. You couldn't have children with this.' Resident referring to hallucinations, dog, cat, snake. On 03/06/2025 at 9:01 AM, Staff B, Director of Nursing Services (DNS) and a Registered Nurse (RN), said Resident 162 was started on Seroquel for delirium while at the hospital and no longer needed the medication. Staff B said after reviewing Resident 162's medical record, the medical director was notified by e-mail of these distressing hallucinations on 01/20/2025 with physician's direction to continue to monitor. When asked to provide further notifications to the physician regarding Resident 162's ongoing hallucinations over the next 10 days, Staff B indicated she was unable to provide documentation of further physician notifications. Staff B said there should have been notes in the chart reflecting the nurses had reported Resident 162's ongoing hallucinations to the physician. Reference WAC 388-97-0320 (1)(b)(c)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication side effects by failing to provide side effect monitoring for 1 of 5 sampled residents (38) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medication side effects, unmet care needs, and a diminished quality of life. Findings included . Resident 38 was admitted to the facility on [DATE] with diagnoses including Dementia with Other Behavioral Disturbances. The Quarterly Minimum Data Set assessment, dated 01/22/2025, documented Resident 38 was severely cognitively impaired. A physician's order, dated 11/08/2024, documented Resident 38 was prescribed Zyprexa (an antipsychotic medication). Resident 38's February 2025 and March 2025 Medication Administration Record (MAR) did not show documentation of medication side effect monitoring. On 03/06/2025 at 11:04 AM, after reviewing Resident 38's Zyprexa order and the February 2025 and March 2025 MAR, Staff B, Director of Nursing Services and Registered Nurse, indicated she was unable to locate documentation of antipsychotic medication side effects monitoring. Staff B said there should have been side effect monitoring documented in the MAR every shift. Reference WAC 388-97-1060 (3)(k)(i)(4) .

Based on interview and record review, the facility failed to ensure resident centered activities were provided that incorporated the resident's preferences for 1 of 4 sampled resident (37) reviewed for activities. This failure placed residents at risk for a diminished quality of life. Findings included . Resident 37 was admitted to the facility on [DATE]. The Admission's Minimum Data Set assessment, dated 11/06/2024, showed the resident was alert and oriented and preferred to have books, newspapers and magazines. The Activity - Admission Evaluation, dated 01/24/2024, documented activities will provide car magazines. The Activity - Quarterly Evaluation, dated 01/23/2025, documented activities has provided Resident 37 with car magazines. The February 2025 and March 2025 activity participation reports did not show Resident 37 had been offered and/or refused car magazine. On 03/04/2025 at 8:37 AM, Resident 37 said one of his activity preferences was cars or motorsports. Resident 37 said he would be interested in magazines or books related to motorsports if offered. On 03/06/2025 at 10:33 AM, Staff H, Activities Director, said if a resident had a preference for an activity they would do what they could to meet that resident's preferences. Staff H said they have supplied magazine, books, calendars and pictures. At 2:10 PM, Staff A, Administrator, said activities should develop a plan for the resident's preferences and provide services. Reference WAC 388-97-0940 (1)(2)

Based on observations, interview and record review, the facility failed to ensure physician orders were implemented for edema (the presence of excessive fluid in the body tissue) treatment for 1 of 1 sample resident (21) and failed to ensure bowel interventions were initiated for 1 of 5 sample residents (24) reviewed for quality of care related to following physician orders and bowel management. These failures placed residents at risk of complications related to untreated medical conditions and a diminished quality of life. Findings included . <Edema> Resident 21 was admitted to the facility on [DATE] with diagnoses including chronic congestive heart failure. The 5-day MDS Assessment, dated 01/28/2025, indicated Resident 21 was moderately cognitively impaired. A Physician order, dated 01/31/2025 at 8:00 PM, indicated Resident 21's ted hose (a type of compression stocking used to treat swelling) were to be put on in the morning and to be taken off at bedtime for the treatment of edema. On 03/03/2025 at 3:06 PM, Resident 21 was observed sitting on the side of the bed and indicated her right leg was so swollen that fluid was starting to leak through the skin. There was visible moisture on the outer calf side of Resident 21's right leg. Resident 21 said her right pant leg was wet, and the pant leg did appear to be damp. Resident 21 was not wearing the ted hose. When asked if she had ever used compression stockings, Resident 21 stated, Oh, they talked about it, but that is all that ever happened. I have never been given any. On 03/04/2025 at 3:40 PM, Resident 21 was observed sitting on the side of the bed and not wearing the ted hose. Resident 21 said by the evening time she had to change her pants due to the moisture from the right leg dripping onto her clothing. On 03/05/2025 at 8:48 AM, Staff D, Nursing Assistant (NA), said for residents that wore ted hose, there would be a place on the task list to prompt the nursing assistants to put on the ted hose. Staff D said there would also be a prompt for removing them in the evening. Staff D said Resident 21 did not wear the ted hose. Staff D indicated they were unable to find a cue on the task list indicating the placement of ted hose for Resident 21. At 9:10 AM, Resident 21 was observed sitting on the side of the bed and not wearing the ted hose. Resident 21's legs were visibly swollen. At 9:10 AM, when asked to assess Resident 21's edema and locate the physician order for ted hose, Staff C, Licensed Practical Nurse and Resident Care Manager (RCM), Resident 21's legs were observed to be visibly swollen and shiny in appearance. Staff C asked Resident 21, Where are your compression stockings. Resident 21 stated, I have never had any. They talked about getting me some, but that's it. On 03/06/2025 at 9:01 AM, Staff B said the nurse would tell the nursing assistant verbally to put on ted hose for a resident. Staff B said the nurses should chart in the EHR if the resident refused the treatment. Staff B was unable to find documentation for refusals in Resident 21's EHR. At 3:10 PM, Staff E, NA, said she would find information about ted hose in the charting area of the EHR. Staff E said she worked during the evening time, and would be responsible to take the [NAME] hose off if a resident was wearing them. Staff E said she had never seen any of the residents have [NAME] hose, including Resident 21. 37934 <Bowel Interventions> A facility's document entitled, Bowel Protocol, undated, documented, If no BM (Bowel Movement) after 4 days: 1. Administer Miralax (Laxative) 17gm (grams) in 6-8oz (ounces) of choice of beverage on day shift of day 4. Resident 24 was admitted to the facility on [DATE]. The Annual MDS assessment, dated 11/26/2024, showed the resident was alert and oriented. The BM task sheet documented Resident 24 had a BM on 02/18/2025 at 8:10 PM. Resident 24's next BM was on 02/23/2025 at 12:59 PM, over 112 hours, five days since the last BM. The February 2025 Medication Administration Record did not show documentation Resident 24 received any interventions between 02/18/2025 and 02/23/2025. On 02/07/2025 at 9:40 AM, Staff F, RCM and Licensed Vocational Nurse, said the bowel protocol should be initiated if the resident did not have a bowel movement after four days. After reviewing Resident 24's Bowel task, Staff F said the bowel protocol should have been initiated on 02/22/2025. At 9:29 AM, Staff B said the bowel protocol should be initiated on day 4 of no BM's. After reviewing Resident 24's Bowel task, Staff B said the bowel protocol should have been initiated on 02/22/2025. Reference WAC 388-97-1060 (1)(3)(c)

Based on observations, interviews and record review, the facility failed to ensure oxygen therapy was accurately monitored for 1 of 4 sampled residents (21) reviewed for oxygen therapy. This failure placed residents at risk for a compromised respiratory status and a decreased quality of life. Findings included . The facility policy/procedure for oxygen administration, updated 02/2023, indicated the facility will document all appropriate information in the medical record including oxygen therapy, respiratory assessment findings, method of oxygen delivery, flow rate, resident's response, any adverse reactions or side effects. Resident 21 was admitted to the facility on [DATE] with diagnoses including oxygen dependence related to chronic respiratory failure. The 5-day Minimum Data Set assessment, dated 01/28/2025, indicated Resident 21 was moderately cognitively impaired. The physician order for oxygen therapy, dated 01/23/2025, indicated oxygen was to be delivered at 2L/min (liters per minutes) when at rest, or 2-3L/min with activity. On 03/03/2025 at 1:34 PM, Resident 21 was observed sitting on the side of their bed with oxygen delivery. The oxygen concentrator dial indicated 3.5 L/min of oxygen was being administered. On 03/04/2025 at 3:49 PM, Resident 21 was observed in their bed receiving oxygen with the concentrator dial set to 3.5 L/min. On 03/5/2025 at 8:47 AM, Resident 21 was observed sitting on the side of their bed receiving oxygen with the concentrator dial set to 3.5 L/min. At 9:10 AM, Staff C, Resident Care Manager and Licensed Practical Nurse, said the oxygen order was determined by the nurse. The determination would be made to increase the oxygen setting if the resident was working with therapy and required more oxygen. Staff C indicated she was unable to find the amount of oxygen Resident 21 was receiving in the medical record. On 03/06/2025 at 9:01 AM, Staff B, Director of Nursing of Services and Registered Nurse, said the nurses monitor the oxygen on the Medication Administration Record. Staff B indicated she was unable to provide documentation showing Resident 21's oxygen use was being monitored as per the oxygen order. Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview and record review, the facility failed to ensure nursing hours were accurately posted and updated daily for each shift. This failure placed residents, resident representatives and visitors at risk of not being fully informed of the current staffing levels and census information. Findings included . On 06/14/2021 at 9:15 AM, the survey team entered the building. The staff posting was observed on the wall left of the nursing station on the 3rd floor. No staff posting was found on the 2nd floor, also known as the sub-acute floor of the building. On 06/15/2021 at 8:16 AM, Staff posting was found on the wall left of the nursing station on the 3rd floor. No staff posting was found on the 2nd floor/sub-acute floor of the building. On 06/17/2021 at 8:32 AM, Staff posting was found on the wall left of the nursing station on the third floor. No staff posting was found on the 2nd floor/ sub-acute floor of the building. At 8:40 AM, Staff A, Administrator, said he was in charge of staff postings for the time being. Staff A said he made up the postings every night and left them for the morning nurse to post. If there was a change from the time he left them and when he returned he would fix them. Staff A said he did this Monday through Friday, and on Fridays he made up the postings for Saturday and Sunday for the weekend nurse to post. Staff A was asked if the postings were placed on both floors of the facility and stated, No, just the 3rd floor. We have a sign on the 2nd floor indicating the posting can be found on the 3rd floor. Staff A was asked if the postings were updated at any time during the shifts for any reason and stated, No they are not. Staff A was asked who did the postings when he was unavailable and said they are saved to a common drive the staff have access to so basically anyone could do it. No Associated WAC

Based on interview and record review, the facility failed to ensure consents for immunizations were accurately and individually depicted for the type of immunization being received for 5 of 5 sampled residents (Residents 14, 17, 22, 38, & 42) reviewed for immunizations. This failure placed residents and/or resident representatives at risk of not being fully informed to make decisions regarding health care choices. Findings included . 1) Resident 14 was admitted to the facility on [DATE]. Resident 14's consent for Influenza and Pneumococcal Vaccines dated 10/12/2020, documented the resident consented to receive a pneumococcal vaccine but did not indicate whether it was for PPSV23 or [MEDICATION(S)]. The Electronic Health Record (EHR) documented the resident received a PPSV23 prior to admission on 03/15/2007 and documented the consent status as historical. No other documentation was found. 2) Resident 17 was admitted to the facility on [DATE]. The resident's EHR documented the resident received [MEDICATION(S)] prior to admission on 10/24/2016, and listed the consent status as complete. Documentation showed the PPSV23 as consent refused. There was no documentation to show the resident had refused the vaccine. 3) Resident 42 was admitted to the facility on [DATE]. The resident's EHR documented the resident had received [MEDICATION(S)] prior to admission on 10/24/2017, and listed the consent status as historical. Documentation also showed the resident received PPSV23 prior to admission on 06/13/2011, and listed the consent status as historical. Documentation also showed the PPSV23 as consent refused. There was no documentation to show the resident had refused the vaccine. 4) Resident 22 was admitted to the facility on [DATE]. Resident 22's consent for Influenza and Pneumococcal Vaccines dated, 03/17/2021, indicated the resident declined the vaccines but did not make a distinction between the [MEDICATION(S)] and the PPSV23.The resident's EHR documented the resident had received PPSV23 prior to admission, on 01/01/2004, and listed the consent status as historical. Documentation also showed the [MEDICATION(S)] as consent refused. 5) Resident 38 was admitted to the facility on [DATE]. Resident 38's consent for Influenza and Pneumococcal Vaccines dated, 05/12/2021, did not select whether the resident wished to receive the vaccines or declined it, and also did not make a distinction between the Prevnar13 and the PPSV23. The resident's EHR documented the Prevnar13 and PPV23 as consent refused. On 06/18/2021 at 9:54 AM, Staff E, Licensed Practical Nurse/Infection Preventionist, said on admission a resident's pneumococcal status was assessed and if the resident was unsure the facility could look in the hospital records or talk to the family. Staff E said the findings were documented in the resident's EHR under the immunization section. Staff E, said the Pneumonia Vaccine Consent Form, used when the vaccine was administered, does differentiate between Prevnar13 and PPSV23. Review of the Pneumonia Vaccine Consent Form provided, did not make a distinction between the Prevnar13 and the PPSV23 pneumococcal vaccines. Staff E, was asked how she would know which vaccine the resident was consenting for and stated, Makes sense and we may need to change the process in the admission packet. On 06/21/2021 at 11:57 AM, Staff E stated, When a resident is admitted we ask if they have had the flu or pneumonia shot, when and if not would they like it. If they want it they sign a consent which also has a place for refusals. When asked about meaning of the facility documentation of historical and consent refused, Staff E said, Historical documented in the EHR, means they had told us they already had it or we looked it up in hospital records and saw they had it. Staff E also said Consent refused documented in the EHR means that they refused the vaccination not the consent or declination. Staff E was asked about the consent for Influenza, Pneumococcal Vaccine Immunizations signed, 10/12/2020 for Resident 14 indicating she wanted the vaccine but did not differentiate between PPSV23 and Prevnar13, I guess I missed that. She is on hospice now so I will have to ask hospice if she can receive it now. I see how the current consents can be confusing in the state they are now. Reference WAC 388-97-1340 (2).

Based on observation, interview and record review, the facility failed to consistently and accurately identify, monitor and document non-pressure skin injuries for 2 of 3 sampled residents (Residents 34 & 205) reviewed for pressure injuries. This failure placed residents at potential risk for unidentified and untreated skin issues, potential for discomfort, a change in health status and a diminished quality of life. Findings included . 1) Resident 205 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 06/08/2021 documented the resident required extensive assistance from staff for activities of daily living (ADL's) and had no documented skin issues on admission. On 06/14/2021 at 12:29 PM, during an interview, Resident 205 said she had a bed sore on her butt cheek. A LN (Licensed Nurse) Skin Evaluation form, dated 06/16/2021, documented, Pink blanchable (indicates blood flow to area) area to left buttocks 2 x 1 cm (centimeters), no open areas noted, no other skin issues notes. Barrier cream applied. On 06/17/2021 at 9:40 AM, Staff C, Licensed Practical Nurse (LPN) said if a skin issue was found, there was a skin risk evaluation form in the computer staff were to fill out. Then they were to notify the Resident Care Manager (RCM) and the Director of Nursing Services (DNS) who led the skin team. The resident was to be placed on alert, call the physician and get treatment orders started and advise the family. At 12:01 PM, Resident 205's buttocks were observed to have a circular, dark pink, blanchable area approximately 2 cm in circumference at the base of the buttocks, just between the cheeks. In the middle of the left buttock cheek there was an area that appeared as a dry scabbed area approximately 2 cm long by 0.5 cm wide and slightly round in nature. 2) Resident 34 was admitted to the facility on [DATE]. The MDS, dated [DATE], documented the resident required extensive assistance from staff for ADL's and had no current skin issues. On 06/15/2021 at 9:54 AM, Resident 34 said during an interview he had sores on his bottom. A LN Skin Evaluation form dated 06/11/2021 documented, Resident continues with red buttocks/groin with small open area noted to both buttocks. Order changed to A and D oint (ointment) TID (three times a day) and PRN (as needed). No other skin issues at this time. WTCM (will continue to monitor). There were no measurements or other description of the skin issue. On 06/17/2021 at 12:10 PM, Resident 34's buttocks were observed. Both sides of the buttocks were red, unblachable(lacks blood flow) and extremely excoriated and measured approximately 15 cm in length by 10 cm in width in total area. The skin at the edges of this excoriation were delineated by a thin strip of skin that looked like the edge of a blister that had broken. In the center of the left buttock there was an open area measuring approximately 1 cm by 0.5 cm. At 1:30 PM Staff D, LPN/RCM stated, When a skin issue is found the aide tells the nurse, the nurse assesses and documents in the computer on a skin risk evaluation form and then lets myself or the DON know. The nurse does the weekly checks and measurements and documents that. Then the next time the skin committee meets we would go over the case. The skin committee follows to be sure we are getting the right treatments and the skin issue is improving, sometimes the skin team is looking at the skin issue. Staff D was asked if he or any one from the skin committee goes to visualize the wound. Staff D said he, as the RCM, tries to get a look at it as soon as he is made aware. Staff D was asked if it was an expectation that the nurses measure the areas of redness or that of an open area and he stated, Yes it is and they should be describing it as well. Staff D was asked if he had seen Resident 205's bottom and said yes. Staff D was asked if the charting the nurses were doing matched what he saw and he stated, Well I see they charted an area on the right side of the buttocks and what I saw was on the left side. Staff D was asked if he had seen Resident 34's bottom and said yes. Staff D was asked if the documentation of Resident 34's skin issue matched what he saw and said not really. At 2:00 PM, Staff B, Registered Nurse/DNS was asked about the process for documenting and monitoring skin issues with residents. Staff B stated, The floor nurses do weekly skin checks, if an issue is found they do a skin evaluation and let the RCM know and call the doctor for any needed treatment. The RCM and the Interdisciplinary Team (IDT) skin team follow it weekly to make sure the treatment is working and we have all the needed people involved like the RD (Registered Dietician), therapy, etc. Staff B was asked who was responsible to get the measurements of the skin issues and said the floor nurses. Staff B was asked if she had seen the skin issues for Resident 34 and Resident 205 and said yes. Staff B was asked to review the documentation for Resident's 34 and 205 and state whether it accurately reflected what she saw. Staff B stated, I can see from the readers point of view and then seeing the actual wound you would wonder what was going on. The nurses should be doing weekly measurements and descriptions then documenting accurately and I think they need some training on the whole process and skin stuff. We may also need to look at how the Skin IDT team is addressing skin issues and we may need to adjust what we are doing as well. I can see where having the same person consistently looking at the skin issue would make a difference. Reference WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (Resident 41) reviewed for resident to resident altercations. This failure placed residents at risk for abuse and a diminished quality of life. Findings included . Resident 41 was admitted to the facility on [DATE]. On 06/14/2021 at 10:18 AM, the doorway to Resident 41's room was observed to have a STOP sign across the entrance to the room. During an interview, Resident 41 said a male resident (Resident 22), in the room next to hers, had come into her room and hit her on the head and the STOP sign had been placed to deter him from coming into her room. Resident 41's electronic health records had a care plan, initiated 06/10/2021, related to the resident to resident altercation. Interventions included placing a STOP sign on the doorway to her room. A provider progress note, dated 06/11/2021, showed he [Resident 22] was noticed to be agitated and had a physical altercation with another resident. On 06/21/2021 at 3:07 PM, Staff F, Licensed Practical Nurse/Case Manager, said her knowledge of the altercation was Resident 41 reported Resident 22 had hit her. Staff F said Resident 22 had another incident where he had gone into another female resident's room and was upset with the resident thinking she had her feet on his bed. At 3:41 PM, Staff B, Registered Nurse/Director of Nursing Services, said the afternoon of the altercation Resident 41 was heard calling out in her room. When staff went into the room Resident 22 was in his wheelchair next to Resident 41. Resident 41 said Resident 22 had wacked her in the head. Staff B said Resident 22 had one other similar incident where he had gone into a female resident's room believing it was his room. Staff B said Resident 22 was on 15 minute checks off and on because he had an episode where he wandered into another resident's room. A nurse progress note, dated 05/29/2021, showed Resident 22 was confused and wandered into another resident's room. Resident 22 moved the other resident's legs off the bed, thinking it was his bed. Resident 22 was placed on 15 minute checks An incident investigation, dated 06/10/2021, documented Resident 41 was heard calling for help from the hallway. Resident 41 was found in her room, on her knees, next to her wheelchair with Resident 22 sitting next to her in his wheelchair. Resident 41 said Resident 22 yelled at her, struck her in the head and told her to get out of his room. The investigation concluded abuse was substantiated. Reference WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure adequate monitoring of behaviors, intervention effectiveness and interdisciplinary team (IDT) review was in place for 1 of 5 sampled residents (Resident 22) reviewed for unnecessary medications. This failure placed residents at risk of adverse medication side effects, continued behavioral issues and a diminished quality of life. Findings included . <Behavior Management> Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 22's May 2021 Medication Administration Record (MAR) was reviewed for behavior monitoring. The MAR instructed to monitor episodes of targeted behaviors every shift. The target behaviors were not specified and no behaviors for May 2021 were documented on the MAR. The MAR included behavioral interventions to be used as needed. No behavioral interventions were documented for May 2021 on the MAR. Resident 22's June 2021 MAR showed a target behavior of wandering was documented on 06/11/2021, 06/15/2021 and 06/17/2021. Resident 22's June 2021 MAR showed a target behavior of refusal of care was documented on 06/10/2021, 06/15/2021, 06/16/2021 and 06/17/2021. Resident 22's June 2021 MAR showed a target behavior of restlessness was documented on 06/09/2021, 06/10/2021, 06/11/2021, 06/15/2021, 06/16/2021 and 06/17/2021. Resident 22's June 2021 MAR showed a target behavior of frustration was documented on 06/15/2021 and 06/16/2021. Resident 22's June 2021 MAR was updated effective 06/09/2021 with behavioral interventions to be used as needed including: offer ice cream, offer Skip Bo and offer TV Land (likes Golden Girls, Westerns & Frasier). There was no documentation of behavioral interventions being used between 06/09/2021 and 06/17/2021. On 06/16/2021 at 2:48 PM, Resident 22 was observed in an agitated state. The resident hit a caregiver in the stomach when she approached him, from behind, to offer assistance to the bathroom. Staff F, Licensed Practical Nurse/Case Manager, attempted to intervene and the resident was verbally abusive to her. The resident then propelled down the hallway, past his room, tore the STOP sign down in the doorway and attempted to enter another resident's room. Staff A, Administrator, interacted with the resident and offered a snack, to which Resident 22 responded with vulgarity and threatened the staff member. Eventually, after Staff A was able to calm Resident 22 by talking about music and Staff F was able to redirect the resident back into his room. Review of Resident 22's progress notes for 06/16/2021 showed no documentation of the observed incident. The behavior tracking for 06/16/2021 showed refusal of care, frustration and restlessness were documented. There was no documentation of behavioral interventions used and if they were effective. On 06/18/2021 at 10:21 AM Staff H, Certified Nursing Assistant (CNA), said Resident 22 has behaviors including getting upset and loud and has been aggressive at times. Staff H said the CNAs report behaviors, interventions used and if they were effective to the nurse and the nurse documented them. At 10:29 AM, Staff J, LPN, said Resident 22 had angry outbursts and approaching from behind tended to set him off. Staff J said behaviors and interventions used were documented in the daily skilled notes and/or on the MAR. Staff J was not sure if the CNAs document behaviors. <IDT> A Behavior/Psychoactive Medication IDT Review, dated 03/22/2021, showed Resident 22 was taking [MEDICATION(S)] for depression. Target behaviors of frustration, restlessness and worry were identified. The IDT conclusion was to continue with current regime as it was effective. Review of Resident 22's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *Zoloft, a medication used to treat dementia, was ordered 04/30/2021. The dose was increased 05/14/2021 and 06/10/2021. *Namenda, a medication used to treat dementia, was ordered 05/17/2021. The dose was increased on 05/25/2021, 06/02/2021 and 06/09/2021. *Compazine, an antipsychotic medication used to treat nausea, was ordered 05/25/2021. *Depakote Sprinkles, an anti-[CONDITION(S)] medication used as a mood stabilizer, was ordered on 6/10/2021. Review of Resident 22's medical records showed no other Behavior/Psychoactive Medication IDT Reviews had been completed to address the addition and changes of psychoactive medications, the increase in behaviors and if the care planned behavioral interventions were effective or not. On 06/18/2021 at 10:35 AM, in a joint interview with Staff B, Registered Nurse/Director of Nursing Services, Staff G, Social Services and Staff F was had to review IDT involvement with behavior management and monitoring. Staff G stated IDT Behavioral/Medication meetings were held every 2 weeks and quarterly residents were reviewed for behaviors, medication, interventions, if a new medication was started or increased behaviors, quarterly. Staff G aid the meetings were done more often if medications were added, changed or there was an increase in behaviors. Staff A stated Resident 22 had an increase in behaviors since his admission and he had gotten more aggressive. Staff A, G and F said behaviors, behavior interventions and effectiveness of interventions were documented on the MAR. Staff G said the last IDT Behavior/Medication meeting was on 03/22/2021. On 06/21/2021 at 3:04 PM, Staff B said it depended on the situation as to when an IDT Behavior/Medication meeting would be done. When asked if two increases in an antidepressant medication dose, the addition of a mood stabilizing medication, the addition of a medication to treat dementia and documented increase in behaviors including aggression would warrant more frequent IDT meeting to review medications, behaviors, interventions and effectiveness of interventions, Staff B replied, Yes, I see what you are saying. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview and record review, the facility failed to implement a Legionella (Legionnaires disease pneumonia, caused by bacteria found in drinkable and non-drinkable water) Water Management Program, failed to ensure ice machines were maintained in a sanitary manner in 1 of 2 sampled ice machines (2nd floor), and failed to ensure hand hygiene was performed during wound dressing changes for 1 of 2 sampled residents (#35) reviewed for infection prevention and control. These failures placed residents at risk of infection, illness and a decreased quality of life. Findings included . <Hand Hygiene> Resident #35 was readmitted to the facility on [DATE]. The Minimum Data Set, an assessment tool, dated 03/21/19, showed the resident was cognitively intact, required extensive assistance with activities of daily living, had one Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) and four Unstageable pressure ulcers (suspected deep tissue injury). A provider order, dated 03/18/18, documented, Stage 4 pressure ulcer - coccyx: Cleanse with normal saline. Apply quarter inch plain packing strip moistened with Dakin's packed into the wound bed and undermining. Cover with [MEDICATION NAME] dressing every day. Every day shift for Stage 4 pressure ulcer. On 04/05/19 at 9:57 AM, Staff P, Registered Nurse was observed changing #35's Stage IV pressure ulcer wound dressing on the coccyx. Staff P did not perform hand hygiene (HH) or change gloves after handling the resident's bed linens and before removing a wound dressing and wound packing material from inside his pressure wound. At 10:47 AM, Staff P was observed performing a second dressing change to the Stage 4 coccyx pressure ulcer and the left second toe Unstageable pressure ulcer due to active bleeding from both wounds and dressing saturation. The following was observed during this dressing change: -While wearing gloves Staff P pulled a pen from her uniform pocket and wrote the date and time on a piece of tape, opened new dressing supplies and grabbed 2 inch x 2 inch dressing pads from 8 separate packages. Staff P touched a clean roll of Kerlix (gauze) wrap, rolled back the resident's upper bed sheet and touched the resident's blood soaked dressing. Staff P changed gloves and did not perform hand hygiene before removing the saturated toe dressing and did not wash hands and change gloves before applying a new toe dressing. -After performing HH and applying new gloves Staff P handled the resident's bed controller, bed sheet and blanket and placed a new draw sheet under one side of the bed. Staff P changed gloves and did not perform HH. -Staff P did not perform HH after removing the resident old coccyx pressure ulcer dressing and packing, and before placing new packing in the wound and dressing over the wound. On 04/09/19 at 3:34 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, said during a dressing change she would expect nurses to use hand sanitizer upon entering the resident's room, and to wash hands after removing old dressings, packing and before placing new packing and new dressing. When asked what staff would be expected to do after handling blood tinged/soaked supplies, Staff E stated, Wash their hands with soap and water. <Legionella Water Management Program> The facility's Legionella water management program, undated, showed the flow chart diagram did not identify areas where Legionella could grow & spread. The program did not identify how the facility would implement control measures and limits, how the control measures would be monitored and did not document what corrective actions would be taken if control measures were not met. The water management program did not identify contingency responses or identify how the facility would communicate the water management plan to residents, staff and others. On 04/04/19 at approximately 3:00 PM, Staff A, Administrator, said he and Staff N, Maintenance and Housekeeping Supervisor, were in charge of the facility's Legionella water management program. On 04/08/19 at 3:10 PM, Staff A said the Center for Disease Control's Legionella water management toolkit was used to create the facility's water management program. Staff A said the facility's emergency response plan letter, that was sent out to all residents, did not address the Legionella water management plan. Staff A and Staff N could not provide documentation in the facility's Legionella water management plan showing how the facility would train staff responsible for implementing and monitoring the program and how the facility would identify and investigate Legionnaire's disease cases. Staff A and Staff N could not provide facility policies and procedures directly related to processes identified in the Legionella Water Management Program. <Ice Machine Maintenance> The preventative maintenance task sheet documented the 2nd floor ice machine was cleaned by Staff N on 04/02/19. Parts of the machine identified to be cleaned did not include the water dispensing tube with the black substance. On 04/05/19 at 8:46 AM, a black, thick, slimy substance was observed on the end of the water dispensing tube of the 2nd floor ice machine. When touched with a paper towel a portion of the black substance disconnected from the end of the tube and hung down approximately one-quarter inch. At 8:50 AM, Staff N said the facility did not have a policy addressing who would clean the ice machine and the cleaning process to be done. Staff N said he cleaned the internal parts of the machine monthly, and housekeeping would be responsible for cleaning the external parts. At 9:03 AM, Staff O, Housekeeper, said she wiped down the outside of the machine daily and had not been trained on how to clean the water spout. WAC 388-97-1320 (1)(a), (1)(c) & (2)(a)

Based on observation and interview, the facility failed to ensure air flow vents were maintained in a sanitary manner for 1 of 1 kitchen food preparation area. This failure placed residents at risk of foodborne illness and a diminished quality of life. Findings included . On 04/08/19 at 11:43 AM, one vent hood fan, which blew air over the stove and the food prep and distribution area, was observed to have areas of accumulated gray dust on all metal slats. Staff K, Cook, said the vent hood fan was used for ventilation. At 3:15 PM, Staff I, Dietary Supervisor, said ventilation in the kitchen included the hood vent fan above the stove, which was not cleaned by kitchen staff. On 04/09/19 at 8:14 AM, Staff J, Maintenance Supervisor, said he did not clean the kitchen fans. At 8:38 AM, Staff A, Administrator, said kitchen fans were cleaned by the Maintenance Department. Staff A said he was alerted to the dirty vent cover and had Staff J clean it. Reference WAC 388-97-1100 (3)

Based on interview and record review, the facility failed to provide a written notice of transfer, including the reason for the transfer, to the resident and/or representative and to the Office of the State Long-Term Care Ombudsman (OSLTCO) for 4 of 6 sampled residents (#23, 53, 36 & 42) reviewed for hospitalization . This failure placed residents at risk of not having the opportunity to make informed decisions about transfers and have access to an advocate who informs residents about options and resident rights. Findings included . 1) Resident #23 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 03/06/18, documented the resident was cognitively intact. The MDS history showed the resident was transferred and admitted to the hospital on [DATE], 03/13/19 and 03/22/19. Review of the Electronic Health Records (EHR) showed no documentation the resident, resident representative or OSLTCO received written notification of the resident's transfer to the hospital including the reason. 2) Resident #53 was admitted to the facility on [DATE]. The MDS, dated [DATE], documented the resident was cognitively intact. The MDS history showed the resident was transferred and admitted to the hospital on [DATE]. Review of the EHR showed no documentation the resident, resident representative or OSLTCO received written notification of the resident's transfer to the hospital including the reason. 3) Resident #36 was admitted to the facility on [DATE]. The MDS, dated [DATE], indicated the resident was moderately cognitively impaired. Review of the EHR showed Resident #36 was transfer and admitted to the hospital on [DATE]. A nursing progress note, dated 03/14/19 at 1:35 PM, documented a licensed nurse called the provider, and received orders to send the resident to the emergency room (ER). The family and resident were notified The EHR showed no documentation the resident, resident's representative or OSLTCO received written notification of the resident's transfer to the hospital including the reason. 4) Resident #42 was admitted to the facility on [DATE]. The MDS, dated [DATE], documented the resident was cognitively intact. The MDS history showed the resident was transferred and admitted to the hospital on [DATE]. A nursing progress note, dated 09/18/18 at 6:40 AM, documented MD was notified, attempted to contact family without success, left message . A Nursing Home to Hospital Transfer Form, dated 09/18/18 at 3:12 PM, documented the resident was sent to the hospital on [DATE]. Review of Resident #42's health records showed no documentation the resident, resident representative or OSLTCO received written notification of the resident's transfer to the hospital including the reason. On 04/08/19 at 1:53 PM, Staff F, Licensed Practical Nurse (LPN), said nothing was provided to the resident or the representative about why the resident was being transferred to the hospital. At 2:30 PM, Staff D, Case Manager and Registered Nurse (RN), said it was explained verbally to a resident/representative why a resident was being transferred to the hospital and nothing was provided in writing. On 04/09/19 at 9:23 AM, Staff E, MDS Coordinator and RN, said they did not provide residents or the residents' representative written notice of transfer to the ER. Staff E said for a resident with a cognitive deficit, the facility contacted the family, by phone, and documented in the EHR. At 9:39 AM, Staff B, Director of Nursing Services and RN, said residents or their representatives did not receive anything in writing regarding the reason for transfer to the ER. Staff B said for a cognitive intact resident, nursing verbally informed the resident for the reason to transfer. Staff B said for a cognitively impaired resident, the nurse contacted the family, by phone, and documented in the EHR. At 9:50 AM, Staff A, Executive Director, said he did not realize a resident needed to have a written notice of transfer, to the ER, if the resident was returning to the facility. Staff A said they were not currently sending the OSLTCO information regarding the reason for hospital transfers. Reference WAC 388-97-0120 (2)(a-d)

Based on interview and record review, the facility failed to ensure potential abuse was investigated for 1 of 4 sampled residents (#18) reviewed for abuse. This failure placed residents at risk of abuse, harm and a decreased quality of life. Findings included . Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 01/28/19, indicated the resident had moderate cognitive impairment and required extensive assistance with activities of daily living. A skin sheet, dated 03/17/19 at 12:10 AM, documented, Skin is clean, dry intact . No new skin issues at this time. A skin sheet, dated 03/23/19 at 12:52 AM, documented, .nails clean and trimmed. Noted to have 3 areas of abrasions to midline abdomen noted in shower this AM. Free of (signs and symptoms of) infection . Appears to have scratched belly as some of abrasions seem to have small bruising fading to purple. Denies pain. Power of Attorney and Primary Care Provider notified with alert initiated. The resident's medical record and facility's (MONTH) 2019 incident reporting log, reviewed 04/05/19, showed no documentation an incident report was initiated or the facility had investigated the resident's scratched and bruised abdomen to determine if abuse had occurred. On 04/05/19 at 1:19 PM, Staff B, Registered Nurse (RN), said typically the resident would be interviewed, a chart note would be done, an incident report would be initiated and an investigation would be done. At 1:51 PM, when asked if anyone at the facility had hurt her, Resident #18 was observed to point towards the television and to the wall next to her bed. The resident did not speak. On 04/09/19 at 1:23 PM, Staff E, Resident Care Manger and RN, said an incident report should have been initiated to investigate if the scratches and bruising were or were not abuse. Reference WAC 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to ensure physician documentation was completed regarding the basis and necessity for a facility-initiated discharge for 1 of 6 sampled residents (#42) reviewed for hospitalization . This failure placed residents at risk for unmet care needs, a delay in treatment and a decreased quality of life. Findings included . Resident #42 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 03/26/19, documented the resident was cognitively intact. The MDS history showed the resident was admitted to the hospital on [DATE]. A nursing progress note, dated 09/18/18 at 9:42 AM, documented (resident) was admitted to (intensive care unit) for acute (gastrointestinal) bleed, [MEDICAL CONDITION] (high potassium level), and an abnormal EKG (electrocardiogram). No documentation was found in Resident #42's chart showing the physician documented the basis for the hospitalization . On 04/08/19 at 3:44 PM, Staff E, MDS Coordinator and Licensed Practical Nurse, said Resident #42's physician came to the facility every two months and as needed. The house medical doctor (MD) was in the facility one time per week. On 04/09/19 at 11:31 AM, Staff E said the MD usually visited the resident after a hospitalization , but could not locate any documentation in Resident #42's chart from the physician. Reference WAC 388-97-0120 (1)

Based on interview and record review, the facility failed to provide residents with the option to accept or decline the completion of an advanced directive (AD) for 2 of 6 sampled residents (#42 & 53) reviewed for AD. This failure placed residents and/or representative not being informed to make desired choices regarding end of life care. Findings included . 1) Resident #42 was admitted to the facility on [DATE]. Resident #42's health records showed no documentation of the resident requesting or declining the completion of an AD. On 04/08/19 at 2:21 PM, Staff L, Medical Records, said Resident #42 did not have an AD on file. 2) Resident #35 was admitted to the facility on [DATE]. The MDS, dated [DATE], indicated the resident was cognitively intact. Resident #35's medical records did not include documentation showing the resident requested or declined to formulate an advance directive. The medical record did not show the facility address the resident formulating an advance directive during quarterly care conferences. On 04/09/19 at 10:09 AM, after reviewing the residents care conference notes, Staff M, Social Services Director, said the facility reviewed the resident's POLST (Physician order [REDACTED]. Reference WAC 388-97-0280 (3)(c)(i-ii) and 388-97-0300 (1)(b), (3)(a-c)

Based on observation, interview, and record review, it was determined the facility failed to ensure potentially hazardous foods were cooled properly after cooking. This failure placed all residents at risk for eating potentially hazardous food and was determined to be an immediate jeopardy. In addition, it was determined the facility failed to serve food in a sanitary manner during 1 of 2 meal services observed to prevent contamination of food served to the residents. This failure placed residents at risk of being served potentially contaminated food. <Food Cooling Concerns> Introduction from the Washington State Retail Food Code: (1) Cooked POTENTIALLY HAZARDOUS FOOD must be cooled: (a) Within two hours from 135°F (57°C) to 70°F (21°C); (b) Within a total of six hours from 135°F (57°C) to 41°F (5°C) or less; or (c) As alternatives to the cooling provisions of (a) and (b) of this subsection, the Following rapid cooling procedures are allowed: (i) Continuous cooling of FOODS in a shallow layer of two inches or less, uncovered, protected from cross contamination, in cooling EQUIPMENT maintaining an ambient air temperature of 41°F (5°C) or less; or (ii) Continuous cooling of intact pieces of MEAT that is not COMMINUTED and is no greater than four inches thick, uncovered, unwrapped, not touching other pieces of FOOD, protected from cross contamination, in cooling EQUIPMENT maintaining an ambient temperature of 41°F (5°C) or less. On 6/1/16 at 10:23 a.m., three turkey roasts were in metal containers covered with tin foil. One larger turkey roast was approximately 7 pounds, 2 feet long, 6 inches wide and 5 inches tall. The other two turkey roasts were smaller in size and approximately 2-3 pounds each. A cooling log taped on the outside of the refrigerator was observed to be blank with no entries documenting cooling of any foods. At 10:49 a.m., when asked about the process of cooling food, the Dietary Manager (DM) stated the food should be cooked up to proper temperature, cut in quarters if it is a big roast and left uncovered and placed in the fridge. The DM indicated the temperature of the cooling food should be checked hourly and documented on the cooling log which was taped on the outside of the fridge. At 10:43 a.m., when asked about the turkey roasts that were covered and in the fridge, Kitchen Staff (KS) A stated those had been cooked in the afternoon on 5/31/16. When asked why the cooling logs were blank, KS A indicated she had cooked the smaller two roasts and stated, You know, I just forgot to temp them. I'm sorry. I don't usually cook them. I'm pretty sure those roasts cooled on time. At 10:59 a.m., the DM indicated the temperatures should have been checked and documented on the cooling log. The DM stated, I don't know why it isn't there. At 12:50 a.m., KS B stated she had cooked the larger turkey roast (from a raw state) early in the afternoon of 5/31/16. KS B indicated it didn't look like enough meat, so KS A cooked the 2 additional smaller turkey roasts later in the afternoon on 5/31/16. When asked about the cooling log for the larger turkey roast, KS B stated, It was really hectic in here, so I didn't do the cooling temperatures on the bigger roast. KS B stated, Sometimes I cut the bigger roasts into smaller pieces, but not always. At 12:54 p.m., KS A was observed slicing the larger turkey roast and indicated it would be served to the residents for dinner that night. At 12:55 p.m., the surveyor requested the cooling logs from the month of May. At 12:59 p.m., the DM indicated she was unable to find the cooling logs. The DM stated there should be temperature cooling logs for all the roasts and all the soups. The DM stated, We cook the roasts ahead of time, usually the day prior. It makes it easier to slice them if they are cool. At 1:05 p.m., the DM indicated she usually keeps 6 months of the cooling logs and stated, I don't know where they are at. I must have thrown them away. At 1:35 p.m., the DM provided a Food Temperature Cooling Log dated from 2/19/16 through 3/21/16 which documented eight separate roasts had been cooled in that time frame. The Cooling Log documented the roasts were placed in fridge when the temperatures decreased below 140 degrees Fahrenheit (F). No temperatures were documented after the roasts were placed in the fridge. At 1:56 p.m., KS A was asked to take the temperature of the turkey roasts that were in the fridge. The smaller roasts each were 39 degrees F. The larger turkey roasts was now sliced. The slices were 7 inches wide and 4.75 inches tall and approximately ½ inch thick. The temperature of the turkey slices, taken in several different spots/slices was 44.6 degrees F. KS A agreed the sliced turkey was above the safe cooled temperature of 40 degrees. At 2:42 p.m., an outside official from the State Department of Health indicated that if a potentially hazardous food remained in the danger zone (40-140) for more than 12 hours, it was unsafe to eat, even if reheated, due to the potential of spore-forming bacteria being present in the food. At 3:07 p.m., when informed of the surveyors concern regarding the lack of proper food cooling, the Administrator (ADM) stated, I thought we went over that with them a while ago. If doing temperature logs and it didn't cool in time, we'd have to dump it. <Maple Terrace Dining Room> On 5/25/16 at 12:03 p.m., NA C picked up a resident's soup bowl with her ungloved thumbs on the inside of the bowl. On 06/01/16 at 11:47 a.m., NA F picked up a resident's glass of juice by gripping her fingers around the top of the glass, an area the resident's mouth would touch while drinking. On 6/2/16 at 4:51 p.m., the DM stated plates and bowls should be picked up from the side and fingers should not ever be on the inside surface of a residents serving dish. At 4:20 p.m., NA F stated staff should grab a bowl on the outside toward the bottom without touching the food or inside of the bowl. At 4:37 p.m., NA B stated staff should always grab the base of the bowl and never place their fingers inside. On 6/1/16 between 11:49 a.m. and 12:04 p.m., while filling bowls of soup, the DM touched the inside rims of each soup bowl. On 6/2/16 at At 4:20 p.m., NA F stated staff should grab a bowl on the outside toward the bottom without touching the food or inside of the bowl. At 4:37 p.m., NA B stated staff should always grab the base of the bowl and never place their fingers inside. At 4:51 p.m., the DM stated plates and bowls should be picked up from the side and fingers should not ever be on the inside surface of a residents serving dish.

Based on interview and record review, it was determined the facility failed to ensure a safe and orderly discharge occurred and/or would occur for 1 of 4 former/discharged residents (#1) reviewed for discharge. Resident #1 discharged from the facility to a living environment that was not set up to meet his complex care needs. He had multiple medical conditions, impaired capability and judgment and lacked self-demonstrated and caregiver ability to assist with the resident's complicated care regimen. In addition, the apartment where he was discharged lacked appropriate equipment and supplies to meet his care needs. The first morning after discharge, the resident fell . The second morning after discharge, the resident was found in a weakened condition, unable to sit upright and with a critically low oxygen level. This failure placed all residents at risk of unsafe discharges. This failure was determined to represent an immediate jeopardy for Resident #1. Findings include: 1) Former Resident #1 was admitted to the facility on [DATE] with multiple medical conditions that included recent surgery for [REDACTED]. He had a history of [REDACTED]. He was to receive physical and occupational therapies and oxygen therapy to keep saturation levels above 90%. According to the record, the resident weighed 114 pounds on admission to the facility and the physician documented the resident was very thin and frail . and would likely need long-term care placement. In addition to his dementia and limited physical ability, the resident had a urinary catheter (tube inserted into the bladder) and urinary tract infection [MEDICAL CONDITION], both of which the resident had during his stay and at discharge on [DATE], the day after his Medicare qualified stay ended. <Interviews and Record Reviews> Review of the Occupational Therapist's (OT) note, dated [DATE], indicated the resident was discharged from OT services after one month to remain in this long-term facility for 24-hour care and had achieved his highest level of function which was dependent for toileting and putting on footwear; needed substantial/maximum assistance with lower body dressing and shower/bathing. The emergency room (ER) physician saw the resident on [DATE], one day after discharge from the facility, for a fall. The physician documented: Failure to thrive, dementia, needs placement. Extensive social history with difficulty involving placement options and finances. Will need assistance with discharge planning, placement, protective and home care services. Case management to assist with placement. The second morning after discharge from the facility, the home health (HH) nurse's assessment, dated [DATE], revealed the resident was: .older male with little energy and strength, right hip replacement, catheter care, Oxygen saturations of 72 on room air (normal range ,[DATE]%) after checking multiple times .slumped over on table 90% of the visit .wound care supplies ordered, bowel incontinence accidents, high fall risk, fell yesterday ([DATE]-see above ER note). The note continued: .living situation/caregiver status: current procedures/treatment required for patient to remain safely in the home which cannot be performed by patient or caregiver due to documented lack of knowledge, skill, complexity and lack of available, able and willing caregiver, catheter changes. Personal care needed due to self-care deficits . The note indicated all of the resident's Medicare days were up and the facility discharged the patient to wife's apartment, under her protests she could not offer him better care. The couple had been married [AGE] years but had lived separately for the last [AGE] years. The wife felt unable and was not willing to take care of the resident. In addition, the resident had been on continuous oxygen for his [MEDICAL CONDITION] prior to his hospitalization in [DATE]. His wife sent the oxygen concentrator back once the resident was admitted to the skilled nursing facility (SNF) as she thought the resident would remain in the facility. The HH service contacted the physician, reordered the concentrator and restarted the resident's oxygen at 2 liters/minute per nasal cannula to keep his oxygen levels above 90%. The physician's nursing home visit note, dated [DATE], indicated the resident had additional health problems with [MEDICAL CONDITION] (low oxygen level) positive [MEDICAL CONDITION] test, [MEDICAL CONDITION] and [MEDICAL CONDITION] (decreased alertness). The resident had problems with catheter blockage, urine infections and blood in his urine. He was on medications for pain related to the catheter and antibiotics for the urine infection. The most recent Minimum Data Set (MDS), an assessment tool, completed on [DATE], indicated the resident was total dependence for bathing/showers . Not steady, only able to stabilize with staff assistance when moving from seated to standing position; moving on and off the toilet and for transfer between bed and chair or wheelchair. The resident was frequently incontinent of bowels. On [DATE] at 2:00 p.m., the Social Services Director (SSD) said the resident was discharged home as his 100 days of Medicare expired on [DATE] and his spouse said she would not pay any participation .we can't keep residents who don't pay. When asked why the resident was moved from the 2nd floor (where residents needing specialized therapies were admitted for short term) to the Medicaid long-term care 3rd floor within a month of admission, she said it was because at the time, it was thought the resident was going to need long-term care. When asked about the resident's condition at discharge on [DATE] given the previous assessments and his medical history, the SSD said the resident had made really significant improvement and blossomed since moving to the Medicaid floor and that he wanted to go home. She could not say specifically what contributed to such significant improvement in one week. There was no Significant Change MDS assessment found in the record to validate the improvement. When asked how the resident's abilities were assessed for safe discharge, the Director of Nursing Services (DNS) acknowledged there were no nursing notes (NN) to reflect the resident's self-care abilities, medication management or the spouse's training and demonstration of care nor was there documentation to indicate when the resident's oxygen saturation was monitored to reflect need for oxygen therapy after admission and before discharge and when the oxygen was discontinued. The DNS indicated the resident did have a wife at home who could care for him and acknowledged the wife had only visited the resident once since admission because she did not drive. As of [DATE], the comprehensive care plan (CCP) indicated the resident was totally dependent on staff for toilet use, total assistance with transfers, and he needed encouragement and cueing to eat. Review of the resident's Bowel and Bladder assessment, dated [DATE], indicated the resident was incontinent of bowel, occasional incontinence of bladder, and he was confused. The Physical Therapist's (PT) progress note, dated [DATE], included the following: Precautions/contraindications: Catheter. The patient was trained today on catheter emptying. He was able to perform the skills, but the retaining clip came off. He was unable to put the clip back on without assistance Patient and Caregiver training: Catheter training. Response to Session interventions: Fair demonstration. Complexities/Barriers to Impacting Session: NONE. On [DATE] at 2:00 p.m., the PT was asked about the home evaluation he completed on [DATE] and how the resident's spouse demonstrated knowledge of training and care to the resident. The PT stated he had not provided any care training to the spouse. The record indicated the resident weighed 114 pounds on admission and was being given nutritional supplements. When asked if the resident had any home care training related to preparing meals and doing personal care in the facility's home training kitchen, the PT said no as he thought the resident's wife would make the meals and assist the resident. The PT said he did not know if the resident could even make a sandwich for himself. The PT was asked about the resident's [MEDICAL CONDITION] and the need for oxygen and stated the resident was weaned off oxygen about 2 months ago and oxygen saturations taken by the therapy staff were in the 90%. Oxygen saturation monitoring could not be consistently validated in the nursing notes (NN)/Medication/treatment records. Review of the SSD's bed request, provided by the facility on [DATE], indicated a semi-electric bed with mattress was ordered by the facility on [DATE] for delivery to the resident's home on [DATE] for [DIAGNOSES REDACTED]. No other equipment or care supplies were ordered. When asked about the resident's need for a hospital bed at home, the PT said he was not aware a hospital bed had been ordered, and said the resident was ambulatory and could transfer well to and from bed and on and off the toilet. According to the record on [DATE], the PT noted the resident's prognosis was: Good with strong family support .assistance available .spoke to spouse and she has her own health concerns and will be unable to provide much physical assistance for him .needs daily supervision .from the time of evaluation to his discharge, the patient made a truly noteworthy journey to achieve his current level of function. He is now able to ambulate 350 feet with walker, he is self-transferring to the commode and can empty his own catheter .the home evaluation assessment--able to perform all the skills needed to be graded safe for return to home with his spouse. He is safe to return there. The statements by the therapist were confusing because, while it indicated the resident had good strong family support, that support was not documented at any time of the resident's stay nor did it include any care training to validate the spouse was included and observed as able and/or willing to provide any care and assistance to the resident. Although the PT stated and documented the resident was making truly noteworthy progress, there was a lack of NN's and significant change assessment in the record to support the PT's or the SSD's accounts of the resident's progress or spouse involvement to ensure a safe discharge home or the reasons for ordering a hospital bed and no oxygen. The OT, MDS, HH and ER physician's assessments represented a completely different picture of the resident's condition at discharge than the facility's discharge SSD and PT's notes as of [DATE]. The PT's discharge summary, dated [DATE], documented: No barriers to discharge; able to verbalize needs, overall improved cognition .aware, alert, oriented, home with wife. Additional needs included: home physical therapy, catheter care and bathing. The facility PT determined the resident could manage catheter care, can ambulate safely with walker. The discharge record indicated the resident left the facility via a wheelchair transport van and unaccompanied by any family. On [DATE] at 4:30 p.m., during interview with a person not associated with the facility but who had assisted the resident and his wife for years to obtain needed services, indicated the apartment the resident had been discharged to had no bed for the resident or his wife .both fell over the couch on [DATE] while she was trying to help him. She is very frail and unable to help him. She is in a wheelchair too. She would not have been able to care for the urinary bags due to inability to follow directions. Looks like she had no in-house care and no services had even been set up. Wife called the outside agency due to injury while trying to help husband. When asked if the wife or husband could provide care to and for each other, the source said: I was at his house and he was so confused, he couldn't clean up spilled coffee .there was no way he could care for a catheter. Failure of the facility's interdisciplinary team to recognize the resident's needs/abilities to ensure a safe, orderly discharge home for the resident to include a capable, trained caregiver, available equipment/supplies, and awareness the resident could perform daily living skills resulted in harm to the resident when he demonstrated inability to care for himself prior to and within the first day after discharge.

Based on interview and record review, it was determined the facility failed to ensure medically-related social services were aggressively pursued for 2 of 4 sampled residents (#1, and #3) reviewed for social services safe discharge planning. The failure to advocate for safe discharges created the potential for harm to the residents and resulted in harm to Resident #1 when alternatives to placement at discharge were not considered; when transfer options were not immediately explored due to caregiver's repeated expressed concerns about inability to care for the resident and when the resident lacked necessary equipment and care supplies to manage at home. Findings include: 1) Former Resident #1 was admitted to the facility on [DATE] with multiple medical conditions that included recent hip fracture; history of stroke with abnormal gait, anemia, heart attack, dementia, poor circulation to his legs, chronic obstructive pulmonary disease (COPD) with continuous oxygen (2 liters per nasal cannula and he used inhalers daily) at home, prior to and during admission to the facility. The resident weighed 114 pounds on admission to the facility and #123 pounds at discharge. In addition to his limited physical ability, the resident had a urinary catheter (tube inserted into the bladder) and urinary tract infection (UTI), both of which the resident had during his stay and at discharge on [DATE], the day after his Medicare qualified stay ended. <Interviews and Record Reviews> The Comprehensive Care Plan (CCP) for discharge was initiated on [DATE] with a goal to discharge home when he was safe with independent transfers and toileting and if more care than wife can manage, to consider an adult family home or remain in long-term care with a target date of [DATE]. Interventions included to assist with Medicaid and home care referrals as needed; maintain contact with wife and resident for changes in placement and explore alternative care if needing more assistance; Social Services Director (SSD) to assist with planning and changes for discharge, arrange for in-home care and equipment needs. The Occupational Therapist's (OT) note, dated [DATE], indicated the resident was no longer on services because he was going to remain dependent for toileting and putting on footwear; needed substantial/maximum assistance with lower body dressing and shower/bathing. The emergency room (ER) physician saw the resident on [DATE], one day after discharge and documented: Failure to thrive, dementia, needs placement. Extensive social history with difficulty involving placement options and finances. Will need assistance with discharge planning, placement, protective and home care services. Case management to assist with placement. The second morning after discharging from the facility, the home health (HH) nurse's assessment, dated [DATE], revealed the resident had little energy and strength, catheter care, Oxygen saturations of 72 on room air (normal range ,[DATE]%) after checking multiple times .slumped over on table 90% of the visit .wound care supplies ordered, bowel incontinence accidents, high fall risk, fell yesterday ([DATE]-see above ER note). The physician's nursing home visit note, dated [DATE], indicated the resident had problems with catheter blockage, urine infections and blood in his urine. As of [DATE], the comprehensive care plan (CCP) indicated the resident was totally dependent on staff for toilet use, total assistance with transfers, and he needed encouragement and cueing to eat. The resident weighed 114 pounds on admission to the facility and ,[DATE] pounds at discharge. The Bowel and Bladder assessment dated [DATE] indicated the resident was: incontinent of bowel, occasional incontinence of bladder and he was confused. On [DATE] at 2:00 p.m., the Social Services Director (SSD) said the resident was discharged home as his 100 days of Medicare expired on [DATE] and his spouse said she would not pay any participation .we can't keep residents who don't pay. The resident was discharged on [DATE] per wheelchair van without family and taken to his wife's apartment. When asked about the resident's condition at discharge on [DATE] given the previous assessments and his medical history, the SSD said the resident had made significant improvement and wanted to go home. There was no Significant Change MDS assessment found in the record to validate the improvement. Review of the SSD's bed request, provided by the facility on [DATE], indicated a semi-electric bed with mattress was ordered by the facility on [DATE] for delivery to the resident's home on [DATE] for [DIAGNOSES REDACTED]. No other equipment or care supplies were ordered. The HH notes dated [DATE] indicated care supplies for incontinence, oxygen equipment, wound care and catheter tubes and bags were ordered for the resident. The OT, MDS, HH and ER physician's assessments represented a completely different picture of the resident's condition at discharge than the facility's discharge SSD assessment noted as of [DATE]. On [DATE] at 4:30 p.m., during interview with a person not associated with the facility but who had assisted the resident and his wife for years to obtain needed services, indicated the apartment the resident had been discharged to had no bed for the resident or his wife .both fell over the couch on [DATE] while she was trying to help him. When asked if the wife or husband could provide care to and for each other, the source said: I was at his house and he was so confused, he couldn't clean up spilled coffee .there was no way he could care for a catheter. Failure of the SSD and interdisciplinary team to recognize the resident's needs/abilities to ensure a safe discharge home for the resident to include a capable, trained caregiver, available equipment/supplies, and awareness the resident could perform daily living skills resulted in harm to the resident when he demonstrated inability to care for himself prior to and within the first day after discharge. The Resident was placed in a Hospice facility on [DATE] where he passed away shortly thereafter. Refer to F 204 2) Resident #3 was admitted to facility on [DATE] with multiple health conditions including Dementia and recent surgery (urostomy--tube inserted in the belly to drain urine away from the bladder). A review of the CCP dated [DATE]: At risk for falls related to unawareness of safety needs secondary to confusion, At risk for nutritional decline related to urostomy, impaired cognition. The CCP, dated [DATE], indicated: Discharge Home with some in home care if resident needs can safely be met. Alternate care if needing more assist than can be met at home. The CCP, dated [DATE] indicated: Antibiotic therapy related to Urinary Tract Infection (UTI). There was no follow-up documentation on these care plans or the facility's goal target dates as all were expired, and there were no staff members identified on the plans to know who was accountable/responsible/monitoring care of the resident. On [DATE] 9:12 a.m., the SSD stated the facility was in regular contact with the resident's daughter about discharge planning. The daughter was involved in this resident's care decisions and the SSD was having difficulty placing the resident elsewhere because of the resident's low Medicaid reimbursement rate of $70.00 per day. The SSD stated an outside agency found possible placement for the resident but she was not sure where the facility might be and could not recall a name. She said: The goal was for the resident to discharged by [DATE]. On [DATE] 10:25 a.m., Resident #3's daughter stated, The facility initiated the discharge and she did not feel the facility worked with her to coordinate the resident's care and discharge. She said she was concerned about how her mom will get supplies, had not heard anything from the facility about coordinating care for discharge. She stated she never met anyone from PT or OT and she was not aware of any care conferences for resident. The SSD called her once just after admission to talk about discharge plans and beginning in September, 2015, she has received one to two calls every week from the SSD stating that she needed to find placement for the resident but no discussions about options for discharge or the changing needs of the resident. According to the resident's daughter, one of the last phone calls she received from the SSD was She (Resident) needs to go. She needs to find another home. The daughter stated she felt the facility was pressuring her to find another home for the resident and the SSD was frustrated with her because things should be moving faster. The daughter said the SSD's continuous phone calls like this was very stressful. According to the resident's daughter, she was initially told the resident would be staying at the facility after her skilled services as this would be a good back up plan. After being told the resident was medically stable for discharge, the daughter asked the SSD, on three separate occasions, if the resident could stay in the facility. Each time she was told there is no room. When the daughter asked if the resident could go on a waiting list for a bed, she was told by SSD, I guess we could put her on one. As of today, [DATE], the daughter had not heard back on an available bed and had notified the resident's caseworker who has been trying to coordinate services and placement. In [DATE], the SSD said that facility could not find a place for resident anywhere in the area but there was a locked dementia unit in Vancouver. The daughter contacted that facility and was told her mother would not meet the requirements for admission. She said in January, this same facility was contacted to do an assessment on her mother while in the facility and she was not informed of this visit nor did she request it. On [DATE] 10:35 a.m., Resident #3's advocate was asked about communication with the facility, and said it consisted of the SSD saying She (Resident #3) needs to leave. She doesn't need to be here. S/he expressed concern about considering a locked dementia unit as it would not be appropriate placement for the resident. Review of SSD's progress note dated [DATE], revealed a BIMS (Brief Interview for Mental Status) to provide how well a person is functioning cognitively at the moment) score of 6 that indicated the resident was not able to adequately understand her care needs or the need for other placement. The therapy note, dated [DATE], indicated the therapy sessions would be discontinued the following week and the resident would need a lesser care facility as of ,[DATE]. At this time, the daughter began looking into other homes as resident was unable to live alone due to impaired cognition and higher level care needs. The therapy note, dated [DATE], identified the resident's skilled needs with the decision made to issue a discharge notice for [DATE]. The resident signed the form indicating an awareness, understanding of the need to discharge from the facility. The SSD note, dated [DATE], indicated the resident's daughter was given a list of lesser care homes with a note the resident's condition was guarded as appropriate alternate care has not been determined. On [DATE], the notes indicated placement was difficult because of the Resident's urostomy bag and low Medicaid reimbursement rate and concerns about potential elopement. On [DATE], the SSD note indicated the resident continues to talk about the desire to return home. There was lack of documentation to indicate this would be a safe discharge as the resident would be living alone. On [DATE], the notice of discharge indicated a target date for [DATE] yet no specific location was identified. On [DATE] at 4:00 p.m., the advocate said the resident was going to be discharged Tuesday, [DATE], to an Alzheimer's facility.

Based on interview and record review, it was determined the facility neglected to follow their own described policy and procedures for administering an anticoagulant medication, as well as known standards of practice, for 1 of 5 current and/or discharged sampled residents (#21) reviewed for anticoagulation therapy. These failures included: 1) Failure to ensure a physician order was obtained prior to [MEDICATION NAME] administration. 2) Failure to obtain physician orders to ensure lab work was completed to monitor a resident newly on [MEDICATION NAME]. 3) Failure to immediately phone the physician regarding a known critical lab value. 4) Failure to hold the [MEDICATION NAME] for a resident with a pending INR result (which ended up being critically high). 5) Failure to administer vitamin K, after documenting the on-call physician had ordered it. 6) Failure to investigate and rule out abuse, neglect, and medication error when a resident was hospitalized with acute [MEDICAL CONDITION]. These failures caused harm to Resident #21, and resulted in the resident having a dangerous abnormally high blood clotting level, [MEDICAL CONDITION] and the need for blood [MEDICAL CONDITION] and hospitalization . Findings include: <Introduction> [MEDICATION NAME], also known as [MEDICATION NAME], is an anticoagulant medication used to reduce the formation of blood clots. [MEDICATION NAME] dosing is determined by taking a blood sample and running two similar tests, [MEDICATION NAME] time (PT) and international normalization ratio (INR). The PT and INR are used to monitor the effectiveness of the anticoagulant medication and to adjust the dosage of the medication depending on the level of clot prevention needed. The PT/INR test is also used to monitor and ensure that a resident does not receive too much [MEDICATION NAME] and thus become at high risk for bleeding. Normal range for an INR in someone not taking anticoagulation medication is 0.9-1.2. Goal INR for people on anticoagulation therapy is between 2.0 and 3.5 depending on the therapeutic goals. Values above 6 are considered critically high. PT/INR tests should be taken frequently in people newly on [MEDICATION NAME] to adjust the dose according to the therapeutic goals. Receiving too much [MEDICATION NAME] can cause the PT/INR to go out of range placing the individual at risk for severe bruising, uncontrolled bleeding, bleeding in the gastrointestinal tract and places the individual at risk of death from hemorrhagic shock if the bleeding cannot be stopped. Vitamin K is a medication given to reverse the effects of too much [MEDICATION NAME]. Hemoglobin is a measure of the protein in red blood cells that carries oxygen to the tissues. The hematocrit measures the volume of red blood cells compared to the total blood volume. Together these tests are referred to as the H&H and are used to determine blood volume status and the need for a blood transfusion. Normal hemoglobin levels for females are between 12 and 16. Normal hematocrit levels for females are between 36 and 48%. Acute and/or chronic blood loss can cause both the hemoglobin and hematocrit to drop. Resident #21 was admitted , from the hospital, to the facility on [DATE] with bilateral ankle fractures. The 5-day Minimum Data Set, an assessment tool, dated 12/19/14, documented the resident had received an anticoagulant medication seven (7) times in the previous seven (7) day period. <No Physician order for [REDACTED]. Record review of the hospital outpatient medication list did not include [MEDICATION NAME], an anticoagulation medication, as an ordered medication. Review of the hospital records do not show the resident was administered [MEDICATION NAME] while at the hospital. In the hospital Discharge Summary, dated 12/12/2014, the hospital physician stated, The patient is at very high risk for [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clots) from immobility and will be started on SCD devices (Sequential Compression devices-placed on legs to promote circulation) while at Beacon Hill. [MEDICATION NAME] was briefly entertained, but I feel the risk of hemorrhage with a combination of aspirin, [MEDICATION NAME], and [MEDICATION NAME] is unacceptably high. If she is maintained on SCD devices that should be adequate to help prevent [MEDICAL CONDITION] during her period of immobility. Review of the December and January MARs document the resident received [MEDICATION NAME] and aspirin throughout her facility stay, as ordered by the hospital discharge physician. [MEDICATION NAME] and aspirin are both medications that can increase a resident's risk of bleeding. The hospital physician orders, dated 12/12/14, noted to cancel the resident's [MEDICATION NAME] clinic referral, and the resident, must use SCD's to both legs daily for [MEDICAL CONDITION] while at the facility. On 06/09/2015 at 2:54 p.m., the resident's primary physician stated Resident #21 had never taken [MEDICATION NAME] prior to hospitalization . The December Medication Administration Record [REDACTED]. The documented dose was 5 milligrams (mg) to be given on Sunday, Tuesday, Wednesday, Thursday and Saturday and 7.5 mg to be given every Monday and Friday. A physician order could not be located, in the resident's medical record, to indicate the [MEDICATION NAME] was to be administered beginning 12/15/14. On 06/09/2015 at 2:54 p.m., the resident's primary physician stated, I do not see any [MEDICATION NAME] or [MEDICATION NAME] that I ordered for (the resident). The physician indicated that another provider, such as the orthopedic doctor, may have prescribed it. The physician indicated there was nothing from her office ordering [MEDICATION NAME] or indicating the resident was, or should have been, on [MEDICATION NAME] during her stay at the facility. On 6/10/2015 at 10:14 a.m., a fax from Resident #21's orthopedic physician stated, (Resident #21) was not prescribed any anticoagulation medications from our office. <Lack of Monitoring and Physician Involvement> Record review showed, Resident #21 did not have a care plan in place to address anticoagulant use. On 6/8/15 at 12:28 p.m., the Director of Nursing Services (DNS) stated residents receiving anticoagulant medication have a log to record dosage and when the next laboratory blood draw for monitoring was to occur. The DNS indicated the form was kept as a paper copy at the nurse's station. A [MEDICATION NAME] Log was not located for Resident #21. On 6/10/15 at 10:36 a.m., the DNS indicated a resident with a new order for [MEDICATION NAME] should be placed on alert charting for 3 days to monitor for changes and any adverse side effects (ASE) of the medication. Review of the Resident #21's progress notes, from 12/15/14 through 12/18/14, did not document the resident started on [MEDICATION NAME] or that monitoring for ASE had occurred. Monitoring noted on the MAR (described as anti-coagulation therapy: report any unusual bleeding, bruising, pale skin, weakness, black/tarry stool. Notify MD/NP) did not begin until 12/19/2014, four days after the facility started giving Resident #21 [MEDICATION NAME]. On 12/15/14 at 6:06 p.m., a blood draw was taken for laboratory analysis to monitor the PT/INR. This was the same day that Resident #21 received the first dose of [MEDICATION NAME]. The PT/INR result was 11.2/1.03. No physician order could be located directing staff to obtain a PT/INR test on 12/15/14. No documentation could be located to indicate additional PT/INR testing was completed until 1/4/15, 20 days later. On 1/4/15 at 6:37 p.m., a blood work sample was collected for analysis and the results were received on 1/5/15 at 4:19 p.m. The results indicated the PT was greater than 150, critically high and out of range. The INR was unable to be calculated due to the out of range PT. The lab report suggested a repeat analysis on a new sample. No physician order could be located directing staff to obtain a PT/INR test on 1/4/15. No documentation could be located indicating the physician had been notified the resident had been receiving a new medication, [MEDICATION NAME], for 20 days without checking a PT/INR level. On 6/8/15 at 12:00 p.m., the Laboratory's Quality Assurance Coordinator (LQAC) stated the blood draw taken on 1/4/15, at 6:37 p.m., was not requested as an urgent lab and was sent to Seattle for processing as a routine lab. The LQAC stated, The PT result was crazy high, greater than 150. A normal PT range is 11.5-13.5 so the result would suggest a repeat analysis. It doesn't look like they did that. The LQAC indicated Licensed Nurse (LN) F was notified, by phone, of the critically high result on 1/5/15 at 4:36 p.m. The January 2015 MAR indicated [REDACTED]. The January MAR indicated [REDACTED]. On 6/8/15 at 12:25 p.m., LN D stated if blood was drawn, in the evening, for a PT/INR, the results should be received before giving the next dose of [MEDICATION NAME]. The staff would be informed of the protocol when report is given between shifts. LN D indicated with a critical INR they would notify the coagulation clinic, therapy, limit the resident's activities, and have the aide monitor the resident for bruising and bleeding with mouth care or peri care. If the result is critically high, they would hold the medication until they hear back from the physician. LN D said during report, they would specify the INR was pending to let the nurse know to wait for results before giving the next dose of [MEDICATION NAME]. The resident's MAR indicated [REDACTED]. This placed the resident at higher risk for bleeding. A fax form to the physician, dated 1/5/15, documented the resident was slow to respond verbally. The note included vitals, time of pain medication administration, a urine analysis was obtained and blood work was scheduled to be drawn that evening. The note asked if there would be any new orders, for the physician to advise and indicated the daughter had been notified. A hand written note from the physician on the same fax form, dated 1/10/15, stated, Next time page me for urgent concerns! A progress note, dated 1/5/15 at 11:50 p.m., documented an order had been received to hold [MEDICATION NAME] tonight related to the increased PT. The note documented, on-call (physician) would like (anticoagulation clinic) to address further orders tomorrow. Two of the facility's licensed nursing staff had knowledge of the critical INR level and there was no evidence of the physician being called until almost 7 hours later. On 6/8/15 at 1:12 p.m., staff from the Anticoagulation Clinic stated, I am not pulling her name up in our system. It is safe to assume we did not have (Resident #21) as a patient. An order was not provided, by the facility, documenting the on-call physician's order to hold the [MEDICATION NAME]. Records provided by the resident's primary physician on 06/11/2015 showed no communication from the facility to the primary physician regarding the critically high PT/INR. <hospitalization > A progress note, dated 1/6/15 at 4:02 a.m., documented the resident had a PT of greater than 150 today. It was noted the resident had multiple large bruises all over her body, blood in her stool and was pale in color. The note documented, Assessment: Possible internal bleeding from over anticoagulation. The note showed a call was placed to the on-call physician at the hospital, an order received to give Vitamin K (orally) and transport to (hospital emergency department) for eval and possible blood transfusion. (Ambulance) called and (resident) left facility by ambulance at (4:00 a.m.) A physician's order could not be located to direct staff to give Vitamin K. The January MAR indicated [REDACTED]. Review of the emergency department (ED) Clinical Report, dictated by the emergency room physician at 01/06/2015 at 10:07 a.m., described the chief complaint for the resident as dark/tarry stools. This started today, has been severe and is still present. It has been constant. (The resident) has had dark stools and rectal bleeding. The ED Clinical Report indicated the resident's hemoglobin was 7.0 and hematocrit was 23%. This is a significant drop compared to the resident's hemoglobin and hematocrit obtained on 12/15/14 which was 10.6 and 33.7%. The ED Clinical Report described the resident received 2 units of fresh frozen plasma and 2 units of packed red blood cells. The resident was transported to another hospital because she required admission to the intensive care unit. Under the Clinical Impressions Heading, the ED Clinical Report listed GI (gastrointestinal) bleed acute,profound [MEDICAL CONDITION] secondary to acute blood loss, and supratherapeutic (high) INR. <Lack of Investigation> On 06/08/15 at 12:35 p.m., when asked about the facility's procedures after they identify a resident with bruising, the DNS stated when bruising is identified, they look at what medications the resident is on. The DNS said there would be an investigation about the bruising. The DNS stated this situation should have been investigated and it should be on the accident/incident log. It may have been missed. Record review of the accident/incident log, showed there was not an entry about the multiple large bruises all over the body of Resident #21 and/or medication error resulting in a critical PT/INR. <Conclusion> Resident #21 required hospitalization , blood [MEDICAL CONDITION] and transfer to another hospital for intensive care services. At the time of this onsite visit no current failed practice was found in medication delivery or monitoring of anticoagulant therapy or investigations of incidents or accidents. In information provided by the facility on 06/09/15, the Administrator described steps taken to improve resident care, I can point to things we have identified and changed since the beginning of the year, which I believe were reflected in our current processes, in the current records and the other closed records. Such things as changing our lab draw process for pro-times, changing how the [MEDICATION NAME] logs are reviewed, order verification and entry, med errors, notification to M.D.s, etc. The failures were determined to be past non compliance at jeopardy level.

Based on observation, interview and record review, it was determined the facility failed to ensure necessary care and services were provided for 3 of 32 current sampled residents (#152, #80 & #60) reviewed for pain management, non-pressure skin conditions and change in condition. These failures placed residents at risk of delayed treatment to reach the highest level of physical, mental and psychosocial well-being and caused harm to Resident #152. Findings include: <Pain Management> 1) Resident #152 was admitted to the facility on [DATE] from the hospital. The hospital transfer/referral form indicated the resident had recent abdominal surgery with a foreign body in his intestinal tract from the surgical cholecystotomy tube (a drainage tube placed in the gallbladder to keep it from getting too swollen) which was "cut too short and slipped into the colon." The facility's 04/04/14 Minimum Data Set (MDS assessment tool) indicated a pain level of 8 (10 levels with 0=none and 10 = worst) and no pain managment program. Review of the Narcotic Record (sign-out) Book (NRB) and the Medication Administration Record (MAR, for charting medications given) were not the same. More narcotics were signed out for the resident than had been administered. The MARs failed to consistently identify the effectiveness of the pain medication that was administered. On 4/7/14, after survey, additional information was provided by the facility including additions to the MAR with dosage amounts, post pain ratings and comments documented for 4/2/13 - 4/3/14 that were not present on copies made during the onsite survey period. Observations and interviews with the resident and staff members about his pain revealed: On 4/2/14 at 9:34 a.m., the resident stated no one had talked to him about the medications he was taking. "I am in so much pain and since I came back from the hospital I have less pain medication than I did when I went there." The resident also stated he tried to go to therapy and, "it's just a ridiculous amount of pain." He stated his testicles and right leg had been extremely swollen and getting into a wheelchair to transport to therapy was "excruciating." The resident stated, "(Therapy Staff) seem to come when I am midway through my meds and think I'm being a baby about the pain." At 9:42 a.m., PT A entered the room, with the surveyor present, to check on the resident and confirm a therapy session for 3:30 p.m. At 10:10 a.m., Two (2) Nursing Assistants (NAs) entered Resident #152's room. Through a closed door, the resident could be heard moaning and stating "Ow". The resident was seen exiting the room with the two (2) NAs. The resident was seated in a shower chair and observed with a furrowed brow and looked to be in pain. At 10:20 a.m., Licensed Nurse (LN) C stated the resident was sent to the hospital to be assessed for pain on 4/1/14. Records indicated the transfer to the hospital was due to a lack of pain medication available in the facility. Licensed Nurse C also stated the resident had pain medication at 6:45 a.m. that morning. No documentation was noted on the Pain Monitoring Flowsheet located in the Medication Administration Record (MAR). On 4/3/14 at 1:29 p.m., LN A stated, therapy and care should be coordinated with pain medication administration. She also stated Resident #152 was new and they were still trying to figure out what works for him. The resident did not have a routine pain medication, only [MEDICATION NAME] P.R.N. (Pro re nata (P.R.N.) meaning as needed; medication that is not scheduled; instead, the decision of when to administer the drug is left to the nurse and resident). At 3:23 p.m., PT B was observed entering the resident room. The MAR did not indicate pain medication had been given or documented on the Pain Monitoring Flowsheet since 11:00 a.m. The PT Staff was observed asking an NA for a bed pan and assistance with the resident's bowel incontinence. At 3:28 p.m., PT A stated Resident #152 was tolerating about 30 minutes of physical therapy due to pain. At approximately 3:30 p.m., the resident was observed being transported via wheelchair to therapy by the PT. The resident was in a hospital gown, disheveled and appeared in pain. His eyes were closed and he was moaning and grimacing. He complained of severe abdominal and scrotum pain. He told the therapist he could not participate in therapy that day because the pain was too severe. The therapist tried to reassure the resident therapy was needed and despite the residents continued pain complaints, took the resident to the therapy department. At 4:45 p.m., during interview with the Director of Nursing Services (DNS), she stated there was a problem with missing and inconsistent documentation on the Pain Monitoring Flowsheet, MAR and Narcotic Record Book. The DNS also stated the medication should be given to coincide with care or therapy. At 4:51 p.m., LN B stated the resident dozes off at night and doesn't request his medication. The nurses will wake him up if he looks restless. He has a fluctuation in pain. The resident was sent to the hospital for pain and when he returned the [MEDICATION NAME] decreased to 5 mg. The LN stated "the resident is new to us. We are still trying to figure out what will be useful for him." LN B stated the resident was not on routine pain medication and there had been issues communicating with the resident's doctor which resulted in a long delay in providing the resident with pain medication. The resident would not have a routine doctor until his appointment on 4/7/14 at a health center. LN B stated, Resident #152 would not always ask for his pain medication and at times when his pain was stronger he was adamant about getting his pain medication. On 4/3/14, after discussions about the resident's pain management with the staff, a progress note documented a new physician order for [REDACTED]." Resident #152 stated, "I need the nurse to remind me when I'm due for a medication, I don't always remember what time I had the last one and by the time I remember it's because the pain is coming back. Once I feel the pain, it's too late and I've timed it, it takes 40 minutes for me to get relief." He then added, sometimes he would ask the aides about pain medication and they would tell him they would ask the nurse but they forget and then too much time goes by and then it's too late." The resident explained he had a shower that had felt great but, "getting out of bed and back into bed was very painful." He also stated he had an episode of bowel incontinence earlier, "having to get on my side to get cleaned up was excruciating." The facility provided a written statement by NA A, one of the aides that provided Resident #152 a shower on 4/3/14. The document stated the resident, "seemed in a lot of pain when he was suspended off the bed. It took several minutes once the resident was positioned in the shower chair for the pain to lessen. Again, when the resident was Hoyered (mechanically lifted) back into bed, he showed pain discomfort when he was suspended" (in the lift). <Pain Monitoring Flowsheets & Information Provided After Survey> According to the Pain Monitoring Flowsheet and MAR for 4/3/14, no pain medication had been given since 2:40 a.m. and only one signature was noted in the MAR for the as needed 5 mg [MEDICATION NAME]. On 4/7/14, after survey, additional information was provided by the facility. Pain Monitoring Flowsheets provided by the facility on 4/7/14 with additions to the dosage amounts, post pain ratings and comments documented for 4/2/13 - 4/3/14 that were not present on copies made during the onsite survey period. A progress note provided by the facility for 4/3/14 at 7:08 p.m. read, "(Patient) states that increase in pain meds is helping." The Pain Monitoring Flowsheet documented on 4/4/14, 10 mg of [MEDICATION NAME] had been administered at 8:00 a.m., 11:45 a.m. and 4:00 p.m. per the every four (4) hours PRN orders. The additional therapy notes provided by the facility for 4/4/14 noted the resident, "was able to stay up in (wheelchair) for 1 ? hours and eat lunch...the resident stated that his therapy was getting easier." In a separate therapy note for 4/4/14, it was documented the resident reported less pain and was more agreeable. The resident's care plan dated 3/31/14 noted chronic pain related to diabetic [MEDICAL CONDITION]. Interventions included, monitoring medications for effectiveness and anticipating need for pain management. The resident's admission orders [REDACTED]. The dose indicated on the order was 5-10 milligrams (mg) by mouth every four (4) hours as needed (PRN). On 4/1/14 a physician's order noted [MEDICATION NAME] tab (5 mg) 1 tablet by mouth every 4-6 hours PRN. On 3/31/14 at 4:06 a.m., a fax to the physician was sent reporting the resident had eight (8) tabs of [MEDICATION NAME] remaining on the script. According to the Narcotic Record Book after the 3:25 a.m. dose on 3/31/14 five (5) tablets remained. A return fax, noted on the original request form to the physician stated, "No, I've never seen this patient. Please schedule an (appointment) with (primary care provider)." The Narcotic Record Book documented one (1) 5 mg tablet of [MEDICATION NAME] was administered at 9:00 p.m. on 3/31/14. No other pain medication was documented as given on the Medication Administration Record (MAR) for 3/31/14 or 4/1/14. On 4/1/14, a 9:54 a.m. the progress note indicated the resident was transported to the hospital via ambulance due to increased pain. The facility's failure to assess, monitor, evaluate and accurately document the effectiveness of interventions for the constant and intense pain experienced by Resident #152 resulted in delayed treatment and administration of inadequate dosages of medication required to prevent the resident from experiencing uncontrolled pain. <Non-Pressure Skin Condition> 2) Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated a wound infection/[MEDICAL CONDITION] to her foot. According to Understanding [MEDICAL CONDITION] of the Lower Limb (Wound Essentials, Volume 2, 2007), [MEDICAL CONDITION] is a bacterial infection of the skin. "It presents as a swollen, red area that feels hot and tender, and which may spread rapidly. If the patient develops any complications or the condition becomes more serious, if left untreated, the spreading bacterial infection may quickly become life-threatening." The facility's Preventative Skin Care policy documented, "The patient receives care and treatment to heal and reduce the possibility or prevent further development of skin breakdown." Procedures include, "Assess patient from head to toe for skin breakdown and effectiveness of care plan interventions at least weekly." The annual MDS assessment dated [DATE], did not identify a wound infection/[MEDICAL CONDITION] to her foot and she was assessed as alert, oriented and could make her needs known. On 03/31/14 at 2:53 p.m., the resident's left foot was observed to be swollen with yellow, crusty matter on the skin. The resident stated she did not know what was happening. On 04/02/14 at 4:45 p.m., a dressing change was observed to the resident's left lower extremity. The leg was red from below the knee and onto the foot of the resident. The foot and toes were severely swollen. The top of the foot, from the base of the toes, to the middle of the shin of the left leg was covered in a crusty, scaly, yellow dry substance. The red skin beneath could be seen under the crusty substance on the foot and shin. The skin was not draining and was dry. Licensed Nurse (LN) F used a washcloth dampened with water to rub the shin and foot. The resident stated that (rubbing the skin with the washcloth) felt good and wanted the nurse to use a second washcloth to rub the skin again. The resident did not appear to be sensitive to the LN lightly scrubbing the shin and foot. At 5:05 p.m., LN F stated the leg and foot was not warm to the touch. The resident's foot was [MEDICAL CONDITION] (swollen with fluid) and the leg was not. At 5:07 p.m., the DNS indicated the facility had tried quite a few treatment options and those options were documented in the resident chart. The DNS stated the resident's leg "will get better but never completely resolve." <Care Plan> The resident's care plan was last updated 01/13/14, and included the following: Chronic [MEDICAL CONDITION] including intervention to apply compression stockings prior to rising from bed and remove when retiring to bed at night. Chronic Stasis Ulcers (also known as venous ulcers caused by a lack of blood venous flow to the leg) to the left lower extremity (LLE) including interventions of compression stockings, elevation of legs, and monitoring for sign and symptoms of infection. The MDS assessments dated 10/16/13 and 1/8/14 did not identify stasis ulcers. [MEDICAL CONDITION] including interventions monitoring for [MEDICAL CONDITION] of legs and feet. Potential Impairment to Skin Integrity with a goal to prevent altered skin integrity and no interventions related to the resident's current left lower leg non-pressure skin condition. <Weekly Skin Condition Reports> Review of the Weekly Skin Condition Reports showed the following inconsistent assessment documentation of wound care. From 11/06/13 through 11/20/13, documented the resident had redness and [MEDICAL CONDITION] to LLE. On 11/27/13, documented [MEDICAL CONDITION], redness, dry flaky skin on the resident's LLE. From 12/05/13 through 12/26/13, documented rash redness and swelling to the resident's LLE. On 12/26/13 and 01/02/14, documented [MEDICAL CONDITION] and rash to the resident's LLE. From 01/09/14 through 02/27/14, documented rash, swelling, and redness on the resident's LLE. On 03/06/14, documented [MEDICAL CONDITION] on the resident's LLE. On 03/13/14, documented redness and swelling to the LLE of the resident. The Nursing Home Visit Note by the physician, dated 03/13/14, documented the resident had [MEDICAL CONDITION] of left lower leg and noted, in the section under exam, "no [MEDICAL CONDITION]." On 03/20/14 and 03/27/14, documented [MEDICAL CONDITION] on the resident's LLE. <Treatment Administration Records (TAR)> The October 2013 TAR documented a treatment order, dated 08/27/13, for a specialty boot on LLE for 5 days, and "Continue cleansing with warm soapy water between changes on day of change." The MDS dated [DATE] indicated cellulits infection of her foot. Documentation showed to discontinue the cleansing on 10/17/13. The November 2013 and December 2013 TAR showed, on 11/23/13, a treatment order for "lightly scrub LLE c (with) warm soap and water using washcloth prior to re-wrapping qd (every day)." The January 2014, February 2014 and March 2014 TAR did not document the 11/23/13 treatment order to lightly scrub the LLE with warm soap and water after each dressing change. <Physician Orders> The October 2013 and November 2013 Physician Orders, showed the order, dated 08/27/13, that included "continue cleansing with warm soapy water between changes on day of change." The November 2013 through March 2014 Physician Orders, did not show the 11/23/13 treatment order for lightly scrubbing LLE with warm soapy water after the daily dressing changes. On 04/03/14 at approximately 2:00 p.m., when asked about the resident's order for lightly scrubbing the LLE with warm soapy water using washcloth after each dressing change, LN E stated she was unable to find the order for the soap and water treatment. Record review showed the facility did not have an order to discontinue the soap and water treatment directive. Physician's Progress Notes, dated 12/15/13, documented, "Re-evaluate LLE which has stopped draining. Has large amt (amount) scly (scaly) skin. Some easy to remove, some attached. Staff to wash w/soap & (with soap and) water to try to exfoliate..." At 4:06 p.m., LN E stated the resident's skin condition started with chronic [MEDICAL CONDITION]. The facility tried a (specialty) boot and it made the condition worse. LN E stated they used pads on the leg because the leg will "weep" (drain) at times. LN E indicated the left lower leg has [MEDICAL CONDITION] and [MEDICAL CONDITION] in for the foot. LN E said the facility could not find the order for lightly scrubbing the leg and foot with warm soapy water prior to re-wrapping. "The wound nurse has a bad habit of verbalizing orders and not writing it down." When asked if the resident would benefit from the scrubbing with the warm soapy water, LN E indicated the resident would benefit. The resident "may continue to like it. We can try it." LN E stated the facility could not find the 11/23/13 order, and "I don't know where it went." When asked about the Physician Note on 12/15/13, LN E stated, "It could be that I could not find the order so I did not put it in...I should have looked for a DC order for it." "We can get a new order for it." "It must have just got missed." The facility's failure to manage the treatment and accurately document the condition of Resident #80's left lower leg skin condition, placed this resident at risk for inconsistent care and services that had the potential to slow down, prevent and/or worsen the healing of this non-pressure related skin condition. <Change in Condition> 3) Resident #60 was admitted on [DATE] from the hospital with multiple medical conditions including severe heart failure, low blood pressure, [MEDICAL CONDITION], infections, dementia and history of rectal bleeding. At the time of admission, the Resident's Physician's Order for Life Sustaining Treatment (POLST) indicated the resident and family elected to have limited interventions that included hospitalization if necessary. On 1/31/14, the nurse's notes (NN) indicated the resident's condition changed at 1:52 p.m. and the resident was confused and lethargic with a drop in oxygen levels to 60% (normal range between 92-100%). At 9:40 p.m., the NN indicated: "hypotensive (drop in blood pressure not noted in records), decreased O2 saturations (drop in oxygen levels not noted in records). Will continue to monitor." On 4/3/14 at noon, the DNS stated she would look for documentation as to the resident's change in condition and any discussion that may have occurred related to why the resident's preference/POLST was not honored to transfer to the hospital if needed. .