Every finding on record at Bremerton Trails Post Acute

Based on observation, interview and record review, the facility failed to provide assistance with meals and mobility for 2 of 3 residents (Resident 1 and 2) reviewed for activities of daily living (ADL). This failure placed residents at risk of hunger, frustration, decreased mobility and clinical complications.Findings included.On 08/17/2026 at 10:26 AM, Collateral Contact 1 (CC1), said when they visited their family member at the facility they found them with dirty clothes, food on their clothes and left in bed to fend for themselves.RESIDENT 1Resident 1 was admitted on [DATE] with diagnoses including multiple sclerosis (a progressive neurologic disease causing fatigue and muscle weakness) and dementia. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/24/2026, showed Resident 1 had moderate impairment in cognition and was dependent on staff for bed mobility, transfers and was independent in eating once the meal was placed before the resident.Resident 1's fall risk care plan, dated 01/03/2019, showed staff were to keep needed items, water, etc. in reach of Resident 1.Resident 1's ADL care plan, revised 03/04/2026, showed Resident 1 required set up assistance with meals, and staff were to encourage OOB [out of bed] in dining room for lunch.On 08/26/2026 at 12:30 PM, Resident 1 was observed lying in bed. Resident 1 said they wanted to get out of bed, but no one was helping them.On 08/26/2026 at 1:02 PM, Staff A, Licensed Practical Nurse (LPN), was notified that Resident 1 would like to get out of bed and up to their wheelchair. Staff A said they would let someone know.On 08/26/2026 at 1:21 PM Resident 1 was observed lying in bed with the head of the bed slightly elevated. Resident 1's lunch tray was observed on the overbed table positioned parallel to the bed and out of reach of Resident 1.On 08/26/2026 at 1:22 PM, Staff A, LPN, entered Resident 1's room and asked the resident if they wanted to get out of bed for lunch. Resident 1 responded that they would like to get out of bed.On 08/26/2026 at 1:40 PM Resident 1's lunch tray was observed on the overbed table positioned against Resident 1's bedroom wall, out of reach of Resident 1. Resident 1 said they would like to eat their lunch, but no one had helped them.On 08/26/2026 at 1:48 PM, Staff B, Resident Care Manager (RCM), entered Resident 1's room and asked Resident 1 why there were not eating their lunch. Resident 1 said they were waiting for it. Staff B pushed the overbed table in front of Resident 1 and set up their lunch tray. Resident 1 began eating their lunch.On 08/26/2026 at 1:49 PM, Staff B, RCM, said Resident 1 should have been in their wheelchair for lunch and the lunch tray set up for them to eat. Staff B said they did not want Resident 1 to reach for their table and/or have cold food.On 08/26/2026 at 2:05 PM, Staff A, LPN, said they had checked with Resident 1, and Resident 1 had wanted to get out of bed and into their wheelchair for lunch, but they needed an aide to assist them and they were all busy.On 08/27/2026 at 12:48 PM, Resident 1 was observed in their wheelchair in the Olympic Dining Room. Staff were observed handing out lunch trays to the residents in the dining room.On 08/27/2026 at 1:11 PM, Resident 1 was observed in their wheelchair in the hallway outside of their room. When asked how lunch was, Resident 1 said they had not had lunch, it wasn't there.On 08/27/2026 at 1:12 PM, Staff C, Certified Nursing Assistant (CNA), was observed walking in the hallway past Resident 1. Staff C was questioned why Resident 1 did not have lunch in the Olympic Dining Room. Staff C said Resident 1 should not be in the Olympic Dining Room because their tray is delivered with the Bayshore Unit Hall trays. Staff C said they usually set up Resident 1 in their room for meals.RESIDENT 2Resident 2 was admitted on [DATE] with diagnoses including stroke (blood flow to a part of the brain stops and/or gets blocked causing brain cells to die) and dementia. The quarterly MDS, dated [DATE], showed Resident 2 had severe cognitive impairment and required substantial/maximal assistance from staff to roll left and right in bed, to sit on the side of the bed, to transfer from the bed to a chair and was dependent on staff for personal hygiene.Resident 2's ADL care plan, dated 02/20/2025 showed Resident 2 required staff assistance for bed mobility, staff participation to dress and was able to eat independently with set up assistance.Resident 2's respiratory care plan, dated 08/27/2025, showed Resident 2 had aspiration precautions (safety measures used to prevent food, liquids, or stomach contents from entering the airways and lungs) and the head of the bed should be elevated, and Resident 2 should be in an upright position when eating.On 08/26/2026 at 1:24 PM Resident 2's lunch tray was observed sitting on a chair in the hallway. Resident 2 was observed lying in bed, the room lights were off, the head of the bed was elevated at a 90 degree angle and Resident 2 was slumped down in bed. Resident 2's breakfast tray was on the overbed table and Resident 2 was eating. Resident 2 had food on the front of their shirt.On 08/26/2026 at 1:27 PM, Staff D, CNA, observed Resident 2's lunch tray on the chair and asked, whose lunch tray is this? Staff D reviewed the tray card and proceeded to enter Resident 2's room and deliver the lunch tray and remove the breakfast tray. Resident 2 was observed with the head of the bed elevated at 90 degrees and slumped in their bed with the lunch tray in front of them.On 08/26/2026 at 1:43 PM, Staff B, RCM, entered Resident 2's room and asked Resident 2 why they were eating in the dark and said they needed to go and get an aide to assist them in pulling Resident 2 up in bed and repositioned.On 08/26/2026 at 1:49 PM, Staff B, RCM, said the nursing staff should have pulled Resident 2 up in bed and positioned them upright and turned on the lights when they delivered the lunch tray.On 08/26/2026 at 1:59 PM, Staff E, CNA, said the breakfast tray was in Resident 2's room because when they delivered breakfast trays in the morning and if Resident 2 was sleeping, they would leave it in the room in front of Resident 2 so they could eat it when they woke up.FINAL INTERVIEWOn 08/27/2026 at 3:34 PM, Staff F, Director of Nursing, said it was very important for nursing staff to read resident's care plan and make sure residents received the care they were supposed to. Staff F said they expected residents to receive complete ADL care in the morning to include; changing clothing, oral care, toileting, incontinent care and assisting them out of bed. Staff F said they expected residents to be up in their wheelchair for meals and if they were in bed per their choice, they expected them to be positioned upright in bed and their tray set up and accessible to them. Staff F said Resident 1 should have been out of bed for meals and taken to the dining room on their unit. Staff F said Resident 2's breakfast tray should not be left in the room for that length of time, and a fresh meal could have been obtained when they woke up. Staff F said if Resident 2 wanted to remain in bed they should have been positioned correctly in bed and morning care provided.Reference WAC 388-97-1060(2)(c)

Based on observation, interview and record review, the facility failed to provide social services to identify, assess, evaluate and advocate for a cognitively impaired resident involved in a physical relationship with another resident to prevent possible abuse for 1 of 3 residents (Resident 3) reviewed. This failure placed residents at risk of sexual abuse, lack of advocacy and a diminished quality of life.Findings included.Resident 3 was admitted on [DATE] with diagnoses including dementia and mental health disorders. The quarterly Minimum Data Set (MDS), an assessment tool, dated 08/03/2026, showed Resident 3 had severe cognitive impairment, required substantial/maximal assistance from staff for transfers and bed mobility and dependent on staff for wheelchair mobility. Review of Resident 3's care plan, revised 05/12/2025, showed a focus area of impaired cognitive function, goals of being able to communicate basic needs on a daily basis and needs will be anticipated by staff 100% of the time. Interventions included; ask yes/no questions as appropriate in order to determine needs, orient to time/place/person, provide resident with necessary cues-stop and return if agitated and provide consistent, simple, directive sentences and break tasks into one step at a time.Review of Resident 3's care plan, revised 02/02/2025, showed a focus area of Resident 3's tendency to refer to male residents as boyfriends, enjoyed flirting with other residents and they spoke with resident's POA [power of attorney] who stated that they are ok with resident displaying physical affection and their references to having boyfriends. The goal was to monitor and intervene as necessary. Interventions included; document behaviors, and Resident 3's response to interventions, encourage Resident 3 to meet with their male friends in the dining room or by the nurses station and to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention and remove from situation and take to alternate location as needed.Resident 4 was admitted on [DATE] with diagnosis of a disease affecting their body movement and muscle coordination. The quarterly MDS, dated [DATE], showed Resident 4 was cognitively intact, dependent on staff for transfers and used a motorized wheelchair independently.Resident 4's care plan, revisited 04/24/2026, showed that Resident 4 engaged in frequent interaction with a cognitively impaired peer, requiring support to maintain appropriate social boundaries with a goal that Resident 4 would maintain respectful and appropriate interactions with peers. The interventions included; monitor interactions to ensure they remain comfortable and appropriate for all parties and provide guidance on appropriate boundaries when needed.On 08/27/2026 at 11:38 AM, Resident 3 was observed sitting in their wheelchair in the dining room and Resident 4 entered the dining room in their electric wheelchair, approached Resident 3 and took their hand, kissed the hand and then reached over and kissed Resident 3 on the lips. Resident 3 appeared to welcome the interaction. During the interaction no staff persons were present.On 08/27/2026 at 12:19 PM, Resident 3 was observed sitting in their wheelchair in the dining room, Resident 4 was sitting beside Resident 3 and held their hand, and kissed Resident 4 on the lips.On 08/27/2026 at 12:21 PM, Staff G, Certified Nursing Assistant, said they are aware Resident 3 and Resident 4 hold hands and kiss. Staff G said they had no concerns and there was nothing they needed to monitor and/or watch for, they like each other, they are good for each other.On 08/27/2026 at 12:24 PM, in a joint interview with Staff H, Social Service Assistant and Staff I, Social Service Director, Staff I said they did not know what type of physical affection Resident 3's care plan was referencing. Staff I said they did not know if kissing and/or intimate touching was ok and they were not aware Resident 3 and Resident 4 had kissed. Staff H and Staff I said there was not a current process to determine if Resident 3 had the capacity to consent to kissing, touching and/or other intimate actions due to their cognitive impairment. Staff I said they would rely on staff observations and reporting. Staff H said there was not currently any monitoring and/or on-going evaluation of Resident 3's ability to communicate boundaries and/or consent. Staff I and Staff H said they were not aware of any discussion with Resident 3 about their relationship with Resident 4 and how they felt about touching and kissing. Staff I and Staff H were not aware of any evaluations and/or ongoing discussions with Resident 4 about their relationship with Resident 3 and what were appropriate social boundaries. Staff H said they were not aware of when and/or how they would want staff to intervene as necessary per Resident 3's plan of care.On 08/27/2026 at 3:34 PM, Staff F, Director of Nursing, said a resident's care plan should be individualized, based on a resident's needs and staff monitoring for changes. Staff F said Resident 3's care plan was not specific to types of affection and/or how and when staff were expected to intervene. Staff F said they were not aware of Resident 3 and Resident 4's relationship.Reference WAC 388-97-0960(1)

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 residents (Resident 1) reviewed for abuse. Resident 1 experienced harm when they were punched and grabbed around the neck, causing bruising and abrasions by a resident with a known history of physical abuse. The facility's failure placed residents at risk of physical injury, fear, intimidation and a decreased quality of life.Findings included.Resident 1 was admitted on [DATE] with diagnoses including severe dementia and dysarthria (slurred and/or slowed speech) following a cerebral vascular accident (interruption of blood supply to the brain causing brain tissue damage). The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/05/2026, showed Resident 1 had severe cognitive impairment.On 08/06/2026 at 11:20 AM, Resident 1 was observed with a bruise surrounding their left eye that was blue and yellow in color and a dark red area below their left collar bone. Resident 1 said they had been hit repeatedly by a man. Resident 1 said the man hit them because they did not like them. Resident 1 said it hurt when the man hit them.Review of the Facility's incident investigation, dated 08/03/2026, showed Resident 1 was observed being grabbed and punched by Resident 2. The investigation showed Resident 1 was assessed at the time of the incident and presented with an abrasion on the right eyebrow of approximately 0.4 Centimeters (CM) and redness on the lower side of the neck. The investigation showed Resident 1 was asked what happened and they stated Resident 2 had held them by their chin and neck creating skin issues. The investigation showed Resident 2 was asked what happened and they said they did not want Resident 1 in their room and they would do the same thing again if Resident 1 entered their room again. The investigation showed Resident 2 had another altercation with a resident in the past and had been on one to one (1:1) observation and a trial of every 15-minute monitoring was in place which failed hence the current incident. The investigation showed the facility contacted emergency services and Resident 2 was arrested and removed from the facility.Review of Resident 1's nursing notes, dated 08/03/2026, showed Resident 1 with latent (a condition that was hidden) edema over the left eye and slight abrasion under the eye and redness around their neck.Review of Resident 1's medical provider notes, dated 08/04/2026, showed that Resident 1 was alert and oriented to self only, which was their baseline and was conversant and cooperative, given their advanced dementia and significant dysarthria they were a poor historian. The notes showed the nursing staff reported Resident 1 received a fist punch to their left periorbital ridge by another resident. The notes showed Resident 1 reported they felt good, denied pain and/or feeling scared and/or upset but Resident 1 had advanced dementia diagnosis and could not express themselves fully. The notes showed a physical examination showed a bruise over Resident 1's left lateral periorbital bone with no significant finding to their eyeball.Resident 2 was admitted on [DATE], The quarterly MDS, dated [DATE], showed Resident 2 was cognitively intact and had physical and verbal behavioral symptoms directed toward others.Review of Resident 2's risk of verbal and physical aggression care plan, initiated on 04/08/2025 and revised on 07/03/2026, showed Resident 2's behavior history: 07/01/2024 verbal resident-to-resident altercation, 03/29/2025 verbal resident-to-resident altercation, 05/23/2025 verbal aggression, 11/18/2025 verbal aggression with another resident, 11/24/2025 verbal aggression toward staff, 01/02/2026 aggressive behavior, 03/04/2026 escalated conflict with resident, nearly physical, 03/04/2026 verbal aggression during care conference, 05/28/2026 physical aggression initiated, 06/05/2026 physical aggression toward another resident. The care plan showed Resident 2 had target behaviors of verbal and physical aggression with triggers that included: arguments/disagreements with others, crowded environments, frustration r/t [related to] communication difficulties, feeling provoked/challenged/misunderstood and residents repeatedly walking by their door.Review of Resident 2's nursing notes, dated 07/25/2026, showed Resident 2 was taken off 1:1 observation due to request from Resident 2 and their family member. The notes showed Resident 2 was initially on 1:1 due to physical and verbal aggression with other residents and they would be reassessed at a later date pending findings.On 08/07/2026 at 2:52 PM, Staff B, Social Service Director, said Resident 2's room was across from the nursing station. Staff B said the nursing station could be loud at times, residents frequently walked and/or wheeled past the nursing station and residents sat in their wheelchairs across from the nursing station, outside Resident 2's door. Staff B said Resident 1's normal routine was to self-propel up and down the hallway and frequently wheeled past Resident 2's door and talked with staff at the nursing station. Staff B said Resident 2 had previously resided at the end of the hallway, but they were triggered by other residents in that location, and they thought there would be more oversight across from the nursing station. Staff B said they were unaware the 1:1 staff had been discontinued until the incident with Resident 1 had occurred, Staff B said keeping the 1:1 staff in place would have been the best idea.On 08/07/2026 at 4:00 PM, Staff A, Director of Nursing, said Resident 1 was physically abused by Resident 2 and had sustained a scratch and a bruise on their eye and a bruise on their neck.Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to report allegations of physical abuse within two hours to the state agency and failed to report allegations of neglect and injuries of unknown origin to the state agency for 3 of 5 residents (Resident 1, 3 and 4) reviewed for abuse.Findings included.Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 09/2024, showed if resident abuse, neglect or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy showed immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.RESIDENT 1Review of the Facility's incident investigation, dated 08/03/2026, showed on 08/03/2026 at approximately 1650 (4:50 PM) Resident 1 was observed being grabbed and punched by Resident 2 and sustained a mild injury to their eye, neck and eyebrow. The investigation showed the state agency was notified on 08/04/2026 at 12:05 PM (approximately 19 hours after the incident).On 08/07/2026 at 4:00 PM, Staff A, Director of Nursing (DNS) said the incident between Resident 1 and Resident 2 was physical abuse and Resident 1 had sustained an injury. Staff A said they would have reported the incident within the two-hour timeframe, but they were locked out of their office. Staff A said the allegation of abuse was not reported timely.RESIDENT 3Resident 3 was admitted on [DATE]. The discharge Minimum Data Set (MDS), an assessment tool, dated 06/11/2026, showed Resident 3's short term memory was ok.On 08/06/2026 at 9:58 AM, Resident 3 said they were being transported in a wheelchair van from their appointment. Resident 3 said the driver secured their wheelchair but did not use the seatbelt to secure them. Resident 3 said the van had a sign in it that stated to ensure the person was strapped in. Resident 3 said the driver was driving fast and slammed on the brakes and they flew forward and hit their leg on a board. Resident 3 said the driver attempted to pick them up but was unable and they requested emergency services be contacted. Resident 3 said the ambulance arrived and transported them to the hospital.Review of Resident 3's progress notes, dated 06/11/2026, showed a transportation provider arrived at the facility and reported that Resident 3 had a gash on their leg that occurred during transport and the paramedics were contacted and Resident 3 was taken to the hospital emergency room. Review of Resident 3's Hospital Emergency notes, dated 06/12/2026, showed Resident 3 was riding in a handicap/wheelchair transport vehicle and Resident 3 stated that the driver slammed on the brakes and they were not secured properly with the seatbelt and proceeded to fall forward out of the wheelchair and landed on their right knee and sustained a laceration on their right foot.Review of the facility's state reporting log, dated 06/01/2026 through 06/30/2026, showed no entry for Resident 3's incident and injury during transport that occurred on 06/11/12026.On 08/06/2026 at 1:41 PM, Staff C, Assistant Director of Nursing, said if a service provider failed to secure a resident in a transport vehicle with the seatbelt it would be neglect. Staff C said they had not reviewed the emergency room report and/or asked Resident 3 what happened when they returned from the hospital. Staff C said they did should have reported the incident to the state agency.RESIDENT 4Resident 4 was admitted on [DATE]. The admission MDS dated [DATE], showed Resident 4 had moderate cognitive impairment and was dependent for transfers and bed mobility.Review of the facility's incident investigation, dated 07/28/2026, showed that during a transfer from the bed to the wheelchair, the staff noticed a laceration on Resident 4's left leg. The investigation showed Resident 4 was unaware of the injury and did not know how it happened. The investigation showed Resident 4 was assessed by the medical provider and it was determined the laceration required staples. Resident 4 was transferred to the hospital emergency room for further evaluation and treatment. The investigation showed the exact mechanism of injury could not be determined.Review of the facility's state reporting log, dated 07/01/2026 through 08/03/2026, showed no entry for Resident 4's incident and injury to their leg that occurred on 07/28/2026.On 08/07/2026 at 4:00 PM, Staff A, DNS, said Resident 4 was found with a laceration on their leg that required an emergency room visit and the laceration to be repaired with stiches. Staff A said they were unable to determine the exact cause of Resident 4's injury. Staff A said the injury was substantial and should have been reported to the state agency.Reference WAC 388-97-0640 (5)(a)

Based on interview and record review, the facility failed to investigate an allegation of neglect for 1 of 3 residents (Resident 3) reviewed. This failure placed residents at risk for further neglect, fear and a decreased quality of life.Findings included.Resident 3 was admitted on [DATE]. The discharge Minimum Data Set (MDS), an assessment tool, dated 06/11/2026, showed Resident 3's short term memory was ok.On 08/06/2026 at 9:58 AM, Resident 3 said they were being transported in a wheelchair van from their dialysis (medical treatment to remove waste from the body when the kidneys stop working) appointment. Resident 3 said the driver secured their wheelchair but did not use the seatbelt to secure them. Resident 3 said the van had a sign in it that stated to ensure the person was strapped in. Resident 3 said the driver was driving fast and slammed on the brakes and they flew forward and hit their leg on a board. Resident 3 said the driver attempted to pick them up but was unable and they requested emergency services be contacted. Resident 3 said the ambulance arrived and transported them to the hospital.Review of Resident 3's progress notes, dated 06/11/2026, showed a transportation provider arrived at the facility and reported that Resident 3 had a gash on their leg that occurred during transport and the paramedics were contacted and Resident 3 was taken to the hospital emergency room.Review of Resident 3's Hospital Emergency notes, dated 06/12/2026, showed Resident 3 was riding in a handicap/wheelchair transport vehicle and Resident 3 stated that the driver slammed on the brakes and they were not secured properly with the seatbelt and proceeded to fall forward out of the wheelchair and landed on their right knee and sustained a laceration on their right foot.On 08/06/2026 at 1:41 PM, Staff C, Assistant Director of Nursing, said if a service provider failed to secure a resident in a transport vehicle with the seatbelt it would be neglect. Staff C said the staff were not aware they needed to investigate the injury because it did not occur within the facility. Staff C said they thought Resident 3 had fallen out of their wheelchair. Staff C said they did not discuss the injury with Resident 3, contact the driver and/or the transportation company. Staff C said they did not investigate the injury and did not remember if they had reviewed the emergency report. Staff C said they did not know if the driver was still transporting Resident 3.On 08/06/2026 at 2:25 PM, Staff D, Health Information Manager, said they arranged Resident 3's transportation to dialysis on 06/11/2026 with Para Transit. Staff D said Para Transit at times contracts with other drivers to complete their appointments. Staff D said if an incident occurred during transport of one of the facility residents, they would contact Para Transit. Staff D said Para Transit had a process for investigating incidents that occur during transport. Staff D said they had not contacted Para Transit regarding Resident 3's injury on 06/11/2026 because they were unaware the incident occurred.On 08/07/2026 at 4:00 PM, Staff A, DNS, said the facility did not investigate Resident 3's incident and injury and should have.Reference WAC 388-97-0640(6)(c)

Based on interview and record review, the facility failed to provide enter post hospital discharge wound care orders and provide consistent wound care treatments for pressure ulcers for 1 of 3 residents (Resident 1) reviewed for wounds. Resident 1 experienced harm when the sacral pressure ulcer (injury to the skin and underlying tissue over the tailbone), present on hospital discharge and readmission to the facility, worsened became infected and required surgical incision and drainage of the wound. The facility's failure placed residents at risk of worsening wounds, clinical complications and pain.Findings included.Resident 1 was readmitted to the facility on [DATE] with diagnoses of diabetes and kidney disease. Resident 1's discharge Minimum Data Set Assessment, an assessment tool, dated 06/11/2026, showed Resident 1's memory was ok and they had three unstageable pressure ulcers (locations not identified - full thickness pressure injuries in which the base of the wound is covered with dead tissue).Review of Resident 1's alteration in bowel elimination/continence care plan and bladder incontinence care plan, dated 03/31/2026, showed resident frequent had both bowel and urinary incontinence.Review of Resident 1's skin care plan, dated 05/24/2026 and revised 07/13/2026, showed resident 'Has/potential for a pressure ulcer of the sacrum r/t [related to] history of ulcers, decreased mobility with an intervention, dated 06/23/2026 (the day after resident's return to the hospital), to ensure resident had an air mattress to promote wound healing. Additional interventions included staff were to assess/record/monitor wound healing weekly and as needed, measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed healing progress and report improvement and declines to the MD.Review of resident 1's Hospital Provider Orders-Nursing Home Transfer, dated 06/16/2026, showed wound care ordered per facility protocol and/or attached wound care notes.Review of Resident 1's hospital wound care notes, dated 06/12/2026 and uploaded to Resident 1's electronic medical record on 06/17/2026, showed a sacrum (large bone at the base of the spine) unstageable pressure ulcer (wound where dead tissue covers the wound bed so completely a clinician cannot see how deep the damage goes) that had serosanguineous drainage (normal type of wound fluid), no odor, and a full thickness stage 3 pressure ulcer (pressure ulcer with full thickness loss of skin exposing subcutaneous tissue) on the left gluteal fold (skin crease below the buttocks separating them from the upper thigh). The notes showed recommendations for wound care; cleanse wounds with wound cleaner, allowing cleaner to soak for five-10 minutes, pat dry, apply SilvaSorb (antimicrobial [kills microorganisms or stops them from growing] wound dressing) to wound bed and cover with gauze and a foam dressing and change every two days.Review of Resident 1's Skin Issues evaluation, dated 06/17/2026, showed an unstageable pressure ulcer on the rear left thigh that measured 3.5 Centimeters (CM) x 2.5 CM x 0.0 CM with a wound area of 6.34 CM2 (squared) and an unstageable pressure ulcer on the coccyx (bone at base of the spine directly below the sacrum) that measured 6.69 CM x 7.64 CM x 0.0 CM with a wound area of 41.05 CM2. The Skin Issues evaluation showed sections for interventions and clinical suggestions to be documented, the sections were blank.Review of Resident 1's medical provider notes, dated 06/18/2026, showed Resident 1 had multiple non stageable pressure wounds to the sacrum, and left ischium (bone forming the lower and back part of the hip located underneath the buttock) and the plan was to continue wound care per wound care team recommendation.Review of Resident 1's medical record on 07/15/2026, showed no documentation the facility implemented and/or provided wound care for Resident 1's left gluteal fold and sacral pressure ulcers from readmission on [DATE] through 06/22/2026. Review of Resident 1's Wound Consultant Assessment, dated 06/22/2026, showed Resident 1 had a left ischium pressure ulcer that was a stage 2 and measured 3.0 CM x 3.5 CM x 0.2 CM with a wound area of 10.5 CM2. The Assessment showed Resident 1 had a full thickness sacrum pressure ulcer vs [versus] terminal skin failure (the irreversible death of skin and underlying tissue caused by the body's natural shutdown process) with a strong wound odor, 8.5 CM x 6.0 CM x 0.3 CM with a wound area of 51.0 covered in slough (layer of dead tissue) with moderate purulent exudate (commonly known as pus, a thick, milky fluid that indicates an underlying infection). The Assessment showed that given Resident 1's history and how quickly the wound developed that they were considering terminal wound failure but if it improved over the next week would consider adjusting the dx [diagnosis] to pressure injury. The assessment recommended a wound culture and to speak with the medical provider regarding starting Resident 1 on antibiotics.Review of Resident 1's wound culture of their sacral wound [though documentation identified it incorrectly as the buttocks as explained in interview below], collected 06/23/2026, showed heavy growth of bacteria.Review of Resident 1's progress notes, dated 06/25/2026, showed Resident 1 was discharged to the hospital due to their dialysis port being blocked.Review of Resident 1's hospital wound notes, dated 07/01/2026, showed Resident 1's sacral wound was an unstageable pressure ulcer, with purulent drainage and moderate odor.Review of Resident 1's hospital progress notes, dated 07/03/2026, showed Resident 1 had an infected sacral decubitus ulcer that was scheduled for debridement and I &D [incision and drainage] by general surgery. On 07/04/2026 at 1:14 PM, hospital staff, Collateral Contact 1, reported that Resident 1 said the wound on their bottom was not being cleaned consistently and they were unaware it was severe enough to require surgery.Review of Resident 1's hospital wound care notes, dated 07/06/2026, showed Resident 1's sacral wound was treated with sharp debridement and incision and drainage of an abscess (localized pocket of pus from an infection) on 07/03/2026.During an interview on 07/15/2026 at 12:22 PM, Staff A, Assistant Director of Nursing, said Resident 1 had pressure ulcers on their sacrum, identified additionally as the coccyx and the left rear thigh, identified additionally as the ischium and gluteal fold. Staff A said these wounds had been treated by the facility during Resident 1's prior stay at the facility before they were readmitted on [DATE] from the hospital. Staff A said nursing staff did not notify them that Resident 1 was missing wound treatment orders in the electronic medical record and no wound care orders were entered on admission on [DATE]. Staff A reviewed Resident 1's electronic medical record and said there was no documentation and/or evidence that the facility had provided wound care for Resident 1's pressure ulcers on their sacrum and left ischium from readmission on [DATE] until the wound consultant's assessment on 06/22/2026. Staff A said it was unacceptable and the nursing staff should have notified the medical provider and followed the wound care orders per the hospital transfer orders on 06/16/2026.Reference WAC 388-97-1060(3)(b)

Based on observation, interview, and record review, during a COVID-19 (contagious viral respiratory illness) outbreak, the facility failed to evaluate residents and staff for their COVID-19 vaccination status, to have a system in place to evaluate residents for being removed off of isolation precautions that was consistent with local health jurisdiction recommendations, to provide/order COVID-19 vaccinations, to update resident representatives about the outbreak, and/or to follow personal protective equipment (PPE) recommendations which included: having current N-95 fit tests (yearly or as needed testing to ensure proper fit of the available N-95 mask)for staff entering aerosol precaution (requires the use of gown, gloves, N-95 face mask, and eye protection) rooms, male staff wearing N-95 masks had clean shaven faces (no stubble or beard), and all PPE removed upon exiting the aerosol precaution rooms for 1 of 1 outbreak reviewed. This failure placed residents and staff at risk for spread of infectious diseases, contracting COVID-19, and a diminished quality of life. Findings included.COVID OUTBREAK INFECTION CONTROL SURVEILLANCEReview of the document titled, Bremerton Trails PA - COVID Timeline, showed the facility had 46 residents and 20 staff that contracted COVID-19. Review of the facility's correspondence with their local health jurisdiction, dated 06/11/2026 at 10:52 AM, showed they were given guidance on resident isolation that stated, Resident IsolationIsolation ends for patients who are not severely immunocompromised when:At least 10 days have passed since symptoms first appeared, ANDAt least 24 hours have passed since last fever without fever reducing medications, ANDSymptoms have improved.Review of the document titled Resident Demographics, undated, a COVID-19 surveillance form (how the facility was keeping track of infections), showed 11 residents were listed as exposed and 24 residents were listed as asymptomatic (no symptoms). All these residents tested positive for COVID-19. The 11 exposed residents did not have symptoms listed to show if they were asymptomatic or had symptoms that needed to be followed. This form had a column for vaccination status (if up to date, if needing vaccination, etc.) to be reviewed, it was blank for all 46 residents. Review of the document titled Staff Demographics, undated, a staff COVID-19 surveillance form, showed the 20 staff all had a blank column for vaccination status. For the column of the staff's last day worked, 11 staff had blanks. The last date of a positive staff test, was on 06/12/2026. Review of Resident 2's electronic health record, showed Resident 2 on 06/12/2026 tested positive for COVID-19 and a provider had seen them and assessed them to have nasal congestion, generalized weakness, and loss of appetite. On 06/14/2026, a progress note had documented Resident 2 had cough and runny nose observed. During an interview on 06/23/2026 at 9:40 AM, Resident 2 said they had not been tested since their initial positive COVID-19 test result, they had just gotten released from isolation that day. When asked if they were having any symptoms, Resident 2 said they were having a scratchy throat, but they were unsure what it was from. During an interview on 06/23/2026 at 1:06 PM, Staff A, Assistant Director of Nursing/Licensed Practical Nurse/Infection Preventionist, regarding the Resident Demographics form, said they should have written asymptomatic and exposed, the residents were all exposed, and they should have put they were asymptomatic. Regarding Resident 2 being listed as asymptomatic, Staff A said the log was not updated to reflect symptoms after the initial testing. When asked how the facility was tracking that symptoms had resolved to take residents off isolation precautions, Staff A stated, Good question, I don't have an answer for that. Regarding the form Staff Demographics, Staff A acknowledged the blanks and said they still had some work to do with this outbreak. Staff A said they had not reviewed COVID-19 vaccinations for staff or residents, they did not have time for it, and they absolutely should have reviewed them. RESIDENT REPRESENTATIVE NOTIFICATION AND COVID VACCINATIONReview of Resident 1's electronic health record, showed no record Collateral Contact 1 (CC1), Resident 1's durable power of attorney (POA, decision maker when unable), had been notified of the outbreak.During an interview on 06/22/2026 at 7:33 PM, CC1, said they had not received notification there was any kind of outbreak. CC1 said Resident 1 called them and told them they were in lockdown due to a COVID-19 exposure. During an interview on 06/23/2026 at 9:46 AM, Resident 1 said they wanted CC1 to have been notified at the start of the outbreak. Resident 1 said they were lucky and had not gotten COVID-19, they had not been vaccinated for COVID-19 yet and CC1 had been trying to get them the vaccine, and they would take the vaccine today if offered. During an interview on 06/23/2026 at 1:06 PM, Staff A, Assistant Director of Nursing/Licensed Practical Nurse/Infection Preventionist, said Resident 1 would have been the person notified of the outbreak. Staff A after reviewing 1's POA paperwork, said they were unaware of Resident 1's POA and they would need to send the notification email to the appropriate people (CC1). Staff A said yes, that Resident 1's POA should have been notified when they went into isolation. Staff A said Resident 1 was due for the COVID-19 vaccination and had consented, they had not ordered the vaccine yet. AEROSOL PRECAUTIONS AND PERSONAL PROTECTIVE EQUIPEMENTDuring an observation on 06/22/2026 at 9:42 AM, Staff B, Certified Nursing Assistant, was observed leaving room [ROOM NUMBER], an aerosol precaution room, without removing their face shield or N-95 mask. At 9:43 AM, they were observed returning to room [ROOM NUMBER] with a beverage. After leaving room [ROOM NUMBER], they were then observed wearing the same N-95 mask and face shield as they went into room [ROOM NUMBER], an aerosol precaution room. Staff B left room [ROOM NUMBER] still wearing the same N-95 mask and face shield, and continued on down the hallway carrying a pitcher from that room. During an observation on 06/22/2026 at 10:44 AM, Staff C responded to a call light for room [ROOM NUMBER], an aerosol precaution room. After leaving the room, they took off their gloves, face shield and gown, threw their gown in the trash bin, put their face shield on a medium glove container on the PPE cart, then lifted the face shield and walked down the hallway with their shield and the same N-95 on, to alert nursing to room [ROOM NUMBER]'s need, then walked to their office.During an observation on 06/22/2026 at 12:22 PM, Staff B was observed standing at the meal cart, in the hallway near room [ROOM NUMBER], already wearing a face shield. At 12:30 PM, Staff B was observed coming out of room [ROOM NUMBER], they were still wearing their N-95 mask and face shield and proceeded on down the hallway. During an observation on 06/23/2026 at 10:07 AM, review of a sign outside of room [ROOM NUMBER], showed how staff were supposed to put on and take off PPE for aerosol contact precautions. Staff were to take off PPE and dispose of the PPE in this order: 1. gloves2. gown3. wash or gel hands4. respiratory and eye cover (face shield): remove from earpiece or ties to discard- do not grab from front of respirator. 5. wash or gel hands (even if gloves used). During an interview on 06/23/2026 at 10:25 AM, Staff D, Housekeeper, was visualized wearing a N-95 mask over a beard. Staff D said they were taught to wear a N-95 mask if the room was labeled as an aerosol precaution, they would wear a face shield, N-95, and gown. When asked when they change their N-95 mask, Staff D said once an hour because of the sweat and beard. Staff D said they were not fit tested for it, and they did go into aerosol precaution rooms. Staff D said they had tested positive for COVID-19 on 06/12/2026. During an interview on 06/23/2026 at 10:29 AM, Staff B, Certified Nursing Assistant, said for taking off PPE after being in an aerosol precaution room, they would remove their gown in trashcan in room and gloves, hand hygiene, then out of the room they should remove mask and face shield. During an interview on 06/23/2026 at 11:45 AM, Staff C, Staffing Coordinator, when asked about the observation of them the previous day, said they had gone to their office to wipe down their face shield and change their mask (was not done directly outside of room [ROOM NUMBER]). During an interview on 06/23/2026 at 1:00 PM, Staff E, Certified Nursing Assistant, said they were fit tested for an N-95 mask a couple years ago. When asked about their visible facial hair and if there were any precautions related to that with wearing an N-95 mask, Staff E said they normally do wear one, it did not affect them. Staff E said they shaved once a week, and they had not received education on shaving more frequently during this outbreak. During an interview on 06/23/2026 at 1:06 PM, Staff A, Assistant Director of Nursing/Licensed Practical Nurse/Infection Preventionist, acknowledged that general staff were not up to date on fit testing. Regarding Staff D, Staff A said this staff had just started working and had not been fit tested yet. Regarding Staff E, Staff A said they believed they were agency. Staff A said they had forgotten to tell the male staff to shave. Regarding removing PPE after entering an aerosol precautions room, Staff A said staff should complete care, then take off their gloves and gown in room, then outside of room hand hygiene, then remove their face shield and mask and then hand hygiene again. Staff A said Staff C and Staff B should have removed their face shields and masks after leaving the room, but before leaving the area outside of the room and acknowledged this was not done in these observations. Staff A said the face shield should not have been put on a box of gloves, and any item the face shield was on should have been thrown away. Reference WAC 388-97 -1320 (2)(a)(b)

Based on interview and record review the facility failed to ensure residents were free of physical abuse from other residents for 2 of 4 residents (Resident 1 and 2) reviewed for abuse. This failure placed residents at risk of physical injury, fear and a decreased quality of life.Findings included.Review of the facility's policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, undated, showed that each resident had the right to be free from abuse, the definition of abuse was willful infliction of injury, intimidation resulting in physical harm, pain or mental anguish and instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.RESIDENT 1Resident 1 was admitted on [DATE] with diagnoses including a stroke with hemiparesis (brain injury with weakness or inability to move one side of body) and dementia. The quarterly Minimum Data Set Assessment (MDS), an assessment tool, dated 04/28/2026, showed Resident 1 had severe cognitive impairment and required substantial assistance to self-propel and turn in the wheelchair.On 06/08/2026 at 1:26 PM, Resident 3 said Resident 1 entered their room in a wheelchair and stopped at the sink. Resident 3 said Resident 1 was touching Resident 3's belongings at the sink and they asked Resident 1 three times to get out of their room. Resident 3 said staff members were sitting at the nursing station directly outside of their room and could hear them ask Resident 1 to leave the room. Resident 3 said the staff did nothing to assist them so Resident 3 approached Resident 1 to get them out of the room and Resident 3 said Resident 1 drew back their arm to position it to strike Resident 3. Resident 3 said they fired on Resident 1 and cracked them in the jaw. Resident 3 said they told Resident 1, you raised your hand to me and take that. Resident 3 demonstrated the motion of punching with a closed fist. Resident 3 said it was not the first time Resident 1 had entered their room but in the past Resident 3 said Resident 1 left when they were asked.On 06/08/2026 at 2:04 PM, Staff A, Licensed Practical Nurse (LPN), said they witnessed the altercation between Resident 1 and Resident 3. Staff A said they were in the nursing station completing tasks during change of shift. Staff A said they witnessed Resident 1 passing the nursing station and veered into Resident 3's room. Staff A said they told Resident 3 to hold on but before they could assist Resident 1, Resident 3 punched Resident 1 in the face with a closed fist and kicked Resident 1's wheelchair. Staff A said Resident 1 was in the doorway when it happened and Resident 1 was attempting to leave the room but due to their physical limitations struggled to turn the wheelchair around. Staff A said Resident 3 was very reactive and became verbally aggressive with noise and anyone that had cognitive impairment. Staff A said Resident 3 did not like other residents to pass by their room. Staff A said staff tried to redirect any residents that got close to Resident 3's doorway but they did not always see them in time and there was not always someone available to watch Resident 3's room.Review of the facility's incident report, dated 06/05/2026, showed Resident 3 was observed to strike Resident 1 in the face and kicked the wheelchair as Resident 1 passed by Resident 3's room.Resident 3's risk of verbal and physical aggression care plan, initiated on 04/08/2025 and revised on 06/06/2026, showed Resident 3's behavior history: 07/01/2024 verbal resident-to-resident altercation, 03/29/2025 verbal resident-to-resident altercation, 05/23/2025 verbal aggression, 11/18/2025 verbal aggression with another resident, 11/24/2025 verbal aggression toward staff, 01/02/2026 aggressive behavior, 03/04/2026 verbal aggression during care conference.Resident 3's Psychiatry (medical provider specializing in mental, emotional, and behavior disorders) provider notes, dated 04/29/2026, showed Resident 3 was seen due to concerns of increased behaviors. The notes showed there was little documentation to suggest what the behaviors were that were of concern. The notes showed Resident 3 acknowledged that they got angry at times and used the example when a peer might be outside of their room yelling at the nursing station and how it was disruptive to them. The notes showed the concern of worsening behavior appeared likely to be rooted in Resident 3's expectations, their personality and communication breakdown between them and the staff. The notes showed Resident 3 would likely benefit from a behavior plan and clear communication about expectations as well as the opportunity to clearly articulate their care needs.RESIDENT 2Resident 2 was admitted [DATE] with diagnosis of dementia. The annual MDS, dated [DATE], showed Resident 2 had severe cognitive impairment, required supervision to ambulate with a walker (medical equipment that provides stability with walking) and had verbal behavioral symptoms directed at others.On 06/08/2026 at 1:45 PM, Resident 3 said Resident 2 hollered at staff when they needed something, and the staff knew that Resident 3 would come out of their room. Resident 3 said they had came out of their room and were talking to Resident 2 when Resident 2 started cussing at them and Resident 2 spit on Resident 3. Resident 3 said they grabbed Resident 2's arm and said, you aren't going to spit at me. Resident 3 said they told the staff to keep troubled residents away from their door because it took away their peace and quiet.On 06/08/2026 at 3:34 PM, Staff B, LPN, said they were at the nursing station when Resident 2 came out of their room making noise and wanted pain medication. Staff B said Resident 3 came out of their room and went towards Resident 2. Staff B said they tried to intercept Resident 3 but Resident 3 was too strong and pushed them away and grabbed Resident 2's arm. Staff B said Resident 3 was aggressive with any noise and had hatred towards Resident 2 when they made screaming noises. Staff B said when Resident 2 made noise it triggered Resident 3's behavior.Review of the facility's incident report, dated 05/28/2026, showed Resident 2 was observed coming from their room to the nursing station and while in the hallway was attacked by Resident 3 and in the process Resident 3 grabbed Resident 2's hand.FINAL INTERVIEWSOn 06/09/2026 at 1:51 PM, Staff C, Social Service Director, said Resident 3 did not like to be around people with dementia, it made Resident 3 easily irritated. Staff C said they did not think Resident 3 was triggered by noise. Staff C said Resident 2 talked but they had never heard that Resident 2 made loud noises and/or yelled. Staff C said Resident 3 was seen by the psychiatric provider, but they only managed medications and did not provide behavioral interventions and/or recommendations. When asked if they had reviewed the 04/29/2026 Psychiatry provider notes and implemented any of the recommendations, Staff C said, I don't think so.On 06/09/2026 at 2:20 PM, Staff D, Assistant Director of Nursing, said Resident 3 had a history of aggression, yelling and cursing but now they were hitting. Staff D said they did not review the 04/29/2026 psychiatric provider notes and/or implement any of the recommendations. Staff D said hitting was physical abuse. Staff D said they thought Resident 3 did not mean to grab Resident 2 but acknowledged that would be physical abuse if Resident 3 grabbed a resident aggressively. Staff D said after the incident between Resident 3 and Resident 1 they had placed Resident 3 on one-on-one staffing because Resident 3 said they would do it again if any resident came in his area.Reference WAC 388-97-0640(1)

Based on observation and interviews, the facility failed to have a functioning call light system on 1 of 3 Resident Care Units (Cove unit). This failure placed residents at risk of delayed response to emergencies, care needs and fear for their well-being.Findings included.On 05/14/2026 at 11:34 AM, Resident 3 said their call light was not working. Resident 3 said it had not been working since the day before. Resident 3 was observed pushing the call light. The call light above the resident's door did not illuminate, there was no audible sound and the room number on the call system panel across from the nursing station did not illuminate. Resident 3 said if they needed assistance they had to get into their wheelchair and wheel out into the hallway to flag someone down for assistance. Resident 3 said the staff were aware and they had not been given anything to alert the staff they needed assistance.On 05/14/2026 at 11:37 AM, Staff B, Certified Nursing Assistant (CNA), said the call light in Resident 3's room had stopped working the day before. Staff B said the system was still not working on the Cove unit and the staff had given some of the residents bells but they did not have enough for all the residents.On 05/14/2026 at 11:38 AM, Resident 4 said their call light was not functioning. Resident 4 said it had stopped working the previous day. Resident 4 said they had to yell when they needed assistance and they had to yell if their roommate needed assistance because their voice was not loud enough for anyone to hear. Resident 4 said it had taken longer to get help, and they were not given a bell to alert staff they needed assistance. Resident 4 was observed pushing the call light. The call light above the resident's door did not illuminate, there was no audible sound and the room number on the call system panel across from the nursing station did not illuminate.On 05/14/2026 at 12:17 PM, Resident 5 said they had not had a functioning call light since yesterday at about 5:00 PM. Resident 5 said the staff told them the call light system was down. Resident 5 said they were not given a bell and/or any other instructions for alerting staff when they needed assistance. Resident 5 said they would just wait until they happened to see staff or just bear it.On 05/14/2026 at 12:19 PM, Resident 6 said they had been pushing the button and no one was coming yesterday and the staff let them know the call light system was down. Resident 6 said they had not been given a bell to alert staff. Resident 6 said they just had to wait until staff made rounds, that made them very nervous because they had chronic shortness of breath and had no way of yelling loud enough.On 05/14/2026 at 12:37 PM, Resident 7 said the day before about 2:30 PM they had pushed the call light, and no one came. Resident 7 said an aide poked their head in the room about 3:30pm and told me the call light system was not working. Resident 7 said they used their cell phone to contact the front desk and asked to speak with a manager about the situation. Resident 7 said no one came and/or contacted them. Resident 7 said later that evening they expressed their concern to their aide, and the aide went and retrieved their supervisor. Resident 7 said the nurse listened to the concern and gave them a bell to alert staff. Resident 7 said the staff could not always hear the bell and they were dependent on staff for assistance and were incontinent. Resident 7 said the wait was longer. Resident 7 said they would yell but a lot of residents yelled in the unit, so it was not very effective. Resident 7 said they believed it was a very risky situation and although they had a phone to contact people, they knew a lot of the residents were helpless.On 05/14/2026 at 12:44 PM, Staff C, Licensed Practical Nurse, said they were the evening supervisor on 05/13/2026 and had talked to Resident 7 regarding the concern of the call light system not functioning. Staff C said Resident 7 had explained they were fearful that something could happen in the middle of the night. Staff C said they were aware there were bells in the nursing carts and they did not know why no one on the prior shift had not given Resident 7 one. Staff C said they obtained the bell and gave it to Resident 7. Staff C said they sent a message through the staff phone app for all employees and Staff E, scheduling coordinator, responded they already had a work order in.On 05/14/2026 at 12:54 PM, Staff A, Assistant Director of Nursing, said they had a stand down meeting on 05/13/2026 around 3:00 PM and it was discussed a few call lights on the Cove were not working. Staff A said they were told the corporate Maintenance person had been notified and would be at the facility on 05/14/2026.On 05/14/2026 at 1:00 PM, observed Staff B, CNA's, message on the staff phone app that read; Cove lights not working, dated 05/13/2026 at 3:24 PM.On 05/14/2026 at 1:14 PM, Staff A, ADON said they saw the message on the phone app at 3:24 PM but did not investigate the amount of call lights not working on the Cove and/or ensure all residents had ways to alert staff or ensure staff knew how to proceed.On 05/14/2026 at 1:19 PM, Staff D, Plant Operations/Maintenance Director Consultant, said they were already scheduled to come to the facility on [DATE] for other repairs to the call light system. Staff D said they were contacted on 05/14/2026 at 10:47 AM and notified the call light system was down on the Cove unit. Staff D said that was their first notification that the system was down. Staff D said if they had been notified on 05/13/2026 that the call light system was not working they would have sent someone out and/or came themselves at that time. Staff D said it was an urgent matter because it related to resident safety and the expectation was the facility would notify them immediately when there was a resident safety issue.On 05/14/2026 at 1:46 PM, Staff E, Scheduling Coordinator, said they were notified around 4:00 PM on 05/13/2026 that some of the call lights on the Cove unit were not working. Staff E said between 6:00 PM and 6:30 PM they found out no call lights on the Cove unit were working. Staff E said all the staff knew at this point and Staff F, Maintenance Director, was notified and they reported that Staff D, Plant Operations/Maintenance Director Consultant, was coming on 05/14/2026 at around 11:00 AM.On 05/14/2026 at 3:17 PM, Staff G, Administrator, said they found out the call light system was not functioning by reading a grievance they retrieved from the grievance box that morning. Staff G said they were not aware the call light system had been down since 05/13/2026. Staff G said if they knew they would have contacted Staff D, Plant Operations/Maintenance Director Consultant, for immediate repair.Reference WAC 388-97-2280(1) (a-c).

Based on interview and record review, the facility failed to provide physician ordered pain medications for 2 of 3 residents (Resident 1 and 2) reviewed for medication administration. This failure placed residents at risk of increased pain, clinical complications, frustration and a decreased quality of life.Findings included.RESIDENT 1Resident 1 admitted on [DATE] with diagnoses of metastatic (cancer that has spread) cancer and femur (thigh bone) fracture. The Minimum Data Set Assessment (MDS), an assessment tool, dated 05/04/2026, showed Resident 1 received scheduled and as needed pain medication. The MDS showed Resident 1 had frequent pain that made it hard to sleep and limited their day-to-day activities. On 05/12/2026 at 1:37 PM, Collateral Contact 1 (CC1), said Resident 1 was living with an inoperable (not a candidate for surgery) femur fracture and advanced metastatic cancer that caused Resident 1 extreme pain. CC1 said Resident 1 was receiving routine pain medication at the hospital prior to transferring to the facility. CC1 said approximately an hour after Resident 1 transferred to the facility they were left in excruciating pain. CC1 said Resident 1 was left for greater than eight hours without narcotic (a potent pain medication used to relieve moderate to severe pain) pain medication and was only given Tylenol (medication for mild pain). CC1 said the facility staff told them they were unable to obtain the narcotic pain medication any faster. CC1 said Resident 1 endured unnecessary suffering.Resident 1's physician order, dated 04/28/2026, showed an order for Oxycodone (narcotic pain medication) 5 milligrams every eight hours as needed for pain.Resident 1's physician order, dated 04/28/2026, showed an order for Acetaminophen (generic name for Tylenol) as needed for mild pain (1-3 on pain scale).Resident 1's Medication Administration Record (MAR), dated 04/01/2026 through 04/30/2026, showed Resident 1 was assessed for pain on 04/28/2026 at 11:00 PM with pain score of 8 (pain monitoring scale: 0=no pain, 1-3 mild pain, 4-5 moderate pain, 6-10 severe pain).Resident 1's Administration History Record, dated 04/28/2026 through 04/29/2026, showed Resident 1 received acetaminophen on 04/28/2026 at 11:58 PM and Resident 1's first dose of Oxycodone was administered on 04/29/2026 at 7:40 AM.On 05/29/2026 at 1:45 PM, Staff A, Assistant Director of Nursing (ADON), said the facility was unable to order medications for residents until the resident was physically in the facility. Staff A said Resident 1 was not admitted until after 6:00 PM on 04/28/2026. Staff A said the medications would not arrive until after midnight. Staff A said the facility had an emergency medication dispensing cabinet that licensed staff could obtain medications from. Staff A said the licensed staff notified the pharmacy they needed to obtain the medications from the emergency cabinet and the pharmacy would supply an access code. Staff A said they were aware that Resident 1 did not receive their narcotic pain medications timely when they were experiencing severe pain on admission but did not know why the licensed nurse did not follow the facility process for accessing medications from the emergency dispensing cabinet. Staff A said the expectation was for licensed staff to contact another licensed nurse, management and/or the resident's physician if they were unable to access medications per the physician's orders. Staff A said there was no reason Resident 1 should not have had their narcotic pain medication available to them. RESIDENT 2Resident 2 was admitted on [DATE] with a diagnosis of fibromyalgia (chronic disorder causing widespread body pain). The MDS, dated [DATE], showed Resident 2 was cognitively intact.On 05/15/2026 at 12:49 PM, Resident 2 said their narcotic pain medication was never available on time, the medication did not get reordered on time and they had to go without the medication. Resident 2 said when that happened, they would go through withdrawals and that made them not want to be touched, they did not want to do anything and they were in a lot of pain, it is horrible.Resident 2's physician orders, dated 04/27/2026, showed to give Oxycodone every four hours for pain.Resident 2's MAR, dated 05/01/2026 through 05/31/2026, showed Resident 2's Oxycodone was not administered on 05/06/2026 at 8:00 PM and 05/26/2026 at 4:00 PM and 8:00 PM.Resident 2's progress notes, dated 05/06/2026, showed Oxycodone was not administered because on call from pharmacy and not able to get pull code at that time.Resident 2's progress notes, dated 05/26/2026, showed Resident 2's Oxycodone was not administered because staff contacted the pharmacy and the pharmacist stated they required a new script.On 05/29/2026 at 3:48 PM, Staff A, ADON, said they reviewed Resident 2's medical chart and said they did not know why Resident 2 missed their dose on 05/06/2026 and/or why the staff could not obtain a code to access the emergency medication dispensing cabinet if the resident did not have their medication available. Staff A said there was a new script for the Oxycodone signed on 05/26/2026. Staff A said the licensed nurse should have pulled the Oxycodone from the emergency medication dispensing cabinet. Staff A said they did not know why licensed staff did not follow the facility process and/or contact management or the resident's physician if they did not have access to the physician's prescribed medication.Reference WAC 388-97-1300(1)(a)(4)(e).

Based on observations, interviews and record reviews, the facility staff failed to follow droplet precautions (infection control measures used to prevent the spread of pathogens transmitted through respiratory droplets) for residents with influenza for 3 of 3 staff (Staff A, B and C) reviewed for infection control practices. This failure placed residents and staff at risk of influenza.Findings included.Review of the Center for Disease Control's webpage, Infection Prevention and Control Strategies for Seasonal Influenza in Healthcare Settings, dated 04/28/2025, showed droplet precautions should be implemented for patients with suspected or confirmed influenza in healthcare settings.Review of the facility's droplet precaution sign, dated 08/10/2023, showed before entering a resident's room, staff should wash or gel hands, wear a mask and wear eye protection. The signage showed staff should remove the mask, eye protection and perform hand hygiene upon exiting the room.On 04/15/2026 at 12:17 PM, Staff A, Certified Nursing Assistant (CNA), performed hand hygiene and entered room [ROOM NUMBER] wearing a mask. A droplet precaution sign was posted next to the resident's doorway. Staff A exited the room, performed hand hygiene, did not remove their mask and continued down the hallway passing lunch trays to resident rooms wearing the same mask.On 04/15/2026 at 12:17 PM, Staff B, CNA, performed hand hygiene and entered room [ROOM NUMBER] wearing a mask. A droplet precaution sign was posted next to the resident's doorway. Staff B exited the room and performed hand hygiene, did not remove their mask and continued down the hallway passing lunch trays to resident rooms wearing the same mask.On 04/15/2026 at 12:24 PM, Staff A said when passing trays, they only needed to perform hand hygiene and wear a mask in rooms on droplet precautions. Staff A said they should have removed their masks after they exited the resident rooms that were on droplet precautions, but they forgot.On 04/15/2026 at 12:28 PM, Staff B, CNA, said the residents on droplet precautions in the facility had influenza and staff should wear a mask and face shield upon entering their rooms. Staff B said staff should remove the mask and face shield when they exited the room. Staff B said they were not aware and/or did not see that room [ROOM NUMBER] was on droplet precautions.On 04/15/2026 at 12:33 PM, Staff C, Registered Nurse (RN), was in room [ROOM NUMBER] wearing a mask. A droplet precaution sign was posted next to the resident's doorway. Staff C exited the room and performed hand hygiene. Staff C did not remove their mask and continued down the hallway administering medications to residents wearing the same mask.On 04/15/2026 at 12:37 PM, Staff C, RN, said the resident in room [ROOM NUMBER] was on droplet precautions due to influenza. Staff C said they did not think they needed to remove and/or change the mask upon exiting the room.On 04/15/2026 at 1:31 PM, Staff D, Infection Preventionist, said residents with influenza are placed on droplet precautions. Staff D said residents in room [ROOM NUMBER] and 59 were positive for influenza and placed on droplet precautions. Staff D said staff were expected to wear a mask and eye protection and use hand hygiene prior to entering the room. Staff D said upon exiting the room staff were expected to remove the eye protection, mask and perform hand hygiene. Staff D said the staff did not follow the facility's infection control policies when caring for the residents on droplet precautions.Reference WAC 388-97-1320(2)(b), 1640(7)

Based on interview and record review, the facility failed to notify the resident's guardian of clinical changes for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of lack of advocacy, support and assistance with medical decision making.Findings included.Review of the facility's policy titled, Resident Representative, revised 02/2021, showed that the facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated by the resident or the extent required by the court, the term resident representative is defined as the court-appointed guardian or conservator of a resident.Resident 1 was admitted on [DATE] with diagnosis of cerebral palsy (neurological disorder affecting body movement due to abnormal brain development or injury).Review of Resident 1's Superior Court of [NAME], Guardianship Letter, dated 02/07/2025, showed Resident 1 had a court appointed guardian of person and conservator of the estate with full authority. The letter showed Collateral Contact 1 (CC1), was appointed as Resident 1's guardian.On 03/25/2026 at 3:54 PM, CC1 said when Resident 1 stopped eating no one contacted them. CC1 said the facility did not respect their guardianship and did not contact them when Resident 1 started to have stomach issues. CC1 said it was frustrating because Resident 1 did not fully understand their medical issues and that is why they had a guardian. CC1 said they finally had a care meeting, but it took too long for the facility to involve them.Resident 1's progress notes, dated 02/02/2026, showed Resident 1 had one episode of nausea and vomiting reported. There was no documentation that Resident 1's representative was notified.Resident 1's medical provider notes, dated 02/05/2026, showed Resident 1 was seen by the medical provider for complaints of frequent loose stools, abdominal discomfort and bloating of 24 hours duration and complaints of worsening fatigue and generalized weakness. The note showed medical care planning was reviewed and discussed with the resident and the plan was close monitoring for deterioration and to send stool to the lab. There was no documentation that Resident 1's representative was notified.Resident 1's progress notes, dated 02/13/2026, showed Resident 1 refused to eat breakfast and lunch and did not want to have anything because it made them feel upset and refused anti-nausea medications. There was no documentation that Resident 1's representative was notified.Resident 1's medical provider notes, dated 02/17/2026, showed that Resident 1 was being seen after a report that they had refused to take any meal and/or medications for last 24 hours. The notes showed Resident 1 had no energy/interest to talk and felt exhausted. The notes showed Resident 1 appeared frailer and more fatigued than usual. The notes showed the plan was to rehydrate the resident with intravenous fluid (administration of fluid through a vein) and to call family members/POA [power of attorney] for a discussion. There was no documentation that Resident 1's representative was notified.Resident 1's progress notes dated 02/19/2026, showed intravenous fluids were initiated. There was no documentation that Resident 1's representative was notified.Resident 1's provider notes, dated 02/24/2026, showed CC1 and Resident 1 had a care meeting with the provider and facility staff to discuss current over all conditions.On 03/31/2026 at 3:03 PM, Staff B, Director of Nursing, said that resident's guardians should be notified of any change in a resident's condition and/or plan of care. Staff B reviewed Resident 1's medical record and said there were many opportunities to notify the guardian when Resident 1's condition changed from their baseline and there was no evidence the staff notified them. Reference WAC 388-97-0320(1)(a)-(d)(2)(a)(b).

Based on interview and record review, the facility failed to thoroughly investigate and provide resolution for a grievance for 1 of 3 residents (Resident 2) reviewed. This failure placed residents at risk of inadequate care, disrespect and a diminished quality of life.Findings included.Review of the facility's undated policy titled, Grievances: Resident/Resident Representative, showed the facility provided residents and resident representatives with an uninhibited grievance procedure and encouraged the resident/resident representative to discuss any and all grievances so issues may be resolved, communicate with the resident/resident representative and attempt to resolve the issue within five days, and follow up with the resident/resident representative about the grievance to ascertain satisfaction with the resolution of the reported concern.Resident 2 was admitted on [DATE] with diagnoses of depression and anxiety. The Quarterly Minimum Data Set Assessment, dated 02/08/2026, showed the resident had moderate cognitive impairment, occasionally incontinence of urine and required moderate assistance with toileting.Resident 2's care plan, revised 06/02/2025, showed the staff were to check the resident every two hours, ask if they needed to use the restroom and check to make sure the resident was clean and dry.On 02/27/2026 at 10:27 AM, Collateral Contact 2 (CC2), said they had gone to visit Resident 2 on 02/19/2026 and found them soaking wet and agitated. CC2 said Resident 2 usually giggled when they saw CC2 and when they walked in that time they knew something was wrong. CC2 said a staff member was reassigned and they assisted the resident with being changed. CC2 said they wrote a grievance, but they had not heard from the facility and did not know what action the facility had taken.Resident 2's grievance, dated 02/19/2026, showed CC2 documented when they arrived at the facility Resident 2's IPAD (computer tablet) was off and they seemed upset. The grievance showed CC2 asked Resident 2 if they wanted the IPAD on and Resident 2 said they had to wait five minutes to be changed and they were told they would change their nasty *ss in five minutes. The grievance showed CC2 said it was evident through Resident 2's upset behavior and what they were telling CC2 they had been given a consequence of no IPAD and sitting in wet clothes. The grievance showed CC2 felt this was abuse/neglect of a resident and they wanted immediate removal of the staff responsible and a report filed.Resident 2's incident report, dated 2/23/2026, showed the facility had received the grievance from CC2 regarding Resident 2 being upset and had to wait to be changed before using their IPAD. The incident report showed they reported the incident to the state agency. The incident report showed Staff C, Unit Manager, had interviewed CC2 and Resident 2 and Resident 2 had confusion and denied they were soaking wet. The incident report showed Staff C assigned a different nursing assistant to assist with the brief change and CC2 was present. Staff C indicated Resident 2 was not soaking but the brief was still changed and they followed up with the nursing assistant and reminded them to check on all residents in a timely manner when they needed to be changed/cleaned. Staff C said Resident 2 and CC2 were satisfied when they left the room.On 03/24/2026 at 12:39 PM, Staff D, Certified Nursing Assistant, said they cared for Resident 2 often and were familiar with their care. Staff D said on 02/19/2026 they were not assigned to Resident 2, but the nurse had asked them to change the resident. Staff D said CC2 was present in the room when they arrived. Staff D said Resident 2 was sitting in their wheelchair and was not acting like themselves. Staff D said Resident 2 appeared timid and kept saying I have to sit here for five minutes. Staff D said Resident 2 was acting timid when entering the bathroom, which was not typical behavior for them. Staff D said Resident 2's brief was soaked through their pants onto the wheelchair, and their socks were soaked too. Staff D said they had never seen Resident act like this and/or this wet. Staff D said CC2 was the only one present when they changed Resident 2. Staff D said they had not been interviewed and/or asked about the grievance or Resident 2's condition.On 03/26/2026 at 3:34 PM, Staff B, Director of Nursing, said they had not interviewed Staff D about Resident 2's condition. Staff B said they did not investigate the behavior of Resident 2 and why they were upset.On 03/31/2026 at 4:51 PM, Staff C, Unit Manager, said they had responded to Resident 2's room when they were told of CC2's concerns on 02/19/2026. Staff C said they ensured an aide assisted Resident 2 with care and left the room to give them privacy. Staff C said they returned later to the room and Resident 2 looked great. Staff C said they did not remember if CC2 was present. Staff C said they did not believe they followed up with CC2 regarding the grievance.On 03/31/2026 at 5:45 PM, Staff A, Administrator, said they were the Grievance Official, and the facility should have thoroughly investigated the grievance and discussed their findings and the resolution with CC2.Reference WAC 388-97-0460.

Based on interview and record review, the facility failed to obtain emergency medical services timely for 1 of 3 residents (Resident 3) reviewed for quality of care. This failure placed residents at risk of medical complications, physical distress and a decline in condition.Findings included.Resident 3 was admitted on [DATE] with diagnoses of dementia, respiratory failure and heart failure. The admission Minimum Data Set Assessment, dated 10/30/2025, showed Resident 3 had severe cognitive impairment and required substantial assistance with activities of daily living.On 03/25/2026 at 3:46 PM, Collateral Contact 3 (CC3), said they visited Resident 3 daily at the facility. CC3 said the day Resident 3 was sent to the hospital they were at the facility visiting and Resident 3 was having difficulty breathing and not able to get enough air. CC3 said they told the staff to contact the doctor. CC3 said Resident 3 appeared to be sleeping and/or unconscious. CC3 said they went home and were later contacted in the middle of the night by hospital staff and told Resident 3 was admitted to the hospital. CC3 said it should not have taken that long to get Resident 3 to the hospital.Resident 3's SBAR Communication Form, dated 12/19/2025, showed Resident 3 was experiencing shortness of breath and the symptom had not occurred before. The SBAR showed Resident 3's oxygen saturation (measures the percentage of oxygen-carrying red blood cells in the blood with normal ranges typically between 95% and 100%) was 90%. The SBAR showed the physician was notified on 12/19/2026 at 6:45 PM and ordered Resident 3 to be sent to the ED [emergency department] for tx [treatment] and eval [evaluation]. The SBAR showed CC3 was contacted on 12/19/2026 at 6:48 PM.Resident 3's progress notes, dated 12/20/2026 at 3:53 AM, showed that approximately 0250 [2:50 AM] the resident was still not picked up by Olympic transportation and the dispatcher advised they were on the list with no ETA [estimated time of arrival]. The notes showed at 030 [3:30 AM] the dispatcher called the facility and stated that 911 needed to be called as they could not provide transportation after all, 911 was called and the resident was transported to the hospital for respiratory distress via ambulance.On 03/26/2026 at 12:02 PM, Staff E, Registered Nurse, said they were caring for Resident 3 on 12/19/2026. Staff E said they completed the SBAR for Resident 3 and contacted the physician and the family. Staff E said it was the end of their shift, and they gave report to the oncoming nurse. Staff E said they reported that Resident 3 needed to be sent to the emergency department for respiratory distress and to contact the paramedics. Staff E said they left the facility and assumed the oncoming nurse had contacted 911. Staff E said the facility only transports residents with Olympic Ambulance for non-emergent conditions. Staff E said for shortness of breath and breathing issues, 911 should always be contacted.On 03/26/2026 at 3:34 PM, Staff B, Director of Nursing, said staff are expected to contact 911 for emergency services to transport residents to the hospital for emergent conditions. Staff B said Olympic Ambulance is utilized for non-emergent transport. Staff B said nursing staff should contact emergency services for a resident experiencing shortness of breath and/or respiratory distress.Reference WAC 388-97-1060(1)-(3)

Based on observation, interview and record review, the facility failed to provide social service advocacy following an abuse allegation and assistance with representation for 1 of 3 residents (Resident 4) reviewed. This failure placed residents at risk for abuse, lack of a healthcare advocate and emotional wellbeing.Finding included.Resident 4 was admitted on [DATE] with diagnoses of anoxic brain injury (brain damage caused by lack of oxygen), dysarthria (speech disorder caused by brain damage that results in difficult to understand speech). The Quarterly [NAME] Data Set Assessment, dated 03/12/2026, showed Resident 4 had moderate cognitive impairment and was dependent on staff for activities of daily living.Resident 4's hospital's Palliative Care Follow Up Note, dated 02/04/2026, showed Resident 4 did not have decisional capacity for medical decision making. The note showed there was no DPOA [durable power of attorney] (delegated legal authority for decisions), and the LNOK [legal next of kin] Collateral Contact 4 (CC4) did not want to be part of the care decisions. The note showed the care decisions were deferred to Collateral Contact 5 (CC5).Resident 4's admission summary, dated [DATE], showed Resident 4 was admitted and accompanied by CC5. The summary showed CC5 signed all admission forms.Resident 4's medical record profile showed CC5's contact information listed first in the priority of contacts.Review of a report made to the state agency on 02/16/2026, showed that during communication therapy, Staff F, Speech Therapist, reported on 02/16/2026, Resident 4 said that CC5 had done something to them and pounded their hands on their chest, they remembered someone had hit them in the back of the head but didn't know who it was and they were sometimes afraid of CC5.Resident 4's progress notes dated, 02/17/2026 and 02/18/2026, showed CC5 was at Resident 4's bedside.Resident 4's progress notes dated 02/22/2026, showed CC5 was at Resident 4's bedside and the room smelled like foreign substances and CC5 was seen waking Resident 4 and then asked nurse to administer pain medications.Resident 4's medical provider notes dated 03/09/2026, showed Resident 4 was disoriented to time and place with a new onset of paranoia and continued delirium with agitation throughout. The note showed Resident 4 had fast waxing and waning consciousness with brief span of mentation.Resident 4's social service notes dated 03/09/2026, showed the DON [Director of Nursing] educated CC5 that they could visit if they agreed to follow rules by not spending the night and bringing substances into the facility.Resident 4's psychiatry note dated 03/11/2026, showed there had been concern about CC5 provided Resident 4 with elicit substances and Resident 4 appeared to be able to make wishes known at that time and it would be prudent for Resident 4 to identify a POA [power of attorney].Resident 4's progress notes dated 03/14/2026, showed Resident 4 was found unresponsive and was transported to the hospital.Resident 4's medical provider notes dated 03/19/2026, showed Resident 4 was readmitted to the facility from the hospital on [DATE] after altered mental status and overdose. The note showed CC5 posed a significant danger to Resident 4 and was banned from visiting Resident 4. The note showed Resident 4 tried to express themselves, but it was hard to understand what they were trying to say due to severe dysarthria, it seemed Resident 4 was able to comprehend what was said to them and attempted to respond verbally.Resident 4's progress notes dated 03/19/2026, showed Resident 4 was readmitted to the facility, experiencing severe anxiety and staff contacted CC4 for consent to treat Resident 4 but the person at the phone number indicated they were not CC4.On 03/24/2026 at 1:10 PM, Resident 4 was observed lying on their bed. Resident 4 was speaking unintelligibly and motioning with hands. Resident 4 was unable to make clear sounds and/or follow yes/no answers. Resident 4 appeared in distress and an aide was summoned.On 03/26/2026 at 12:39 PM, Staff G, Social Service Director, said the social service department reported Resident 4's allegation of abuse on 02/16/2026. Staff G said they reported the allegation but did not put any other interventions in place and/or take other actions following the report. Staff G said they continued to utilize CC5 as Resident 4's representative following the 02/16/2026 allegation. Staff G said CC5 was not allowed to visit Resident 4 at the facility for a little while around 03/09/2026, because staff had concerns about CC5 bringing substances in the facility and spending the night. Staff G said Staff B, Director of Nursing, talked with CC5 and they agreed not to bring any substances into the facility and CC5 continued to visit Resident 4. Staff G said they had not spoken to Resident 4 since readmission on [DATE]. Staff G said they did not believe Resident 4 could make complex medical decisions, but they were not sure because they were not good with medical stuff and did not really understand why Resident 4 was at the facility. Staff G said they called CC4 on 03/26/2026 and CC4 said it would be ok if the staff contacted them about Resident 4. Staff G said CC4 had not been in contact with Resident 4 prior to Resident 4's facility admission. When asked who the staff had been talking to about medical issues since Resident 4 was readmitted , Staff G said they thought they had been trying to contact CC4, but CC4 had not agreed to act as a contact until 03/26/2026. Staff G said they changed Resident 4's medical record profile on 03/26/2026, listing CC4 as the primary contact because Staff B, Director of Nursing, had asked them to change it. Staff G said they had not thought about updating it before 03/26/2026. When asked if Staff G had explored legal authority for decision making for Resident 4 since the allegation of physical abuse on 02/16/2026 and/or the concern of CC5 bringing in substances on 03/09/2026 to Resident 4, Staff G said they did not think so.On 03/26/2026 at 2:41 PM, Staff F, Speech Therapist, said they could not fully assess Resident 4's cognitive status because of Resident 4's dysarthria and physical condition. Staff F said they did not have a test that would definitively determine if Resident 4 was cognitively aware to make informed medical decisions.On 03/31/2026 at 11:56 AM, Staff H, Social Service Assistant, said they made the report to the state agency on 02/16/2026 because Resident 4 made an allegation of physical abuse. Staff H said they did not complete a facility incident report or make any care plan changes/interventions and/or take any further action. Staff H said CC5 continued to be Resident 4's representative. Staff H said on 03/25/2026, they reached out to a Guardian service to inquire if they would represent Resident 4 because CC5 was no longer allowed to visit Resident 4 since readmission to the facility on [DATE]. Staff H said they had not attempted to speak with Resident 4 about the hospital stay and/or CC5 and they did not know if anyone else had either.On 03/31/2026 at 3:04 PM, Staff I, Unit Manager, said they were unaware of Resident 4's 02/16/2026 allegation of physical abuse. Staff I said CC5 was considered Resident 4's representative. Staff I said approximately around 03/06/2026 they thought CC5 was acting weird, they had contacted CC4 and made them aware. Staff I said CC4 was aware of Resident 4's and CC5's substance abuse issues. Staff I said they called CC4 because they suspected CC5 of bringing Resident 4 elicit substances. Staff I said Staff B, Director of Nursing, met with CC5 on 03/09/2026 and after that meeting CC5 was allowed to visit Resident 4 and Resident 4 indicated they wanted CC5 to visit. Staff I said between 03/09/2026 and 03/18/2026 when Resident 4 was readmitted from the hospital, CC5 was Resident 4's representative and the staff were notifying CC5 of any medical changes. Staff I said the staff began contacting CC4 after Resident 4 returned from the hospital. Staff I said Resident 4's medical record was not updated to indicate CC4 was the primary contact, but the nursing staff knew. Staff I said CC4 would sometimes answer the phone when they contacted them but acted like they did not care.On 03/31/2026 at 3:10 PM, Staff B, Director of Nursing, said they did not put any interventions in place and/or update the care plan after meeting with CC5 regarding bringing in substances to the facility because they had no proof. Staff B said they were unaware of the physical abuse allegation on 02/16/2026 and they were only monitoring for substance abuse. Staff B said they believed they did not make it clear to the nursing staff who was Resident 4's representative. Staff B said they thought the managers were aware, but it did not trickle down to the floor staff. On 03/31/2026, Staff A, Administrator, said they were the abuse coordinator at the facility, and they were unaware of Resident 4's allegation of abuse on 02/16/2026. Staff A said an investigation should have been initiated by the facility process and Staff G and Staff H should have investigated a representative for Resident 4 at a minimum.Reference WAC 388-97-0960(1)

Based on observation, interview and record review, the facility failed to assist residents with positioning in bed, eating and toileting for 2 of 3 (Resident 1 and 2) residents reviewed for care. This failure placed residents at risk of malnutrition, dehydration, poor hygiene, pain and loss of dignity.Findings included.Review of the facility's policy titled, Activities of Daily Living (ADLs), revised March 2018, showed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, including support and assistance with hygiene, mobility, toileting, and dining. The policy showed if residents with cognitive impairment or dementia resisted care, staff would attempt to identify the underlying cause of the problem and not just assume the resident was refusing or declining care and would approach the resident in a different way or at a different time or have another staff member speak with the resident.RESIDENT 1Resident 1 was admitted to the facility on [DATE] with diagnoses including depression, anorexia, stroke and hemiparesis (loss of movement on one side). The Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 1 had moderate cognitive impairment, was at risk of malnutrition, had experienced a weight loss, required substantial/maximal assistance from staff for bed mobility, personal hygiene, dressing and required set-up assistance for eating. The MDS showed Resident 1 was dependent on staff for toileting and frequently incontinent of bladder and bowel.Resident 1's Kardex (Nursing Assistant's care instructions), as of 03/02/2026, showed Resident 1's call light and needed items, water was to be in reach. The Kardex showed Resident 1 was independent with eating but required supervision and needed encouragement to get up, and to offer alternative meals/snacks if low intake occurred. The Kardex showed staff were to report to the nurse when Resident 1 refused to eat or drink and required extensive assistance with check and change for toileting and bed mobility.On 02/27/2026 at 10:16 AM, Collateral Contact 1 (CC1), said when they visited Resident 1 the resident complained of sitting in urine and feces, not receiving assistance with getting out of bed, eating, and was unable to turn himself. CC1 said Resident 1 was completely dependent on staff for care and the resident smelled, the call light was behind the bed and out of reach, the floor was sticky and the resident appeared to not have received care. CC1 said they were concerned for the resident.Durning a continuous observation in Resident 1's room on 03/02/2026 from 11:47 AM until 1:33 PM the following observations were made:On 03/02/2026 at 11:47 AM, Resident 1 was observed lying in bed. Resident 1's room had a strong odor of urine present. Resident 1's bedside table was out of reach of the resident and a meal tray with breakfast food and drinks were on the table and they appeared untouched and/or opened. Resident 1's call light was observed pinned to the mattress at the head of the bed on the resident's right side. Resident 1's left arm was in a splint, and the resident said their right arm hurt and they could not use it. Resident 1 said I need water. Staff E, Resident Care Manager (RCM), was at the nursing station and agreed to assist Resident 1. Staff E brought a pitcher of water to Resident 1. Resident 1 said they had not had water in two days. Staff E assisted Resident 1 with the water, and the resident drank the entire pitcher and requested more water. Staff E obtained another pitcher of water and Resident 1 continued to drink the water. Resident 1 said they wanted food. Staff E checked the tray on the bedside table and said they would find an aide to assist the resident. Staff E said they could smell the urine in the room, Staff E checked Resident 1's brief and said it was a little bit wet. Staff E said they would have housekeeping come to the room and an aide to assist Resident 1. Staff E placed the water pitcher onto the bedside table out of reach of the resident and exited the room.On 03/02/2026 at 12:05 PM, Resident 1 asked for assistance with the call light. Resident 1 said they could not see the call light and did not know where it was. Resident 1 was observed attempting to reach the call light but was unable to. Resident 1 said their arm hurt and they couldn't raise it.On 03/02/2026 at 12:10 PM, Staff F, Certified Nursing Assistant (CNA), was observed entering Resident 1's room. Resident 1 said they wanted help with food and water. Staff F said they were assisting Resident 1's roommate and told Resident 1 to wait a minute. Staff F exited the room.On 03/02/2026 at 12:16 PM, Staff G, CNA, entered the room. Resident 1 said they wanted water and food and had not eaten in three days. Staff G told Resident 1 it was almost lunch time. Staff G said they were assigned to Resident 1 and had been on shift since 6:00 AM. Staff G said they had checked Resident 1's brief at 8:00 AM, it did not need to be changed, and they took Resident 1's blood pressure. Staff G said Resident 1 did not want breakfast at that time and wanted to sleep. Staff G said they had been checking on Resident 1 and they had been sleeping. Staff G said they were not sure if Resident 1 needed assistance with eating. Staff G acknowledged that Resident 1 was awake, and said they were wondering if they should wait until lunch was served. Resident 1 said, I want food, I haven't eaten in two days. Resident 1 asked Staff G to assist them to turn on their call light. Staff G exited the room and said they would bring food.On 03/02/2026 at 12:24 PM, Staff G was sitting at the nursing station.On 03/02/2026 at 12:27 PM, Staff E, RCM, entered Resident 1's room with a lunch tray. Resident 1 said they needed an ambulance for their arm and they wanted water, Staff E said they would go and check their chart. Staff E assisted Resident 1 with water and said they would get someone to assist Resident 1 with eating.On 03/02/2024 at 12:29 PM, Staff H, Licensed Practical Nurse (LPN), entered Resident 1's room. Staff H said they had Resident 1's medication. Resident 1 said they did not want their medications, but they needed an ambulance because their arm was twisted and wanted the police called because the roommate had stolen their wife and twisted their arm. Staff H assisted Resident 1 with water, and the resident finished the pitcher of water. Staff H offered the juice on the lunch tray and Resident 1 drank the entire carton of juice. Staff H brought the table over and positioned it across the bed within Resident 1's reach and opened the food containers. Resident 1 told Staff H they could not move their arm. Staff H assessed the resident's arm and said they had good strength, Resident 1 reiterated they were still unable to move their arms and told Staff H they needed someone to assist them to eat. Staff H left the room and said they needed to discuss the concerns with their supervisor.On 03/02/2026 at 12:37 PM, Staff G, CNA, was observed in the hallway with the coffee cart.On 03/02/2026 at 12:39 PM, Staff H, LPN, entered the room with a water pitcher. Resident 1 said they could not hold it; Staff H assisted the resident to drink. Staff H asked the resident why they had not eaten their lunch. Resident 1 said they could not reach it and they were hungry. Staff H cut up the food and gave Resident 1 a couple of bites. Staff H left the room. Staff E, RCM entered the room with Staff C, Physician (MD) and Staff I, Social Service Director (SSD). Resident 1 said they feared their roommate and they hurt on the right side of their body. Staff C, MD, assessed Resident 1. Resident 1 said they were hungry and needed help because they could not move their arms. Staff C, MD asked Staff E, RCM to have someone assist Resident 1 with eating.On 03/02/2026 at 12:56 PM, Staff C, MD, told Staff G, CNA that Resident 1 needed assistance with eating and to be repositioned. Staff G acknowledged the request and exited the room with Staff C.On 03/02/2026 at 12:57 PM, Staff I, SSD, told Resident 1 they would find the resident a new room so they felt safe and they would find someone to assist the resident with eating because Staff I heard Resident 1 was hungry. Resident 1 said they needed assistance to eat their lunch. Staff I said they were unable to assist the resident, but they would stay with them until someone came.On 03/02/2026 at 1:07 PM, Staff C, MD, entered the room and told Resident 1 they were ordering tests to determine the cause of the resident's arm pain. Resident 1 said with a loud voice, I want to eat. Staff C told Staff I that they needed a staff person to assist Resident 1 with their lunch tray.On 03/02/2026 at 1:18 PM, Resident 1 asked Staff I to assist them to put on the call light. Staff F, CNA entered the room and Staff I asked them if they could assist Resident 1 with their lunch.On 03/02/2026 at 1:33 PM, Staff F, CNA, assisted Resident 1 with their lunch (1 hour since the tray was brought to Resident 1). Resident 1 said the mashed potatoes tasted bad and were cold. During the continuous observation Resident 1 was not provided with incontinent care. On 03/04/2026 at 12:33 PM, Staff D, Director of Nursing, said they expected staff to assist residents at mealtimes. Staff D said the licensed nurses should have made rounds and when a resident has not eaten their meal there was to be a change communicated to the Resident Care Manager. Staff D said Resident 1's immediate need was for food, water and incontinent care. Staff D said Resident 1 should have been changed and repositioned. Staff D said that should have been the focus for the staff and acted on. Staff D said when the nursing assistants began their shift, they should ensure the residents had fresh water in reach and was available to them. Staff D said it was Staff G's first day in the facility and was they were not familiar with Resident 1.RESIDENT 2Resident 2 was admitted on [DATE], with diagnoses to include rib and pelvic fractures. The Minimum Data Set Assessment, dated 02/08/2026, showed Resident 2 had severe cognitive impairment and required extensive assistance from staff for bed mobility and transfers.Resident 2's ADL Care Plan, dated 12/24/2025, showed Resident 2 was totally dependent on staff for bed mobility and transfers.Resident 2's Pain Care Plan, dated 12/25/2025, showed Resident 2's pain was related to multiple fractures. The care plan showed staff were to observe for and report to nurse any s/sx [signs or symptoms] of non-verbal pain: mood/behavior (restless, squirmy, constant motion), eyes (wide open/narrow slits/shut, glazed, tearing, no focus), face (sad, crying, worried, scared, clenched teeth, grimacing) body (tense, rigid, rocking, curled up, thrashing).On 02/05/2026 at 11:17 AM, Resident 2 was observed lying in their bed, the head of the bed was upright at 90 degrees and Resident 2 had slid down the bed and their back was unsupported by the mattress due to the position of the bed. Resident 2's legs were moving up and down, their facial expression was a grimace and they were whining softly. Resident 2 was dressed in a gown with their brief exposed. Resident 2 was visible from the hallway in this position.On 02/05/2026 at 11:35 AM, 11:46 AM, 11:49 AM, 12:04 PM, and 12:05 PM, Resident 2 was observed lying in their bed, the head of the bed was upright at 90 degrees and Resident 2 had slid down the bed and their back was unsupported by the mattress due to the position of the bed. Resident 2 was dressed in a gown with their brief exposed. Resident 2 was visible from the hallway in this position. During these observations facility staff were observed to walk by Resident 2's room and glance into the room but did not enter the room and/or assist the resident.On 02/25/2026 at 12:18 PM, Staff J, Occupational Therapist, entered Resident 2's room. Resident 2 was observed lying in their bed, the head of the bed was upright at 90 degrees and Resident 2 had slid down the bed and their back was unsupported by the mattress due to the position of the bed. Resident 2 was dressed in a gown with their brief exposed. Staff J said Resident 2 was not positioned correctly in the bed and appeared uncomfortable and in pain. Staff J said Resident 2 had pelvic fractures and it would be painful to be in that position in bed.On 02/25/2026 at 12:44 PM, Staff K, Certified Nursing Assistant, said they were assigned to care for Resident 2. Staff K said they had repositioned Resident 2 between 11:45 AM and 12:00 PM. When asked what care they had provided, Staff K said they had made sure Resident 2's legs were not hanging off the bed and were straight. Staff K said they did not need to adjust Resident 2 in the bed and Resident 2 had blankets covering them.On 02/25/2026 at 4:02 PM, Staff L, Assistant Director of Nursing, said they expected staff would position residents correctly in their bed and would expect all staff to assist when they observed a resident in an uncomfortable position.Reference WAC 388-97-1060(2)(c)

Based on interview and record review, the facility failed to provide physician ordered medications for 1 of 3 residents (Resident 3) reviewed for medication administration. This failure placed residents at risk of increased pain, frustration and a decreased quality of life.Findings included.Review of the facility's policy titled, Pharmacy Services Overview, revised April 2019, showed pharmaceutical services consisted of: pharmacy services were available to residents 24 hours a day, seven days a week, and residents had sufficient supply of their prescribed medications and received medications in a timely manner. Resident 3 was admitted on [DATE], with diagnoses including chronic pain and spinal stenosis (narrowing of the spinal canal, causing pressure on the spinal cord, typically resulting in pain and numbness). The Minimum Data Set Assessment, dated 11/26/2025, showed Resident 3 was cognitively intact.On 03/02/2026 at 2:10 PM, Resident 3 said the facility continually ran out of their oxycodone (pain medication). Resident 3 said they were on every four-hour cycle and when they missed a dose they were in a lot of pain. Resident 3 said the staff told them different reasons why they would run out; it wasn't ordered, agency nurse did not order, mix up between shift nurses, doctor did not sign prescription, insurance won't cover and other excuses. Resident 3 said they were tired of the delays.Resident 3's physician orders, dated 01/31/2026, showed Resident 3 was to receive oxycodone 10 MG [milligrams] six times per day and oxycodone 10 MG tablet every six hours as needed for pain management.Resident 3's Medication Administration Record (MAR), dated 02-02-2026 through 02-28-2026, showed the oxycodone was not administered on 02/07/2026 at 12:00 AM, 4:00 AM, 4:00 PM and 8:00 PM, on 02/20/2026 at 12:00 AM and 02/28/2026 at 4:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.Resident 3's progress notes, dated 02/07/2026, showed oxycodone was not available and awaiting pharmacy delivery.Resident 3's progress notes, dated 02/19/2026 at 9:15 PM showed medication administration notes for oxycodone two tablets six times per day. The note showed only one tablet was available and the medication was on order.Resident 3's progress notes, dated 02/19/2026 at 11:56 PM, showed Oxycodone was on order.Resident 3's progress notes, dated 02/28/2026 at 4:30 AM, showed no access to Pixis (secure medication storage) and the resident was aware that the AM shift would come shortly.Resident 3's progress notes, dated 02/28/2026 at 9:34 AM, showed oxycodone tablets unavailable in Omnicell (medication storage unit) and the pharmacy was informed.Resident 3's progress notes, dated 02/28/2026 at 4:56 PM and 9:09 PM showed the oxycodone was pending pharmacy delivery.On 03/04/2026 at 10:09 AM, Staff C, Medical Provider, said they expected the license nurse to administer medication per their order.On 03/04/2026 at 12:33 PM, Staff D, Director of Nursing, said they investigated the reason for Resident 3 not receiving their oxycodone consistently and they discovered the pharmacy was not sending the amount of oxycodone the facility had requested to be refilled. Staff D said they spoke to the supervisor of the pharmacy, and they were unable to communicate a reason for not sending the requested amount of medication. Staff D said the facility would have to begin ordering refills twice per week to correct the situation.Reference WAC 388-97-1300(1)(a)(4)(e)

Based on interview and record review, the facility failed to investigate an allegation of misappropriation of a phone for 1 of 3 (Resident 1) residents reviewed. This failure placed residents at risk of loss of property, lack of communication with the community and a decreased quality of life.Findings included.Resident 1 was admitted on [DATE] with diagnoses including depression, and anxiety. The Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 1 had moderate cognitive impairment, required substantial/maximal assistance from staff for bed mobility and moderate assistance to transfer to a chair. Resident 1's progress notes, dated 02/13/2026, showed Resident 1 reported their family member had removed their personal phone and would not return it. The notes showed the SSA [Social Service Assistant] staff completed a report to the state agency for concern for possible exploitation/control of resident communication device by family members.On 03/04/2026 at 9:17 AM, Staff A, Social Service Assistant, said Resident 1 alleged their family member had taken their cell phone from them. Staff A said they reported it to the state agency. Staff A said they had not completed an investigation and/or attempted to locate the phone. Staff A said their only action related to the allegation was reporting it to the state agency and leaving a voice mail on the family member's phone. Staff A said they had not heard back from the family member and/or taken any further action.On 03/04/2026 at 10:40 AM, Resident 1, said their family member had taken their cell phone and they wanted it back, it's the only way I have to communicate to the outside world.On 03/04/2026, Staff B, Administrator, said they were unaware of Resident 1's allegation of their cell phone being taken by their family member. Staff B said the staff should have initiated a grievance about a missing item when they were made aware of the missing phone and initiated an investigation. Staff B said if the phone was not located, an incident report would be initiated with the ongoing investigation and a report to the state agency. Staff B said staff did not follow the facility's policy for an allegation of misappropriation.Reference WAC 388-97-0640(6)(a)(b)

.Based on observations, interviews and record review, the facility failed to evaluate the effectiveness of current pressure offloading treatment plan, document weekly wound assessment and measurements, consistently re-position the resident as care planned every two to three hours and follow physician wound treatment interventions as ordered to prevent development or worsening of pressure ulcers (PU) for 1 of 1 sampled resident (Resident 2) reviewed for PU. Resident 2 experienced harm when their previously healed chronic PU re-developed and worsened from Stage II (a shallow, open sore that has broken through the top two layers of skin, the epidermis and dermis) to Stage III (a deep wound that has gone through the top two layers of skin and into the fatty tissue underneath), and caused an increase in pain level during wound care that required stronger pain medication management.Findings included .Findings included .Resident 2 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS, an assessment tool) dated 07/13/2025, documented Resident was severely cognitively impaired and required maximum assistance with cares. The MDS documented Resident 2 had no current PU but was at risk for PU. Interventions listed on the MDS included pressure reducing device for bed, turning and repositioning, pressure ulcer care and applications of ointments and medications.A contacted wound consultant progress note, dated 07/08/2025, documented As of today, the wound has completely closed with no evidence of erythema [redness or discoloration of the skin], edema [swelling caused by excess fluid trapped in the body's tissues], or tenderness to palpation. All wound care caregivers have been notified about preventive measures which include turning and repositioning, offloading and nutritional supplements. Stage II, Status closed. A contacted wound consultant progress note, dated 08/05/2025, documented The wound has been present for approximately 30 days and has increased in size. Previous treatments included offloading. The patient's underlying comorbidities are being managed by the agency's [facility] primary care physician. The goal is to facilitate complete closure of the patents chronic wound. Because of numerous comorbidities, the aim is to also prevent the progression of the wound, prevent infection, as well as prevent hospitalization. Stage II. Status increased in size. The patient education was shared with facility staff as patient is forgetful.Resident 2's PU care plan, initiated 09/02/2023, revised 08/12/2025, documented the following: Has pressure ulcer center midline coccyx: r/t [related to] dermal frailty [frail skin], disease process, history of ulcers, decreased mobility, incontinence-Assess/record/monitor wound healing weekly and PRN. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvement and declines to the MD.-Avoid positioning on resident's buttocks. Reposition every 2-3 hours for off-loading, use pillows.- Educate resident/family/caregivers as to cause of skin breakdown: including: transfer/positioning requirements; importance of taking care during ambulating/mobility; good nutrition; and frequent repositioning.- Apply topical skin protectant to protect from fecal and/or urinary incontinence.A nursing progress note, dated 08/17/2025, documented, Resident c/o [complaining of] increasing pain during coccyx [tailbone] wound dressing changed. Dressing changed x2 [two times] this shift secondary to soiling. Note to MD [Medical Director]. Resident states Tylenol not helpful.A nursing progress note, dated 08/19/2025, documented, Resident seen by provider, new order for oxycodone [pain medication] PRN [as needed] during treatments.A contacted wound consultant progress note, dated 08/19/2025, documented The wound has been present for approximately 30 days and is deteriorating. Previous treatments included off-loading, wound debridement [process of removing dead, damaged, or infected tissue and debris from a wound to promote healing], daily dressing changes and advanced wound care dressings. The patient's underlying comorbidities are being managed by the agency's [facility's] primary care physician. The goal is to facilitate complete closure of the patient's chronic wound. Because of numerous comorbidities, the aim is also to prevent the progression of the wound, prevent infection, as well as prevent hospitalization. Stage III. Status deteriorating. Wound Stage progressed from Stage II to Stage III. The reason is changed wound stage to Stage 3, slough has developed.A physician's order, dated 09/04/2025, stated, WOUND CARE: center midline coccyx: Clean the wound with saline [salt water], pat dry with gauze sponge. Apply Santyl [ointment with enzymes that breaks down dead tissue], nickel thick, to the wound bed. Top with impregnated gauze (oil emulsion) to the wound bed, followed by calcium alginate [high absorbent dressing]. Apply skin prep [a liquid barrier film to protect the skin around a wound from moisture, friction, and adhesives] to peri [around] wound. Cover with 6x6 (centimeter - cm] foam with silicone bordered dressing and secure with tape daily and PRN soilage or dislodgement every dayshift for skin impairment and as needed for skin impairment soiled and dislodgement. On 09/22/2025 at 11:00 AM, Resident 2 was observed lying in bed on their back, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open. On 09/22/2025 at 3:08 PM, Resident 2 was observed sitting at a 45-degree angle, in bed, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open.On 09/23/2025 at 8:39 AM, Resident 2 was observed lying in bed on their back, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open. On 09/24/2025 at 8:51 AM, Resident 2 was observed lying in bed on their back, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open.On 09/24/2025 at 11:15 AM, Resident 2 was observed lying in bed on their back, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open.On 09/24/2025 at 9:58 AM, observation of Resident 2's wound cleaning was completed with Staff L, Licensed Practical Nurse (LPN). Staff L prepared all wound treatment supplies on top of cart with barrier. At 10:09 AM, Staff L performed hand hygiene, donned (to put on) Personal Protective Equipment (PPE), obtained wound treatment supplies and entered Resident 2's room. Staff L, applied wound cleanser to gauze, cleaned the wound and then threw the gauze away. Staff L said they used that wound cleanser because it was nothing more than saline. Staff Removed his gloves, preformed hand hygiene and donned a new pair of gloves. Staff L took the backing off of dressing bandage, picked up the dressing with alginate, santyl, oil emulsion gauze and applied to wound. Staff L said the dressing change was completed and doffed (to take off) gloves. On 09/24/2025 at 10:18 AM, when asked why they used wound cleanser, versus saline (as ordered), Staff L stated, because we got this. I don't know what the ingredient is besides normal saline, I know there is something in there. Staff L said they were used to using wound cleanser. Staff L wrapped up barrier supplies and placed them in the garbage and took wound cleanser bottle out of the room. Staff L doffed gown but did not complete hand hygiene. When asked why they did not apply skin prep as ordered, Staff L stated, That particular bandage works so well it doesn't need skin prep, I don't like skin prep, it gets the skin outside the bandaged area sticky. That foam dressing is really nice and gentle on the skin.In an observation and interview on 09/24/2025 at 12:41 PM, Resident 2 was sitting up in bed (at a 45-degree angle). When asked about pain level, Resident 2 said their pain level was currently about a 7 (on scale from 0-10, 0 being no pain, 1- being extreme pain). When asked about repositioning, Resident 2 said staff would sometimes offer repositioning, but not often and would not offer any other non-pharmacological inventions for pain relief. This was the first time Resident 2 was observed awake.On 09/25/2025 at 8:32 AM, Resident 2 was observed sitting at a 45-degree angle, in bed, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open.On 09/29/2025 at 12:58 PM, Resident 2 was observed sitting at a 45-degree angle, in bed, with blankets pulled over their body.In an observation and interview on 09/29/2025 at 12:58 PM, Resident 2 was sitting up in bed, (at a 45-degree angle). When asked about pain, Resident 2 said their pain was at a 7, but they were given an oxycodone earlier and it is helping with the pain. Resident 2 said they had a wound treatment today, they checked on my bottom, it hurt like hell, because they scrubbed it. Resident 2 said they told the doctor and nurse that they wanted to get out of bed after the wound treatment but was told they could not do that because they had never gotten the resident out of bed before. When asked about the PU, Resident 2 said they believe the PU was getting worse and it hurts. Resident 2 said he had been repositioned that morning, because they did wound care.On 09/29/2025 at 2:32 PM, Resident 2 was sitting at a 45-degree angle, in bed, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open.On 09/29/2025 at 3:52 PM, Resident 2 was sitting at a 45-degree angle, in bed, with blankets pulled over their body. Resident 2's eyes were shut and mouth was open.On 09/30/2025 at 12:51 PM, Staff PP, Certified Nursing Assistant (CNA) said residents were required to be repositioned every two hours and the resident's repositioning care plan/schedule was located in the Kardex (CNA's documentation record) or resident's chart. When asked what staff should do when the resident was asleep and needed to be repositioned, Staff PP said they would double check to see if it was ok to wake the resident and then reposition them.On 09/30/2025 at 1:17 PM, Staff OO, CNA, said residents should be repositioned every two hours or as needed or requested. Staff OO said all information for repositioning was located in the Kardex. Staff OO said if residents were asleep during the repositioning time frame, they would ask staff if it was ok to wake the resident during sleep, if not then they would let the resident sleep without repositioning themOn 09/30/2025 at 1:42 PM, Staff B, Director of Nursing Services, said staff should be repositioning residents every two hours, during rounds and as needed. Staff B said if the resident was sleeping, staff could wake the resident if they knew the resident would be ok with being woken up. When asked about identifying, documenting and reporting skin changes/conditions, Staff B said all skin conditions should be documented on the shower sheet, given to the charge nurse, unit managers and contracted wound consultants. When asked about Resident 2's PU, Staff B reviewed the electronic health record (EHR). Staff B said Resident 2 was admitted to a Stage II PU, measurements were taken, and contracted wound consultants provided treatment. Staff B was asked to review the July 2025 contracted wound consultants note. Staff B confirmed that Resident 2's PU was documented as resolved. Staff B was asked to review what current inventions were in place to minimize the return of the PU. Staff B confirmed there had been a repositioning intervention that had been discontinued on 07/11/2025 and had never been reinstated. Staff B said the expectation of offloading pressure should have been implemented as far as the resident could tolerate. Staff B was asked to confirm what stage the PU was in currently and said it was Stage III, from resolved. Staff B said the expectation was that further interventions should have been implemented for Resident 2. When observations were explained about staff providing wound care, not using saline or skin prep, Staff B said they would have to check into the difference between the wound cleanser and saline, but yes, staff should have followed the physician's orders. Additional follow-up was not provided. On 09/30/2025 at 1:07 PM, Resident 2 was observed lying in bed on their back, with blankets pulled over their body. Resident 2's eye were shut and mouth was open.On 09/30/2025 at 3:44 PM, Resident 2 was observed lying in bed on their back, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open.On 09/30/2025 at 3:55 PM, Staff BB, CNA, with Staff B, DNS present, said Resident 2 had a wound on his lower back, staff have attempted to have Resident 2 turn on their side and use the wedges, however Resident 2 does not like to sleep on their side and will often refuse to use the wedges/pillows.On 10/01/2025 at 8:59 AM, Resident 2 was observed sitting at a 45-degree angle, in bed, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open.On 10/01/2025 at 11:10AM, Resident 2 was observed sitting at a 45-degree angle, in bed, with blankets pulled over their body. Resident 2's eyes were shut, and mouth was open.Reference F684.Reference F757.Reference WAC 388-97-1060 (3)(b)

.Based on observation, interview and record review, the facility failed to ensure care and services were provided in a dignified manner which maintained and enhanced quality of life for 3 of 5 sampled residents (Resident 65, 8 & 12) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, unmet care needs, decreased self-worth and a diminished quality of life. Findings included 1) Resident 65 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS, an assessment tool), dated 06/06/2025, documented Resident 65 was severely cognitively impaired and required maximal assistance with cares. On 09/24/2025 at 12:04 PM, Resident 65 was yelling from their room Hello, I need to be cleaned up. Staff L, Licensed Practical Nurse (LPN), was standing at the medication cart parked outside Resident 65's door. Staff L walked away from the cart, down the hallway away from Resident 65's room and returned to the medication cart two minutes later. At 12:07 PM, Staff L, entered Resident 65's room and stated, You need some attention. [Staff P, Certified Nursing Assistant, (CNA)], will be here in a little bit. The odor of feces could be smelled from across the hall. Resident 65 was sitting on their bed, wearing only a brief and a shirt. A liquid brown substance was observed coming out from under their brief and was trailing down the left side of the resident's outer thigh and bed. Staff L pulled the privacy curtain shut, turned on call light, exited Resident 65's room and returned to the medication cart. On 09/24/2025 at 12:09 PM, Staff M, CNA, walked past Resident 65's room, observed the call light on and asked Staff L, LPN, if Resident 65 needed assistance. Staff L said Resident 65 could wait for their CNA to return to the floor. On 09/24/2025 at 12:11 PM, Staff N, CNA, entered Resident 65's room, spoke briefly with Resident 65, turned off the call light and exited the room without assisting Resident 65 with personal hygiene care. At 12:14 PM, Staff M, CNA, returned to Resident 65's room and asked, Oh no, has anyone checked on you yet? At 12:15 PM, Staff M exited the room, found a second CNA on the hall and returned to the room at 12:16 PM to provide care to Resident 65. Resident 65's assigned CNA, Staff P, did not return to the hallway until 12:21 PM. On 09/29/2025 at 1:14 PM, Staff J, Charge Nurse (also called Unit Manager at this facility, often called Resident Care Manager in other facilities)/LPN, said they expected staff to show dignity to residents by introducing themselves, pulling the curtain shut while providing care, asking the residents what their concerns were, and providing care in a gentle and timely manner. Staff J said residents should receive care at the time the staff were in the room. When told of the observation of staff telling Resident 65 they would have to wait for care, Staff J said staff should not have left the resident in that condition, it was not acceptable to leave a resident and the resident should have been changed. Staff J said this was not their expectation and the inaction was not okay. On 09/30/2025 at 1:42 PM, Staff B, Director of Nursing Services (DNS), said staff should provide privacy, have supplies ready and speak with the resident when providing care. When told of the observation of the staff telling Resident 65 they would have to wait for personal hygiene care, Staff B said it was not their expectation nor was it acceptable to tell a resident to wait or to leave a resident in a soiled brief. 2) Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 8 was cognitively intact, and was independent with toileting. On 09/26/2025 at 6:05 AM, Resident 8, in the hallway, said they wanted to report a nurse for not being kind. Resident 8 said the nurse had given them Tylenol, which was unnecessary. At 6:08 AM, Staff S, LPN, entered the conversation and said that Resident 8 had requested eye drops but they had been busy on the floor and with training new staff. Staff S said when they remembered to give the eye drops, Resident 8 asked for their thyroid medication and Tylenol. Staff S said when they went to give the Tylenol, Resident 8 refused and it was not given. Staff S, in front of Resident 8, then said Resident 8 had memory issues, and was rude to her. At 6:08 AM, Resident 8 responded by pointing at Staff S and saying they needed a new job. Staff S continued to say that they had written the request for Tylenol down. Review of Resident 8's Medication Administration Record on 09/26/2025 at 6:53 AM, showed no Tylenol was given that morning or overnight. During an interview on 09/26/2025 at 7:12 AM, Staff B, DNS, when asked if it met expectations if a nurse had called a resident rude in front of them, Staff B said no, this was their home, and that was bad customer service. Staff B said Staff S should have redirected Resident 8 in a calm and gentle way; and with Resident 8 being confused, should have veered away from an argument while in the hallway. During an observation on 09/26/2025 at 10:45 AM, Resident 8 was seen telling Staff Q, LPN, that at about 10:00 PM the night before, a young staff member had checked Resident 8's underwear to see if they needed to be changed, despite the fact they could independently use the bathroom. Resident 8 said this was no longer a safe place. Staff Q said the staff member must have gotten a bad report. Resident 8 said that it was when they were sleeping, and this was unsettling. Staff Q said they understood the concern and recognized that Resident 8 was continent. Resident 8 thanked Staff Q for understanding, then told them their nurse overnight (Staff S) was not nice, should stop and be kinder to people, and should not work in this kind of job. 3) Resident 12 was admitted to the facility on [DATE], with diagnoses of depression and anxiety. The Quarterly MDS, dated [DATE], showed Resident 12 was cognitively intact and dependent on staff for cares. During an observation on 09/26/2025 at 6:01 AM, Staff S opened the door to Resident 12's room and was heard telling the staff caring for Resident 12 to pull the curtain for privacy. Resident 12's roommate was in the room at the time. During an interview on 09/26/2025 at 1:41 PM, Resident 12's roommate, Resident 67, said the curtain was not pulled this morning, Resident 12 was exposed several times that morning when staff went to change Resident 12, and they personally had to close the curtain one of the times. During an interview on 09/30/2025 at 8:20 AM, Resident 12 said they did not like the curtain being open, and regarding the curtain being left open on 09/26/2025 stated, I am laying here naked and the curtain is open. During an interview on 10/01/2025 at 8:44 AM, Staff D, Charge Nurse/RN, when told of Resident 12's curtain not being pulled while staff provided care with their roommate being in the room and asked their expectation for staff in maintaining resident privacy and dignity, said their expectation was that staff would pull the curtain. Reference WAC 388-97-0180(1-4).

Based on interview and record review, the facility failed to consistently assess, monitor, provide timely wound care, and notify the provider of change in wound condition for 1 of 3 residents (Resident 1) reviewed for wound care. This failure resulted in physical harm for resident 1, who was severely cognitively impaired, when they had itching, stinging, and the physical appearance of pain and distress when they experienced a maggot (fly larvae) infestation and worsening of their scalp wound. This failed practice residents at risk for infection, psychological harm and a diminished quality of life. Findings included . Review of the facility's policy titled, Wound Prevention and Treatment, revised 02/03/2023, showed that skin conditions would be monitored weekly and documentation of size, color, odor, healing progression, notifications, and other pertinent information related to the skin conditions would be documented in the electronic medical record (EMR) and physician notification and resident/resident representative notification would be completed as needed. Review of the Journal of the American College of Clinical Wound Specialists, dated 2016, showed that female flies may visit wounds to feed or to lay eggs. They generally lay 50-300 eggs at a time that hatch and emerge as larvae (maggot). Resident 1 was admitted to the facility 07/10/2021 with medically complex conditions and dementia. The Minimum Data Set (MDS), an assessment tool, dated 07/19/2024, showed Resident 1 was dependent on staff for transfers and was severely cognitively impaired. Resident 1's skin care plan, dated 02/13/2024, showed the resident had a skin concern related to hyperkeratosis (a skin condition that causes thick, rough patches of skin) scab to her head. Care plan interventions showed facility staff were to assess/record/monitor wound healing weekly, as needed and measure length, width and depth where possible, assess and document status of wound perimeter, wound bed, healing progress and report improvement and declines to the MD. Resident 1's risk of infection care plan, dated 03/13/2024, showed the resident was at risk of infection related to a skin picking disorder. The care plan showed that scabbed areas would remain free of infection and staff were to monitor, document and report to the MD any signs and symptoms of infection; increased drainage, foul odor, redness, swelling, excessive pain and fever. Resident 1's physician orders, dated 12/28/2023, showed an order for antibiotic ointment to be applied to the resident's scalp two times per day and an order, dated 02/07/2024, for ammonium lactate solution (a solution to treat the hyperkeratosis) to be applied two times a day to the scab on the scalp and monitor the scab on the scalp every shift for s/s [signs and symptoms] of infection/bleeding and notify the PCP [primary care provider]. Resident 1's Medication Administration Record, dated September 2024, showed Resident 1's antibiotic ointment for the scalp was scheduled for 8:00 AM and 8:00 PM every day and the ammonium lactate solution was to be applied at 8:00 AM and 7:00 PM every day. Resident 1's wound specialist's progress note, dated 07/30/2024, showed the resident had a cyst on their scalp measuring 5.0 centimeters (cm) x 5.3 cm x 0.8 cm. The wound specialist recommended shaving around the site to better visualize and treat the site. Review of the EMR showed no further documentation of the scalp wound from the wound specialist after 07/30/2024. Resident 1's Total Body Skin Evaluation Weekly, dated 08/03/2024, showed no assessment and/or documentation of the scalp wound. The evaluation showed see wound care notes for details. Staff were to monitor the wound/scab on every shift for s/s infection/bleeding, and staff were to assess/document wound progress weekly and notify the provider of changes. Resident 1's Total Body Skin Evaluation Weekly, dated 08/14/2024, showed no assessment and/or documentation of the scalp wound. The evaluation showed head wounds, and to see wound specialist notes. Resident 1's Total Body Skin Evaluation Weekly, dated 08/22/2024, showed no assessment and/or documentation of the scalp wound. The evaluation showed head wounds, and to see the wound specialist notes. Resident 1's Total Body Skin Evaluation Weekly, dated 08/29/2024, showed no assessment and/or documentation of the scalp wound. The evaluation showed, top of head, and to see the wound specialist notes. On 09/03/2024 at 3:18 PM, Collateral Contact 1 (CC1), said they usually visited Resident 1 every day and brought them their favorite snack. CC1 said on 09/01/2024 they visited Resident 1 between 3:00 PM and 4:00 PM. CC1 said there was drainage from the resident's head wound running down their face and drainage on the pillowcase. CC1 said that was not unusual and the resident had a horrible habit of picking their wounds. CC1 said they could not visualize the wound because of the resident's wet, matted hair covering the wound. CC1 said around 5:00 AM on 09/02/2024 they were notified Resident 1 was sent to the hospital and when they arrived at the hospital, they were informed that Resident 1 had a maggot infestation in their scalp wound. On 09/04/2024 at 1:45 PM, CC2, hospital staff member, said they were the first person to assess Resident 1's scalp wound at the hospital emergency room . CC2 said there were live maggots coming out of the wound on the scalp and there were bulges in the wound and when you pressed on them more maggots came out. CC2 said there was no evidence of a scab and/or crust on the wound. CC2 said it was an extensive open wound with maggots covering the wound. CC2 said it took two emergency room technicians 30 minutes to remove the maggots with tweezers and a suction machine. At 2:44 PM, CC3, emergency responder, said they arrived at the facility and saw Resident 1 lying in bed. CC3 said the resident's eyes had wet and dry pus surrounding their eyelids. CC3 said the resident was picking at an open sore on their scalp, complaining of itching and stinging and appeared to be in physical and psychological distress. CC3 said the scalp wound was full of maggots, and they were crawling out of the wound. CC3 said the maggots were approximately 6 millimeters long. Resident 1's emergency services patient record, dated 09/02/2024, showed emergency services arrived on scene at the facility on 09/02/2024 at 4:27 AM, to find a three-inch, circular flesh wound on the top of the resident's head covered with maggots. The record showed that facility staff stated they were unaware how the wound got to the point of having maggots or when the last wound care was done Resident 1's hospital record, dated 09/02/2024, showed a large open wound ulceration in the scalp region with maggots in the wound. The record had a picture of the wound with the maggots present throughout the wound. On 09/03/2024 at 2:20 PM, Staff G, Housekeeper, said they had cleaned Resident 1's room on 08/31/2024 and 09/01/2024. Staff G said they smelled something like rotting flesh in the room but did not see anything when they were cleaning. Staff G said they notified the nurse on duty. At 2:56 PM, Staff H, Infection Preventionist, said they had seen flies in the resident care areas due to the windows being open and the facility did not have screens on all windows. Staff H said there should be screens on all windows to keep flies out of the resident areas. Staff H said they were not certain when Resident 1's scalp wound had opened but the resident did have drainage from the wound prior to the discovery of the maggots in the wound. Staff H said to prevent flies from getting into the wound there had to be a barrier on the wound. On 09/05/2024 at 10:19 AM, Staff B, Registered Nurse (RN), said they had cared for Resident 1 on 08/31/2024 and previous shifts. Staff B said the ointment was applied to the wound to prevent infection because the scab on the wound would slough off at times after applying the ointment and/or a shower and there would be open areas on the wound. Staff B said on 08/31/2024 the top layer of the scalp wound was scabbed and it had a foul smell. Staff B said the wound was not open that day, but they saw some drainage on the pillowcase. Staff B said there were times the wound leaked brown drainage. At 10:38 AM, Staff C, Certified Nursing Assistant (CNA), said they were assigned to Resident 1 on 09/01/2024. Staff C said the odor in the resident's room was so bad that day they gave the resident a bed bath. They said the wound was dark brown, bumpy and had a scab on it. Staff C did not see any drainage, but they had given the resident a shower on 8/27/2024 and had seen a stain on the pillow from drainage that day. At 4:47 PM, Staff A, Licensed Practical Nurse, said they were assigned to Resident 1 on the night of 09/01/2024 from 6:30 PM to 6:30 AM on 09/02/2024. Staff A said at approximately 4:00 AM on 9/2/2024, a nursing assistant requested for them to check Resident 1's scalp wound. Staff A said when they arrived in the resident's room there was a lot of drainage coming from the scalp wound and the wound was full of maggots. Staff A said the resident appeared to be in pain and they called the medical provider and emergency services. When asked if they had provided any wound care prior to the discovery of the maggots in the wound, Staff A said they had administered oral medications earlier in the shift to the resident and it smelled like a wound in the room but had not provided any other care. Staff A said they could not recall seeing the wound prior to the discovery of the maggots, to be honest those units are so busy you hit the floor and start pumping out meds, I do not remember doing any wound care before seeing the maggots. On 09/06/2024 at 1:11 PM, Staff E, Resident Care Manager, said they had been overseeing Resident 1's care for approximately the last three months. Staff E said the staff had not reported the odor of the resident's scalp wound or the drainage. Staff E said they had thought the wound was a dry scab that was not open. Staff E said there was no physician order for a bandage on the wound and they had not attempted to place a bandage on the scalp wound. Staff E said the wound specialists had stopped assessing and monitoring the scalp wound after 07/30/2024 and the licensed nurses should have been documenting their assessment of the wound when completing the weekly skin evaluations. Staff E said if a wound had an odor and/or drainage it could be a sign of an infection and the licensed nurses should have reported it to the medical provider. Staff E said there was no assessment of the scalp wound documented since 07/30/2024. Staff E said the licensed nurses had not followed the expectations for wound care and assessments. At 2:31 PM, Staff F, Director of Clinical Operations, said the licensed nurses are expected to monitor wounds weekly and follow the wound care policy. Staff F said they expected the licensed nurses to notify the medical provider if a wound had an odor and/or drainage. Staff F said the wound care had not met their expectations and the licensed nurses had not followed their clinical system for wound care. Refer to F925 Pest Control Program Reference WAC 388-97-1060 (1)

Based on interview and record review the facility failed to ensure staff performed timely Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician's order and had express the with for CPR. This failure to train staff on the facility's expectation on how to respond to a resident requiring CPR resulted in Resident 1 not receiving immediate staff action. The failure of facility staff to initiate timely basic life support potentially contributed to the resident's unsuccessful response to CPR and placed all residents who choose to have CPR initiated at risk for serious injury, harm, impairment or death and represented an Immediate Jeopardy (IJ) situation. On [DATE] at 5:12 PM, the facility was notified of an IJ at CFR 483.24 (a)(3), F678, CPR related to the facility's failure to perform timely CPR. The facility's failure placed residents at risk for serious illness or death. The facility removed the immediacy on [DATE] with an onsite verification from investigator by conducting staff interviews and re-education of all staff regarding CPR policies and procedures which ensured an effective system was in place to safeguard, protect and prevent residents at risk for requiring CPR. Findings Included . Review of the facility policy, titled, CPR, revised ,d+[DATE] showed .UNWITNESSED ARREST FOR RESIDENTS WITH FULL CODE/CPR: 1. The nurse will evaluate the resident for obvious clinical signs of irreversible death. Obvious clinical signs of irreversible death include: a) Lividity or pooling of blood in dependent body parts (livor mortis), b) Hardening of muscles or rigidity (rigor mortis), c) Injuries incompatible with life such as decapitation 2. CPR will be initiated unless at least ONE obvious sign of irreversible death is present. 3. If there are no obvious clinical signs for irreversible death, initiate CPR following process for witnessed arrest. 4. Documentation must include the signs of irreversible death if CPR is not initiated . Resident 1 was admitted to the facility on [DATE] with diagnoses including heart failure, End Stage Renal Disease (ESRD) and type 2 diabetes. Review of a physician's order for Resident 1, dated [DATE], showed an order for CPR. Resident 1's POLST (Physician Orders for Life Sustaining Treatment), dated [DATE], showed to attempt resuscitation/CPR, full treatment-primary goal of prolonging life by all medically effective means. Review of Resident 1's nurse's note, dated [DATE] at 6:31 AM, showed .At 03:50 asked CNA [Certified Nursing Assistant], Staff D to get Resident up and get a set of vital sign for scheduled dialysis. Upon return to nurses station, met by CNA [Staff D] who said that resident was non-responsive. I took the code cart to room. Upon establishing no breathing: CPR started, code blue called. Resident's [family member] at bedside called 911. EMTS [emergency medical technician] /Fire dept.[department] arrived at 04:11. The code run until 0430. Paramedics called time of death at 0430. Coroner notified. DON [Director of Nursing Services - Staff B] notified, Order to release remains from [name of physician] MD . Review of a facility investigation, dated [DATE], showed Staff B met with Staff C (Licensed Practical Nurse) regarding CPR initiation for Resident 1. The facility identified that staff needed immediate re-education on how to use the emergency paging system, code blue/CPR response that included code drills and audit of CPR with all licensed nurses and CNA and all staff identified with no current CPR cards. The timeline of the event showed: On [DATE] between 3:00 and 3:30 AM, Resident 1 was last seen by Staff D when Resident 1 was assisted with toileting by Staff D. On [DATE] at 3:50 AM, Staff C asked Staff D to get Resident 1 ready for dialysis. On [DATE] (before 4:00 AM), Staff D went into Resident 1's room and found Resident 1 was unresponsive. Staff D left Resident 1 to find Staff E (CNA). Both Staff D and E returned to Resident 1's room, and verified the resident was unresponsive. Staff E told Staff D to get the nurse. Staff D went to find the nurse. The front doorbell rang and Staff D stopped to answer the door and let a the resident's family in the building and told the resident's family the resident was unresponsive. Resident 1's family member went directly to the resident's room. Staff D went to find the nurse and told Staff C the resident was unresponsive. Staff C retrieved the CPR cart and went into Resident 1's room to initiate CPR. Resident 1's family called 911. Review of a facility Performance Improvement Plan (PIP), dated [DATE], showed .On [DATE] [Staff D] found the resident unresponsive .and did not have the urgency that it was an emergency situation. Staff D called their peer to check on the resident instead of calling a code blue [code generally used to indicate resident requires resuscitation or in need of immediate medical attention], left the resident unattended to call the nurse, while in the process of calling the nurse .answered the front lobby doorbell and it was the resident's [family member]. It was determined that there was a delay in providing care . In an interview on [DATE] at 2:06 PM, Staff B, Director of Nursing Services (DNS) said after the investigation of the incident regarding Resident 1's CPR was completed, Staff B saw there was a lack of urgency. Staff B said Staff D went to answer the door and did not respond immediately with the nurse. When asked if there was a delay in initiating CPR, Staff B said, Yes. In an interview on [DATE] at 2:10 PM, Collateral Contact (CC), stated on [DATE] at 4:01 AM, they had attempted to call Resident 1 on their cellular phone to tell Resident 1 they had arrived to take Resident 1 to dialysis. CC said they had called Resident 1 a second time and there was no answer. CC said they went to the front door and rang the doorbell and a male staff person came to the door with a confused look. CC said the staff member told them Resident 1 had been unresponsive and may have passed away. CC said they went to Resident 1's room and shook the resident as the resident sometimes had low blood sugar and would get cold and clammy. CC said Resident 1's skin was warm. CC said he was upset and was yelling and CC picked up his personal cell phone and called 911 at 4:09 AM. CC said staff came in the room and started CPR. CC stated EMS and Police arrived at the same time and CC left the room. CC stated the police came out of the room and told him Resident 1 had not survived. In an interview on [DATE] at 3:08 PM, Staff B said Staff C saw Staff D answer the door, Staff C was coming back from break and heading to the unit. After Staff D let CC in the front door, Staff D told Staff C about Resident 1 being unresponsive and Staff C ran to get the crash cart. Staff B was asked why Staff E, after confirming Resident 1 was unresponsive, left to assist other residents? Staff B stated I don't know. In an interview on [DATE] at 5:25 PM, Staff C, Licensed Practical Nurse (LPN) said on [DATE] at 3:50 AM, Staff C asked Staff D to check on Resident 1 and get the resident up for dialysis. Staff C said about six to 10 minutes later, Staff D said they could not wake Resident 1. Staff C said they got the code cart and Staff C and Staff E initiated CPR on Resident 1 until EMS arrived and took over. Staff C said Staff D let CC in the front door. Staff C said the police also came in. Staff C was asked if they had a current CPR certification. Staff C said they did not but they were scheduled to complete it the following day. On [DATE] at 2:10 PM, during a telephone interview, Staff D, CNA, said they had worked the night shift when Resident 1 was unresponsive. Staff D said the resident had diarrhea several times that night and Staff D had assisted Resident 1 to the bathroom for the last time, around 2:30 - 2:45 AM. Staff D said they told Resident 1 they would answer two call lights and would return to help the resident get ready for dialysis. Staff D said Resident 1 wanted to lie down for a few more minutes. Staff D answered the call lights and returned to Resident 1's room and found the resident unresponsive. Staff D said they went to get another CNA (Staff E) to come to the resident's room and verify the resident was unresponsive. Staff D said Staff E went into Resident 1's room and told Staff D to get the nurse. (neither Staff D or Staff E initiated CPR or used the overhead pager to call for help). Staff D went to find the nurse, heard someone at the front door and went to answer the door. Staff D let CC in the front door and told them that Resident 1 was unresponsive, and they were trying to wake the resident up. CC went to the resident's room and Staff D went to find the nurse. Staff D said they told the nurse that the resident was unresponsive, and the nurse brought the CPR cart into the room. Staff D said when the CNA went back in the resident's room, the nurse was doing airway and Staff E was doing compressions. Staff D said I didn't use the overhead paging system .It was so confusing . When Staff D was asked if they could have started CPR, Staff D said, I believe so During an interview on [DATE] at 1:59 PM, Staff A, Administrator, stated that staff had not met their expectations when Resident 1 was found unresponsive and stated, I expected them to follow the policy, respond immediately calling code blue, staying with the resident and initiating CPR immediately with no delay. Staff should not have left [Resident 1] alone. [Staff D] could have initiated CPR immediately. If they would have followed our policy it could have been a different outcome. Reference WAC [DATE] (l)

Based on interview and record review the facility failed to prevent significant weight loss when a resident was not consistently administered their enteral feeding (nutrition delivered via a tube into the stomach) and the facility was neither aware of, nor addressed the lack of nutrition for 1 of 2 residents (Resident 1) reviewed for nutrition. Resident 1 experienced harm when they had a significant weight loss of 6.8 percent in one month. This failure placed residents at risk for weight loss, a lack of nutrition, hunger, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Nutrition/Hydration Program, showed licensed nurses verified the accuracy of the resident's weights and recorded them into the electronic medical record and nutrition services reviewed residents with significant weight changes and assessed their nutritional risk factors. Resident 1 was admitted on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 11/08/2023, showed Resident 1 was dependent for eating and had a feeding tube (a tube that delivers nutrients directly into the stomach). Resident 1's enteral feeding care plan, dated 08/01/2023, showed a goal the resident would maintain adequate nutritional status evidenced by stable weight and to administer enteral feeding per physician orders. Resident 1's physician order dated 09/23/2023 showed an order for staff to administer a bolus (dose delivered at one time) enteral feeding of Jevity (liquid nutrition) four times a day, scheduled at 6:00 AM, 12:00 PM, 6:00 PM and 11:59 PM. Resident 1's October 2023 Medication Administration Record (MAR), dated 10/01/2023 through 10/31/2023, showed no documentation the resident was administered the enteral feeding on 10/04/2023 at 6:00 PM, 10/05/2023 at 6:00 PM, 10/10/2023 at 6:00 AM and 6:00 PM, 10/11/2023 at 6:00 PM, 10/20/2023 at 6:00 AM, 10/22/2023 at 6:00 AM, 10/26/2023 at 6:00 AM, and 10/28/2023 at 6:00 AM and 6:00 PM. (10 missed administrations) Resident 1's November 2023 MAR, dated 11/01/2023 through 11/30/2023, showed no documentation the resident was administered the enteral feeding on 11/05/2023 at 6:00 AM, 11/06/2023 at 6:00 AM, 11/07/2023 at 6:00 AM, 11/13/2023 at 12:00 PM and 6:00 PM, 11/14/2023 at 6:00 AM, 11/20/2023 at 6:00 AM, 11/24/2023 at 6:00 AM and 6:00 PM, 11/25/2023 at 6:00 AM and 11/28/2023 at 6:00 AM. (11 missed administrations) Resident 1's weight record showed an admission weight on 08/08/2023 of 132 pounds, on 10/13/2023 of 111.0 pounds, 11/13/2023 of 103.5 pounds and 12/01/2023 of 103.2 pounds. Resident 1's Nutrition Evaluation, dated 11/07/2023, showed the resident had a very significant weight loss during the quarter of review, of 21 pounds, that was not planned nor desired and the resident was tolerating the enteral feeding. The evaluation showed the enteral feeding provided 100% of the resident's nutritional needs. Resident 1's Interdisciplinary Team progress note, dated 11/15/2023, showed a weight warning for the weight of 103.5 pounds, a 6.8 percent change over 30 days. Resident 1's Dietician progress note, dated 12/08/2023, showed the resident's most recent weight of 103.2 pounds was very less than ideal or safe and the resident was at extremely high nutrition risk. On 12/14/2023 at 11:58 AM, Staff C, Physician Assistant, said Resident 1 had no medical reason for their weight loss. Staff C said the resident had labs drawn approximately one month prior with normal results. On 12/14/2023 at 12:47 PM, Staff A, Registered Dietician, said Resident 1's prescribed enteral feeding order provided the resident with sufficient calories to maintain their weight. Staff A said they had no explanation for the resident's significant weight loss but if the enteral feeding was not administered per the physician order it could cause weight loss. During an interview on 12/14/2023 at 3:26 PM, Staff B, Director of Nursing Services, said licensed nurses documented administration of enteral feeding on the MAR and recorded the resident's weights in the electronic medical record after they verified the weight was accurate. Staff B said Resident 1's weights recorded in the electronic medical record were accurate. Staff B said they did not know how Resident 1 lost weight because the resident's nutritional needs were met with the enteral feeding. Staff B said if a resident was being fed through a tube and they were losing weight, they would review the medication administration records for documentation the enteral feeding was administered per the physician's orders, ensure the facility had the tube feeding formula and investigate if the resident was being administered the tube feeding. Staff B said the facility did not complete these steps for Resident 1. Reference WAC: 388-97-1060 (3)(h)

Based on observation, interview, and record review, the facility failed to implement Infection Control (IC) and Infection Prevention (IP) practices and outbreak management interventions to prevent transmission of COVID-19 (a highly transmissible respiratory virus), ensure Transmission Based Precautions (TBP) were in place, and the proper Personal Protective Equipment (PPE) was donned (put on) and doffed (removed) according to acceptable IC/IP standards for 16 of 16 sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) who tested positive for COVID-19) and in 3 of 6 hallways (Olympic, Mount View, and Bayshore). Resident 2 experienced harm when they were hospitalized with COVID-19 pneumonia (a serious lung infection caused by the COVID-19 virus) and later expired at the hospital. Resident 3 experienced harm when they were hospitalized for respiratory distress (difficulty breathing) and COVID-19. This placed 93 of 93 residents at risk for potential exposure to COVID-19 virus or other communicable illnesses and constituted an immediate jeopardy to protect residents from the risk of serious harm. On [DATE] at 2:16 PM, the facility was notified of an immediate jeopardy (IJ) CFR 483.80 (a)(1), (2)(iv) F880, Infection Prevention & Control, related to the facility's failure to implement transmission-based precautions (TBP) for residents who tested positive for COVID-19 to prevent the spread of the virus. The facility failed to implement the proper use of PPE which placed residents at risk for serious illness or death. The IJ was removed on [DATE] at 2:06 PM, after onsite validation by surveyor. Observations of residents who tested positive for COVID-19 virus had the appropriate TBP signage on the resident's door and bins with PPE for staff and visitor use. Staff interviewed and verbalized appropriate steps taken after a resident tested positive for COVID-19, and utilization of the checklist. Observations of staff donned and doffed PPE correctly. After removal of the IJ, the deficient practice at F880 remained at a G scope and severity, isolated, with actual harm that is not immediate, following the removal of the IJ. Findings included . Facility policy titled, COVID-19 Facility Policy and Procedure, revised ,d+[DATE], showed .all staff and essential personnel must wear appropriate PPE when interacting with residents. For a new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident an outbreak investigation is triggered. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission . A Centers for Disease Control (CDC) update, dated [DATE], titled, Interim Infection Prevention and Control Recommendations for Health Care personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic showed health care professionals who enter the room of a resident with suspected or confirmed COVID-19 infection should adhere to standard precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The N95 mask should be removed and discarded after the resident encounter and a new one should be donned. Non disposable eyewear must be disinfected before reuse. <Positive COVID-19 Cases> Review of the facility's census sheet, dated [DATE], showed the following residents tested positive for COVID-19 virus: Resident 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16. On [DATE] at 12:00 PM Staff D, Infection Preventionist said the line list for COVID-19 positive residents who tested positive on [DATE] had not been updated. Staff D said she had been on leave during the COVID-19 outbreak and the Director of Nursing Services (DNS) was on leave as well and there had been some confusion. Staff D said they had just completed an audit and became aware some residents had tested positive for COVID-19 and did not have TBP in place. Staff D said she was unsure why precautions were not in place and presented the surveyor with the census, with dates which indicated the date residents who tested positive for COVID-19 would stop isolation. On [DATE] at 12:10 PM Staff B, Regional Director of Clinical Operations said she came in to help out when Staff D was on leave during the COVID-19 outbreak. Staff B said residents who have tested positive for COVID-19 should have a TBP sign on the resident's door and a cart with PPE available for staff. Staff B said the Certified Nursing Assistants (CNA) know a resident is positive for COVID-19 when there TBP sign on the door or they could ask their nurse. Staff B said nurses knew a resident was on isolation if a TBP sign was on the resident's door, if the resident was on alert charting, or if the census was highlighted to indicate COVID-19 positive residents or the residents were on an anti-viral medication. 1) Resident 1 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (PVD/poor circulation to extremities) and diabetes. Review of Resident 1's electronic health record (EHR) showed Resident 1 tested positive for COVID-19 on [DATE]. On [DATE] at 11:35 AM, Resident 1 was observed resting in bed and TBP signage was not observed posted outside of Resident 1's room to alert staff and visitors of the required PPE to safely enter the resident's room ., nor was there a supply of PPE outside of the room to use before entering the room. The surveyor entered Resident 1's room to interview resident with a n95 mask (per personal preference), no eye protection, gowns, or gloves as required for COVID-19 positive residents. On [DATE] at 1:31 PM, after surveyor inquiry, Resident 1's room then had a sign on the door for aerosol precaution with a cart containing PPE outside of the resident's room. On [DATE] at 10:30 AM, Staff F, CNA said they were unaware of Resident 1's transmission-based precautions on [DATE] until a TBP sign was placed on the resident's door the afternoon and had not worn appropriate PPE prior to sign testing in the room prior to the TBP sign being posted. Staff F said if the sign wasn't on the door or a cart with PPE outside the resident's room, they would not know to wear PPE in the room. 2) Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (loss of thinking, remembering, and reasoning skills) and congestive heart failure (CHF/chronic condition which the heart does not pump blood well). Review of Resident 2's EHR showed the resident tested positive for COVID-19 on [DATE] and later expired. Review of Resident 2's nurse progress notes, dated [DATE], showed Resident 2 had respiratory distress with low oxygen saturation levels (measure of how much oxygen is in the blood) and was transferred to the hospital for evaluation. Review of Resident 2's hospital records showed the resident was admitted to the hospital on [DATE] with diagnosis of respiratory failure from COVID-pneumonia and was transitioned to comfort care on [DATE]. On [DATE] at 1:35 PM, Staff C, DNS, stated Resident 2 had expired at the hospital. 3) Resident 3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD/lung disease that blocks airflow and makes it difficult to breath) and diabetes. Review of Resident 3's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:10 PM, Resident 3's room was observed with the door open with no TBP signage on the resident's door or a cart with PPE was outside of the resident's door. Resident 3 ' s progress note, dated [DATE] at 12:08 AM, documented resident had been eperiencing respiratoy distess and generalized pain and had an oxygen saturation of 78% (normal oxygen level for adults is ,d+[DATE]%) and resident had been sent to the emergency room at 8:08 PM earlier that evening. Review of Resident 3 ' s hospital summary, dated [DATE], showed the resident was brought to the emergency roiagnom on [DATE] with diagnoses of COVID-19 and was discharged [DATE]. Resident 3 had reported body aches, shortness of breath and was on oxygen was on at 6 liters per minute. The resident received a breathing treatment and medication to treat pain and nausea and returned to the facility on [DATE]. 4) Resident 4 was admitted to the facility on [DATE] with diagnoses including COPD and diabetes. Review of Resident 4's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:15 PM, Resident 4's room was observed with the door open, no TBP signage on the resident's door or a cart with PPE available for staff or visitor use. 5) Resident 5 was admitted to the facility on [DATE] with diagnoses including Parkinsons disease (disorder of the nervous system that affects movement). Review of Resident 5's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:40 PM, Resident 5's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 6) Resident 6 was admitted to the facility on [DATE] with diagnoses including COPD and heart failure. Review of Resident 6's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:40 PM, Resident 6's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 7) Resident 7 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (abnormal development or damage to the brain that control movement) and diabetes. Review of Resident 7's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:20 PM, Resident 7's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 8) Resident 8 was admitted to the facility on [DATE] with diagnoses including COPD and diabetes. Review of Resident 8's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:22 PM, Resident 8's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 9) Resident 9 was admitted to the facility on [DATE] with diagnoses including COPD and a cerebral infarction (blood flow to part of the brain is stopped). Review of Resident 9's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:24 PM, Resident 9's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 10) Resident 10 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (disease that impacts the brain, spinal cord and optic nerves) and dementia (loss of thinking, remembering and reasoning skills). Review of Resident 10's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:26 PM, Resident 10's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 11) Resident 11 was admitted on [DATE] with diagnoses including dementia and COPD. Review of Resident 11's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:28 PM, Resident 11's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 12) Resident 12 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (sleep related breathing disorder) and hemiplegia (paralysis to one side of the body). Review of Resident 12's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:33 PM, Resident 12's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 13) Resident 13 admitted to the facility on [DATE] with diagnoses including dementia and atrial fibrillation (irregular, often rapid heart rate). Review of Resident 13's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:38 PM, Resident 13's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 14) Resident 14 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure and COPD. Review of Resident 14's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:38 PM, Resident 14's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 15) Resident 15 was admitted to the facility on [DATE] with diagnoses including COPD and chronic respiratory failure with hypoxia (body does not get enough oxygen). Review of Resident 15's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:39 PM, Resident 15's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. 16) Resident 16 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and psychotic disorder (severe mental disorder). Review of Resident 16's EHR showed the resident tested positive for COVID-19 on [DATE]. On [DATE] at 1:20 PM, Resident 16's room was observed with the door open, no TBP signage on the resident's door or cart with PPE available for staff or visitor use. <Transmission Based Precautions> On [DATE] at 1:55 PM Staff I, Licensed Practical Nurse (LPN) said she could not verbalize which residents tested positive for COVID-19. On [DATE] at 2:00 PM Staff H, Registered Nurse (RN), said she had been off and could not verbalize which residents had tested positive for COVID-19 On [DATE] at 9:58 AM, Staff F, CNA, was observed with a N95 mask and eye protection on. Staff F donned a gown and gloves and entered the room for Residents' 5 and 6. This room had a TBP sign for aerosol precautions on the door, requiring a N95 mask, gown, gloves, an eye protection to enter. At 10:05 AM Staff F exited the resident room for Residents' 5 and 6 after removing the gown and gloves and sanitized their hands. Staff F did not change the N95 mask or clean the eye protection. On [DATE] at 10:19 AM, Staff E, CNA, was observed entering Resident 11's room (who was positive for COVID-19 and had a TBP aerosol precautions sign on the door) with a N95 mask on but did not have a gown, gloves, or eye protection on, as required for a COVID-19 positive resident. Staff E was observed exiting Resident 11's room, after sanitizing their hands, proceeded down the hallway, and entered a room occupied by a resident who had not tested positive for COVID-19 to provide care. Staff E did not change the N95 mask. On [DATE] at 10:35 AM, Staff F, CNA, was observed entering Resident 4's room with a N95 mask, gown, gloves, and eye protection. Resident 4's door had a TBP sign for aerosol precautions on the door. Staff F was observed exiting the resident's room and did not change the N95 mask or clean the eye protection. On [DATE] at 10:36 AM, Staff G, CNA, was observed entering Resident 15's room with a N95 mask, gown, gloves, and eye protection. Resident 15's door had a TBP sign for aerosol precautions on the door. At 10:56 AM Staff G was observed exiting Resident 15's room and removed the gown and gloves. Staff G did not change the N95 mask or clean the eye protection. Staff G was then observed going down the hall, through the Olympic Unit and to the front entrance where they spoke to staff and residents in the hallway and spoke to a unidentified resident who did not have a TBP precautions sign on the door. In an interview at 11:03 AM, Staff G stated, I change my mask a couple times a day, to be honest I don't change it every time, did I do it wrong? An observation on [DATE] at 11:05 AM showed five isolation carts were observed outside resident rooms in the Bayshore Unit. N95 masks were not observed to be stocked in five of five isolation carts or at the nurse's station. On [DATE] at 2:15 PM, Staff B said she did not know why the TBP signage was not posted on residents' doors who had tested positive for COVID-19. In an interview on [DATE] at 3:00 PM, Staff D said if a resident tested positive for COVID-19, the Infection Preventionist was responsible for implementing TBP, which included posting a TBP sign on the resident's door that described what kind of precautions the resident was on and what PPE was required. Staff D said a cart was to be placed near the resident's room with PPE supplies for staff. If the Infection Preventionist was not present, then the Infection Preventionist's responsibility would go to the DNS, Regional Director of Operations or the Licensed Nurse. Staff D said staff were to wear appropriate PPE before entering the room and were to change the N95 mask after exiting the COVID positive residents' rooms. Staff D confirmed she was responsible for tracking the positive COVID-19 cases and resident symptoms and was unsure why residents who tested positive for COVID-19 did not have TBP signs on the door or carts with PPE near the resident's door. Staff D said an ICAR (a non-regulatory Infection Control Assessment and Response) was scheduled by the facility but it had been canceled by Staff D. Staff D stated, It was a mistake on my part and said she had been pulled to work the floor or medication cart two to three times a week and was unable to complete all the duties of the Infection Preventionist role. In an interview on [DATE] at 2:16 PM, when discussing the identified infection control findings with Staff A, Administrator and Staff B, Regional Director of Clinical Operations, Staff A said he understood the reason for the concern and stated, we realized this was a problem and would need to be fixed. Staff B said she understood the reasoning and the severity. Staff B said she didn't know why the signs were taken down and were unable to determine what happened. Reference WAC [DATE] (1)(a) (2)(a)

Based on interview and record review, the facility failed to implement measures to prevent development of avoidable pressure ulcers (PU), timely identify, assess, monitor, obtain treatment orders and implement interventions to prevent or heal pressure ulcers, for two of three residents (Resident 1 & 2) reviewed for pressure ulcers. These failures to perform an admission skin assessment, carry out and implement physician ordered treatments and interventions, develop a resident specific plan of care, complete weekly skin checks as ordered, and to ensure identified PUs were assessed and monitored, placed residents at risk for unidentified decline in wounds, delayed treatment and resulted in harm to Resident 1 who developed full thickness PUs to the right and left heels, and worsened sacral PU. Resident 2's PU worsened while at the facility. Findings included . Review of the undated facility's policy Admission Process, showed it identified each step, tool and timeframe required to complete the admission process. Nursing Services were directed to complete the admission skin assessment and Braden scale [standardized tool used to predict pressure ulcer risk] within 2 hours of admission. The Admission Evaluation and Skin Integrity Evaluation: Prevention and Management Care Plan [CP] were to be completed within 24 hours. A skin grid would be initiated for residents with pressure or [CONDITION(S)] ulcers and other skin issues as appropriate. Review of the facility's undated policy Wound Prevention and Management the facility strived to ensure residents who entered the facility without PUs, did not develop them unless the resident's clinical condition demonstrated breakdown was unavoidable. If a resident developed a PU in the facility, interventions would be directed at managing risk factors, providing preventative interventions and treatments. A resident with PUs would receive continued preventative interventions and necessary treatment and services to promote wound healing and prevent infection. Wounds (pressures, arterial, diabetic, venous stasis, significant skin tears, and other wounds) would be monitored weekly and include documentation of size, color, odor, and healing progression. Notifications and other pertinent information related to the skin conditions would be documented on the medical record. RESIDENT 1 Review of an anonymous complaint dated on 03/01/2022 showed that, [Resident 1] admitted to [the hospital] on 03/01/2022 with extensive skin breakdown to the bottom area [which was] not previously there two weeks prior, as evidenced by photographs we have from previous admission. Record review showed Resident 1 was admitted to the facility on [DATE]. Review of the hospital Discharge Summarydated 02/09/2022 showed the physician documented under Assessment/Plan the resident had a Pressure ulcer on sacrum. Continue wound care. Patient would benefit from an air bed. Review of Resident1's Hospital Physician's Discharge Orders dated 02/09/2022 showed wound care the physician documented Buttocks,[See] attached, wound care notes dated 01/27/2022 identified the resident had: a 4 centimeter (cm) by 4 cm partial thickness [Stage II, partial-thickness wound, with loss of epidermis (erosion or blister) without exposure of subcutaneous tissue] sacral PU, with moisture associated skin damage (MASD, an inflammation and erosion of skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate/ drainage, [MEDICATION(S)] or saliva.) to the surrounding skin; and a 1 cm by 1.5 cm maroon area to the right heel, assessed to be Suspicious for deep tissue injury [a classification of PU, indicative of damage of underlying soft tissue from pressure and/or shear.] The wound note included recommendations to paint Resident 1's right heel with [MEDICATION(S)] daily, allow to air dry, and to keep the resident's heels offloaded, and to cleanse the resident's sacral area with water, apply Triad (skin protectant cream) approximately 1/16 inch thick three times a day and with brief changes. Review Resident 1's Admission Minimum Data Set (MDS, an assessment tool) dated 02/16/2022, showed the resident was cognitively intact, required extensive assistance with activities of daily living, had MASD, and was at risk for PUs development. Review of Resident 1's Medical Record showed facility staff failed to complete: an admission skin assessment; a braden scale assessment; skin grids for the resident's sacral PU, right heel PU and MASD to buttocks, an admission evaluation; and a skin integrity prevention and management CP as directed by facility policy. Additionally, review of the resident's progress notes showed no admission progress note, or any progress note was written until 02/12/2022, the resident's fourth day in the facility. Review of Resident 1's February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's February 2022 Treatment Administration Record (TAR) showed there no direction to staff to assess, monitor or treat Residents 1's sacral PU, MASD to buttocks, right heel DTI or to offload the resident's right heel. The TAR directed facility nurses to perform a weekly skin checks and document a (+) for any area of impairment whether new or old and document (-) for No area of impairment. According to the TAR, the resident was assessed on 02/10/2022 to have no areas of impairment. Review of Resident 1's progress notes dated 02/12/2022 showed resident requested to be sent to the emergency room (ER) due to excoriating discomfort to buttocks area, groin, and private area with excoriation and redness. The resident voiced that lopermide (an anti-diarrheal medication) was ineffective and they'd rather go to the emergency room for treatment. Review of ER provider notes dated 2/12/2022 , showed Resident 1 reported they continued to have chronic loose stools and reported it took facility staff too long to provide care. Resident 1 stated, It can take them up to 45 minutes to arrive and provide incontinent care. During the ER visit Resident 1 was diagnosed with a Stage I (superficial reddening of the skin) bordering on a [ Stage II, partial-thickness wound, with loss of epidermis (erosion or blister) without exposure of subcutaneous tissue] sacral PU. The physician also documented [Resident 1] has known and in his prior hospitalization it is recorded, that he had a sacral decubitus [PU]. Review of Resident 1's ER provider notes dated 02/12/2022 showed under Emergency Department Course the physician documented, We contacted [Resident 1's] skilled nursing facility to confirm his medications and made recommendations. The recommendations included offloading the residents buttocks and applying a barrier ointment such as [MEDICATION(S)] 10 percent. Resident 1 was transferred back to the facility the same day 02/12/2022 after evaluation at the ER. Review Resident 1's nursing progress notes showed no documentation indicating the resident returned to the facility, or acknowledgement of the the treatment recommendations/orders from the ER physician. After the 02/12/2022 progress note that indicated the resident was sent to the ER, no further notes were written until 02/27/2022, five days after the resident returned. Review of Resident 1's February 2022 TAR, showed facility nurses failed to transcribe and implement Resident 1's treatment orders. Review of the facility's 02/17/2022 and 02/24/2022 weekly skin checks showed facility nurses assessed the resident had no areas of skin impairment. Review of Resident 1's comprehensive CP showed no PU, MASD to buttocks or potential for skin problem had been developed. Review of Resident 1's progress notes dated 02/28/2022 showed that resident was discharged to the hospital due to a change of condition, which included increased confusion, hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't there) and pain. Review of Resident 1's hospital provider notes dated 03/01/2022 showed Resident 1's left and right heels were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the National Pressure Injury Advisory Panel full thickness PUs are either Stage III, (full-thickness skin loss with damage to subcutaneous tissue extending down to the underlying fascia) or Stage IV (full-thickness skin loss with extensive destruction, tissue necrosis, and damage to the underlying muscle, tendon, bone, or other exposed supporting structures). During an interview on 03/28/2022 at 2:49 PM, Staff B, Director of Nursing, stated that the facility did not: assess the Resident 1's skin upon admission; identify the PUs to the resident's sacrum and right heel which were identified in the residents admission paperwork. Staff B, acknowledged that facility staff did not transcribe and implement the resident's admission treatment orders, implement a low air loss mattress as recommended. Staff B, again stated that facility staff did not ensure the resident's MASD to buttocks and right heel PU were assessed and monitored weekly. Staff B, further stated that facility staff did not develop a PU and/or MASD CP; transcribe and implement the 02/12/2022 ER physician's treatment orders and offloading recommendations. In addition, Staff B stated that facility staff did not identify during care or with weekly skin checks that the Resident 1 had developed full thickness PUs to the right and left heels, continued a partial thickness PU to the sacrum, or identify the resident's MASD to buttocks had worsened. Resident 2. Record review Resident 2. Admission (MDS) dated [DATE] showed Resident 2 admitted to the facility on [DATE], was cognitively intact, required extensive assistance with activities of daily living, had Stage 2 PUs to the buttocks, and used a pressure relieving device for chair and bed. Review of Resident 2's hospital Discharge Summary dated 11/19/2021 showed the physician documented that Resident 2 had a Pressure ulcer of buttocks stage 2 needs to continue placing hydrophilic dressing [a specialty wound treatment]. Review of Resident 2' Hospital Physician's Discharge Orders dated 11/19/2021 showed an attached 11/09/2021 wound care note that identified that Resident 2 had an area measuring 6 centimeters (cm) length by 8 cm width. This note showed the presence of open areas at a Stage 3, measured 0.3cm in diameter to 1 cm in diameter, had scant ( small amount) and clear drainage, and the surrounding skin was erythematous (Redness of the skin, either in a limited area or all over). The documentation attributed the skin breakdown to Incontinence Associated [CONDITION(S)] (IAD, skin inflammation), with a pressure component The physician instructed the staff to, Perform to buttock daily and prn (as needed) with episodes of incontinence and brief changes; Cleanse skin with bath wipes to remove residual Triad. Reapply Triad [and] hydrophilic wound dressing in layer approximate 1/16 thick. Regular turning, off-loading as per usual nursing care. Review of Resident 2's TAR showed November 19th 2021 through January 14th 2022 the staff did not conduct weekly skin assessments. There were no weekly measurements and/or documentation of the resident's PU condition. Review of Resident 2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Offload buttocks while in bed to facilitate healing and relieve pressure in the area. Another Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This referral order was not implemented. During an interview on 04/04/2022 at 1:49 PM, Staff B, Director of Nursing stated that the facility had not assessed the resident's skin on admission, identify the PUs to the resident's buttocks on admission, implement the physician treatment and referral orders. Staff B, further stated that the facility staff did not ensure the resident's PUs were assessed, monitored and measured weekly. Reference WAC: 388-97-1060(3)(b)

Based on interview and record review, the facility failed to provide adequate supervision of staff and residents to prevent falls for one of two residents (Resident 1) reviewed for falls. This failure resulted in Resident 1 incurring an acute fracture of the right hip, and subsequent hospitalization for a surgical repair of the fracture. Resident 1 was assessed to require two staff assist for bed mobility when one staff assisted resident and resulted in a fall with injury constituting harm to the resident. Findings included . Review of a 06/04/2020 facility policy titled Fall Management, showed the facility promoted resident safety and reduced falls by proactively identifying, care planning and monitoring the resident's fall indicators through a Fall Risk Assessment. This policy showed that accurate assessment of the resident was fundamental in determining indicators for potential falls. Review of a 01/07/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], diabetes, and dementia. This assessment showed that Resident 1 required extensive assistance of two people for bed mobility, transfers, and toilet use. Review of Resident 1's 10/05/2021 comprehensive Care Plan (CP) showed the resident was at risk of fall/injury related to deconditioning with generalized weakness and required 1-2 person assist for toileting assistance and bed mobility. A 02/12/2022 progress note showed that at 9:21 PM, Resident 1 fell out of bed and one staff was present. Resident 1 fell to the floor on the left side of bed, ending on their stomach. Staff noted Resident 1 with a small and superficial abrasion to their left knee, and that the resident complained of moderate pain, 6 out of 10. The facility managed resident's pain with oral pain medication. A 02/14/2022 progress note created on 02/16/2022 at 9:23 PM showed Late Entry: Note Text: Resident assessed related to recent fall, no s/s of pain during assessment, palpated both hips with no s/s of pain or discomfort. No swelling noted to LE and even. No new bruising noted, abrasion left knee open to air. Skin check completed with no other skin injury or any s/s of latent injury noted. Continue to monitor related to fall on 2/12/22. A 02/15/2022 progress note showed that a Certified Nursing Assistant (CNA) notified Licensed Nurse (LN)'s resident was yelling out when trying to move resident while providing personal care. Resident c/o right hip and right leg pain. DNS report resident having fall on 2/12/22. New order for stat x-ray called in. Pain is on movement 7/10 pain. Resident resting in bed with call light within reach waiting for x-ray. Review of facility radiology results report dated 02/15/2022 showed Resident 1 had pain in right hip, X-ray findings: There is a right intertrochachanteric comminuted fracture (a type of broken hip) with moderate displacement. The joint shows no disclocation. Conclusion: Acute appearing right proximal fracture (in the hip region). Review of Hospital Admission notes dated 02/15/2022 showed Resident 1 was presented from her nursing home with Right hip pain, for which an outpatient x-ray was done today revealing moderately displaced intertrochanteric fracture of the right hip. On 03/07/2022 at 10:05 AM, Staff D, Certified Nurse Assistant (CNA), stated that Resident 1 required one to two staff assist with bed mobility. Staff D stated that they provided Resident 1 incontinent care when Resident 1 rolled out of bed. Staff D stated that a nurse assisted them to help Resident 1 back to bed and that the resident complained of pain to the right hip. On 03/07/2022 at 1:24 PM, Staff C, Licensed Practical Nurse (LPN), stated that they responded to Staff D's call for help, observed Resident 1 on the floor, assessed the resident and assisted the resident with a Hoyer (mechanical) lift to bed. Staff C stated that Resident 1 needed total help with transfers and bed mobility. Staff C stated that Resident 1 was impulsive due to advanced dementia and had a history of falling out of bed. On 03/04/2022 at 2:30 PM, Staff E (Physical Therapist), stated that Resident 1 could not stand and required complete staff assistance with a Hoyer lift for transfers. Staff E stated that Resident 1 required maximum assistance of two staff with bed mobility as the resident had history of constant falls and cognitive impairment. On 03/07/2021 at 3:00 PM, Staff B, Director of Nursing, stated that the MDS assessment directed the resident's care plan. Staff B stated that Resident 1 rolled out of bed while one staff provided incontinent care on 02/12/2022, contrary to the MDS assessment of two people assistance for bed mobility and transfers. Staff B stated that [Resident 1] fractured their right hip when staff failed to provide the required assistance for bed mobility. Reference WAC 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to follow-up and offer the completion of COVID-19 immunizations for 4 of 8 residents (Residents 1, 2, 3 and 4) reviewed for COVID-19 immunization. This failure resulted in harm to Resident 1, who contracted COVID-19 which may have contributed to the resident's death. In addition, this failure placed other residents at risk for not getting the intended full efficacy of the COVID-19 vaccine and the potential for contracting the COVID-19 infection that could result in severe illness or death. Findings included . Review of the facility's policy and procedure titled, Policy and Procedure for COVID-19 Vaccine Immunization Requirements for Residents and Staff, dated 05/19/2021, showed the following: -The facility must offer the vaccine unless it was medically contraindicated, or the resident had already been immunized and to document whether the resident received the vaccine. -The facility will review data periodically to identify unvaccinated staff and residents and follow-up with them or their families as the vaccination program continues. -The resident's medical record must include documentation that indicated at a minimum that the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine and that the resident (or representative) either accepted and received the COVID-19 vaccine or did not receive the vaccine due to medical contraindications, prior vaccination, or refusal. Resident 1 Review of Resident 1's annual Minimum Data Set (MDS, a required assessment tool) dated 08/27/2021 showed that Resident 1 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further showed that Resident 1 was cognitively intact. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the immunization section of Resident 1's electronic health records (EHR) dated 01/24/2021 showed Resident 1 received the first dose of the Pfizer COVID-19 vaccine on 01/24/2021. The immunization section showed no documentation that Resident 1 received the second dose of the COVID-19 vaccine. During an interview on 09/22/2021 at 11:40 AM, Staff C, Infection Preventionist (IP), stated that the facility did not have access to vaccines until June or July 2021. Staff C, IP, further stated that Resident 1 consented to one dose of the COVID-19 vaccine. Review of Resident 1's EHR, showed no documentation that the facility offered a second dose of the Pfizer COVID-19 vaccine or that Resident 1 refused the second dose. Review of Resident 1's COVID-19 test result dated 09/14/2021, showed Resident 1 tested positive for COVID-19 infection. Review of Resident 1's hospital records dated 09/15/2021, showed that Resident 1 passed away from respiratory failure caused by the COVID-19 infection. Resident 2 Review of Resident 2's admission MDS dated [DATE], showed that Resident 2 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further showed Resident 2 had cognitive impairment. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the immunization section of Resident 2's electronic health records (EHR) dated 07/14/2021 showed Resident 2 received the first dose of the Moderna COVID-19 vaccine. The immunization section showed no documentation that Resident 2 received the second dose of the COVID-19 vaccine. During an interview on 09/22/2021 at 1140 AM, Staff C, IP, stated that whatever documentation that the facility had on vaccination consent was placed in the resident's medical records. Review of Resident 2's EHR dated 09/22/2021, showed no documentation that the facility offered the second dose of the Moderna COVID-19 vaccine or that the resident refused a second dose of the COVID-19 vaccine. Review of Resident 2's COVID-19 test result on 09/17/2021, showed that Resident 2 tested positive for COVID-19 infection. Resident 3 Review of Resident 3's quarterly MDS dated [DATE], showed Resident 3 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 3's COVID-19 immunization card dated 03/05/2021 showed Resident 3 received the first dose of the Moderna Covid-19 vaccine from an outside provider. Review of Resident 3's admission records dated April 2021, showed no documentation that the facility provided education on the risk and benefits of the COVID-19 vaccination. There was no documentation that showed the facility offered the second dose of the Moderna COVID-19 vaccine or that Resident 3 declined the second dose of the vaccine. Review of Resident 3's COVID-19 test result dated 09/15/2021, showed Resident 3 tested positive for the COVID-19 infection. Resident 4 Review of Resident 4's quarterly MDS dated [DATE], showed that Resident 4 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further showed Resident 4 had severe cognitive impairment. Review of the Guardian Ad Litem's (an individual appointed by the court to represent the best interest of an incapacitated person) Motion for Instruction from the court dated 04/22/2021, showed that efforts shall be made for Resident 4 to obtain the COVID-19 vaccine as soon possible. Review of the immunization section of Resident 4's EHR, undated, showed that Resident 4 refused the COVID-19 vaccine. Review of Resident 4's EHR on 09/22/2021, showed no documentation that the facility informed the Guardian Ad Litem about Resident 4's refusal of the COVID-19 vaccine and that the resident had been reapproached at a different time. Review of Resident 4's COVID-19 test result dated 09/09/2021, showed Resident 4 tested positive for the COVID-19 infection. During an interview on 09/22/2021 at 11:10 AM, Staff B, Director of Nursing Services, stated that the expectation when it comes to resident and staff COVID-19 vaccination was for Staff C, IP, to keep track of the vaccination status of the staff and residents. The facility did not track the vaccination status of the residents. WAC reference 388-97-1780 (1)(2)(c)(d)

Based on observation, interview and record review the facility failed to implement an effective discharge planning process that included all preparation needed for safe discharge for two of five residents (Resident #1 and 17) reviewed for discharge. Pre and post discharge care plans were not individualized, comprehensive, documented or updated, with identified specific measurable goals and interventions to address all resident needs. These failures resulted in harm to Resident #17, when the resident did not have all medical equipment available after discharge and the resident required re-hospitalization when home oxygen supplies depleted, and to Resident #1 when the resident was discharged without adequate medication supplies, and the facility did not send required medical information to the provider, to be able to refill prescriptions. Findings included . Facility procedure titled Discharge Planning Manual directed staff to formulate a projected discharge plan within 24 to 72 hours of admission based on the resident level of care. The manual showed for the unit, manager or designee would compare medications taken at home to discharge medications and reconcile them with the primary provider with a call and/or fax. RESIDENT #1 Admission Minimum Data Set assessment dated [DATE] (MDS, required assessment tool) showed Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/31/2020, the facility discharged Resident #1 to an adult family home (AFH). Prior to the current admission to the facility, MDS assessments dated between 03/14/2014 and 01/31/2020 showed Resident #1 previously resided in multiple nursing homes. The resident admitted to nursing homes following hospitalization s and discharged back to the community five separate times. A Discharge Planning note dated 01/22/2020 showed Resident #1 needed home health orders for physical and occupational therapy, and to advise when the referral was made and accepted. No further documentation was found in the record to show the facility sent a referral to the home health agency and, if or when the home health agency would provide services after discharge. Resident #1's current record did not include a discharge plan of care to identify individualized interventions necessary to provide for a safe discharge that included measurable long and short-term goals, to maximize opportunity for a successful community discharge. MEDICATIONS RAN OUT A physician order [REDACTED].#1 to discharge with current medications. During an interview on 03/04/2020 at 10:20 AM, Staff D Social Services Director (SSD) stated there was a snafu regarding Resident #1's medications and did not have enough medications when discharged from the facility to last until her physician appointment. Staff D stated the facility faxed a prescription to the pharmacy after discharge. During a telephone interview on 03/02/2020 at 12:40 PM, Anonymous Adult Family Home Provider O (AAFHP O) stated that the nursing home did not send enough medications for Resident #1 to last until the resident saw the physician on 02/12/20. During an interview on 03/16/2020 at 2:15 PM, Anonymous Pharmacy Staff P (AP Staff P) stated that on 01/31/2020, the facility sent a list of Resident #1's medications to the pharmacy without a physician signature and could not fill prescriptions for the AFH, the day the resident discharged . APS Staff P stated that the pharmacy immediately contacted the facility and requested signed medication physician orders, and did not receive them until 02/04/2020 (four days later). AFH medication records showed Resident #1 did not receive [MEDICATION NAME] (anti-anxiety) for 15 days starting 8:00 PM on 02/11/2020 until 8:00 PM until 2/26/2020. The record also showed the resident received two doses of [MEDICATION NAME] (narcotic pain medication) one to two times daily and did not receive any beginning 02/21/2020. During an interview on 03/16/2020 at 3:42 PM, AAFHP O stated that Resident #17 ran out of [MEDICATION NAME] on 02/11/2020 and [MEDICATION NAME] (narcotic pain medication) on 02/20/2020. AAFHP O also stated when Resident #17 ran out of medication she demonstrated increased anxiety by increase in body shaking and verbalized being anxious. NO RECORDS PROVIDED FOR PHYSICIAN APPOINTMENT An Interdisciplinary Resident Discharge Note signed 01/31/2020, showed Resident #1 had an appointment with a provider to obtain prescription refills on 02/12/2020 following discharge. During an interview on 02/28/2020 at 11:08 AM, Staff F Licensed Practical Nurse (LPN) stated that Resident #1 was given a packet of discharge paperwork that should have included medications, course of treatment and recapitulation of stay. Staff F stated that he gave the packet for Resident #1 to the facility van driver who drove the resident to the adult family home. Staff F also stated he did not know how the AFH provider would know what to do with the packet and would think nursing staff would call them to discuss it. On 03/04/2020 at 10:20 AM, Staff D Social Services Director (SSD) stated that the facility put together a packet of information to send to the AFH for Resident #1. Staff D stated the packet included the Transfer/Discharge report that listed all medications and orders for the resident along with other discharge information. Staff D also stated that Resident #17 should have been educated at the time of discharge to bring the discharge packet to the physician appointment. Staff D also stated the AFH should be responsible to make sure the resident took the packet to the appointment. During an interview on 03/04/2020 at 10:20 AM, Staff D SSD stated that when the facility made an appointment with Resident #1's new primary care physician, the office did not request copies of the discharge documents. During an interview on 03/16/2020 at 2:59 PM, Anonymous Outside Agency Registered Nurse Q (AORN Q) stated that when Resident #1 arrived at the physician appointment, the physician could not refill prescriptions for the resident because the nursing home did not send medical information in advance. AORN Q stated that the facility did not inform the AFH the packet sent with the resident to the AFH should go to the physician appointment. AORN Q also stated that the nursing home made the appointment with the physician and it was standard practice the person who made the appointment should fax documents to the physician. During an interview on 03/04/2020 at 10:20 AM, Staff D SSD stated the facility needed to find a new primary care provider for Resident #1 two days before discharge. Staff D also stated the new primary care provider did not request the facility to fax over the discharge information, and later found out the packet did not go with the resident to the appointment. Staff D stated, in hindsight we should have faxed it over. Resident #1's medical record did not contain evidence nursing or social service staff contacted the AFH and informed them of the importance to send the information in the discharge packet with the resident to the appointment with the physician. When the resident got to the appointment, the physician did not have information necessary to refill prescriptions needed and had to reschedule the appointment for a later date. Failure to send adequate supply of medications and provide medical documents to a new medical provider that were needed to write prescriptions for renewal, resulted in harm for Resident #1 when medications ran out and the new provider could not refill them. RESIDENT #17 Resident #17 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. A physician history and physical dated 02/07/2020, showed to monitor oxygen levels every shift and continue supplemental oxygen, inhalers and nebulizer treatments and to continue [MEDICAL CONDITION] (breathing device) with routine settings. Progress notes dated 02/09/2020 and 02/19/2020 showed staff sent the resident to the hospital on both dates for two to four days due to respiratory related decline. On 02/24/2020, the physician ordered to discharge Resident #17 home with a bedside commode and wheelchair. Resident #17's medical record did not contain evidence staff obtained discharge physician orders [REDACTED]. On 02/24/2020, the facility discharged Resident #17 with medications and appointment to follow up with a primary care provider, two days after the resident returned from hospitalization on [DATE]. The following concerns were identified regarding the discharge process: NO DISCHARGE CARE PLAN Resident #17's record did not contain a discharge care plan with measureable goals, timelines and interventions to determine when the resident was safe to discharge home. LACKED ARRANGEMENT FOR MEDICAL EQUIPMENT A therapy to nursing communication note dated 02/24/2020 recommended Resident #17 transfer with a gait belt from a wheelchair for mobility and activities of daily living. A Discharge Planning Note written 02/24/2020, showed Resident #17 would be sent home with a walker. The record did not show why staff did not implement physician orders [REDACTED]. During an interview on 03/18/2020 beginning 1:07 PM, Staff D Social Service Director (SSD) stated that Resident #17 used a walker to go to Bingo. Staff D stated that the resident took the facility rented breathing device machine home with her, and the facility did not know it at the time. During the same interview, Staff S Resident Care Manager (RCM S) stated that Resident #17 received oxygen via nasal cannula while in the facility and nebulizer treatments four times a day. During the same interview, Staff D SDS stated that Resident #17 informed the facility she had two oxygen tanks at home and an oxygen concentrator. Staff S stated that the resident's significant other brought a tank to the facility at the time the resident discharged . Discharge records did not show the name of oxygen and nebulizer suppliers, or contain evidence the facility confirmed oxygen tanks were full or needed to be refilled; or if supplier accounts were active and arrangements were made to restart home deliveries. The record did not show staff provided education to the resident to validate understanding how to operate all equipment. UNKNOWN DISCHARGE LOCATION A Discharge Planning Note dated 02/24/2020 written at 10:51 AM showed the resident would discharge to Tacoma with current medications and own equipment of walker/cane. Resident #17's medical record did not identify the address or location where the resident planned go. The record did not identify staff attempted to review or assess the resident's home discharge location to ensure it met the resident's needs to be able to maintain and manage health conditions safely, or discussed concerns regarding unresolved care issues as potential for unsafe discharge. During a telephone interview on 03/10/2020 at 2:46 PM, Staff F Social Services (SS), stated that Resident #17 stated she would discharge to the same location and would not provide an address for the facility. During an interview on 03/04/2020 at 10:20 AM, Staff D SSD stated that discharge planning started the first day of admission. The interdisciplinary team looked at all barriers for discharge such as oxygen needs, nebulizers, equipment, home health therapy and if residents had wounds and dressing supplies. A Hospital Discharge Summary dated 02/26/2020 showed on 02/24/2020, the evening the resident discharged home, Emergency Medical Services took Resident #17 to the emergency room with low oxygen levels that measured 62% on room air and rapid heart rate. Notes showed the resident ran out of oxygen and attempted to obtain oxygen delivery that night and the supplier was closed. Hospital history written 02/27/2020 showed the resident discharged to a home camper (2/24/2020) and found out that the camper did not have a wheelchair ramp or electricity to power home oxygen tanks. The note showed the resident had to connect equipment to a neighbor's garage using an electrical extension cord. Reference WAC 388-97-0080

Based on observation, interview and record review the facility failed to implement their pressure ulcer policies and provide the care and services necessary to prevent and treat in house acquired pressure ulcers for one of three Sample Residents. This failure resulted in Resident #1 acquiring a full thickness pressure ulcer, thus resulting in harm. Findings included . Review of the facility's policy dated (MONTH) (YEAR), titled Pressure Ulcer Prevention/Treatment, showed staff were to assess residents on admission, identify interventions to prevent and treat, develop prevention and treatment care plans, manage nutrition, manage friction and shear, and remove underlying risk factors. RESIDENT #1 Resident #1 was no longer in the facility. Review of Resident #1's medical records showed she admitted to the facility on [DATE]. Review of an admission skin assessment dated [DATE] showed Resident #1's skin was intact when she admitted to the facility. Further review of Resident #1's medical record showed a Braden skin assessment (an assessment tool that shows if a resident is at risk for developing a pressure ulcer) dated 12/10/18 which scored 15, indicating Resident #1 was at low risk for developing a pressure ulcer. WEEKLY SKIN MONITORING Review of Resident #1's medical record showed a physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) showed documentation supporting the weekly skin assessment was completed one time, on 12/16/18, which included a note indicating no new skin issues were identified. Review of the (MONTH) 2019 TAR showed only one weekly skin assessment was documented on 01/27/19, which included a - symbol, indicating no new skin issues were identified. Review of the (MONTH) 2019 TAR showed a documented skin assessment dated [DATE], which showed no new skin issues. The next skin assessment dated [DATE] included a + symbol, indicating there was a new skin issue identified. The +symbol was also documented on 02/17/19 and on 02/24/19. Directions to staff on the TAR instructed staff to document the + if a new skin concern had been identified, and then document in the progress notes where the condition was and what type of condition had been identified. Review of the progress notes in Resident #1's records showed no progress notes documented on 02/10/19 or on 02/17/19 to describe what type of skin condition had been identified or where on the body the skin condition was located. There was only one progress note documented between 01/20/19 and 02/24/19, which only described a medication being received from the pharmacy. A progress note dated 02/24/19 indicated the Res (resident) wound worsening. The note showed documentation Skin Assessment 1) 0.1x1x0.5cm (centimeters) excoriation 2) 0.1x5.5cm excoriation 3) 1.5x1.5cm slough indicating there were two separate areas with excoriation (a reddened or scraped appearing area) and one area of slough (skin which is dead and falling off). The note did not describe where on Resident #1's body the areas were found. The note indicated the physician was notified and wrote an order for [REDACTED].#1's skin monitoring sheet indicated the excoriated areas were over the resident's sacrum and right buttock. The next weekly skin assessment documented on the (MONTH) 2019 TAR showed a + on 03/03/19. Review of the nursing progress notes showed no documentation on 03/03/19 to show what changes in the skin were noted. The next weekly assessment documented on 03/10/19, also showed a + symbol indicating there was a new skin condition noted. Review of the nursing progress notes indicated no progress notes were documented between 02/24/19 and 03/12/19. In an interview on 04/04/19 at 3:50 PM, Staff B, Director of Nursing, DON, stated she had attempted to review Resident #1's wound in order to track its condition,and determine factors such as cause, avoidable, unavoidable, but found that the nursing staff had not been documenting the resident's skin/wound condition. Staff B, DON, stated without the documentation she was not able to assess the factors that may or may not have contributed to the wound. Staff B, DON, stated she was educating nursing staff related to skin documentation. WOUND CARE Review of Resident #1's medical record showed a physician's orders [REDACTED]. The order indicated the treatment was to be completed during day shift and to be done every other day. Review of the (MONTH) 2019 TAR showed the treatment was scheduled six times prior to Resident #1 going out to the hospital on [DATE]. Of the six scheduled days, only three days had documentation to show the treatment had been administered. The treatment was scheduled but not documented on 03/01/19, 03/05/19 and on 03/09/19. Additional review of Resident #1's record showed a physician's orders [REDACTED].#1 to be referred to the wound care specialty team. Resident #1's record showed she was not seen by the team until 03/12/19, more than two weeks later. When Resident #1 was seen by the wound team on 03/12/19 her wound had deteriorated and was described in the wound team's notes as being 17cm long by 12cm wide by 3cm deep, with full thickness skin and tissue loss, heavy, purulent drainage with a foul odor and was 76-100% slough (dead tissue). Resident #1 was sent to the hospital on that same day. CARE PLANNING Review of Resident #1's record showed a section dated 01/04/19 which indicated Resident #1 was at risk to develop moisture associated skin damage related to urinary and bowel incontinence. Interventions listed included: Refer to the pressure ulcer care plan, dated 03/13/19 Report signs and symptoms of moisture associated skin damage to the physician, dated 03/13/19 Treat moisture associated skin damage per physician order, dated 03/13/19. The interventions were added to the care plan on 03/13/19, the day after Resident #1 had discharged from the facility. Further review of Resident #1's care plan showed the section titled Has pressure ulcer of sacrum/coccyx r/t (related to) Dermal Frailty, Other non-compliance with repositioning, decreased mobility. This section was dated 03/13/19, the day after Resident #1 discharged from the facility. The pressure ulcer care plan included a list of interventions including; Administer treatments apply moisture barrier apply skin protectant turn and reposition manage friction and shear, pressure relieving mattress All of the interventions listed were dated 03/13/19, the day after the resident had discharged from the facility, and more than four weeks after the first identified skin condition was documented on the (MONTH) 2019 Treatment Administration Record on 02/10/19. Additionally, the pressure ulcer care plan indicated the pressure ulcer developed due to Resident #1's non-compliance with repositioning. There was no documentation in Resident #1's record to show she had been non-compliant, until 03/13/19, after Resident #1 had discharged . PRESSURE ULCER MANAGEMENT Review of the facility Pressure Ulcer Management and Prevention policy dated (MONTH) (YEAR) showed staff were to manage pressure by using appropriate surfaces, turning and repositioning, or offloading pressure areas such as heels. The policy directed staff to encourage protein intake, supplemental vitamins and to consult with a dietician. Review of Resident #1's medical record showed a progress note dated 03/13/19, the day after she discharged from the facility, that staff placed an air mattress on the resident's bed to provide pressure relief. There was no previous documentation to support Resident #1 had been given a pressure reducing mattress or cushion for her wheelchair. There was no documentation or physician's orders [REDACTED]. Additionally, there was no documentation the dietician had been made aware of Resident #1's wound. With the Registered Dietician not being aware of the wound, he/she was not aware to reassess Resident #1's increased nutritional needs and determine if Resident #1 needed additional vitamins and/or protein intake to promote healing of the wound. MANAGING FRICTION AND SHEAR Review of a physical therapy note dated 01/04/19 showed Resident #1 had been assessed by the therapy department and it was recommended that the resident be transferred by use of a mechanical lift when moving from her bed to her wheelchair, or from wheelchair to bed. Review of Resident #1's progress note showed notes almost daily indicating Resident #1 was a heavy two person transfer, indicating staff were transferring Resident #1 using stand by assist method instead of the mechanical lift recommended by the therpay department. In an interview on 04/01/19 at 12:30 PM, Staff N, Certified Nursing Assistant, CNA, explained Resident #1 was only able to support a small amount of her own body weight with her legs, which made her a heavy transfer. Staff N, CNA, described Resident #1 standing with staff assisting her by one staff member being on each side of her and providing support since she was not able to support her weight with her legs. In an interview on 04/01/19 at 11:50 AM, Staff H, Physical Therapy, PT, explained that it was difficult for two therapists in the therapy department to transfer Resident #1 safely due to her leg weakness, therefore, the therapy department had recommended staff use the mechanical lift to transfer the resident. Staff H, PT, reported the therapy department documents their recommendations and that goes to the nursing department to update in the care plan. Staff H, PT, stated he did not know why Resident #1 was not being transferred with the use of a mechanical lift. Staff H, PT, confirmed, by sliding Resident #1 to a sitting position on the edge of the bed and using a two person transfer technique, there would be increased friction and/or shear to the resident buttocks/sacral region than there would be if the resident was transferred by the use of a sling and mechanical lift. PRESSURE ULCER REVIEW TO DETERMINE CAUSE Review of the facility incident log showed no entries listed related to Resident #1 developing a skin condition. In a phone interview on 04/04/19 at 3:50 PM, Staff B, Director of Nursing, DON, confirmed the facility had not completed an investigation to identify the cause or contributing factors of the wound when it was identified in (MONTH) 2019. Staff B, DNS, stated the facility would normally complete an investigation when a new skin concern is identified, and identify the potential causes. Review of Resident #1's medical record showed a progress note written by Staff B, DON, dated 03/13/19, the day after the resident discharged from the facility, which indicated Resident #1 was non-compliant with scheduled turning and repositioning, and allowed minimal pressure relief while up in her chair. Additionally, the note indicated the resident insisted on using [MEDICATION NAME] skin cream on the MASD (Moisture Associated Skin Damage) area instead of the treatment recommended by the physician. Although the nursing progress notes included documentation indicating Resident #1 had refused a skin treatment to her lower legs (not the sacrum or buttocks areas), there was no documentation to support the resident was non-compliant positioning, non-compliant with treatment to her sacrum, or had been using a personal skin cream to her sacral area, as documented in the 03/13/19 progress note. Additionally, there was no documentation that staff had educated Resident #1 of the risks involved with these behaviors and the potential damage it could do to her skin. In an interview on 04/04/19 at 3:50 PM, Staff B, DON, stated although she documented in a progress note on 03/13/19 that Resident #1 had been non-compliant with treatments and postioning, there was no documentation in the medical record during Resident #1's stay at the facility to support her statement. Resident #1 was identified as being at low risk for developing a pressure ulcer when she was admitted to the facility in (MONTH) (YEAR). Staff failed to document that they were monitoring Resident #1's skin on a routine basis. When changes were identified, staff failed to document what changes had occurred or where they had occurred. The staff failed to develop a care plan that included interventions to be used by staff to prevent skin breakdown, and to heal pressure wounds that had already developed, such as a turning schedule or increased nutritional intake to promote healing. Once the wound developed, staff failed to provide the treatments as ordered by the physician. There was no documentation staff conducted an investigation to determine the cause of the pressure ulcer. Without an investigation, staff were not able to identify potential causes and remove them in order to prevent future pressure ulcers from developing and to prevent current pressure wounds from worsening. All of these failures resulted in Resident #1 developing two excoriated areas roughly the size of a quarter in the sacral area. That excoriated area increased into a wound roughly the size of a cantaloupe with full thickness of skin and underlying tissue loss, and infection. The facility's failure to monitor, prevent and treat and pressure related skin condition resulted in harm to Resident #1. WAC Reference 388-97-1060(3)(b)

Based on interview and record review the facility failed to ensure one of three residents (Resident #3) was provided adequate supervision to prevent accident hazards. Failure to timely develop specific individualized interventions to address all risk factors and ensure care planned interventions to provide supervision and assistance were consistently provided, resulted in harm when Resident #3 sustained a fall that resulted in a [MEDICAL CONDITION]. Findings included . Resident #3 was no longer in the facility. Review of the quarterly Minimum Data Set (MDS, a required assessment tool), dated 11/27/18, showed Resident #3 had significant memory impairments, difficulty communicating wants and needs, had no behaviors (including resisting care, wandering, etc.), was one person physical assistance for bed mobility, transfers, walking, dressing and toileting. The MDS further showed the resident was always continent. Review of the annual MDS dated [DATE], showed Resident #3 admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was hard of hearing and had difficulty understanding others and making needs known. Resident #3's cognitive status, mood and half of the behavioral indicators were not assessed. The resident did not wander and rejected care one to three days a week, and had no skin issues. The MDS further showed that Resident #3 required one person physical assistance for transfers, bed mobility, dressing, bathing, and grooming. Additionally, the resident was unable to answer questions about pain, had two or more falls since the last review period, and was incontinent with no toileting program. The MDS showed Resident #3 had no change, indicating no decline or improvement in health status since the last review period approximately three months prior on 11/27/18. Review of the Care Area Assessment (CAA) dated 02/27/19, showed that Resident #3 was impulsive and had a history of [REDACTED]. The assessment indicated Resident #3 was now incontinent, at risk for altered nutritional status, at risk for pressure ulcers and injuries and exhibited resistive behaviors, all symptoms were not present the time of the previous assessment. The 02/27/19 CAA indicated Resident #3 had several changes in his health status since the prior assessment, but the medical record did not show documentation to support staff had noted the changes or attempted to determine potential reasons for the decline. Review of the care plan dated 03/16/19, showed Resident #3 had confusion with routine tasks, poor safety awareness, multiple falls, often rejected care, demonstrated wandering behaviors and wore a wanderguard. The care plan further stated the resident was at risk for falls. Interventions included bolster mattress, self-locking brakes and anti-tip bars on the wheelchair, keep needed items in reach, keeping the door closed to resident's room when he is in his wheelchair and not in his room, provide reminders (a sign in his room and verbal cues from staff) to use call light and ask for assistance, improved visualization by strategic room placement (room located near the nursing station), offered the resident to get up when stirring in bed and at the beginning of the AM shift, offer toileting assistance first of last rounds of night shift and every two hours, and 15-minute checks. MEDICATIONS AND TREATMENTS Review of the (MONTH) 2019 Medication Administration Record (MAR) showed Resident #3 was prescribed [MEDICATION NAME] (a mood stabilizer medication) used for dementia with behavioral disturbances. Review of the Medication Regimen Review (MRR) dated 05/01/18, showed, [MEDICATION NAME]: The following centrally-mediated effects occurred in more than 5% of patients treated for [REDACTED]. The recommendation was to, consider above when evaluating possible contribution of current med regime to falls. There was no documentation in the record to show staff had considered the recommendation made by the pharmacist that the use of [MEDICATION NAME] may have contributed to Resident #3's increased falls. THERAPY RECOMMENDATIONS Review of Resident #3's Occupational Therapy Treatment notes dated 12/07/18, showed, Training with restorative staff member on patients transfers and ambulate for safety for patient and staff members. Patient requires encouragement when asked to stand secondary to confusion. Patient has no carryover with verbal and tactile cues to lock wheelchair brakes. Staff needs to make sure everything is set up safely for patient before having him stand . Patient is high fall risk and should be contact guard with all transfers. DIAGNOSTICS Review of various labs dated 01/09/19, 02/28/19, 03/10/19, 03/15/19, and 03/24/19 showed Resident #3 had abnormal lab values. Review the resident's medical record showed that there was no analysis to determine if they could have contributed to the falls, and were not identified or addressed as a possible risk factor. FALL HISTORY Review of (MONTH) 2019 and (MONTH) 2019 Incident and Accident Log showed Resident #3 had falls on 01/04/19, 02/04/19, 02/11/19, 02/13/19, 02/20/19, and 03/07/19. The fall on 03/07/19 resulted in a [MEDICAL CONDITION] that was discovered on 03/15/19. Interventions put in place after each fall were not individualized to meet the resident's needs. Review of the investigation of the fall dated 03/07/19 showed Resident #3 sustained an unwitnessed fall in his room at 4:10 PM. The incident was not thoroughly investigated, timely follow-up was not performed to identify the change in in condition in a timely manner including increased complaint of pain, social isolation, decreased mobility and task performance, and update assessments to identify and address the underlying risk factors. The fall interventions put in place were ineffective. Review of the investigation dated 03/15/19, showed Resident #3, noted with green and yellow bruising to the hip as well as pain. The resident was sent to the emergency room (ER) for evaluation and treatment, and returned with a [DIAGNOSES REDACTED]. The investigation summary showed that Resident #3 did not get out of bed after the fall on 03/07/19, and began to feel better on 03/15/19, when he tried to get up and complained of pain and the bruising was first identified. Further review of the 03/15/19 investigation showed that staff educated the resident to ask for help when he needs to transfer. Resident #3's cognitive assessment indicated he was not a reliable candidate to remember to ask staff for assistance. An additional intervention discussed on 03/11/19 was to get him a drop down seat for his wheelchair (a device on a wheelchair that triggers the brakes to lock when the resident stands up). There was no evidence that staff initiated this intervention or if not, why staff did not implement the safety measure as a way to prevent falls. PAIN Review of Resident #3's medical record showed the last comprehensive pain assessment was performed on 02/09/19, despite having four falls and an MDS review since 02/09/19. The pain and fall risk assessments were not updated after the falls on 02/20/19 and 03/07/19. Review of the (MONTH) 2019 MAR and pain monitor showed Resident #3 had little to no pain until 03/09/19, and steadily increased in severity and frequency. There was no documentation to support staff assessed the cause of the pain to ensure it was not a result of an injury from the fall. INTERVIEWS In an interview on 03/28/19 at 1:42 PM, Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM), stated Resident #3 had poor safety awareness, liked to be independent with transferring and tasks though he was not safe, was resistive with care, had decreased insight to abilities (started eating non-edible objects like a Styrofoam cup), poor attention span, and occasionally had visual hallucinations. There was no documentation in Resident #3's medical record that showed staff had considered these behaviors as potentially contributing to increased falls. Additionally, Staff J, LPN/UM, stated that after the 03/07/19 fall, Resident #3 had a harder time getting up and complained of pain. The resident received pain pills that week which probably masked the pain and the fracture. Staff J, LPN, RCM, further stated that she was not aware that Resident #3 had a routine, was always up and down, even when he appeared ill between 03/07/19 and 03/15/19. In interview on 03/28/19 at 2:00 PM, Staff B, DNS stated she did not know why there was not a pain assessment performed after Resident #3 fell on [DATE], and stated should have been an assessment. Staff B, DNS, further stated that Resident #3 refused skin assessments (to assess for injury) after the fall between 03/07/19 and 03/15/19, which was why the bruises on his right was not identified any sooner. Additionally, Staff B, DNS, stated she was not sure why the resident refused each skin check or what was done to reattempt the next several days after the fall, or if any aides saw the bruise when they helped dress him or bathe him, as there was no documentation. When asked if staff had considered Resident #3's behaviors on 03/06/19 as contributing factors to the fall on 03/07/19, Staff B, DNS, stated she did not know if the fall was due to agitated behavior or lack of supervision. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide adequate supervision to residents who expressed thoughts of suicide with a plan to carry through with the act for two of two Sampled Residents (#s 1 & 15) reviewed for suicidal ideation. Facility staff failed to include mental health services to determine if resident was safe to be downgraded to less supervision. Facility failed to remove dangerous objects used by the resident during suicide attempts. These failures allowed Resident #1 to have continued access to sharp objects and had less supervision while experiencing a change in condition due to urinary track infection. This failure placed resident at potential risk for acting on plans to self-harm. Failure to ensure residents were in a safe environment and had adequate staff supervision, resulted in determination of Immediate Jeopardy on 6/8/17. Immediate Jeopardy was removed on 6/13/17 with staff from all shifts being trained in suicide prevention and resident behavior monitoring. Additionally, the facility failed to ensure smoking materials were secured for two of two Sampled Residents (#s 7 & 18) reviewed for smoking. This failure placed all resident and staff at potential risk of fire hazards. The facility also failed to ensure safety measure for fall prevention were in place for one of two Sampled Residents (#19) reviewed for falls. These failures resulted in substandard care. Findings included . RESIDENT #1 Resident #1 admitted to the facility in 2015. Review of the facility policy titled Resident Supervision, dated July 2015, Kitsap Mental Health Services progress note dated 05/09/17 showed Resident #1 was first treated at age 13 for a mental breakdown related to history of abuse and treatment of [REDACTED]. The same note stated Resident #1 has ongoing depression for years without relief, but acknowledges that she is has had increased irritability depression and anxiety since moving into nursing home last year. Resident #1 stated she didn't want to move into nursing home and doesn't like the one she is in, but didn't have any choice because she no longer can care for herself. Resident #1 has minimal support. Resident #1 complains of irritability, anger, depression and anxiety but she relates all to her current situation: being in nursing home, how long she has to wait once her call light is on and ongoing pain which she states is not controlled with medications Review of Resident #1's Minimum Data Set (MDS- an assessment tool) showed she had been assessed for cognitive function two times in 2017, on 01/01/17 and on 04/04/17. Resident #1 scored 15 on both assessments, indicating she had no cognitive deficits. SUICIDE PREVENTION Review of the facility policy Suicide Prevention, dated July 2015, showed directives to staff if a resident has changes in mood or shows signs of suicidal ideation, report immediately to a supervisor, and assess resident's environment for safety and remove and store objects which could be used for self-harm. Observations on 06/07/17 at 3:30 PM, showed Resident #1's room. In the room on the bedside table was a plastic container with craft supplies. There were multiple safety pins visible in the container. Next to the bed were extra medical supplies, including a tube of ostomy glue which read for external use only. During an interview on 06/07/17 at 3:35 PM, Staff B, Director of Nursing, (DNS), stated all sharp or harmful items had been removed from Resident #1's room. Staff B, DNS, was asked if she considered the ostomy glue or safety pins potentially harmful items. Staff B, DNS, stated she did not believe the identified objects were potentially harmful. Review of Resident #1's medical record showed progress notes dated 12/30/16, which indicated Resident #1 had made suicidal statements on 12/29/16. Review of social services progress notes dated 01/11/17 showed Resident #1 had been sent to the emergency room due to suicidal ideation and threats to harm herself. Review of social services progress note dated 01/13/17 showed Resident #1 continued to have outbursts of behaviors. The note stated interventions included ensuring Resident #1's environment was free of items that could be used as a method of hurting others or herself. During an interview on 06/13/17 at 11:50 AM, Staff D, Social Services,(SS), stated Resident #1 had been having more agitation and increased behaviors since roughly December 2016. Staff D, SS, stated Resident #1 had a history of [REDACTED]. Review of Resident #1's record showed a social services note dated 04/13/17 showed on 03/07/17 Resident #1 alleged verbal and physical abuse. Resident #1 was noted to have a UTI at the time. The note stated Resident #1 stated she has no outlet to express her feelings, and that she is sad due to her family does not come to the facility to visit her. Further review of social services notes showed a note dated 04/20/17 that indicated Resident #1 was diagnosed with [REDACTED]. Behaviors during this time frame; 04/13/17- Resident #1 became angry with kitchen staff when dinner was ten minutes late. 04/15/17- Resident #1 ran her power wheelchair into another resident while in the dining room for lunch. 04/18/17- Resident #1 was informed she would have to use a manual wheelchair until assessed for safety with the power chair. Resident #1 became agitated and refused all medications, food, and blood sugar checks. Later that evening, Resident #1 was attempting to throw herself from her wheelchair to the floor. Once on the floor, Resident #1 refused assistance to get back into the chair and lay on the floor for 10 minutes. Review of a facility investigation dated 05/01/17 showed staff witness statements that Resident #1 was attempting to throw herself out of bed, scratch herself and was choking herself. Resident #1 stated she wanted to die and if there was something sharp in her room she would have done it already. The witness statement further showed during the 05/01/17 incident, Resident #1 stated she wanted to kill herself and others. Resident #1 was sent to the emergency room and was admitted to the hospital. During an interview on 06/08/17 at 2:25 PM, Staff D, SS, stated she went to the hospital to see Resident #1 after the 05/01/17 incident, and observed her to have what looked like ligature marks and bruising around her neck. Review of hospital notes dated 05/01/17 showed Resident #1 was diagnosed with [REDACTED]. Review of Resident #1's medical record showed notes dated 05/03/17, by the Interdisciplinary Team (IDT), including the social services manager, the Director of Nursing, the Administrator, and the physician who had been working with Resident #1's mental health. The team documented Resident #1 continued to be a threat to herself and other residents in the facility. The note stated if Resident #1 returned to the facility, she would require medication changes, one to one supervision at all times, and a room free of items that she could use to harm herself or others. The note further described Resident #1 as being emotionally unstable, and unable to regulate her emotions or actions. During an interview on 06/08/17 at 2:25 PM, Staff D, Social Services, (SS), described Resident #1 as explosive. Staff D, SS, stated Resident #1 is very volatile, and if she is not getting what she wants she explodes, and her reaction can be immediately. Staff D, SS, stated it is hard for staff to predict when Resident #1 will have an explosive episode, and stated it can happen at any time. During an interview on 06/08/17 at 2:25 PM, Staff D, SS, reported after the first incident the staff decided to move Resident #1 to a private room. Staff D, SS, stated since the 05/01/17 incident, Resident #1 has been meeting with a physician from senior connections on a regular basis, however, he is not her prescriber, but they talk about emotions and how to deal with them. Staff D, SS, stated there is a physician's assistant who also comes in to see Resident #1, and he manages her mental health medications. Review of a facility incident report dated 05/14/17 showed Resident #1 was found in her room sitting in her wheelchair with a pair of scissors from her craft basket. Resident #1 had used the scissors to cut her wrists. Staff ZZ, Nursing Assistant Certified, (NAC), wrote a statement indicating she entered Resident #1's room and noticed blood on her right hand/wrist. As Staff ZZ, NAC, approached Resident #1, she noticed a huge puddle of blood. Review of hospital records dated 05/14/17 showed an emergency room social services note indicating Resident #1 had cut her wrist deep enough to need 4 or 5 stitches. The note also indicated Resident #1 had a UTI. 05/20/17 nurse practitioner note- reason for visit - after discharge care from hospital for attempt to terminate life on 5/14/17. According to nursing reports used sharp object to cut her right wrist she was found when she already was bleeding largely, required five interrupted sutures. No suicidal per self report, but hard to believe .patient is high risk. Plan continue with one to one close observation. Kitsap Mental Health provider note dated 05/22/17 by now it is well established that (Resident #1) has the impulsivity and lack of judgement to hurt herself again. The note also showed monitoring and acute responses needed for (Resident #1's) volatile behaviors. Statements that she will behave in a controlled and appropriate manner are not backed up with how she has acted historically. IDT meeting note dated 05/23/17 showed Resident #1 remained on one to one monitoring for safety. The nurse practitioner stated she feels Resident #1 remains at risk for others and herself. Provider progress note dated 5/24/17 showed Resident #1 returned from the hospital following a suicide attempt by cutting her wrists. RESIDENT MONITORING Review of the facility policy titled Resident Supervision, dated July 2015, showed residents who are at risk to self or others, such as suicide attempts should have documentation every 15 minutes using the 24 Hour Resident Flow Record. Review of a nursing progress note dated 06/05/17 showed staff was decreasing Resident #1's one to one for night shift and implementing every 15 minute checks. During an interview on 06/08/17 at 7:20 PM, Staff B, DNS, stated when Resident #1 returned from the hospital after the 05/01/17 incident, the IDT team decided in was not necessary to place Resident #1 on one to one monitoring. During an interview on 06/08/17 at 7:20 PM, Staff B, DNS, stated on 06/05/17, the IDT staff decided to decrease Resident #1's level of supervision, and remove the one to one monitoring during an eight hour period at night. Staff B, DNS, was asked if the mental health specialist that had been working with Resident #1 was involved in the decision to remove one to one monitoring. Staff B, DNS, stated no, he was not involved. During an interview on 06/08/17 at 5:25 PM, Staff UU, Physician's Assistant Certified, PAC, stated he had been working with Resident #1 and treating her mental health [DIAGNOSES REDACTED]. Staff UU, PAC, stated he was not involved in the decision to remove the one to one monitoring during the night, and in fact had not been made aware of the change by staff. Staff UU, PAC, stated he felt Resident #1 recently had many of her pain medication discontinued due to an overdose for which she was sent to the emergency room . Staff UU, PAC, stated he felt due to Resident #1 having increased pain, she was potentially at an increased risk of self-harm currently. Staff UU, PAC, stated Resident #1 had multiple medication changes recently, and he felt that she could not be determined no longer at risk to herself or others until approximately a month after the changes were made in order to make an accurate assessment of her mental state. Staff UU, PAC, described Resident #1 as being very destructive, and actually intended to harm herself. Staff UU, PAC, stated Resident #1's behaviors are not predictable, and are extreme. Staff UU, PAC, stated these behaviors are exacerbated when Resident #1 has a UTI. Staff UU, PAC, stated Resident #1 has hallucinations is not able to rationalize. Staff UU, PAC, stated Resident #1 is not able to rationalize the outcome of her behaviors. Resident #1 is not reliable when she says she will not harm herself. During an interview on 06/08/17 at 3:45 PM, Staff R, Advanced Registered Nurse Practitioner, (ARNP), was asked if she felt Resident #1 was safe to have her supervision decreased. Staff R, ARNP stated I don't have a good guideline for her (Resident #1) safety. She is explosive, if wants it, she wants it now. It's hard to know if she will injure herself. During an interview on 06/08/17 at 2:25 PM, Staff D, SS, stated Resident #1 had less behaviors when she had more attention from staff. Staff D, SS, was asked if there could be a potential problem since Resident #1 has had one to one attention since returning from the hospital, and has had staff available to assist her instantly when needed. Now with the night shift one to one removed, Resident #1 will need to use her call light and wait for assistance. Staff D, SS, confirmed going from having constant staff to not could cause Resident #1 to act out. The staff IDT team determined to remove one to one supervision during the night shift and place Resident #1 on every 15 minute checks starting on 06/05/17. Review the every 15 minute check flow sheet showed; 06/06/17- no documentation between 6:30 AM and 10:45 AM, and no documentation after 10:30 PM for remainder of the day. 06/07/17- no documentation until 6:30 AM, and no documentation after 10:30 PM. 06/08/17- no documentation until 6:30 AM. The lack of documentation during the night shift, the time Resident #1 did not have one to one supervision was reported to the Director of Nursing and the Administrator on 06/09/17. Review of the June 2017 MAR showed orders dated 05/19/17 directing staff to documents the hours of sleep every shift. Review on 06/08/17 of the night shift starting on 06/05/17, when the one to one monitoring was removed showed no documentation on 06/06/17 and 06/07/17, indicating two of the three days since the one to one monitoring at night was stopped, the staff failed to document if Resident #1 slept during the night. Review of Resident #1's record showed lab results of a urine test. The urine was collected on 06/02/17 and the results were signed as received by Staff R, ARNP, on 06/05/17. The results indicated Resident #1 had a urinary tract infection. Further review of Resident #1's record showed a physician's order for antibiotics to treat the urinary tract infection. The antibiotics were started on 06/07/17 and were ordered to be given for seven days. During an interview on 06/08/17 at 5:30 PM, Staff B, DNS, stated the IDT team review nursing documentation to determine that Resident #1 was safe to have decreased supervision. However, nursing staff were not consistently documenting if the resident was sleeping at night and failed to consistently document that they were checking Resident #1 every 15 minutes through the night. During interviews the social services staff and the physician's assistant both reported Resident #1's behaviors were exacerbated whenever she had a UTI. The IDT team removed supervision of Resident #1 while she was being treated with antibiotics for a UTI. Additionally, the facility staff failed to include the mental health team that had been working with Resident #1 to assess her safety prior to removing supervision during the night. FORMER RESIDENT #15 Review of the facility policy titled Resident Supervision dated July 2015, showed when a resident has a condition that puts them at risk, staff should ensure safety of the resident. The policy showed if a resident expresses suicidal statements, staff should increase supervision of the resident and document the supervision using the 24 hour Resident Flow Sheet. Resident #15 admitted to the facility 2/10/17, and was no longer in the facility. Review of Resident #15's medical record showed a social services note dated 5/10/17 which stated she had made suicidal statements, and stated she could drive her wheelchair into the road and get hit by a car. During an interview on 6/14/17 at 1:20 PM, Staff D stated that Resident #15 was in the parking lot on 5/10/17 when she stated that she wanted to drive her wheelchair into the road. Review of Resident #15's medical record revealed no progress notes which mentioned the incident in the parking lot or that the resident had made suicidal statements. Further review of Resident #15's medical record showed a nursing progress note dated 5/22/17 which indicated Resident #15 was on alert charting with every 15 minute checks due to suicidal ideation with a plan. The note stated Resident #15 told staff she would drive her wheelchair into traffic, because she did not have a gun or a knife. Review of social services note dated 5/22/17 showed that Resident #15 exited the facility and was at the entrance of parking lot. The note showed Resident #15 was placed on alert and every 15 minute checks due to suicidal ideation. Review of Resident #15's medical record showed a sheet titled 24 Hour Resident Flow Record which staff are to document every 15 minutes the status of the resident. There was no documentation in the chart that the 15 minute checks had been completed on 5/22/17, and did not start until 10:30 PM on 5/23/17. The 15 minute checks continued from 10:30 PM on 5/22/17 until 6:30 AM on 5/24/17. There was no further documentation after 6:30 AM. During an interview on 6/14/17 at 1:00 PM, Staff B, DNS, stated the every 15 minute checks should have started on 5/22/17, and confirmed there was no documentation in the medical record to support it had been done. Although staff identified Resident #15 as needing to be checked on every 15 minutes due to having a plan for self-harm, they failed to check on the resident. There was no documentation of checking on Resident #15 for more than 24 hours after the incident. Staff failed to provide adequate supervision for Resident #15. UNSECURED SMOKING MATERIALS Facility's Smoking Policy, instructed that residents assessed as independent smokers may retain possession of their smoking materials if desired. In such circumstances a locked storage cabinet will be provided. Such residents must adhere to requirements including keeping storage cabinet locked at all times. RESIDENT #18 Resident #18 admitted on [DATE], with [DIAGNOSES REDACTED]. Resident had short term memory loss, and early onset dementia, according to a physician's note in May 2016. Observations on 06/13/17 at 12:35 PM, Resident #18 sat at the edge of the bed and said he wanted to smoke and he was bored. Resident showed his smoking supplies were inside an unlocked night stand next to the bed. There was a box of loose tobacco, resident said he rolled them up. Resident said his lighter was either on him or he left it inside the same drawer. During an interview on 06/13/17 at 11:50 PM, Staff Z said Resident #18 forgets to lock his smoking materials, although he is reminded frequently. RESIDENT #7 Resident #7 admitted in January 2017, with [DIAGNOSES REDACTED]. Nursing notes dated 05/22/17 at 6:30 PM indicate Resident #7 was upset and angry after another resident allegedly took him cigarettes out of her room. The note indicated resident was upset and was medicated with antianxiety medication following the incident. During observations and interview with Resident # 7 on 06/12/17 at 12:35 PM, she recalled missing cigarettes and said she thought Resident #18 took them. Resident said she was because someone went through her personal belongings and was also upset because a nurse told her to lock up her cigarettes. Resident #7 said she forgot to lock up the cigarettes and said that she had a memory problem and it was not fair that the nurse got me into trouble. Resident #7 stated she kept the cigarettes and the lighter either in a nightstand next to her bed or in a large cardboard box on the floor. The nightstand where cigarettes were kept was unlocked. Resident also mentioned her lighters disappeared. Staff S, Licensed Nurse on 06/13/17 at 11:56 AM said that cigarettes and lighters should be locked up in residents' rooms. FALLS RESIDENT #19 Resident #19 admitted on [DATE] with [DIAGNOSES REDACTED]. The hospital History and Physical on 02/24/17 indicated resident had a stroke and a fall. Resident broke his ribs and there was possible C7 (neck area) fracture. The occupational therapy notes dated from 5/25/17-6/21/17 showed resident had a stroke on 03/23/17. On 05/23/17 resident fell in his room. A care plan for mobility was dated 05/28/17 and indicated resident had loss of voluntary arm movement, including functional limitation in the range of motion in the left arm and the leg. During interview with a Collateral Contact on 06/08/17 at 12:00 PM, it was reported Resident #19 was pretty upset because staffed walked passed his call light without answering it. On 06/08/17 at 10:30 AM Resident #19 was in bed. Resident demonstrated inability to use his left arm. Resident said he had paralysis on left side from the stroke. The bedside table with personal items and the call light was out of resident's reach. It was located on the left side (paralyzed side) of resident's body. The call light was wrapped around an arm chair which was positioned behind resident's shoulder and away from the bed. Observations of call light location, and bedside table positioning were found outside of resident's reach on the following: 06/09/17 at 10:45 AM; 06/12/19 at 8:37 am; 9:21 AM; 10:05 AM. On 6/12/17 at 10:05 AM; 06/13/17 at 9:45 AM; 10:41 AM; 10:55 AM, 11:00 AM; 11:15 AM, and 11:25 AM. On 6/13/17 at 11:26 AM observations were made with Staff AA, NAC of call light position. Staff AA confirmed it should not be on the left side of resident's body and unwrapped the call light from the chair and clipped it to the sheet in the middle of the chest area. Refer to F312, F315, F241, and F224.

Based on observations, interviews, and record review, the facility failed to provide evidence of thorough investigations for 7 out of 12 Sampled Residents (#'s 1, 2, 3, 4, 17, 19 and 20) reviewed for abuse/neglect, and for timely reporting to the agency. The facility also failed to screen 3 out of 5 employees prior to hire. Without a thorough investigation the facility cannot rule out abuse and neglect. The failure to conduct thorough investigations resulted in a pattern of harm to 4 out of 6 residents. These failures resulted in substandard care. For Resident #17 the facility did not identify triggers of emotional/mental and/or verbal abuse on 5/15/17 & 5/17/17 incidents, and failed to determine the root cause of repeat falls in order to determine effective intervention(s). The facility accused Resident #17 of throwing self out of bed on 04/02/17without evidence of a thorough investigation. Resident #3 was subjected to psychological distress when he felt interrogated on 03/28/17, during interview with faculty staff, after he reported medication concerns. Resident #20 was subjected to potential retaliation when employee continued seeing the resident after allegations were made. Resident #1 had a potential narcotic overdose and Resident #19 had actual narcotic overdose. The facility failed to provide evidence of thorough investigations related to narcotic administration for both residents. Findings included . RESIDENT #17 According to History and Physical dated 03/13/17, Resident #17 had an onset of muscle weakness, spasms and was evaluated for a rare [DIAGNOSES REDACTED] disorder known to affect the nervous system, including encephalitis (inflammation of the brain), and affected the limbic system (emotional part of the brain). Additionally, the resident suffered from [MEDICAL CONDITION] arthritis, was depressed and anxious. Psychological harm related to neglect Interdisciplinary team (IDT) notes on 04/05/17, 04/06/17 and 04/18/17, included the following statements; -Constant and excessive use of call light excessive crying .SS/RCM (social services and resident care manager will provide resident education concerning use of her call light to set boundaries. -Monopolizing CNA time and thereby delaying care of the Residents. - On continuous charting regarding her behaviors of continuously using her call light and monopolizing the NAC time new intervention is in place for staff to offer resident if there is anything more that she needs x3 .and the final question needs to be phrased this is the third time, is there anything else you need? A care plan updated on 03/03/17 directed to provide resident with built up utensils for self-feeding. On 5/19/17 Resident #17 reported when she used the call light staff told her they were busy and alleged being left in a wet brief from 7:30 PM to 10:15 AM on 5/17/17. The facility's evidence of investigation included statements that staff was in resident's room [ROOM NUMBER] times between 4:00 PM and 10:30 PM on 5/17/17. A witness statement described that the resident held me inside her room . having me change positions of chicken on the fork until she was done eating. The facility's investigation did not include evidence of assessing staffing levels on the day of alleged neglect to determine sufficient number of employees were available to care for the acuity of the residents. The investigation also failed to consider if the resident had special eating utensils as care planned before making a statement that resident held an employee in the room for too long. The facility IDT notes demonstrated repeatedly accused the resident of excessive call light use instead of assessing for unmet psychosocial needs. Allegation of verbal abuse and/or neglect On 05/15/17 Resident #17 alleged verbal abuse and neglect. The resident reported staff members were rude during care and she felt belittled. The facility ruled out abuse and neglect without identifying Staff JJ statements as being indicators of verbal abuse or neglect. In a written statement Staff JJ indicated she told the resident she could reach a cup on her own and insinuated the resident rolled out of bed before. The resident yelled, I didn't roll out of bed, I fell . The facility investigation summary disregarded the interaction and did not consider the consequences to resident's mental well-being. Facility concluded, Staff was verbally encouraging resident to be as independent as possible per residents care plan. The investigation failed to consider Staff JJ statement intimidating and a potential indicator of mental abuse. Refer to F319 for details on failure to provide services related to psychosocial well-being resulting in harm. Falls investigations On 02/15/17 Resident #17 slid out of the wheelchair. A written conclusion by Staff G, seven days later on 02/22/17 determined the root cause was due to resident action or internal risk factors. Staff G stated in the summary that resident used pillows in the wheelchair. The investigation failed to determine why resident used the pillows and did not assess if the wheelchair was appropriate. According to facility's evidence of investigation, Resident #17 fell again on 02/25/17. The employee found Resident #17 on the floor next to the bed with the wheelchair behind her. Facility investigation showed the wheelchair was unlocked. The resident scooted self in the chair and that her muscle spasms were a contributing factor to the fall. The same document included a new wheelchair was going to be ordered. The care plan titled FALL/INJURY ASSESSMENT updated on 02/25/17 read ordering a tilt and space for resident. The wheelchair was not ordered until 03/06/17 as indicated in physician orders. On 06/12/17 at 9:10 AM Resident #17 said she had falls out of the wheelchair because it was too big for her. Resident said she used a pillow to fill the extra space and because it was too hard. Resident said she got a new wheelchair that reclined 1-2 weeks ago. On 06/12/17 at 10:00, Staff M said when Resident #17 admitted to the facility, therapy gave her an oversized wheelchair, and it did not fit the resident. Staff M said resident insisted on getting up so the big chair was used. Refer to F246 for failure to accommodate needs. Facility's evidence of investigation dated 04/03/17 showed on 04/02/17 Resident #17 fell out of bed. The investigation showed that resident reported she fell out of bed while reaching for a remote. The staff statements reported hearing resident saying, I am lowering my bed and going on the floor. The fall was not witnessed. The investigation did not include facts and observations following the fall and include critical information such as location of the remote and the call light after the fall. The facility concluded the resident purposefully rolled out of bed. The summary stated that resident was threatening staff that she would roll out of bed. When considering resident purposely fell out of bed, there were evidence social services assessed circumstances about intent to cause self-harm. Failure to Investigate Narcotic Overdose RESIDENT #1 Review of the facility policy titled Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, dated July 2015, showed when there was an allegation, the center shall ensure all allegations are reported immediately, and thoroughly investigate all alleged violations, prevent further potential abuse, neglect, exploitation while the investigation is in process and report to the state survey agency. Review of Resident #1's medical record contained hospital paperwork dated 05/29/17. Review of hospital emergency room notes dated 05/29/17, showed Resident #1 arrived at the emergency room via ambulance with shallow breathing, low oxygen saturation with oxygen use, low blood pressure and had pinpoint pupils. Further review of emergency room notes showed Resident #1 was given [MEDICATION NAME] (a medication with reverses the effects of narcotic pain medication), and then aroused. Once awake, Resident #1 stated my nurse gave me too much narcotics. Resident #1 stayed at the hospital through the night for more testing and observations, and was given a repeat dose of [MEDICATION NAME] at 4:00 AM, the following morning. Review of the facility accident and incident log from May 2017 showed no entries related to Resident #1 alleged improper care or medication overdose. The facility obtained the paperwork from the hospital, which showed Resident #1 stated the nurse gave her too much narcotic medication, however, there was no evidence the facility investigated the allegation made against nursing staff, or conducted an investigation to rule out Resident #1 did not intentionally take the medication as a method of self-harm. Refer to F323 related to suicidal statements and self-harm. Failure to Complete a Thorough Investigation of Narcotic Overdose RESIDENT #19 Resident had physician for [MEDICATION NAME] HCL 100mg/5ml (liquid narcotic medication for moderate to severe pain) and instructions to give 1/4 ml (5 mg) sublingually (under the tongue) every four hours as needed for pain, according to orders dated 05/19/17. Facility's evidence of investigation showed on 06/19/17 at 5:30 PM Resident #19 received 10 mg of liquid narcotic instead of 5 mg. Resident was sent to the emergency room after found lethargic with intermittent absence of pulse. The box containing [MEDICATION NAME] bottle had a picture of visual instructions to use 1 ml syringe with marked dosage increments, such as (0.25 & 0.5 .etc .) to withdraw accurate dose. Facility's investigation showed a nurse used a medication dispensing cup instead of a calibrated syringe when she made the error. The facility's conclusion was based on reconciling the narcotic log with the Medication Administration Record [REDACTED]. The facility evidence of investigation did not include; nurse's written statement, and did not include review of other residents who used similar medications. There were no interviews and/or observations of other nurses on technique for administering liquid narcotics to determine if additional education was necessary. The facility did not determine if resident received the medications via correct route (sublingually or through gastric tube.) The facility investigation did not include review of emergency room notes and/or labs. Facility's investigation also failed to identify and clarify discrepancies in documentation. The MAR indicated [REDACTED]. The back of the pain flow sheet was dated 06/19/17 and documented resident had left shoulder pain. The hand written documentation was unclear if 5 ml or mg was administered, the letter g or l was written over. Nurse's note on 06/19/17 at 8:00 PM documented Oxy 5 ml suspension given. The medication concentration was 100 mg of [MEDICATION NAME] per 5 ml (approximately one teaspoon). Average dose of [MEDICATION NAME] to take at one time is between 5-10 mg. RESIDENT #2 Resident #2 admitted to the facility 3/31/17 and discharged [DATE]. The facility incident investigation dated 06/01/17, showed the facility received a phone call from the hospital about alleged poor quality of care. Review of the facility investigation of the alleged quality of care concerns showed nursing addressed the resident's weight and potential weight loss while in the facility as part of the investigation. Review of Resident #2's record showed a registered dietician note dated 4/5/17 that indicated he had increased protein needs due to wound healing. Further review of the investigation showed the facility determined the resident was placed on protein supplements and had labs drawn and the protein, [MEDICATION NAME], complete blood counts and basic metabolic panels were unremarkable. Review of Resident #2's medical record showed labs dated 4/25/17 which indicated Resident #2's pre-[MEDICATION NAME] level was low at 15.4 (normal 17.6 to 36.0). During an interview on 6/14/17 at 10:30 AM, Staff U, Registered Dietician (RD), stated that pre-[MEDICATION NAME] level is a more significant indicator of nutritional status than [MEDICATION NAME] and protein levels. Staff U, RD, stated pre-[MEDICATION NAME] levels should be considered when determining weight loss or nutritional status. Staff failed to identify Resident #2 had a low pre-[MEDICATION NAME] level when investigating for nutritional status. Further review of the facility investigation dated 06/01/17 showed a weight log for Resident #2. The log had only one weight listed, on 04/05/17. There was no further documentation that showed Resident #2 had been weighed again or staff had attempted to weigh again. Review of the facility policy titled Weight Monitoring, dated July 2015, showed each resident is weighed within 24 hours of admission, and then weighed weekly for four weeks. After four weeks, if the resident's weight is stable, the resident should be weighed monthly. Resident #2 was in the facility from 03/31/17 through 06/01/17, roughly nine and a half weeks. As directed by the facility policy, Resident #2 should have been weighed on admit, then weekly four times, and then monthly one time, giving a total of six weights. The investigation failed to identify Resident #2's weight was not monitored per the facility policy directing all residents to be weighed within 24 hours of admission and weekly thereafter. The facility investigation failed to identify all components necessary to determine if Resident #2 was at nutritional risk. Refer to F325 for failure to monitor nutritional status. GRIEVANCES Review of the facility form titled Resident Grievance Report dated January 2017, showed directions at the top of the form showed directives to staff if the event a grievance amounts to allegation of abuse, neglect, mistreatment or misappropriation follow Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including injuries of Unknown Source, and Misappropriation of Resident Property .complete the reporting in the electronic accident and incident report. Review of the facility policy titled Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, dated July 2015, showed neglect includes failure of staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. RESIDENT #3 Review of the April 2017 grievance log showed an entry dated 04/19/17, concerning Resident #3, with issues listed as dandruff on face and a pill in beard. Review of an Interdisciplinary Team (IDT) note dated 03/28/17, showed Resident #3 had [MEDICAL CONDITION] (unable to move arms or legs), and is total care and relies on staff transfers, eating and dressing. Review of Resident #3 Minimum Data Set (MDS- an assessment tool) showed his cognitive function was assessed three times during his stay at the facility, on 02/24/17, 03/25/17 and 05/25/17. Resident #3 scored 15 on all three assessments, indicating he had no cognitive impairment. Review of the grievance form completed by Staff CC, Activities Assistant (AA), showed Resident #3 was having his beard trimmed and a pill fell out of it. Additionally, the form stated that when Resident #3's beard was trimmed shorter it revealed his face appeared it had not been washed in weeks, and had dandruff on his face and in his beard. Staff CC, AA, also documented Resident #3 stated he had not seen his doctor. The grievance form section Investigation report, completed by Staff G, Resident Care Manager, (RCM), was undated and not signed, showed the resident had a doctor appointment scheduled, Resident #3 appeared well groomed when she had seen him, and unsure about the pill. The grievance did not contain a statement from Resident #3, or a statement from the beautician. There was no documented follow up with Staff CC, AA. There was no documentation to support staff attempted to determine what the pill was, what it looked like, or who it belonged to. During an interview on 06/07/17 at 1:40 PM, Staff G, RCM, stated she was not sure what the pill was, and did not ask the resident or the two staff members who were present when the incident occurred what the pill looked like. Staff G, RCM, stated it wouldn't matter what the pill was. Staff G, RCM, confirmed Resident #3 requires pain medications The grievance form alleged Resident #3 appeared as his face had not been washed in weeks, and that a pill fell out of his beard, indicating he did not receive all of his medications. The grievance form did not identify lack of providing care met the definition of neglect, and therefore should have been logged and investigated. The grievance did not contain evidence staff attempted to identify what the medication was in order to determine when the error occurred or the significance of the medication. Review of Resident #3 medication list showed he took both pain medications and antibiotics. The facility failed to identify an allegation of neglect required a thorough investigation. The identified grievance investigation did not include additional resident or staff interviews, or an analysis to rule out staff neglect of a resident. An interdisciplinary team note dated 03/28//17 revealed the facility staff asked resident about concerns with medications. The note indicated resident felt interrogated. The note stated nursing acknowledged this and excused themselves from resident's room to allow him to self-calm. Refer to F250 RESIDENT #20 Review of the May 2017 grievance log showed a grievance dated 5/11/17 submitted by Resident #20. Resident #20 stated in the grievance that Staff HH, Certified Nursing Assistant, (CNA), was rude to her; had been rough when providing care; and told other staff members not to go into her room to help her. Review of the grievance showed Staff B, Director of Nursing, (DNS), documented she spoke with the resident who stated the staff member was more rushed than rough. The grievance investigation portion did not address the statement Staff HH, CNA, made telling other staff not to go into Resident #20's room. During an interview on 06/07/17 at 1:00 PM, Resident #20 stated staff did come talk to her about her allegation of Staff HH, CNA, being rough, and they agreed the staff was more rushed, than rough. Resident #20, stated nobody asked her about Staff HH, CNA, telling other staff not to go into her room. Resident #20 stated that only half of her concerns had been addressed by the staff. Resident #20 stated she continued to see Staff HH, CNA, following the incident and preferred not to have Staff HH, CNA, assigned to her care. The facility failed to protect Resident #20 from Staff HH, CNA, pending the results of a thorough investigation. Additionally, the facility failed to consult with Resident #20 if she felt comfortable with Staff HH, CNA, continuing to provide care for her. RESIDENT #4 Resident #4 no longer resided in the facility. Review of the facility grievance log showed an entry dated 05/18/17 which indicated Resident #4 submitted a grievance related to a caregiver concern. Review of the grievance dated 05/18/17 showed Resident #4 reported the nurse laughed at him, walked away and told him he did not appear to be in pain when he requested a pain pill. The grievance was signed by Staff A, Administrator, (ADM), on 05/19/17. The grievance included a statement written by Staff BB, Licensed Practical Nurse, (LPN), with her account of the incident. The statement was dated 05/20/19. The resolution section of the grievance was completed by Staff G, RCM, and dated 05/23/17. The grievance was submitted on 05/18/17 and showed documentation indicating Staff A, ADM, was aware on 05/19/17, however the identified staff member did not submit her statement until 05/20/17. There was no evidence the facility took measures to ensure residents were protected between the time they became aware on 05/19/17 and when Staff BB, LPN, wrote her statement. There was no pain assessment documented and no resident interviews to ensure there were no other concerns related to the identified nurse administering medications. The facility failed to identify an allegation of mental abuse required a thorough investigation. The grievance did not contain additional staff or resident interviews to determine if abuse had occurred. EMPLOYEE SCREENING Record review of facility policy titled Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, and Misappropriation of Resident Property dated December 2016, revealed all potential employees were to be screened for a history of abuse, neglect, or mistreatment of [REDACTED]. Screening would include Criminal background checks, which include inquiries into court orders concerning findings of abuse, neglect, exploitation, misappropriation of property, or mistreatment. STAFF W Record review of employee files revealed Staff W, Certified Nursing Assistant, (CNA), was hired on 09/13/16. A background check was completed on 09/07/16. The results stated Review required. A form titled Character, Competence, and Suitability (CCS) for unsupervised access to adults was dated 09/14/16, after the date of hire. The section titled Criminal record and referral history summary (CCS), had incomplete information. STAFF Y Record review of employee files revealed Staff Y, licensed practical nurse (LPN), was hired on 11/22/16. A background check was completed on 11/30/16, eight days after hire. The results stated Review required. A CCS was dated 01/16/17, eight weeks after date of hire. STAFF X In an interview on 06/14/17 at 2:30 p.m., Staff X, Human Resource Director, (HR), stated background checks and CCS were to be completed before potential employees were hired. Staff X, HR, stated the CCS for Staff W, CNA, was incomplete and should have been re-done. In an interview on 06/14/17 at 3:30 p.m., Staff B, DNS, stated background checks should be done prior to hire. Staff B, DNS, stated Staff A, ADM, was responsible for completing the CCS. Failure to complete screening of potential employees prior to hire placed residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Based on observation, interview and record review facility administration failed to effectively use resources to attain or maintain the highest practicable well-being of each resident. Administration failed to ensure they were in compliance with the following regulatory requirements which affected or had the potential to affects all residents in the facility. These failures resulted in an Immediate Jeopardy as referenced in F323 related to adequately supervise resident with [MEDICAL CONDITION]. Findings included . Facility failures resulted in immediate jeopardy, substandard care and harm to residents from lack of effective administration to ensure standards of care were followed and staff practiced accountable management of scheduled medications. Refer to the following regulations for additional information regarding failed facility practice related to scheduled medications: [REDACTED] Substandard Care was found in the following: Refer to 42CFR 483.12(c)(1); F225 Report/Investigate Abuse, Neglect and Misappropriation. Failure to conduct a timely and thorough investigation for individual Residents #'s 1, 2, 3, 4, 17, & 19 and failed to screen employees prior to hire. A pattern of failure to conduct thorough investigations resulted in harm to 4 out of 6 residents. Refer to 42CFR 483.45(f)(2) F333 Significant Medications Errors. Facility failed to ensure residents were free of significant medication errors for Residents (#'s1, 3 & 19). Resident #19 sustained actual harm after a narcotic overdose. Refer to 42CFR 483.21(b)(3)(i); F281: Professional Standards of Care Failure to ensure nursing services met professional standards of practice when administering high risk medications. Resulting in harm to Resident #19. Refer to 42 CFR 483.35(a)(1)-(4); F353: Sufficient Qualified Nursing Staff. The facility administration failed to recognize a pattern of repeat resident complaints. A total of 24 complaints were reported by facility and the public to the state agency between 04/19/17 and 06/20/17. Of the 24 intakes 7 were reports alleged abuse or neglect, 10 allegations of mistreatment by staff, and 4 allegations of misappropriation. The facility failed to analyze repeat allegations and ensure sufficient staffing. Failure to ensure sufficient staffing for provision placed residents at for unmet needs, decline in health and resulted in neglect. Refer to 42 CFR 483.12 (b)(1) F224 Right to be from abuse/neglect. The facility administration did not identify and ensure residents' physical and psychological and emotional needs were met timely and effectively. This failure affected Residents #'s 3, 15, 17, 19), resulting in actual harm. Refer to 42 CFR 483.10(a)(1) F241 Dignity. The facility failed to ensure Residents #3, 17 &19 were treated with respect and dignity. This failure resulted in psychological harm all three residents. Refer to 42 CFR 483.10(e)(3) F246 Accommodations of Needs. The facility failed to accommodate 3 of 3 Residents (#' 3, 17 &19) need for a fitted and safe wheelchair for use while at the facility and at the time of discharge. This resulted in harm to Resident #3 and # 19. Refer to 42 CFR 483.40 (b)(1) F319 Mental & psychosocial well-being. The facility failed to maintain emotional and mental wellbeing of residents who demonstrated psychological distress and coping problems. This resulted in mental anguish, actual harm for Resident #1 and #17. Refer to 42 CFR 483.40 (d) F250 Social Services. The facility had a failed discharge process and residents received ineffective social services as evidenced by unsafe discharge resulted in harm to Resident #3. Resident #3's did not have home health set up timely that lead to failed PICC (peripherally inserted central catheter, intravenous access device which is used for medication delivery in the vein.)

Based on observations, interviews and record review, the governing body failed to provide effective oversight, management and operation of the facility. The governing body failed to ensure that facility's administration implemented corrective measures to address systems failures as evidenced by repeat deficiencies related to medication errors, professional standards and abuse/neglect. The governing body allowed the facility to continue to fail in identifying, and thoroughly investigation abuse and neglect allegations resulting in a pattern of harm. Over a period of 15 months between 01/15/16 and 05/17/17, the governing body failed to ensure substantial compliance with federal regulations as evidenced by a pattern of repeat failed practice during nine surveys. Findings Included . The facility provided substandard care as evidenced by: An immediate jeopardy to resident health and safety existed on 06/08/17 related to failure to identify [MEDICAL CONDITION] and take appropriate measures to ensure resident safety. Repeat noncompliance within the last 15 month survey cycle included: F 225 3/17/17; 1/10/17; 9/19/16 F 281: 3/17/17; 8/8/16; 10/6/16 F 333: 10/6/16; 8/8/16; Refer to F490

Based on observation, interview and record review the facility failed to prevent neglect for 4 out of 4 Sampled Residents (#'s 3, 15, 17, 19 ) reviewed having their basic needs met, including call light access/response and/or maintaining psychological and emotional wellbeing. Facility showed serious disregard for consequences by not taking timely action when a Former Resident #15 demonstrated distress and had [MEDICAL CONDITION], Resident #17 psychological and emotional needs were neglected. Resident #3 and #19 did not receive basic care needs related to hygiene and call light access constituting actual neglect. This failure also resulted in psychological harm to all residents based on a reasonable person concept. Findings included . Facility's policy and procedure on preventing resident mistreatment and neglect revised December 2016, included the following definitions: Neglect is failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Mental abuse can be verbal or non-verbal .includes humiliation, harassment .deprivation . FORMER RESIDENT #15 On 05/10/17 Resident #15 made suicidal statements, according to social services documentation stating she could drive her wheelchair into the road and get hit by a car. On 6/14/17 at 1:20 PM, Staff D said Resident #15 was in the parking lot on, 5/10/17 when she made suicidal statements. The facility records did not show evidence of ongoing increased supervision after Resident #15's mentioned [MEDICAL CONDITION] in the parking lot. On 5/22/17, according to clinical records, Resident #15 was on alert charting and had every 15 minute checks due to suicidal ideation with a plan. The note stated Resident #15 told staff she would drive her wheelchair into traffic, because she did not have a gun or a knife. Review of Resident #15's medical record showed a sheet titled 24 Hour Resident Flow Record which staff are to document every 15 minutes the status of the resident. There was no documentation in the chart that the 15 minute checks had been completed on 5/22/17, and did not start until 10:30 PM on 5/23/17. The 15 minute checks continued from 10:30 PM on 5/22/17 until 6:30 AM on 5/24/17. There was no further documentation after 6:30 AM. During an interview on 6/14/17 at 1:00 PM, Staff B, DNS, stated the every 15 minute checks should have started on 5/22/17, and confirmed there was no documentation in the medical record to support it had been done. The facility had duty to provide supervision for a vulnerable adult who was experiencing severe psychosocial distress. The facility demonstrated serious disregard for consequences by not providing consistent supervision. Refer to F323 for additional information for failure to supervise. RESIDENT #19 Resident #19 admitted to the facility in May 2017 following a stroke two months prior, resulting in a left sided paralysis. MDS (Minimum Data Set, a comprehensive assessment), dated 05/26/17 showed Resident #19 had a BIM (cognitive assessment) score of 15/15 (no memory problems.) Resident relied on staff for assistance with personal hygiene, toileting needs, and mobility. Observations on; 06/09/17 at 10:45 AM; 06/12/19 at 8:37 AM ; 9:21 AM; 10:05 AM; 6/12/17 at 10:05 AM; 06/13/17 at 9:45 AM; 10:41 AM; 10:55 AM, 11:00 AM; 11:15 AM, and 11:25 AM, Resident #19 was without access to call light. It was wrapped around arm chair positioned behind resident's left paralyzed arm and out of his sight. On 06/08/17 between 10:30 AM - 10:45 AM Resident was asked about ways for getting assistance from staff. Resident said, well .I scream .hoping someone walking by will come in that why my voice hoarse. On 06/09/17 at 10:46 AM Resident #19 said they totally ignore me during the night .I get upset and pissed off and start yelling. On 06/13/17 at 9:45 AM resident said, if he desperately needed help he would scream at the top of my lungs, and throw the phone to get attention. During above listed observations and interviews, Resident #19 reported having to wait a long time for help and repeatedly felt forced to urinate in the brief instead of using the urinal. It made him feel degraded. Refer to F323 for information related to accident prevention and supervision. Refer to F241 for additional information related to treatment with dignity and respect. RESIDENT #17 Resident #17 admitted on [DATE] with a rare immune disorder, respiratory disease, and generalized weakness. A nurse practitioner progress note dated 03/30/17 showed, Resident #17 had anxiety and depression. The facility staff made demeaning statements towards Resident #17 during care and disregarded need for pain medication. Facility's investigation of abuse/neglect on 05/15/17 showed resident reported feeling belittled during care. Staff JJ written witness statement described the interaction. Resident needed help with reaching water. Staff JJ stated just lean over and grab the cup just a little lean, but resident said she couldn't. Staff JJ responded to the resident by saying, you can roll back and forth in bed .you rolled out of bed once .you can do it. Staff disrespectful and unprofessional verbal interaction with the resident triggered her emotions. The resident yelled back I did not roll out of bed, I fell . The facility investigation did not recognize inappropriate verbal interactions as a form of neglect resulting in psychological distress to the resident and instead concluded, Resident was displeased with the verbal encouragement Staff JJ gave her for her abilities to lift her water pitcher. Resident was not accepting of this encouragement. The facility blamed the resident for not cooperating with encouragement and disregard staff behavior indicative of neglect. On 06/12/17 9:35 AM during observations, Resident #17 asked Staff NN, Licensed Nurse for pain medication before the shower. Resident told the nurse she was hurting after being repositioned. Staff NN responded with you are not due until 10. Staff NN showed disregard for resident's needs as she did not assess resident's pain severity, offer alternative interventions and left resident's room without addressing pain. After the nurse exited the resident said, 'she can't give me nothing until 10 AM . I am going to have to suffer. Refer to F319 for failure to provide psychosocial care and services. Refer to F241 for additional information related to treatment with dignity Refer to F225 for failure to investigate fall out of bed in April 2017. Interviews on 6/20/107 between 10:00 AM and 10:25 AM were conducted about abuse/neglect with Staff G and J, nurse managers. Staff G explained definition of abuse and/or neglect was willfully not providing care and Staff J said purposely not answering the call light. RESIDENT #3 Resident #3 was dependent on staff for all care including hygiene due paralysis of his lower body and limited arm movement. Review of Resident #3 Minimum Data Set (MDS- an assessment tool) showed his cognitive function was assessed three times during his stay at the facility, on 02/24/17, 03/25/17 and 05/25/17. Resident #3 scored 15 on all three assessments, indicating he had no cognitive impairment. Observations on 05/24/17 at 1:30 PM, showed Resident #3 had chin length hair, and a beard. During an interview on 05/24/17 at 1:30 PM, Resident #3 stated he frequently did not receive showers as scheduled and did not receive assistance with hygiene. Resident #3 stated he went to see the facility beautician to have his hair cut, and was told his hair was too matted to be cut. During an interview on 06/07/17 at 11:12 AM, Staff DD, Beautician, stated Resident #3 had come to the beauty shop to have his hair cut, but she was not able to do it. Staff DD, Beautician stated Resident #3's hair had many areas where his hair was matted together. Staff DD, Beautician, stated the matted areas were large enough that had it gotten caught in her hair clippers, it would have pulled out parts of Resident #3's scalp. Staff DD, Beautician, stated she felt bad for Resident #3. During an interview on 06/07/17 at 11:20 AM, Staff CC, Activities Assistant, (AA), stated she was present in the beauty shop when the beautician had to tell Resident #3 she was not able to cut his hair due to the matted areas. Staff CC, AA, stated Resident #3's hair was matted and his face had flaking skin, which to not have been washed for a period of time.

Based on observation, interview and record review the facility failed to ensure 3 of 6 Sampled Residents (#'s 3, 17, &19), were treated with respect and dignity. This failure resulted in psychological harm and poor quality of life for all three residents. Findings included . Dignity means that in their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth. RESIDENT #19 Resident #19 admitted to the facility in May 2017 after a stroke, and had left sided paralysis. The MDS (Minimum Data Set, a comprehensive assessment), dated 05/26/17 showed Resident #19 had a BIM (cognitive assessment) score of 15/15 (no memory problems.) Resident required assistance with personal hygiene, toilet use, oral hygiene, and transfers. Resident # 19's call light was without reach during multiple observations and resident had to yell for help. Additionally, Resident #19 felt degraded because it took too long for staff to assist with toileting and felt forced to wet himself. On 06/09/17 between 10:30 AM - 10:45 AM during observations and interview, Resident #19 was in bed on his back, wearing a hospital gown, was unshaven and without dentures. During the same observations, the call light was wrapped around an arm chair, positioned away from the bed and behind resident's left shoulder (paralyzed side.) Resident was asked about how he used the call light. Resident said it was out of sight and he could not reach it. When asked how he asked for help resident said, well .I scream .hoping someone walking by will come in that why my voice hoarse. During the same interview, Resident #19 said he could use a urinal but he did not have one. Resident said it took anywhere between 30 minutes to 5 hours to get help. Resident said he needed help with using a urinal and it took staff a long time to assist him. Resident said he could not hold his urine that long and felt forced to urinate in the brief and it made him feel degraded. Resident said, I am a [AGE] years old and I am potty-trained. Resident said this happened every other day. On 06/09/17 at 10:46 AM, family member said I came in this morning and heard him yelling . he did not want to pee in his pants, no one was in the hallway, and I tried finding someone finally after I asked for a urinal he peed. Resident #19 stated, They totally ignore me on night shift . I get upset and pissed off and start yelling. Staff K on 06/09/17 at 11:10 AM stated Resident #19 was continent and used a urinal. Record review showed, a document dated 05/19/17 and titled Comprehensive Admission Data Collection and Assessment, identified Resident #19 was continent and used a urinal. Observations of call light location, bedside table positioning were found outside of resident's reach on the following: 06/09/17 at 10:45 AM; 06/12/19 at 8:37 AM; 9:21 AM; 10:05 AM. On 6/12/17 at 10:05 AM; 06/13/17 at 9:45 AM; 10:41 AM; 10:55 AM, 11:00 AM; 11:15 AM, and 11:25 AM. On 06/09/17 at 10:33 AM, Resident #19 was asked about wearing own clothing versus a hospital gown and getting out of bed. The resident indicated he felt discouraged because it took staff too long to get him up and once he was ready to go back to bed when he became uncomfortable it took too long to get back into bed. Resident said his wheelchair was uncomfortable because he leaned forward and it caused more pain because he had broken ribs. Residents said by the time staff got to him, he would change his mind about getting up. Resident made a statement that he would rather lay in bed all day long then get up and be in a wheelchair for a long time waiting for staff. Refer to F323 for information related to accident prevention and supervision. RESIDENT #17 Resident # 17 felt ignored, when different staff members passed her call light without answering it and was not treated with respect and dignity when she requested pain medication. Resident #17 admitted on [DATE] with a rare immune disorder, respiratory disease, and generalized weakness. A nurse practitioner progress note dated 03/30/17 showed, Resident #17 had anxiety and depression. The note in part read accomplished professional woman and now she feels like she has lost everything .she feels quite distraught at her multiple illnesses and their impact on her life. Continuous observations on 06/12/17 from 8:30 AM to 9:40 AM, resident had the call light on and wanted to get out of bed and was hurting. At 8:45 AM resident said, They always walk by my light they just walk by. Resident said the facility was understaffed. During continuous observations for over an hour, three different nursing staff members were observed (Staff M, KK & NN) coming in and out of resident's room eight different times before getting the resident out of bed. On 06/12/17 at 9:35 AM during observation of staff to resident interactions, Resident #17 requested pain medication. The resident reported to Staff NN, Licensed Nurse she was hurting after being moved around in bed and that she was getting ready for a shower. Resident asked Staff NN for pain medicine prior to showering in anticipation of experiencing additional pain from movement. Staff NN responded stating, You are not due until 10, and said it was normal to hurt when muscles are moved. Staff NN left resident's room without assessing pain severity level and did not offer an alternative method for pain relieve. After Staff NN left the room, Resident #17 said, She can't give me nothing until 10 AM . I am going to have to suffer. Resident's arms were twitching intermittently and she was clenching her fists. Resident reported sharp burning sensation in her legs, rating pain 9/10 (severe) based on the scale of 0-10. Resident said movement made the pain worse. Resident described the pain as being stabbed with a hot knife. On 06/12/17 at 11:15 AM, Staff B, Director of Nursing was informed about Staff NN dismissing resident's pain. Staff B said if pain medications are due too soon staff should try repositioning or try adjunct therapy. RESIDENT #3 Resident #3 was dependent on staff for all care including hygiene due paralysis of his lower body and limited arm movement. Review of Resident #3 Minimum Data Set (MDS- an assessment tool) showed his cognitive function was assessed three times during his stay at the facility, on 02/24/17, 03/25/17 and 05/25/17. Resident #3 scored 15 on all three assessments, indicating he had no cognitive impairment. Observations on 05/24/17 at 1:30 PM, showed Resident #3 had chin length hair, and a beard. During an interview on 05/24/17 at 1:30 PM, Resident #3 stated he frequently did not receive showers as scheduled and did not receive assistance with hygiene. Resident #3 stated he went to see the facility beautician to have his hair cut, and was told his hair was too matted to be cut. During an interview on 06/07/17 at 11:12 AM, Staff DD, Beautician, stated Resident #3 had come to the beauty shop to have his hair cut, but she was not able to do it. Staff DD, stated Resident #3's hair had many areas where his hair was matted together. Staff DD, stated the matted areas were large enough that had it gotten caught in her hair clippers, it would have pulled out parts of Resident #3's scalp. Staff DD, stated she felt bad for Resident #3. During an interview on 06/07/17 at 11:20 AM, Staff CC, Activities Assistant, stated she was present in the beauty shop when the beautician had to tell Resident #3 she was not able to cut his hair due to the matted areas. Staff CC, stated Resident #3's hair was matted and his face had flaking skin, which was due to not have been washed for a period of time. Resident #3 did not receive adequate personal hygiene resulting in psychological harm based on a reasonable person concept.

Based on observation, interview and record review the facility failed to provide reasonable accommodations of needs for 3 of 3 Sampled Residents (#'s 17, 19 & 3) reviewed for safe wheelchair use and access to a communication device. This failure placed all three residents at risk for serious injuries. This failure resulted in psychological harm for Resident #3 and #19 based on reasonable person concept. RESIDENT #19 On 06/08/17 at 10:30 AM observations and interviews were conducted with Resident #17 and a Collateral Contact (CC). The observations revealed, Resident #19 in bed on his back. A standard (regular, non-reclining) wheelchair was located next to resident's bed. During the interview, CC reported Resident #19 was getting depressed because he was in bed all day said. CC thought it would be good for resident's well-being to be up and out of the room. Resident #17 indicated he did not want to get out of bed because his wheelchair was uncomfortable. Resident said when he sat in the wheelchair he leaned forward and/or to the side which caused more pain as he already had broken ribs. Resident said he could stay in the wheelchair for a short time or about 30 minutes and when he started feeling uncomfortable and wanted to get back in bed it took staff a long time to help him. Resident recalled being up in a wheelchair for up to 5 hours and after that experience he felt he would rather stay in bed all day instead of waiting for help that long and to avoid discomfort. CC B, Resident #19's representative on 06/09/17 at 4:40 PM reported seeing resident up in the wheelchair twice a week. CC B said the resident leaned forward when he was in the wheelchair and had pain. According to hospital records dated 02/24/17, Resident had a questionable acute or chronic C 7 spine fracture, lumbar disc herniation, and several fractured ribs. According to facility's therapy notes dated 05/27/17, Resident #19 required ongoing cue for posture, was noted to lean towards the right side of the body. Therapy notes form 05/22/17-05/30/17 showed patient was fitted with a manual facility wheelchair (regular wheelchair that does not recline.) The same documents identified resident was at risk for falls. Physical Therapy Discharge Summary dated 05/30/17 stated pt (patient) will be fitted for facility manual wheelchair and demo good positioning with independent propulsion. Staff I on 06/14/17 at 12:43 PM, identified Resident #19 used a standard wheelchair and indicated the resident was uncomfortable in it as his body leaned to the side. Staff I reported resident tolerated about 30 minutes sitting in the wheelchair. Staff GG, Director of Rehab on 06/14/17 at 11:57 AM said he did not know that that resident had broken ribs. Staff GG was unable to provide evidence that resident was fitted for a wheelchair that would accommodate the need for safe and comfortable positioning. Resident was discharged from therapy due to non-participation on 05/30/17 without being fitted for individualized wheelchair. This failure resulted in resident not having desire or motivation to get out of bed due to discomfort. Access to Communication Device On 06/09/17 at 10:46 AM during an interview Resident #19 said it was important for him to communicate with family and significant other. The phone did not have a dial tone. Resident reported the phone did not work. A family member present during the interview said resident's significant other was unable to visit him and he relied on her for support. The family and significant other were unable to call resident's room directly. The family member said the resident was out of his normal world .one can go crazy just laying here. On 06/13/17 at 11:53 AM, Resident #19 reported again that his phone was not working and he could not use his cellphone because it was dead and the numbers were too small to see. The phone in resident's room had no dial tone. On 6/13/17 at 11:20 AM, Staff C, from the maintenance department, said that each resident room should have a working phone free of charge. On 06/13/17 at 11:24 AM Staff I said there was no portable phone in the hallway. RESIDENT #17 Resident #17 admitted to the facility on [DATE]. Resident was unable to walk and relied on staff for assistance with transfers. According to the Interdisciplinary Team (IDT) notes on 03/21/17, resident was encouraged to get out of bed daily. On 06/12/17 at 9:10 AM Resident #17 said she fell out of the wheelchair several times. Resident said the wheelchair was too big for her and she used a pillow to fill extra space and also to relieve discomfort because it was hard. On 06/12/17 at 10:00 AM Staff M said Resident #17 received an oversized wheelchair from therapy which did not fit the resident. Staff M said the resident insisted on getting up so the big chair was used. Facility's evidence of investigations revealed Resident #17 sustained two falls, on 02/15/17 and 02/25/17 out of the wheelchair. A FALL/INJURY ASSESSMENT updated on 02/25/17 indicated the facility would order a tilt in space wheelchair for the resident. An order was written on 03/06/17 for a tilt in space (reclining) wheelchair, ten days after facility had knowledge that resident had repeat falls from a wheelchair. On 03/23/17 therapy notes identified resident had a strong posterior lean, or leaned backwards, the same note also indicated that therapy could not locate leg rests for the wheelchair. On 04/03/17 therapy notes showed that pt (patient) will be fitted for custom wheelchair to increase independence with functional mobility. On 4/5/17 according to the same notes, Resident #17 was discharged from therapy due to reaching maximum potential. On 06/12/17 at 9:10 AM and on 06/12/17 at 10:00 AM Resident #17 and Staff M both reported the tilt in space wheelchair was delivered approximately two weeks ago. The facility failed to accommodate Resident #17 with appropriately fitted chair causing repeat falls and discomfort. RESIDENT #3 Resident #3 had an [DIAGNOSES REDACTED] disorder that caused body paralysis. Resident had poor trunk control, limited lower body movement and arm movement. Resident was discharged from the facility to a lower level of care setting on 05/25/17. Record review identified a physician order [REDACTED]. On 06/01/17 at 3:30 PM and on 06/08/17 at 1:00 PM a Collateral Contact (CC) E reported Resident #3 was discharged from the facility on 05/25/17 without ordering medical equipment including a special wheelchair. On 06/08/17 at 12:03 PM CC G said Resident #3 arrived from the facility in a wrong wheelchair. The resident was leaning forward out of the wheelchair and almost fell . CC G said it was unsafe to transport resident in vehicle in the provided wheelchair. Discharge records showed Resident #3 had a medical appointment scheduled on 05/26/17 to continue treatment. The appointment was missed. Staff T, physical therapy, on 06/14/17 at 11:30 AM in an interview said Resident #3 needed a tilt in space wheelchair. In an interview at 11:30 AM on 06/14/17 Staff GG, Rehab Director said he had knowledge that resident was not discharged in a tilt in space wheelchair. Staff GG said he was not aware of physician order [REDACTED]. Staff GG was unable to provide evidence that resident was fitted for appropriate wheelchair prior to discharge and while at the facility. Staff GG said that no one asked us (therapy) about a wheelchair for Resident #3. Staff D, social services director said on 06/08/17 at 2:54 PM that medical equipment arrangement was responsibility of home and community services social worker. On 06/14/17 at 1:21 PM Staff B, Director of Nursing said if resident had poor body control or leaned out of wheelchair the facility could utilize a vendor and rent a specialty wheelchair. Staff B indicated the interdisciplinary team relied on rehab staff for wheelchair fitting.

Based on observation, interview and record review, the facility failed to provide medically-related Social Services (SS) for 1 of 3 Sampled Residents #3, reviewed for discharge planning. The facilities failed to effectively communicate with home health services, ensure a safe wheelchair was ready at the time of discharge as ordered, and did not provide immediate supply of critical medication at the time of discharge. Facility's failure to plan an organized and safe discharge contributed to delayed outpatient services resulting in a failed PICC (Peripherally Inserted Central Catheter, a device used to infuse medication into a vein) from clotting, caused avoidable stress and inconvenience to the resident. This constitutes actual harm. Findings included . Resident #3 had [DIAGNOSES REDACTED]. The resident was unable to maintain his body in an upright position. The resident was receiving intravenous treatments through the PICC. Resident was dependent on staff for all care. Review of Resident #3 Minimum Data Set (MDS- an assessment tool) showed three times during his stay at the facility, on 02/24/17, 03/25/17 and 05/25/17, no cognitive impairment. Discharge orders were written on 05/24/17 to send resident home with current medications, treatments, glucometer, and test strips, lancets and sharps container. Resident had a prior order dated 03/21/17 for a tilt in space wheelchair (reclining wheelchair.) According to physician note dated 05/25/17, Resident #3 was little nervous about the discharge. On 06/08/17 at 1:00 PM in an interview, a Collateral Contact (CC) E reported Resident #3 was discharged to a lesser level of care on 05/25/17, without appropriate wheelchair and immediate supply of insulin and a glucometer. On 06/08/17 at 12:03 PM CC G said Resident #3 arrived from the facility without insulin, glucometer, and was leaning forward out of his wheelchair. CC G reported facility representatives assured resident would be discharged with a weeklong supply of medication until pharmacy arrangements were made. CC G said Resident #3 was unable not sit up straight in the wheelchair and almost fell . Because of poor fitting chair CC G was unable to transport resident safely for follow up appointment(s). CC G said the facility set up home health agency that did not provide services in that area. CC G had to find another provider. In the same interview CC G said the PICC line was supposed to be maintained by home health. Due to arrangement with the wrong agency there was delay in home health seeing the resident and the PICC line clotted and had to be removed. Record review for discharge planning showed on 05/26/17, the day after resident discharged the facility faxed primary care provider with information about intravenous treatment. The facility notified the admitting provider the day after discharge about PICC line information via fax. The discharge time line showed the facility faxed orders to the home health agency on the day of discharge, on 05/25/17. Record review showed Resident #3 used long acting insulin to manage diabetes at the time of discharge. The facility discharge documents did not show evidence resident was given a supply of ordered insulin, glucometer, test strips, lancets, and sharps container at the time of discharge. The records did not find evidence of discharge teaching and verifying understanding of the plan. On 06/08/17 at 3:14 PM it was determined that Staff LL, licensed nurse thought she sent the bottle of long acting insulin with the resident. Staff LL did not sent the glucometer or syringes, and said she never sent syringes or glucometers at discharge before. Staff T, physical therapy, on 06/14/17 at 11:30 AM said Resident #3 needed tilt in space wheelchair. In an interview at 11:30 AM on 06/14/17, Staff GG, Rehab Director said resident was not discharged in a tilt in space wheelchair. Staff GG reviewed physician orders [REDACTED]. Staff GG explained that normally he received a list from social services for medical equipment and said no one asked us about a wheelchair for Resident #3. Staff D, social services director said on 06/08/17 at 2:54 PM that medical equipment arrangement was the responsibility of home and community services social worker. Staff D said normally a physician wrote an order for [REDACTED]. Staff D was asked how and when the facility verified that medical equipment company and home health services were aware of the discharge date for Resident #3 in order to provide timely services. Staff D was unable to provide information and referred to Staff E for an answer. Staff E said home health was faxed on 5/10/17, but was unable to find information about notifying and confirming with home health the discharge day of 05/25/17. The discharge records sent from facility to resident's new home showed that resident was still using short acting insulin when it was discontinued prior to discharge. Record review and interviews with Staff G, Staff D, and Staff E on 06/08/17 between 2:15 PM and 2:45 PM could not provide evidence of a safe discharge. The facility failed to timely communicate with all providers/vendors and provide discharge teaching to the resident to ensure safe transition into the community. Resident # 3 had complicated medical condition and required outpatient treatment the facility failed to organize and plan a safe discharge. Staff A, administrator during interview on 06/20/17 at 2:45 PM said the social services were in charge of discharge planning process.

Based on observation, interview and record review the facility failed to provide care and services according to professional standards for 3 of 4 Sample Residents (#'s 1, 3 & 19) reviewed for medication administration practices. This failure resulted in harm to Resident #19 and placed other residents at risk for harm. According to Clinical Nursing Skills, Smith, Duell & Martin, eighth edition, page 572, the nurse is responsible for validating, preparing, and administering medications safely and in accordance with agency policies and procedures. RESIDENT #19 Resident #19 had [DIAGNOSES REDACTED]. Resident had a gastric tube in the stomach through which he received food and/or medications. Physician orders [REDACTED]. On 06/19/17 a licensed nurse used a medication dispensing cup instead of a scored syringe to administer a liquid narcotic resulting in an medication error when resident received twice the ordered dose as stated in facility's incident investigation. Observations on 06/20/17 at 1:25 PM with Staff II, Licensed Nurse revealed a bottle of liquid [MEDICATION NAME] with concentration of 100 mg/5 ml. The box containing liquid [MEDICATION NAME] bottle had visual instructions to use 1 ml syringe with marked dosage increments, such as (0.25 & 0.5 .etc .) to withdraw accurate amount of liquid medication. Two licensed nurses, Staff H and Staff II were interviewed on 06/12/17 between 1:50 PM and 1:55 PM. Staff H said she used a 3 ml syringe to measure 0.25 ml and to withdraw liquid narcotic. Staff II said that liquid [MEDICATION NAME] came with a syringe. The original manufacturer's syringe was missing from residents box that contained liquid [MEDICATION NAME]. Refer to F225 for failure to complete a thorough investigation Refer to F333 for significant medication error RESIDENT #3 During an interview on 5/24/17 at 1:30 PM, Resident #3 stated he was getting his beard trimmed when one of his narcotic pain pills fell out onto the floor. During an interview on 6/7/17 at 11:12 AM, Staff DD, Beautician, stated she was trimming Resident #3's beard when at least one pill fell from his beard. During an interview on 6/7/17 at 1:50 PM, Staff G, RCM, stated Resident #3 has limited motion of his arms and nursing staff must give him his medications on a spoon, so she is unsure how the medications ended up in his beard. Refer to F333 RESIDENT #1 Review of Resident #1's record showed a physician's orders [REDACTED]. Review of the June 2017 Medication Administration Record [REDACTED]. Further review of the June MAR indicated [REDACTED]. The June MAR indicated [REDACTED]. Review of the June 2017 MAR indicated [REDACTED]. Review on 06/08/17 of the night shift starting on 06/05/17, when the one to one monitoring was removed showed no documentation on 06/06/17 and 06/07/17, indicating two of the three days since the one to one monitoring at night was stopped, the staff failed to document if Resident #1 slept during the night. When the MAR indicated [REDACTED]. There was documented late entry. When the same MAR indicated [REDACTED]. There was no documented late entry. Refer to F333.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to address psychosocial well-being for 2 of 3 Sample Residents (#'s 1 &17), reviewed for psychosocial adjustment. Resident #17 demonstrated emotional distress and mental anguish related to experiencing conflict with facility staff and demonstrated signs of grieving related to loss of independence. Resident # 1 experienced severe mental and emotional distress and had [MEDICAL CONDITION]. The facility failed to identify psychosocial needs and take measures to promote coping and provide support. This failure constituted psychological harm for both residents. Findings included RESIDENT #1 Kitsap Mental Health Services progress note dated 05/09/17 showed Resident #1 was first treated at age 13 for a mental breakdown related to history of abuse and treatment of [REDACTED]. Same note stated Resident #1 has ongoing depression for years without relief, but acknowledges that she is has had increased irritability depression and anxiety since moving into nursing home last year. Resident #1 stated she didn't want to move into nursing home and doesn't like the one she is in, but didn't have any choice because she no longer can care for herself. Resident #1 has minimal support. Resident #1 complains of irritability, anger, depression and anxiety but she relates all to her current situation: being in nursing home, how long she has to wait once her call light is on and ongoing pain which she states is not controlled with medications Hospital notes dated 05/30/17 at 6:05 AM, showed nursing staff was preparing Resident #1 to discharge from the hospital back to the facility, when Resident #1 refused to sign the discharge paperwork. Resident #1 told the hospital staff that she was not going to sign an order to die. The facility failed to address Resident #1's psychosocial needs. Refer to F323 for additional information related to Resident #1 RESIDENT#17 Resident #17 admitted to the facility on [DATE]. According to oncology notes on 03/07/17 and History and Physical on 03/13/17, resident was medically complicated. The physician notes indicated resident had an oncologic process (development [MEDICAL CONDITION]), [MEDICAL CONDITION] (decreased ability to move or feel because of nerve damage), and a paraneoplasti[DIAGNOSES REDACTED] (rare disorder where tumor(s) secrete substances and circulate in the blood, may attack the brain, spinal cord, peripheral nerves, muscles, affect sensory perception, movement coordination, and/or thinking skills).The same document(s) indicated resident had a calm demeanor and was cooperative with normal mood, affect and cognition. A psychiatry note dated 03/30/17 stated Resident #17 apparently was a fairly accomplished professional woman and now feels like she has lost everything. She feels quite distraught at her multiple illnesses and the impact they are having on her life. The recommended included exploring other supports such as clergy. Resident # 17 was at actual risk for mental and psychosocial adjustment difficulties, related to adopting to changes in life's circumstances, ongoing health problems with unclear prognosis and had a teenage child at home. Continuous observations conducted on 06/12/17 from 8:30 AM to 9:40 AM. During this time resident's call light was on. Resident said she wanted to get out of bed. At 8:45 AM resident said, They always walk by .they just walk by. During ongoing observations for over an hour, three different nursing staff members (Staff M, KK & NN) came in and out of the resident's room eight different times before getting the resident out of bed. On the same day at 9:35 AM, Resident #17 requested Staff NN for pain medications before showering, the staff responded it was not due for another 30 minutes and it was expected for muscles to hurt with movement. The staff did not ask Resident about her pain level prior to denying resident medications. Observations on 06/20/17 from 9:38 AM to 9:52 AM Resident #17 call light was on for 14 minutes, during this time two nurses and two nursing assistance passed the call light without assisting the resident. During observations and interviews on 06/12/17 between 8:40 AM and 9:30 AM, and on 6/20/17 at 11:13 AM, Resident #17 said she had [DIAGNOSES REDACTED]. Resident said her ability to move arms and legs varied from day to day. Resident said she did not like to be seen by her family in a helpless condition, especially her child. Throughout the interview resident became teary eyed and stated she did not like being in the nursing home and wanted to be with her family or in a different setting. During the same interview Resident #17 said it was difficult being away from her family and she was fearful of unknown future as she did not know if she was going to be able to walk again . Resident indicated she felt that staff treated her differently because she reported a lot of complaints. Resident said she was ignored when staff walked passed her call light without answering it. Resident said she knew that staff talked about her, because she heard them talk about other residents in front of her. Resident did not feel she received support at the facility. Resident described a number of negative experiences at the facility referring to prior allegations and concerns about care. Record review from 02/21/17 through 05/19/17 showed Resident # 17 had a combination of seven Incidents/Accidents and/or Grievances/Allegations: -On 02/15/17 and 02/25/17 Resident fell out of the wheelchair. The wheel chair was too big and a new wheelchair was not ordered until 03/06/17. -On 02/21/17 Resident had an intercepted fall during transfer. -On 04/02/17 resident said she fell out of bed when trying to reach an item. The facility investigation summary stated resident fall was a behavior to get assistance when she wanted it it is believed that the resident placed herself on the floor .resident will be educated that falling out of bed is not safe. Facility's teaching record on 04/03/17 showed resident was educated that throwing self out of bed is not safe. Refer to F225 for failure to conduct a thorough investigation. - On 4/5/17 resident reported a grievance that there was not enough staff. According to the grievance summary, the facility educated resident on appropriate call light use. The interdisciplinary team notes documented repeatedly the resident monopolized staff time, and staff was educated on setting boundaries with the resident as documented on the grievance summary dated 04/14/17, signed by Staff J. -On 05/15/17 Resident alleged that during care two nursing assistants were rude and belittled her. Facility's investigation included written witness statement by Staff JJ. The witness statement showed that Staff JJ told resident to lean over and grab the cup from the table. When resident said she could not reach, Staff JJ said, You can roll back and forth in bed .And you rolled out of bed once, according to the same witness statement. Staff interactions triggered resident to emotionally respond as she became upset and yelled back, I didn't roll out of bed, I fell . -On 05/19/17 Resident alleged abuse. Resident reported when she turned on the call light the staff told her they were busy. Record review of the Interdisciplinary Team (IDT) notes on 04/05/17, 04/06/17 and 04/18/17, included the following statements; - Constant and excessive use of call light excessive crying .SS/RCM (social services and resident care manager will provide resident education concerning use of her call light to set boundaries. -Monopolizing CNA time and thereby delaying care of the Residents. -On continuous charting regarding her behaviors of continuously using her call light and monopolizing the NAC time new intervention is in place for staff to offer resident if there is anything more that she needs x3 .and the final question needs to be phrased this is the third time, is there anything else you need? Comprehensive care plan updated on 04/04/17 indicated resident had behaviors issues, and the psychosocial care plan initiated on 03/09/17 indicated resident was short tempered, accusatory, allegedly waited for hours to be changed. The goals for resident was to decrease behaviors. A note on the same care plan stated, Request facility to authorize payment for 1:1 talk therapy for this resident to assist with depression and anxiety .Increase in behaviors if possible through corporate funding. Behavior chart showed from 04/01/17-06/13/17 Resident #17 had episodes of delusions, however during an interview With social services on 06/20/17 at 1:00 PM Staff D and Staff E did not think resident had delusions. Staff D was asked about performing psychosocial needs assessment and interventions. Staff D said resident was given a number for self-referral to Kitsap Mental Health. Staff D said resident was too young to qualify for senior connections (counseling services.) On 06/20/17 at 1:27 PM Staff B, Director of Nursing said Resident #17 other residents complained because staff was spending a long time in resident's room, indicating residents were not getting equal amount of time from staff. Staff B said they started setting boundaries related to call light use with Resident #17. Record review did not find a care plan specific to resident's individualized psychosocial needs and information about a complex medical condition(s) that maybe contributing to distress. The facility did not attempt to evaluate whether the alleged excessive call light use attributable to organic causes or other risk factors associated with adjustment or coping problems. The IDT team did not use person based and holistic approach to promote mental or psychosocial functioning but considered setting boundaries and limits. The facility demonstrated a pattern of blaming or assigning responsibility to resident when she fell on three different occasions, and when she reported allegations of verbal abuse. Refer to F225 for additional information for failure to conduct thorough investigations to rule out abuse/neglect Refer to F246 for failure to accommodate needs Refer to F241 for dignity

Based on observation, interview and record review the facility failed to ensure 3 of 3 Sample Residents (# 1, 3 & 19) remained free of significant medication errors. All three residents received high risk medications which placed them at risk for serious negative outcomes from medication errors. This failed practice caused harm to Resident #19 when resident was overdosed and had to be hospitalized . RESIDENT #19 Resident #19 admitted to the facility in May 2017 with [DIAGNOSES REDACTED]. Resident had a gastric tube in the stomach through which he received food and/or medications. Physician orders dated 05/19/17 prescribed [MEDICATION NAME] HCL 100mg/5ml (liquid narcotic medication for moderate to severe pain) and instructed to give 1/4 ml (5 mg) sublingually (under the tongue) every four hours as needed for pain. According to facility investigation, on 06/19/17 at 5:30 PM Resident #19 received wrong amount of liquid narcotic medication resulting in an overdose. At 6:50 PM resident was found lethargic and had intermittent absence of pulse. Emergency Services arrived at 6:55 PM and resident was taken to the emergency room . Observations on 06/20/17 at 1:25 PM with Staff II, Licensed Nurse revealed a bottle of [MEDICATION NAME] with concentration of 100 mg/5 ml had approximately 6 ml of liquid remaining. The Medication Administration Record signed on 06/19/17 at 5:30 PM showed 5 mg or 1/4 ml of [MEDICATION NAME] was administered. The box containing [MEDICATION NAME] bottle had a picture or visual instructions to use 1 ml syringe with marked dosage increments, such as (0.25 & 0.5 .etc .) to withdraw accurate amount of medication dose. Two licensed nurses, Staff H and Staff II interviewed on 06/12/17 between 1:50 PM and 1:55 PM indicated 1 ml syringe was absent. Staff H said she used a 3 ml syringe to measure 0.25 ml. Staff II said that liquid [MEDICATION NAME] was delivered with 1 ml syringe. Observations during this time found the original manufacturer's syringe was missing from Resident #19's box. Facility concluded that Resident #19 received double the amount of liquid [MEDICATION NAME]. The order was to administer 1/4 ml of [MEDICATION NAME] or 5 mg with concentration of 100 mg/5ml. The nurse used a medication dispensing cup instead of a calibrated syringe and made an error. It was concluded the nurse gave 10 mg of [MEDICATION NAME] instead of 5 mg. The MAR and physicians order showed this medication should be administered sublingually (under the tongue). The nurses note dated 06/19/17 documented 5 ml suspension given, and stated the medications flushed well, indicating it was given through the gastric tube. The facility's investigation failed to determine whether medication was given sublingually or through the feeding tube and did not explore why the nurse documented in the progress note administering 5 ml suspension. Refer to F225 for failure to conduct a thorough investigation. RESIDENT #3 During an interview on 05/24/17 at 1:30 PM, Resident #3 stated he was getting his beard trimmed when one of his narcotic pain pills fell out onto the floor. Resident #3 stated there had been another incident when a staff member found one of his blood pressure medications on the floor in his room. During an interview on 06/07/17 at 11:12 AM, Staff DD, Beautician, stated she was trimming Resident #3's beard when at least one pill fell from his beard. During an interview on 06/07/17 at 11:15 AM, Staff CC, Activities, stated she was also present and saw a pill fall from Resident #3's beard. During an interview on 06/07/17 at 1:50 PM, Staff G, RCM, stated Resident #3 has limited motion of his arms and nursing staff must give him his medications on a spoon, so she is unsure how the medications ended up in his beard. Review of the incident log showed no entries related to Resident #3 having a potential medication error, therefore, there was no investigation into what medication Resident #3 did not receive, and no investigation into which nurse failed to ensure the medication was given. RESIDENT #1 Review of Resident #1's record showed a physician's order dated 05/19/17 for carvedilol (a medication used to treat high blood pressure) to be given every evening. Review of the June 2017 Medication Administration Record (MAR), showed between 06/01/17 and 06/11/17, the medication was only documented as given three times during the eleven day period. Further review of the June MAR showed a physician's order dated 05/19/17 for [MEDICATION NAME] (a blood thinning medication) to be given every other day. The June MAT showed the medication was documented as being given two days in a row on 06/03/17 and on 06/04/17. Refer to F281. Review of the facility policy titled Medication Administration, dated July 2015, showed when administering medications, nursing staff should ensure the correct medication is given in the correct dose by the correct route.

Based on observation, interview and record review the facility failed to provide care in accordance with accepted professional standards for PICC (Peripherally Inserted Central Catheters) for 3 of 3 Sampled Residents (#'s 6,7 & 8) reviewed for management of PICCs. Failures included not obtaining complete physician orders; not clarifying conflicting orders; not implementing orders consistently; not obtaining accurate baseline information during hospital and facility handoff communication, and not following facility policy and procedures for PICC management. This placed Resident # 7 and Resident #8 at risk for PICC device complications. Failures resulted in harm for Resident #6, who developed PICC associated complication [MEDICAL CONDITION] (severe blood infection) requiring hospitalization and development of a [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clot) in the same extremity of a previously infected PICC. Findings include: According to Lippincott Manual of Nursing Practice (8th ed), pages 95-109) includes the following specific to PICC care: -Bacteremia causes include: contaminated equipment or infused solutions, prolonged placement of the device tubing or solution container, nonsterile dressing change, and cross contamination by the patient or staff. -PICC tip placement must be located in superior vena cava (verified by x-ray). -PICC insertion site and hub should be covered by a transparent dressing. -Venous thrombus (vein which catheter lies becomes partially or fully occluded by a thrombus.) The causes include infusion of irritating solutions, infection along catheter, [MEDICATION NAME] sheath formation with eventual clot formation around the catheter (this clot will eventually occlude the vein.) According to Clinical Nursing Skills by (Smith and Duell, 8th edition) a nursing text book, the following professional standards described on pages 41, 51, 64, 65, & 1130. -When infusing TPN change tubing every 24 hours. -Refusal of medications/treatments must be documented and an explanation regarding the reason entered in the nursing notes. -Handoff communication is a process includes all relevant especially critical elements information about a client to another member. Poor communication is the most frequent cause of sentinel events or adverse events. Refer to F 328 for additional information related to care and management of PICC devices for Resident #6, Resident #7 and Resident #8. RESIDENT #6 Resident #6 admitted with [DIAGNOSES REDACTED]. The resident had increased risk for complications associated with a PICC line, including developing a blood clot due to presence of the catheter in the vein, decreased physical activity due to recent surgery, and use of hormone containing medication. During observation and interview on 03/15/17 at 1:55 PM, Resident #6 was in bed. Resident #6 had a PICC in the left upper arm infusing nutrition fluids. Left arm PICC insertion site was covered by a folded gauze, secured with film like dressing .The gauze obscured visibility. A dime sized bubble was noted on the same dressing slightly above the folded gauze. A second peripheral catheter was noted in the right upper arm labeled midline. On 03/15/17 at 2:20 PM, Staff M, Licensed Nurse (LN), was asked for assistance with observations related to a concern with the dressing over the PICC line. Staff M entered the room, provided a cup to the roommate, touched inanimate objects and then donned gloves without cleansing hands first and proceeded to touch resident's left arm dressing with potentially contaminated hands. Staff said resident's PICC was leaking for three weeks. Record review did not find admitting orders and PICC specific care for admission date of [DATE]. The initial nursing assessment dated [DATE] did not describe the PICC type, tip verification, and baseline length of the external catheter length. On 03/16/17 at 4:58 PM, Staff C, Director of Nursing (DNS), stated that she was unable to locate the original admit orders, and provided a copy of faxed pharmacy orders on 3/16/17. Copy of faxed pharmacy orders for nutritional fluids dated 12/14/16, identified nutritional fluids as a high risk medication. The fluids were to be infused at 69/ml/hr (1 hr), and 132 ml/hr (16 hrs) for total 18 hours daily. Administration records review showed missed nursing care related to Resident #6 PICC management in the December 2016: 1. The administration form was marked to change the IV (intravenous) administration set every 96 hours, which contradicted facility's standing orders that specified to change the set and the filter every 24 hours. 2. From 12/16/16 through 12/31/16, documentation did not contain evidence the set was changed daily when TPN, specialized nutrition infused. The record indicated the set was only changed five times a month. There was no documentation showing that resident refused or there was another reason why it was not changed. 3. Administration record for December 2016, showed to change sterile end cap on administration set with each use. Between 12/16/16-12/31/16, the record did not show evidence staff changed the end cap on 12/20/16, 12/24/16, 12/28/16 and 12/29/16. 4. Administration records had dates boxed out to change the needleless connector after blood draw or every 24 hours with TPN from 12/16/17-12/37/17. The record showed nurses initials on the document for thee dates (12/20/16, 12/24/16, and 12/28/16). 5. The same record showed to measure external catheter length on admission, with dressing change and as needed. From 12/16/16 to 12/31/16, nurses' initials were absent and the length was not recorded. Not having measurements listed does not allow for comparison to the baseline information to determine if the catheter had moved. 6. Flush unused lumens every 12 hours using Normal Saline and [MEDICATION NAME] (anticoagulant) on day and night. Only 8 out of 30 times nurses initialed showing it was completed. Nurses initials indicated [MEDICATION NAME] was used to flush the catheter, however the physician note dated 3/8/17 indicated resident was allergic to [MEDICATION NAME]. Resident #6 was hospitalized from [DATE] to 01/30/17 related to bacteremia secondary to PICC line .sepsis, according to hospital [DIAGNOSES REDACTED]. A hospital physician discharge summary dated 01/29/17 described the resident [MEDICAL CONDITION]. The hospital records showed there were two initial positive blood cultures. One blood culture grew staphylococcus aureus and a second one [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus.) The infected PICC line in the right arm was removed during hospitalization and a new PICC to the left upper arm placed on 01/19/17. An interview was conducted with Collateral Contact (CC) P, IV therapist, on 3/16/17 at 2:02 PM, about standards of practice related to IV therapy. CC P stated PICC line tip cultures were not standard of practice anymore, and not used as a judgement call for bacteremia. The POST-ACUTE CARE ORDERS dated 01/30/17 written at 12:00 PM documented the resident had [DIAGNOSES REDACTED]. Record review showed Resident #6 was in IR ([MEDICATION NAME] Radiology) on 03/08/17 to remove the left arm PICC due to leaking, and had a new catheter inserted through the right upper arm vein. During the procedure, vein occlusion was encountered. The line was left in the vein as a midline (not advanced all the way to superior vena cava, a large vein near the heart). Diagnostic study on the same day identified multiple occlusive blood clots and a small non occlusive blood clot in blood vessels around the midline catheter, (deep vein clots). IR note read it was recommended to remove the midline and place another type of catheter. IR sent Resident#6 back to the facility with a midline catheter and a [MEDICAL CONDITION] on 03/08/17. A physician progress notes [REDACTED].#6 needed to have a PICC line removed, but he was not clear which one. The note indicated the IR physician would have to clarify, and the [MEDICAL CONDITION] needed to be treated with anticoagulants (blood thinners). On 03/16/17 at 2:47 PM during an interview, Resident #6 was asked if blood clot treatment options were discussed. The resident stated the doctor talked about using blood thinners. When asked what treatment option she selected, the resident, stated I don't know and started crying. On 03/16/17 at 3:20 PM, Resident stated I am high risk for blood clot because I don't walk around much . I had surgery and I have a hole in my heart. On 03/16/17 approximately 3:40 PM, Staff O, Registered Nurse (RN) showed a fax dated 03/10/17. The fax included: MD would like a consult as soon as possible. Staff O recalled on Monday 03/13/17, IR was contacted but the hospital physician was out and returned today (3/16/17). Staff O said she did not know why resident had a midline catheter in place and explained it was flushed daily with Normal Saline. Staff O thought it was an additional source for infection. At this time Staff O was informed about missing PICC specific orders, evidence of PICC confirmation at time of admit and absence of catheter length information. during a record review completed at the same time with Staff O, RN, did not find a care plan for PICC line use and [MEDICAL CONDITION] management. During an interview on 03/16/17 at 5:20 PM, Staff C, Director of Nursing (DNS) was asked about Resident #6 developing a blood infection from the PICC. Staff C, DNS, said that the facility alone could not have caused an infection because the resident went out to the hospital a few times. Staff C, DNS, was asked if nurses received training following this event, and she did not think so. During an interview on 03/16/17 at 6:32 PM, Staff N, Physician, (MD) was asked why the resident still had a midline catheter and stated that's a good question and said he recommended to remove it. When asked if he thought if the developed bacteremia from the PICC was avoidable or unavoidable, he stated if nurses did not follow their practice it could be considered avoidable. Staff N, MD, stated we talked about the case and said resident accused us of inappropriately caring for her. RESIDENT #8 Resident # 8 admitted to the facility on [DATE], and received antibiotics to treat infection through a PICC. Staff also used the PICC to draw blood for laboratory use. On 03/15/17 at 4:10 PM, Resident #8 sat in a recliner and had a PICC in the right upper arm infusing medication. On 03/15/17 at 4:13 PM, Staff S, Licensed Nurse (LN) stated that the PICC was supposed to be flushed with Normal Saline. Staff S did not know what type of PICC Resident #8 had. February 2017 intravenous administration records showed documentation the PICC was flushed with [MEDICATION NAME] (blood thinner) on 02/21/17 & 02/24/17. On 3/15/17 at 4:25 PM, during interview and record review, Staff O, Registered nurse (RN) was unable to locate baseline information about Resident #8's PICC including; PICC type/brand, external catheter length, location verification, and instructions on how to flush PICC after blood draws. Orders on a form titled Omnicare, for central venous catheter dated 2/14/17 had a checked box for Minimum Flush/unused Lumens, and listed the device as non-valved PICC. The instructions specified to flush wil 10 ml of Normal Saline (NS) and 5 ml [MEDICATION NAME] every 12 hours. The section for flushes, listed two options under Intermittent Meds for non-valved and valved catheter. Neither boxes were checked. The infusion records for March 2017, conflicted with the orders because the [MEDICATION NAME] flush section was crossed off. A Handover report tool used to communicate between the hospital and facility dated on 02/13/17, identified Resident #8 had a PICC. The handover report did not specify PICC type, or include baseline measurements of the external catheter or PICC line tip location confirmation. Administration record had a space for documenting external catheter length, but was left blank. In the months of February 2017 the administration set (IV tubing) was not changed daily on 14 occasions, and in March 2017 was not changed 16 times, although resident received daily antibiotics and the tubing set should have been changed daily. The same record showed the PICC dressing changed on 03/06/17 and was not changed again until 03/14/17, over 7 days later. Infusion administration record for February 2017 showed staff accessed PICC for blood samples The standing orders did not specify instructions for type of flushes needed with blood draws based on the PICC type. It was unclear if [MEDICATION NAME] should be used to flush the line after the blood draw. Intravenous administration records for the month of February 2017, showed an antibiotic was given at 10:00 AM daily. The PICC required to be flushed after infusing antibiotic. The same record had no evidence the PICC was flushed between 2/14/17 to 2/27/17, a total of 14 missed flushes. According to nurses notes, Resident #8's PICC line had problems with patency on 02/14/17 when the PICC was difficult to flush and [MEDICATION NAME] was ordered. Record review found an undated order for [MEDICATION NAME], but signed on 02/17/17 by the provider, read clogged picc line . flow cath [MEDICATION NAME]. The record contained two orders for [MEDICATION NAME], one signed on 02/17/17 and another dated 03/6/17 which did not specify the dose and which lumens to declot. During an interview on 03/17/17 at 4:24 PM, Staff O, RN, said, she had to declot the line on 03/12/17. Staff O indicated it was unknown if the catheter was valved or non-valved. Staff O, RN said the order for [MEDICATION NAME] administration needed to be clarified. The measurements of external catheter should be done on admission and weekly, and location of catheter tip should be verified prior to use and documented. RESIDENT #7 Resident #7 admitted to facility on 02/18/17 with [DIAGNOSES REDACTED]. On 03/16/17 at 3:05 PM Resident #7 sat on the side of the bed and had a PICC line in the right arm. The resident received antibiotics through the PICC line to treat a wound infection. Record review showed Omnicare Flush orders were initiated on 02/20/17. A checkbox was marked specifying to flush PICC with normal saline followed by [MEDICATION NAME] 10 units/ml. Resident #7's Infusion Medication Administration records for February 2017 and March 2017 showed nursing initials indicating [MEDICATION NAME] flushes. The same infusion record read ELIMINATE [MEDICATION NAME] IF ADMINISTERED VIA SHORT OR VALVED CATHETER. Resident #7's PICC was identified as a valved device according to the manufacturer information. The Omnicare flush order conflicted with the manufacturer's recommendations and guidance printed on infusion sheets. The infusion record for March 2017 had a checked boxed stating to change the tubing administration set every 24 hours. From 03/01/17 to 03/16/17 there was only one initial showing it was changed on 03/01/17, and the rest of the record was blank. Resident #7's central line catheter infusion record also stated to measure central venous catheters external catheter length with dressing change and was only measured once on 3/16/17 for the month of March 2017. There was no baseline measurement to compare this to in order to determine if the line potentially had moved. Staff Q, Licensed Nurse (LN), on 03/16/17 at approximately 4:15 PM , stated she flushed PICC lines. Staff Q, LN indicated she relied on measurements documented on the MAR for ensuring the PICC line was in the right place and referred to orders to determine type of device. During an interview with Staff O, Registered Nurse (RN) on 03/16/17 approximately 3:40 PM, when asked about admission process and PICC line specific orders. Staff O, RN explained, the hospital would call a nurse with the admission report, and at that time, information would be obtained about the device. Staff O, RN said the catheter should be measured at admit and weekly.

Based on observation, interview, and record review, the facility failed to thoroughly assess and monitor following falls and when concerning behaviors were exhibited; develop interventions or supervise staff responses to concerning behaviors for 1 of 5 sampled residents (#3) reviewed for psychological harm. Staff responded to Resident #3's behaviors of disrobing by tying sheets to the bedframe to secure a blanket in place, which resulted in harm for Resident #3 who stated he felt suffocated. The facility also failed to ensure 2 of 2 sampled residents (# 1 & # 2) staff conducted thorough and consistent skin monitoring and assessments or provided timely and consistent wound care as ordered for 2 of 2 sampled residents (# 1 & 2), reviewed who had vascular wounds and attended wound clinic. These failures prevented staff from determining if wounds were healing or worsening, and delayed treatments for residents. These failures had the potential to cause infection, delay wound healing, and diminish quality of life. Findings included: RESIDENT #3 FAILURE TO ASSESS FALLS AND BEHAVIORS Resident #3 admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Admission physician's orders dated 1/23/17 identified the resident had a [DIAGNOSES REDACTED]. The assessment identified the resident had severe cognitive deficits, and spent two to six days feeling down, depressed and hopeless; had little interest or pleasure in doing things, and felt tired without energy. The MDS revealed there had been two or more falls since the resident was admitted . An allegation made to the Department from an anonymous complainant alleged Resident #3 had sheets tied to his lower extremities to keep the resident from moving. Upon investigation, the following facts were discovered: During an observation on 2/15/17 at 05:00 a.m., Resident #3 slept with the left leg off the bed. During an observation on 2/15/17 at 07:15 a.m., Resident #3 was awake with his right leg off the bed and rubbing both legs together. Record review identified the resident had four falls out of bed. The first two falls occurred on 01/23/17 and on 01/28/17. An additional fall, discovered during the Department's investigation, occurred on 02/11/17. Following a fourth fall on 02/16/17, facility investigations revealed the root cause of January falls were poor safety awareness, and did not address the fact the resident had an unstable blood sugar, [MEDICAL CONDITION], and his right leg was very restless. These facts were not reviewed until after the fourth fall incident on 02/16/17 when Staff C did a comprehensive investigation dated 02/17/17 for the fall that occurred on 02/11/17. During an interview on 2/15/17 at 08:20 a.m., Staff H stated he used sheets to secure a blanket around the resident by tying sheets to the bedframe over the blankets and center of the resident to keep him warm, and to give him privacy as the resident kept removing clothing and brief. Staff H added he kept the resident's door open and curtain pulled back so he could monitor the resident's behaviors. Staff H stated he did not let the nurse know about the sheet tying, but did tell Staff G the resident was restless and took clothing and bedding off and the fact that the resident had a fall out of bed. FAILURE TO ASSESS RESIDENT BEHAVIOR ON 2/11/17 In addition, during the night of the incident on 2/11/17, Staff G, licensed Nurse (LN), did not assess the resident when staff reported to him/her the resident was restless, and the resident kept removing blankets, clothing and throwing attends to the floor. In nursing progress notes dated 02/11/17 at 4:30 AM, it was recorded the resident would undress, and throw blankets and attends on the floor. The notes identified the resident was yelling out and behaviors went on throughout the night. Nowhere in the note did the nurse document any type of assessment was done for the resident. According to the facility investigation, Staff G denied knowing the resident was on the floor out of bed and secured in sheets tied to the bed frame. During an interview on 02/15/17 at 08:20 AM, Staff H, Nurse Aide (NAC) reported, prior to securing bed sheets to the bed frame to hold blankets in place, he reported the resident's behaviors and fall to Licensed Staff G. The record did not contain evidence, Staff G assessed Resident #3 for concerning behaviors, or provided supervision to Staff H, to ensure actions taken in response to the resident's behaviors were appropriate. In an interview on 2/15/17, at 06:10 AM., Staff E, Registered Nurse (RN) stated Resident #3 puts himself on the floor, and needs increased supervision, possibly one to one, 1:1, and behaviors needed to be assessed. SHEETS SECURED During record review, a declaration document contained notes of an untimed interview that took place on 03/3/17. The document identified Resident #3, reported to an outside agency Collateral Contact I, he felt restricted and was afraid he was going to suffocate, after a nurse's aide attempted to make the resident warm and comfortable by tying sheets in knots around a blanket while the resident was lying in his/her bed. During an interview on 02/15/17 at 08:20 AM, Staff C, Director of Nursing (DNS) stated he asked the night shift to do an in-service since tying sheets to the bed frame over a resident was not appropriate. Staff C also stated, the intervention should have been to get the resident up in a wheelchair at the nurses station so behaviors could be monitored closely. During an interview on 03/7/17 at 12:45 PM, Resident #3 stated he recalled the sheets being tied to the bed frame, and recalled feeling suffocated. Staff failed to develop a detailed plan of care regarding management of Resident #3's behaviors of disrobing and kicking blankets off the bed. The resident's record did not contain guidance for nursing aide staff to follow when these behaviors were exhibited. FAILURE TO CONDUCT MONITORING FOR PSYCHOLOGICAL HARM-ALERT CHARTING Refer to F 250 for further information In addition, nursing progress notes for 02/11/17, did not mention the sheet tying incident with Resident #3. The record did not contain follow up charting that licensed nurses monitored the resident's psychosocial being for harm until 02/20/17, when a nurse wrote the resident did not have signs or symptoms of psychosocial harm. Review of the resident's care plan dated 02/16/17, identified the resident should be placed on alert for possible signs and symptoms of possible psychological harm, five days after the incident occurred. According to the facility procedure dated 07/2015, regarding episodic documentation, (alert charting) the center will document significant resident care issues each shift until the situation is otherwise resolved, for a minimum of 72 hours. Documentation was expected to have date and time of occurrence, and facts regarding the care issue or incident. The facility did not document in the progress notes any follow through on the incident or evidence of psycho-social harm monitoring in nursing progress notes. Record review showed, Staff J stated in a social service note written on 02/16/17, that she spoke to Resident #3 on 02/15/17 about the sheet tying incident. The note also read At this time (Resident#3) does not appear to have signs or symptoms of psych harm related to incident. In addition, the note read Resident #3 was placed on alert for possible signs or symptoms for psychological harm. During an interview on 03/8/17 at 11:12 p.m., Staff J stated he/she came to the conclusion, Resident #3 did not have any psych harm since facility documentation did not contain entries of sings of harm and she did not see physical signs when she spoke with the resident. Staff J added nursing will chart generally for 48 hours, and it is also identified in the 24 hour report. During an interview on 03/8/17 at 12:00 p.m., Staff C stated nursing progress notes should have been done on the incident and the issue of psycho-social harm monitoring done. Staff C added it was possible, the incident did not make it on the 24 hour report, which alerts licensed staff to do nursing progress notes. VASCULAR SKIN WOUNDS RESIDENT #1 Resident #1 admitted to the facility on [DATE]. A significant change MDS dated [DATE] identified the resident had [DIAGNOSES REDACTED]. The MDS also identified the resident was cognitively intact and had no pressure injuries but at risk to develop them. The MDS revealed the resident had one venous ulcer at the time of the assessment. The resident needed weight bearing assist for most Activities of Daily Living (ADL's) and needed one to two person to assistance, such as for transfers and dressing. Record review showed, wound clinic orders dated 12/14/17 stated Resident #1 needed to return to the wound clinic on a weekly basis due to a wound on her left (L) malleolus (ankle) per orders from wound clinic. The resident's medical chart did not contain returned wound clinic consults for 12/21/16, 12/28/16 and 1/19/17. On 12/14/2016, a consult came back from the wound clinic with orders to change the dressing from three times a day to every other day. These orders were not transcribed timely onto the Treatment Administration Record (TAR) or initiated until 12/21/16. The record did not contain evidence staff completed all required dressing changes. Dressing changes were not documented done three times during December 2016 or ten times during January 2017. In Resident #1's chart did not contain evidence staff conducted weekly skin assessments during the months of December 2016 and January 2017. The record contained only one skin assessment dated [DATE]. During an interview on 01/25/17 at 02:00 PM, Staff A stated it appeared the staff did not transcribe orders for Resident #1 on 12/14/16, and added, There are no new orders as far as I can see. Staff A included nurses should be asking for consult documents when residents come back from the wound clinic. During an interview on 01/25/17 at 03:00 PM, Staff C stated she would try to find the missing information, and did not know where the consults were or why there was missing documentation on wound care in the TAR, except the resident was possibly at a wound clinic that day and received the dressing changes there, but stated, It should be documented on the TAR if that was the case. In faxed documents for Resident #1 to the Department on 1/25/17, the TAR documentation was changed in the month of January to show dressing changes were done the wound clinic on 01/11/17 and 01/19/17. During the remainder of the month (on 9 occasions,) the dressing was not changed every other day. RESIDENT #2 Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was cognitively intact. Resident #2 had no pressure injuries, but was at risk. The MDS revealed the resident had two venous ulcers with application of dressings. The resident needed weight bearing assist for most ADL's with one to two person assistance for care, such as transfers and dressing. Resident #2's record only wound included consults in December 2016 for dates of 12/1/16, 12/5/16 and 12/12/16. According to these consults, the resident was to be seen in the clinic twice weekly. The first complete wound clinic consult was dated 12/1/16. The record showed Resident #2 had a wound to the right (R) heel, a wound to the left 4th toe, and a wound to the right trans metatarsal amputation (all toes surgically removed). The return appointment read the resident attends the wound clinic twice a week for evaluation and dressing changes. On this consult, a hand written note written 12/4/16 noted orders were clarified. Orders were not transcribed onto the Treatment Administration Record (TAR) until 4 days after the 12/1/16 original order was given. The TAR, had orders discontinued from 09/1/16 and 09/9/16 regarding three of the wounds, but no discontinued date was written on the orders to delineate when orders should have stopped; instead it read see new orders across the month. It appeared nurses continued to follow old orders for two to three days after orders where discontinued by initialing the previously discontinued wound treatments. The 12/05/16 and 12/12/16 consults did not address treatment orders for the right heel wound. None of the orders were clarified. The TAR continued to show that dressings were being done per earlier orders written 12/04/16. In addition, there were no other wound consults available in the chart for the month of December 2016. Review of December 2016's TAR showed, the resident should receive weekly skin checks on 12/06/16, 12/13/16, 12/20/16 and 12/27/16. Licensed Nurses (LN) were to write their initials and chart a + (plus sign to indicate area of impairment) and - (minus sign to indicate no area of impairment). No two nurses' initials were the same in the month of December, 2016. On 12/6/16, 12/20/16, or 12/27, there was no + or - sign beside the LN's initials. There were no progress notes or skin assessment forms available in the chart to support any skin assessments were actually done. The last skin assessment form in the resident's chart was dated 08/28/16. Nurses were not consistent in the month of December to evaluate if the resident had a new area of skin impairment, did not measure or describe wounds on a form or in progress notes to identify they assessed, reassessed and monitored areas of skin breakdown. Additionally, wound consult notes contained an order for [REDACTED]. Further chart review showed the resident had a care plan dated 09/01/16, and review date was to be done 12/01/16, which it was not reviewed. A goal was for the skin to remain free of open areas, and an intervention was to inspect the skin for signs and symptoms of breakdown weekly and as needed. During an interview on 01/25/17 at 2:00 PM, Staff A stated it appeared the staff did not transcribe orders for Resident #1 on 12/14/16, and added, There are no new orders as far as I can see. Staff A included nurses should be asking for consult documents when residents come back from wound clinic. During an interview on 02/01/17 at 10:07 AM, Staff B stated the facility can do better at that referring to any resident coming back from a wound consult appointment and not receiving current orders/consults. Staff B added, orders may not come back with the resident, and the nurses don't have time to call the wound clinic to obtain any order changes to wounds. When orders do come though, sometimes the consult is at times five pages long and it is difficult to tell what the orders are, and clarification does not happen for days. During an interview on 02/01/17 at 10:45 AM, Staff C stated she believed the skin system had already been addressed, and added the blank documentation throughout Resident #1 and Resident #2's wounds were of concern. Staff C added Skin assessments are to be done weekly on the skin assessment form, otherwise it is not possible to gauge wound healing. Staff C declared, late orders (after 24 hours) by nurses were unacceptable. Staff did not timely communicate all orders between the wound clinic and the physician, transcribe orders in a timely manner, or timely implement all physician orders for wound care to promote healing of resident wounds. .

Based on observation, interview and record review the facility failed to obtain baseline information at the time of admission regarding Peripherally Inserted Central Catheters (PICC, special intravenous device), to identify and implement appropriate standing orders for care and/or maintain proper infection control practices during PICC care for 3 of 3 Sampled Residents (#'s 6, 7 & 8) reviewed who had Peripherally Inserted Central Catheters. Failure to identify the correct type of PICC device and implement correct orders, had the potential to result in complications for Resident #7 and Resident #8. These failures resulted in actual harm for Resident #6 who developed a PICC related blood infection requiring hospitalization , and developed a [MEDICAL CONDITION]([MEDICAL CONDITION] or blood clot) in the extremity after removal of the device. Findings included: PICC consists of a catheter or a long tube inserted through a vein in the arm, the catheter tip terminates in a superior vena cava, a large vein in the heart. The PICC is used to infuse fluids and/or medications directly into the blood stream via a large vein in the heart. This device requires special care to prevent possible complications including infection, dislodgement, clot formation and vein injury. The facility provided used Omnicare standing orders that should be initiated at the time of admit. The the process was to fill out the standing orders based on the device type and signed by physician. The information then would be transcribed onto the intravenous administration forms used by nurses for maintaining devices. Different types of PICC devices require different types orders for care and maintenance. Resident #6, 7 & 8 did not have complete and accurate standing orders, and administration sheets had conflicting information related to care needed. Refer to F 281 for failure to maintain professional standards of care for PICCs for Resident #6, Resident #7 and Resident #8. RESIDENT #6 During observation and interview on 03/15/17 at 1:55 PM, Resident #6 sat in bed, a PICC in the the left upper arm was infusing nutrition fluids. The left arm PICC dressing had a folded gauze directly over the site and was secured by a dressing. The gauze over the PICC insertion site, located under a sealed film like dressing, prevented staff for visualizing the site to ensure the area would not develop an infection. The resident stated the PICC in the left arm leaked. The right upper arm had another device in the vein. A large tape across the dressing labeled with a sharpie read MIDLINE. The resident stated when she first admitted to facility in December 2016, nurses did not wear masks when changing the central line and did not wash their hands. Resident #6 stated she had a PICC in the right arm in December 2016 and it became infected in January 2017 and had to be treated in a hospital for over two weeks. The resident stated after the right arm PICC infection, she watched nurses during PICC dressing changes to make sure they followed protocol because she was afraid it would become infected again. On 03/15/17 at 2:20 PM, Staff M, Licensed Nurse (LN), was asked for assistance with observations related to a concern with the dressing over the PICC line. Staff M entered the room, provided a cup to the roommate, touched inanimate objects and then donned gloves without cleansing hands first and proceeded to touch resident's left arm dressing with potentially contaminated hands. Resident #6 record review showed orders, infusion administration documentation, and central line catheter treatments lacked evidence of proper maintenance of a PICC. Between 01/13/17 to 01/30/17, Resident #6 was hospitalized for [REDACTED]. A new PICC was placed in the left arm during the hospitalization . According to hospital notes dated 02/05/17, Resident #6's left arm PICC was leaking. On 03/08/17, during attempt to replace the leaking PICC with a new one into the right arm, an occlusion was found by the intravenous therapy staff. A diagnostic study identified multiple thrombi (blood clots) in the upper arm and shoulder location near the area of prior infected PICC. The resident returned to facility on 03/08/17 with the same leaking left arm PICC and a new midline catheter (partially inserted PICC) in the right arm. Resident had the [MEDICAL CONDITION] in the same arm where the new midline catheter was located. Following identification of a [MEDICAL CONDITION] on 03/08/17, Resident #6 suffered from severe anxiety about medical complications [REDACTED]. The facility policy and procedure titled Central Vascular Access Device ([MEDICAL CONDITION]) Dressing Change, for PICC line management, directed staff to obtain upper arm circumference 10 cm above antecubital area when signs and symptoms of complications were present and to compare to baseline. The facility records did not locate evidence measurements of right arm circumference above the midline catheter were done when there was an actual complication of a [MEDICAL CONDITION]. During an interview on 03/16/17 at 6:32 PM, Staff N, Medical Director (MD), was asked why did the resident still have a midline catheter, and stated that's a good question. I recommended to remove it. When asked about measuring arm circumference Staff N did not think it was necessary. When asked if developed bacteremia due to the PICC device was avoidable or unavoidable, Staff N stated, if nurses did not follow their practice it could be considered avoidable. Staff N said we talked about the case and said resident accused us of inappropriately caring for her. RESIDENT #8 Resident # 8 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/15/17 at 4:10 PM, Resident #8 was in a recliner, a medication was infusing into a right upper arm PICC. Facility used a Handover report tool to obtain information from the hospital about resident's specific needs and assessment. A Handover tool dated 02/13/17, identified Resident #8 had a PICC but there was no baseline information was listed about the type of catheter, catheter length, and tip location verification. Resident #8's February 2017 and March 2017 administration records did not include documentation of required maintenance of the catheter. The February 2017 intravenous administration record showed initials indicating Resident #8's PICC was flushed with [MEDICATION NAME] on 02/21/17 and 02/24/17. During an interview on 03/15/17 at 4:13 p.m., Staff S, Licensed Nurse (LN), stated the PICC was supposed to be flushed with Normal Saline. Staff S did not know what type of PICC line resident had to ensure staff flushed the device with the correct type of agent. The February 2017 infusion administration record identified, staff removed blood from this device for laboratory studies. Standing orders did not specify instructions specific for blood draws from the PICC. Resident's PICC line had problems with patency on 02/14/17, and nursing notes showed the PICC was difficult to flush. During an interview on 03/17/17 at 4:24 PM, Staff O, Registered Nurse (RN) said, she had to declot the line on 03/12/17. On 3/15/17 at 4:25 PM, during interview and record review, Staff O, Registered nurse (RN), was unable to locate baseline information about Resident #8's PICC line including external catheter type, location verifications, and flushes requirement after a blood draw. Staff O stated she knew how to draw blood and declot the device based on prior experience outside of this facility. Staff O said this PICC line needed to be flushed with Normal Saline. During an interview on 03/16/17 at 5:20 PM with Staff C, Director of Nursing (DNS), stated that the facility used handoff forms to get reports from the hospital, and it was expected for nurses to obtain information at time of admit related to devices. RESIDENT #7 Resident #7 admitted to facility on 02/18/17 with [DIAGNOSES REDACTED]. A hospital fax dated 02/18/17 at 2:05 PM, showed the resident had a type of PICC called a Power PICC Double Lumen - 40 cm. The fax showed the PICC line was placed on 20/11/17. Record review showed Omnicare Flush orders were not initiated until 02/20/17. A checkbox was marked specifying to flush PICC with normal saline followed by [MEDICATION NAME] 10 units/ml. Resident Infusion Medication Administration Records for February 2017 and March 2017, showed nursing initials indicating the flushed the device with [MEDICATION NAME] (blood thinning agent). The same infusion record read ELIMINATE [MEDICATION NAME] IF ADMINISTERED VIA SHORT OR VALVED CATHETER. Resident #7's PICC was identified as a valved device according to the manufacturer information. Use of [MEDICATION NAME] staff documented they flushed the PICC with conflicted with how Omnicare directions for flushing. The infusion record for March 2017 had a checked boxed directing staff to change the administration set every 24 hours. Between 03/01/17 to 03/16/17 staff documented only once they changed the set on 03/01/17. Other dates were left blank. In an interview on 3/16/17 approximately at 3:40 PM, Staff O, Registered Nurse, (RN) was asked about the admission process and PICC line specific orders. Staff O explained, the hospital would call a nurse with an admission report, and at that time, information would be obtained about device. Staff O stated the catheter was measured at admit and weekly. On 3/16/17 at approximately 4:15 PM, Staff T Licensed Nurse (LN) was interviewed about PICC care. Staff T said she flushed PICC lines. Staff T indicated she relied on measurements documented on the MAR for ensuring the PICC line was in the right place and referred to orders to determine type of device. During an interview on 03/16/17 at 6:06 PM , Staff Q, Licensed Nurse, (LN), was interviewed about PICC care. Staff R explained she knew the PICC was in the right place according to length or measurement of external catheter and relied on information in the chart for information on the device type. During an interview on 03/17/17 at 2:05 PM, Staff O, Registered Nurse, (RN) indicated orders should be clarified on admission, and measurements of external catheter documented weekly an the PICC placement verification should be done on admission and documented.

Based on observation, interview, and record review, the facility failed to provide medically related social services to address increased anxiety and difficulty with critical decision making; or monitor for psychological harm and depression and/or address discharge plans to meet the needs for 3 of 8 sampled residents (#'s 3, 6 & 7) reviewed for psychosocial wellbeing. Resident #7 had the potential for developing psychological harm related to discharge planning. These failures resulted in harm for Resident #6 who experienced a persistent state of psychological distress. Failures for Resident # 3 resulted in psychological harm due to inappropriate staff response to resident behaviors. Findings included: RESIDENT #6 Refer to F328 for facility failures related to PICC management for Resident #6. The CMS (Center for Medicare/Medicaid Services) defines anxiety as: apprehensive anticipation of future danger or misfortune accompanied by a feeling of distress, sadness, or somatic symptoms of tension. Somatic symptoms of tension may include, but are not limited to, restlessness, irritability, psychomotor agitation and hypervigilance. Resident #6 admitted to the facility in December 2016 with [DIAGNOSES REDACTED]. The resident required nutritional supplementation delivered through a special device in the vein, a PICC (Peripherally Inserted Central Line Catheter, a specialized intravenous line.) The resident received an antidepressant and an antianxiety medication prescribed according to January 2017 physician orders. Resident #6 experienced medical complications [REDACTED]. -1/13/17 Infected right arm PICC resulting in sepsis (blood stream infection, life threatening condition) and required hospitalized from [DATE]-1/30/17 as stated in the hospital records. -2/05/17 Resident was in the emergency room (ER) when the length of external PICC catheter was in question, and the PICC leaked. The ER notes dated 2/6/17 indicated unintentional advancement of the PICC. -3/8/17 A deep vein thrombosis found during a Doppler study in the same arm where a prior PICC was in place in December 2016. A psychiatric evaluation note by a Nurse Practitioner (NP) dated 03/2/17, stated she was concerned Resident #6 was not on any medications to treat PTSD, stating the current medication resident was taking was not known to help. The same provider, under recommendation wrote no medications recommended at the time and she (Resident #6) expressed interest in therapy .so you may want to make sure she has the #. There was no further follow up from this provider, although concerns were identified following this 03/2/17 encounter. During observation and interview on 03/15/17 at 01:55 PM, Resident #6 sat in bed, spoke fast and quietly, took frequent short breaths and jumped from one topic to another. Resident had a PICC in the left upper arm infusing nutritional fluids. A second PICC device was visible in the right upper arm, labeled midline. The resident pointed to the left arm and said the PICC leaked, then showed her right arm and said she had blood clots. During the same interview, resident said she was hospitalized in January, 2017 for over two weeks for blood infection from the infected PICC. The resident said she was afraid she would develop another infection, and said she watched nurses during dressing changes to make sure they followed the protocol. The resident indicated she was in theER on [DATE] because there were concerns with the PICC leaking. On 03/16/17 at 2:47 PM during observation and interview, Resident #6 was tearful and anxious. Resident was asked about treatment plan related to the blood clot and stated the doctor spoke about using blood thinners but she was afraid she would bleed to death due to a chronic disease of intestines. The resident indicated using blood thinners could result in ulcers and bleeding. The resident also said she knew that the current blood clot in the right arm could travel and end up in the lungs or the brain if untreated and was concerned about nurses flushing the midline catheter or removing the catheter because it would cause the clot to move. Resident #6 stated she trusted the hospital physicians, and was told the catheter would need to be removed and replaced with another catheter type, but was scared of the procedure. When asked if decision was made about treating the blood, the resident said I don't know and started crying. Resident said she last spoke with a physician on 3/9/17, and no one had updated her on the plan for removal of catheter. She was indecisive about treating the blood clot because she was worried about risks. Record review showed the following: On 12/21/16 during a care conference, facility discussed nutrition and discharge plan. The care conference notes did not contain documentation identifying actual or potential psychosocial needs related to PTSD, depression and OCD. There were no individualized or resident specific goals related to pre-existing mental condition(s) and ongoing medical problems. Nothing was mentioned about resident's coping abilities and if there was a need for additional support. A care conference note on 01/4/17 showed the following topics were discussed; dietary, nursing and financial responsibility. Notes did not identify social services addressed potential or actual psychosocial needs. On 01/10/17, a social services admission summary, identified Resident #6 often appeared anxious and demanded control over daily care. The summary did not contain evidence of social services assessing psychosocial needs and developed individualized interventions. The Mood and Behavior Symptom Assessment/Plan of Care dated 01/10/17, included the following: resident had little interest or pleasure in doing things; was feeling down; had trouble falling or staying asleep; felt tired and had little energy; trouble concentrating; and was short tempered. The goal on this care plan sated return to active participation and adequate rest and stable depression score. Interventions on the same care plan 01/10/17, included: referral to outside mental health services as needed; medications, and allow control over care. The document did not contain individualized interventions for each identified problem. The care plan directed care in pairs on 02/09/17. Also, the care plan included will demonstrate adjustment by accepting that she cannot control everything in her environment or over her own health. The are plan stated have res (resident) work with DNS (Director of Nursing) to problem solve conflicts with staff about care concerns. Nursing assessments of Resident #6, documented in the progress notes from 01/06/17 to 03/12/17, demonstrated the resident experienced ongoing psychological distress with noted deterioration in mental state, manifested as increased anxiety, inability to cope, and thought process disturbances. From 01/6/17 to 03/8/17, nursing records contained statements describing Resident #6: exhibited paranoia when nurses managed PICC pump, resident was crying for hours, and experienced increased anxiety with discharge planning. The record identified the resident was agitated; had anxiety about PICC line displacement; demonstrated refusals; and voiced concerns about medications not given at correct times. The resident also verbalized concerns about Licensed Practical Nurses accessing PICC line. Record review of resident's hospital stay from 1/13/17-1/30/17 for PICC related blood infection. Physician hospital note titled ASSESSMENT AND PLAN, dated 01/29/17, stated resident continued to be fearful of infection secondary to mishandling by the rehabilitation staff. The same note showed resident continued being emotional and refused to discharge back to the facility. Resident #6 readmitted back to the facility on [DATE]. The nursing note dated 01/31/17 showed resident was distressed and worried about developing a blood clot. Resident was concerned about not receiving anticoagulants at the nursing home when she recieved anticoagulant injections during prior hospitalization . The note indicated resident was told there was no reason for blood thinners. There was no evidence social services addressed Resident's psychosocial needs related to fear and anxiety following hospitalization . Nurse Practitioner's (NP) note on 02/28/17, described Anxiety; Unchanged, suffering extreme anxiety . follow up with mental health for evaluation and treatment. The NP documented malfunctioned PICC and recommended replacement. On 03/02/17, the psychiatry note stated concerns of no medications to treat PTSD and the resident had fear in changing medications. The record did not contain evidence the IDT (Interdisciplinary Team), including social services intervened to address Resident #6's untreated PTSD and psychological distress demonstrated by extreme fear and anxiety. On 03/06/17, social services IDT notes relayed information from the psychiatry note on 03/02/17. It stated resident was not on any medications to treat PTSD, she is taking medications that are known to make s/s (signs/symptoms) of PTSD worse. The social services IDT note did not contain evidence for considering resident's ongoing anxiety, fear of medication changes, preoccupation with allergies [REDACTED]. Resident #6 suffered another medical complication as documented in a diagnostic study document dated 3/8/17. The attempt to replace leaking PICC failed, and a new DVT (deep vein thrombosis, blood clots, potential life threatening condition) was discovered in the veins near location of a prior infected PICC (12/2016). On 03/09/17, a physician note indicated resident experienced extreme anxiety in part related to treating the blood clot. The note identified the risk of not treating the blood clot included risk of death. The resident experienced anxiety and tearfulness during this encounter. The note also included the longer we wait to make a decision the more of a chance resident had in developing a problem. Following the physician visit on 03/09/17, the record did not show evidence of IDT including social services had a care meeting to evaluate the situation immediately and intervene when resident had compromised psychological and physical state. There was no evidence resident received psychosocial support to promote coping with critical decision making related to a high risk medical condition. On 03/17/17 the social services staff gave resident a phone number to the outpatient mental health provider, as documented in social services notes. According to nurses notes on 03/11/17, resident anxiously researched catheters. Resident told a nurse she did not know when she was willing to do the procedure, but maybe willing to if she could be placed under. The resident verbalized fear of treatment. On the same day, a visitor reported a concern about the resident's increased anxiety. On 03/12/17, nurses documented again, Res (resident) has increased anxiety. The nurse asked resident if she decided on a treatment, and the resident began to cry. A visiting family member reported concerns again to facility about the resident. The visitor said resident was worried about the blood clot. The above collection of facility documented observations and knowledge, revealed Resident #6 demonstrated apprehensive anticipation of future danger or misfortune accompanied by a feeling of distress, sadness and anxiety, which is psychological harm. In an interview on 03/16/17 at 5:20 PM, Staff C, Director of Nursing was asked about faciltiy approaches to resident refusals. Staff C indicated, initiating resident education and involve the IDT In an interview on 03/16/17 at 6:32 PM, Staff N, Physician, (MD) said Resident #6 had a significant DVT and if it breaks free there is a risk of pulmonary embolism (blood clot travels to the lung and can cause lung tissue to die). When asked about treatment plan, Staff N indicated at this time the plan is no treatment because resident is refusing treatment. During an interview on 03/17/17 at 11:11 AM with Staff L, Social Services, stated, Resident #6 was highly anxious about everything, had [DIAGNOSES REDACTED]. Staff L said resident liked to talk things out. During the same interview, Staff L was asked about what psychosocial needs and interventions were identified related to resident's indecisiveness, trust problems, and what was done to assist resident with coping and decision making about treatment of [REDACTED].? When asked about the resident's support system, Staff L said she invited a family member to a care conference at the time of admit but resident did not want the family member present. Staff L indicated she did not re-approach the resident about involving a family member. Staff L thought the Director of Nursing called the family member. Staff L said she was not aware of the ongoing issue with the resident's indecisiveness about treatment of [REDACTED]. Resident #6, admitted to facility with pre-existing mental health conditions, and after experiencing medical complications, the mental health condition(s) worsened and the resident demonstrated problems with coping, had severe anxiety and needed support in making decisions about medical treatment. The facility's failure to timely identify and manage resident's mental health needs led to a decline in physical and mental wellbeing. The facility allowed the resident to remain in a persistent state of anxiety, psychological distress and markedly diminished ability to think and concentrate as evidence by indecisiveness, preoccupation with fear of developing other complications. RESIDENT #3 Resident #3 admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Also per the MDS, the resident had severe cognitive deficits, and spent to six days feeling down, depressed and hopeless, had little interest or pleasure in doing things, and felt tired without energy. During an observation on 02/15/17 at 5:00 AM, Resident #3 slept with the left leg off the bed. During an observation on 02/15/17 at 7:15 AM, Resident #3 was awake with his right leg off the bed and rubbing both legs together. During an interview on 02/15/17 at 8:20 AM, Staff H, NAC, said the resident kept removing clothing and brief. Staff H added he kept the resident's door open. Staff H stated he told Staff G the resident was restless and taking clothing and bedding off. In nursing progress notes dated 02/11/17 at 4:30 AM, it was recorded the resident would undress, and throw blankets and attends on the floor and was yelling out, the behaviors went on through the night. A document supplied by Collateral Contact I, outside agency staff, (an undated statement) identified Resident #3, reported to CC I, he felt restricted and was afraid he was going to suffocate, after an aide attempted to make the resident warm and comfortable by tying sheets in knots around a blanket when resident was in bed on 2/11/17 at night. During an interview on 03/7/17 at 12:45 PM, Resident #3 stated he recalled the sheets being tied to the bed frame, and recalled feeling suffocated. The facility did not develop an individualized plan of care regarding management of Resident #3's behaviors of disrobing and kicking blankets off the bed. The resident's record did not contain guidance for nursing aide staff to follow when these behaviors were exhibited. During an interview dated 03/09/17 at 11:12 AM., Staff J, Social Services (SS), stated she relied on information in care tracker for psychological harm information. Care tracker is an electronic system where nurses' aides document target behaviors. Care tracker documents dated 02/11/17 to 03/11/17 did not show the resident had any behaviors, and nurses' progress notes did not reveal any alert charting was done for monitoring the after the incident. On 01/31/17 at 6:20 PM, Resident #3 had thrush and was concerned medications were not given at correct times. The resident called the hospital to get orders for nystatin, heparin and SCDs (Sequential Compression Device, applied to legs to promote circulation with goal to decrease blood clot risk). The resident was informed there was no reason for Heparin and SDCS. There was no documentation that staff attempted to explore why the resident had concerns about the need for heparin and SCDs. RESIDENT #7 Resident #7 admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving intravenous antibiotics for infected wound that was not healing well. On 02/28/17, an ARNP (nurse practitioner) note included the resident had multiple follow-ups regarding wound care and has been receiving antibiotics, however the wound continued to get worse and there was a bone infection. Under section titled PSYCHE it showed resident had flat affect, which is one of the symptoms of depression. The social services admission summary, dated 03/06/17, showed resident had major depressive d/o (disorder). The same note stated resident did not received any psychoactive medications and denied depression which contradicted a Minimum Data Set assessment ((MDS) dated [DATE]. The MDS assessment showed a depression score of 5 meaning mild depression. It was documented he felt tired, had little energy, and trouble sleeping. On 03/16/17 at 3:05 PM, Resident #7 sat on the side of the bed not wearing a shirt and had a walker in front of him. Resident was concerned about not having medications once he discharged and said social services did not help him after multiple requests. Resident picked up two envelopes, and with raised voice said he got rejection letters. Resident said in a care conference yesterday, the problems were not resolved and his questions were unanswered. He did not fully understand medication coverage. The resident said I can't get prescription drug coverage once I get discharged . I may have to live out of my car because I can't afford to pay for my needed medications. On 03/20/17 at 9:49 AM, Staff L, social services, was informed of Resident #7's stated concerns to a surveyor during the resident interview on 03/16/17. Staff L said resident was not depressed. Staff L said at this time there was no monitoring of Resident #7 target behaviors. Staff L explained the facility behavior tracking documentation was done by the aids in the care tracker. Staff L said we would monitor if he was showing signs and symptoms but he is not. Resident #7 experienced medical complications, the additional stressors had the potential to exacerbate psychological state given [DIAGNOSES REDACTED]. Facility social services failed to recognize this risk and take a proactive approach, anticipate psychosocial needs including, coping and support, particularly since resident was adjusting to a new environment and had deterioration in health related to wound complications.

Based on observation, interview and record review, it was determined the facility failed to ensure necessary care and services were provided for 3 of 4 residents (#110, 47 and 59) reviewed for pain when referrals for outside services were not arranged, 1 of 3 residents (#34) reviewed for positioning and 3 of 4 residents (#22, 59 and 47) reviewed for skin impairment when complaints of discomfort were not assessed and skin issues were not identified in a timely manner. This failure placed the residents at risk for uncontrolled pain, impaired mobility and diminished quality of life. This failure caused harm to Residents #110, 47 and 59 when they experienced inadequately managed pain. Findings include: 1) Resident #59 admitted to the facility 6/29/16 with multiple medical [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), an assessment tool dated 7/6/16, indicated the resident was experiencing pain frequently and it interfered with sleep and day-to-day activities. Resident #59 was admitted with two pressure sores and was at risk for pressure ulcer development. No other skin issues were identified. The resident required an extensive assist of one person for repositioning and transfers. He was always incontinent of urine and stool. He did not exhibit rejection of care behaviors. The Care Area Assessment identified risk factors for pain and skin breakdown and indicated to proceed with care planning. <Pain> In interview on 9/27/16 at 5:54 p.m., Resident #59 reported having pain all over his body all the time that he rated 7 out of 10, on a 0 to 10 scale with 0 being no pain. He went on to state that he had been told they were scheduling him an appointment with a pain clinic but he had not heard anything more about that. A review of a form titled Pain Data Collection and Assessment, dated 7/28/16, indicated the resident had joint and soft tissues pain he rated 7 out of 10 that occurred almost constantly. A Pain Care Plan, dated 7/15/16, indicated the resident had persistent/chronic pain and the goal was to have no complaints of pain when questioned. A record review on 10/3/16 at 11:26 a.m. revealed a communication, dated 8/9/16, with the physician indicating a pain clinic appointment was pending. In interview on 10/4/16 at 11:58 a.m., Licensed Nurse (LN) B reported not being aware of a referral for a pain clinic for resident #59. He went on to state that it is something the Resident Care Manager (RCM) would have arranged and the RCM for Resident #59 had quit a couple of weeks ago. A record review on 10/5/16 at 2:40 p.m. revealed a nurse progress note dated 8/15/16 at 9:30 a.m. indicating the pain clinic had been called, resident's information was being reviewed and the clinic would call in a day or two to set up appointment. An additional note, made at 12:00 p.m., indicated a referral packet was faxed to the pain clinic and the facility should expect to hear back in 2-3 business days. There were no other notes regarding the referral or whether the appointment had been made. The failure of the facility to follow through with ensuring the resident was seen by a pain clinic as ordered resulted in resident experiencing harm by not having adequate pain control and a diminished quality of life. <Skin> In interview on 9/27/16 at 5:55 p.m., Resident #59 reported pain that he was having on his buttocks for a while that it had not been looked at to assess for sores. During observations on 10/5/16 at 9:01 a.m. Resident #59 was noted to have an open sore, approximate size of a dime, to his left buttock near the ischial tuberosity (known as the sitting bones). LN E was present during observation and stated I'll have to get my charge nurse to look at it. In interview on 10/5/16 at 9:06 a.m., Resident #59 reported his buttocks had been hurting for quite a while and was worse when sitting up in the wheelchair. He further stated I'm in bed all the time because it hurts to sit in my chair. He reported telling staff and after much complaining, a nurse looked at it a couple of days ago and said he had an open sore. When asked if nursing did weekly skin checks he replied no. In interview on 10/5/16 at 9:56 a.m., the DNS stated it was the expectation if a resident complains of pain to buttocks the nurse should visualize the area and determine the cause of the pain. Record review completed 10/5/16 at 10:00 a.m. revealed no documentation in care plans, nurse progress notes or physician orders [REDACTED]. The failure to assess the resident's skin for breakdown when complaining of pain to buttocks placed the resident at risk of pain, worsening skin impairment and diminished quality of life. 2) Resident #22 was originally admitted , May 2011, and was recently readmitted after a short hospital stay 7/19/16 with multiple medical [DIAGNOSES REDACTED]. The resident's annual MDS, dated [DATE], indicated the resident had no pressure ulcers and was at risk of pressure ulcer development. The resident had wounds related to circulation but no other skin impairment identified. The resident required an extensive assist of two persons for repositioning and transfers. Resident was occasionally incontinent of urine and frequently incontinent of stool. Resident did not exhibit rejection of care behaviors. The Care Area Assessment identified risk factors for skin breakdown and indicated to proceed with care planning. A Braden score (an assessment to measure risk of skin breakdown) was completed on readmit from the hospital 7/19/16. Resident scored 15, which equaled a minimal risk. Resident scored 13 on a Braden assessment completed 9/29/16 indicating an increasing risk of developing skin breakdown. In interview on 9/29/16 at 8:31 a.m., Resident #22 stated she had about four places on her buttocks that were sore and had been asking for a new mattress for the bed because she felt the current one was worn and causing her pain. She went on to state that she put pillows on her wheelchair seat for padding and comfort since she has had this butt problem and that she never has had a cushion for the wheelchair. She stated her bottom had been hurting about two weeks and a nurse had not looked to see if she had any sores. On 9/29/16 at 11:40 a.m., incontinent care was provided by Nursing Assistant (NA) A. Resident #22 was noted to have reddened skin on each side of the buttocks and an open area on her left buttock the size of a kidney bean. NA A applied cream to the buttocks and stated the skin looked like it always has, not noting the open area on left buttock. On 9/29/16 at 8:41 a.m. resident was observed in bed positioned on her back with the head of the bed elevated, wheelchair parked next to bed with pillow folded in half sitting on seat, no wheelchair cushion observed. At 2:14 p.m. and 4:43 p.m., Resident #22 was observed sitting in her wheelchair in dining room with pillows under buttocks for cushioning. In interview on 9/29/16 at 11:44 a.m., NA A stated Resident #22 did not have a wheelchair cushion since she had been working with her for the past 7 months. On 10/02/16 at 10:45 p.m., a yellow dot was noted on the name-plate outside of Resident #22's room with a diagonal line through it. In an interview on 10/4/16 at 2:30 p.m., NA A stated the yellow dot meant to reposition the resident every 2 hours but did not know what the line through the dot signified. NA A returned at 2:40 p.m. and stated, the yellow line means there are restrictions to the every 2 hour repositioning for the resident and can be found on the care directives. NA A also stated that Resident #22 is not to lay on her back. A review of the facility's, Turning and Repositioning Program revealed the black line through the yellow dot indicated a resident that could not tolerate laying on their left, right or back; required more frequent turning and repositioning; or personal preference. In an interview on 9/30/16 at 7:41 a.m., Resident #22 reported a nurse put a bandage on her buttock the previous evening. In interview on 9/30/16 at 10:00 a.m., the DNS stated Resident #22 should have a wheelchair cushion and she should be care planned to have one. She went on to state a cushion should be in the wheelchair of every resident using a wheelchair. The DNS explained that a LN would know of a new skin issues by reviewing the 24-hour report, there would be a physician order, and the new treatment would be entered into the treatment book. The failure to assess the resident's skin for breakdown after complaints of buttocks pain, to have preventative measures in place to prevent skin breakdown, to have systems in place for staff to be aware of new skin issues and intervene appropriately placed the resident at risk of pain and allowed for worsened skin impairment and diminished quality of life. 3) Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's 8/12/16 Quarterly Minimum Data Set, MDS, (an assessment tool) showed he had a BIMS (Brief Interview for Mental Status) score of 14/15, indicating he was cognitively intact. It showed the resident experienced trouble falling asleep, had no observed behaviors and it was very important to the resident that he be involved in discussions about his care. He was on a scheduled and non-scheduled pain medication regimen and reported having pain, 5 out of 10 (with zero being no pain) almost constantly that effected his ability to function and limited his day-to-day activities. On 9/29/16 at 9:14 a.m., while lying in bed, Resident #110 stated he was in pain, the pain always increased whenever he moved and he had informed several staff of his desire to take baths to help relieve his pain. The resident was told the facility had a bathtub available. However, as of this interview he had not received any tub baths. At 11:13 a.m., Resident #110 was lying in bed and stated his pain level was usually a consistent 5/10 if he laid still and higher when he moved. On 10/3/16 at 9:22 a.m., while in bed, Resident #110 stated often times he did not want to get out of bed due to his left knee, back and neck pain. On 10/4/16 at 5:16 p.m., the Administrator (ADM) stated he was aware Resident #110 wanted to take baths and stated there was a working tub available in the facility. On 10/5/16 at 10:08 a.m., NA A stated she had worked with the resident on a regular basis since last March. She said the resident complained of being in pain daily and that turning and transferring him caused him increased pain. At 10:27 a.m., the resident was lying on his back with facial grimacing observed. He spoke in a soft voice and stated his pain had increased from his usual 5/10 to a 7/10 and he had received his morning scheduled Tylenol already. Review of the resident's Medication Administration Record's (MARs) on 10/4, 10/5 and 10/6/2016 showed the following: <Prescribed pain medications> Resident #110 had an order for [REDACTED]. An 8/9/16 order showed the resident was to receive Biofreeze (a pain medication applied to the skin) to left knee, wrist, hip and shoulder three times a day. MAR indicated [REDACTED]. <Monitoring for effective pain program> Per nursing documentation the resident was asked Is your pain program effective for you? twice each day in July, August and October, or 72 total times. There were no documented negative responses. On 10/5/16 at 9:27 a.m., the resident was asked if any staff had asked him if his pain program was effective for him twice a day. The resident stated he had never been asked that question and he would not have answered yes. The resident said his pain level was currently 5/10 for his left side, neck and back and that was pretty much normal. He said sometimes it was higher, he would like it to be lower, he complained about his pain, to staff, on a daily basis and he was in constant pain even after he received his pain medication. <Non-pharmacological pain interventions> Cool Compress A 9/23/16 order directed nursing staff to Apply cool compress to left knee TID (three times a day) x 10 days and to Re-evaluate after d/c (discontinuing) this TX (treatment). The September MAR indicated [REDACTED]. Review of the resident's October 2016 MAR, on 10/5/16, showed no telephone orders or Progress Notes that indicated the resident was re-evaluated or that the provider was notified of the resident's self-stated constant pain level of 5 of 10 or higher. On 10/5/16 at 9:27 a.m., when asked if staff had placed any type of cool compress on his left knee over the last three weeks, the resident stated no one had ever offered him anything like that. On 10/5/16 at 10:08 a.m., NA (Nursing Assistant) A stated Resident #110 complained about pain every day she worked with him and that turning and transferring him increased his pain. NA A said she cared for the resident several days a week and she had never observed any icepacks or cold compresses while assisting this resident with position changes. Bathing Review of the resident's records on 9/29, 10/3, and 10/5 showed: A 7/1/16 document completed by MD A, showed Resident #110 had pain secondary to multiple joint and muscle issues, reported his pain was there all the time and MD A felt a hot bath should be something that the center is able to coordinate with the patient and his brother, and the director of nursing says that they will work to do so. Nursing documentation, dated 7/28/16 and reviewed on 10/06/16 at 1:26 p.m., showed Resident has preference to use the bathtub for washing and as a means for non-pharmacologic pain intervention. Facility has bathtub for resident use and Resident has verbalized that taking a 'hot bath' would be helpful for his comfort. A 9/13/16 NH Visit Encounter by the Advanced Registered Nurse Practitioner (ARNP), reviewed on 10/5/16 at 8:42 a.m., showed the resident requested a hot bath to help with his pain and when the ARNP discussed that request with nursing the ARNP was told the bathtub in the facility leaks and was not usable at that time. The ARNP documented she would like him to be able to obtain a hot bath weekly once the facility is able to have the bathtub repaired. The facility caused harm to resident #110 when they failed to accurately monitor, report and respond to Resident #110's pain which caused him to experience constant pain at a level that impacted his quality of life. 4) Resident # 47 was admitted to the facility on [DATE], per MDS, he has no cognitive impairment. He was assessed as 'almost always' having pain. His medications included [MEDICATION NAME] (to treat neuropathic pain), [MEDICATION NAME] and [MEDICATION NAME]. He had a stage II pressure ulcer to his left buttock. On 10/04/16 at 10:05 a.m., the resident stated the pain medicine is pretty good, but most often the pain is so bad that it barely helps. On 7/8/16, a document in the resident's chart signed by the medical director reads that he wanted to refer the resident to the pain clinic. On 8/13/16, the resident was sent to the hospital ER for severe pain in his back. On 8/19/16, an order was written by the ARNP (advanced nurse practitioner) to refer the resident to a pain clinic. On 9/23/16, the nurse faxed an order to the ARNP to request [MEDICATION NAME] to be scheduled regularly due to pain level of 10/10. This request was declined by the ARNP. On 10/04/16 at 3:22 p.m., documentation on the MAR (medication administration record) indicated that the resident asked for [MEDICATION NAME] several times daily. Nursing staff did not document observations of effectiveness after medication administration. There was no documentation that the resident was offered any alternative pain relief methods. LN E stated I guess I should have checked if he feels better. On 10/04/2016 at 4:13 p.m., Licensed Nurse (LN) E was asked about the pain clinic referral. She replied I surely did not know about a referral. On 10/04/16 at 5:04 p.m., the DNS agreed the resident had not been seen at a pain clinic. She stated. I am not sure what happened, but we will be following up with that. <Skin> The resident was admitted on [DATE]. The care plan was initiated for a stage II pressure ulcer (an injury to the deeper layers of the skin) to the left buttock. The care plan was not updated to address the new pressure ulcer to the right buttock on 7/28/16. On 7/28/16, the nurse documented that the resident developed a stage II pressure ulcer to his right buttock. The resident was experiencing discomfort at the same time. The resident was observed in a sitting position in his bed every day of the survey from 9/26/16 thru 10/4/16. On 10/04/16 at 10:19 a.m., the resident stated I still have the pressure ulcer, no one has looked at my butt, the nurse is supposed to put a salve on it. It is too painful to move a lot. On 10/05/16 at 2:00 p.m., a skin assessment was done by LN. Both buttocks had a dry open area with dark discoloration around it. When asked about the weekly skin rounds, he replied, only the pressure ulcers and complicated wounds are seen, all the other skin issues are not rounded on. 5) Resident #34 was admitted to the facility in 2008 with multiple medical [DIAGNOSES REDACTED]. Resident #34's most recent Minimum Data Set (MDS), an assessment tool dated 8/14/16, documented the resident required extensive physical assistance for all activities of daily living, was frequently incontinent of urine and was at risk for developing pressure sores. <Positioning Concerns> The resident was in her wheelchair for extended periods of time throughout the survey period. Observations on 9/27/16 at 8:44 a.m., 11:07 a.m. and 3:45 p.m., 9/29/16 at 9:37 a.m., 10:48 a.m., 11:39 a.m., and 2:40 p.m. and 9/30/16 at 7:45 a.m., 9:25 a.m., 10:29 a.m., 11:00 a.m., 1:10 p.m. and 2:20 p.m., showed the resident to be sitting lower in her wheelchair than prior observations showed her sitting. At times the resident ' s buttocks was on the edge of her seat with a large gap between her body and the back of her chair. Multiple staff walked by the resident ' s room and made no attempt to reposition her. On 9/29/16 At 2:44 p.m., NA C was observed to push Resident #34 in her wheelchair down the hall to an activity. The NA asked Resident #34 at least 5 times, Pick up your feet please, and Feet up please. Resident #34 would briefly pick her feet up, but was unable to hold them up for long. NA C stated to NA D, we need to pull her up. At 2:45 p.m., NA C indicated Resident #34 did not use footrests because of her diagnoses. NA C stated, usually (Resident #34) can hold up her feet. NA C indicated Resident #34's wheelchair used to fit her better and stated, Now we are always having to adjust her. She has lost weight and I guess needs more padding. At 2:46 p.m., when pushing Resident #34 back to her room, NA C could again be heard telling Resident #34 multiple times to keep up her feet. On 9/30/16 at 1:41 p.m., NA M stated he tries to reposition Resident #34 often, but she immediately slides back down. NA M stated, It is especially hard when she is eating because she slides down. NA M indicated he had mentioned his concerns to the Director of Nursing and Administrator 3-4 months ago. At 2:22 p.m., when asked to observe the resident, the Director of Rehabilitation (DR) agreed, Resident #34 was not positioned properly. The DR stated, her hips need to be much farther back in the chair and the chair needed to be tilted back to keep her hips from sliding. The DR stated, the way this wheelchair works, she should always be tilted back unless she is transferring in and out of it. The DR went on to explain he had been in communication with the resident about obtaining a different wheelchair, but the resident had declined because she could still use her feet to move around a little. No indication was given that showed the facility had considered other options, including assistive devices, to improve the resident's positioning. The DR again asked the resident if she would be willing to try a different wheelchair and the resident responded Yes. At 2:35 p.m., at the request of the surveyor, the DR and another therapy staff member repositioned Resident #34. After repositioning, the resident sat much higher in the chair and was able to lean forward and propel around the room with her feet. Resident #34 had not been observed to be able to move her wheelchair until positioned properly. At 2:36 p.m., Resident #34 stated, yes when asked if she felt more comfortable after being repositioned. The facility failed to ensure Resident #34 was repositioned often enough and adequately in order to prevent the resident from sliding down in her wheelchair, effectively making it harder for her to self-propel and increased the difficulty of her feeding herself at meals due to the height of the table her food sat on. This placed Resident #34 at risk for skin impairment, discomfort, and immobility. <Skin> At 9/29/16 at 2:58 p.m., NA C and NA D changed Resident #34's brief. The resident's brief was saturated with urine, heavy in weight, and her pants and wheelchair were wet with urine. The resident's skin on the peri-area, upper thighs and buttocks was bright red. At 2:59 p.m., NA D stated, Oh there are red rashes there! NA C and NA D finished providing peri-care and assisted the resident into a dry brief and pants. No barrier cream or ointment was applied to the resident's peri-area or buttocks. At 2:59 p.m., Resident #34 stated ya and nodded her head when asked if the rash to her peri-area hurt. At 3:06 p.m., NA C and NA D, indicated they were not sure if the rash was new. When asked about a barrier ointment or treatment for [REDACTED]. On 10/3/16 at 4:16 pm., when asked if Resident #34 had any skin impairments, LN C stated, not that I am aware of. At 4:21 p.m., NA L and NA E were observed providing incontinent care to Resident #34. Resident #34's brief was saturated with urine and bowel movement (BM), heavy in weight, and was foul smelling. Resident #34's pants were saturated with urine. BM appeared dried to the resident's bottom. A bright red rash was visible in the resident's front peri-area, upper thighs, and buttocks. At 4:35 p.m., LN C examined Resident #34's skin and stated, I think it is from incontinence honestly. She is pretty bright pink on her buttocks. LN C indicated the resident did not have any orders currently for treatment of [REDACTED]. At 4:43, the resident's Care Manager, LN B, stated he was not aware of any skin impairments for Resident #34. LN B looked in the resident's medical record and confirmed there appeared to be no current skin impairments or treatment orders. When asked why there was no current treatment for [REDACTED].'t be. There should be orders the same day a rash is identified.

Based on interview and record review, it was determined that the facility failed to identify, evaluate and analyze risks associated with falls, and failed to implement adequate interventions to prevent additional falls for 1 of 3 Residents (#1) reviewed for accidents. This failure caused harm when Resident #1 had a fall and sustained a fracture to the right hand. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The minimum data set (MDS), an assessment tool, dated 7/17/14, documented the resident had a (Brief Interview for Mental Status) BIMS score of 5, which identified the resident had impaired cognition, and documented the resident required extensive assist of one person for transfers and locomotion on the unit. The "cognitive assessment/plan of care" dated 7/11/14, documented the resident had impaired cognition due to dementia, cognitive ability for decision making was severely impaired, and documented the resident had short term and long term memory problems. The facility's "fall/injury assessment: prevention and management care plan "dated 7/3/14 and the "ADL/mobility care plan" dated 7/3/14 and updated on 9/10/14, did not identify the resident's dementia and cognitive impairment as problems to be addressed when determining appropriate interventions for Resident #1 who the facility identified to have impaired cognition. Review of the record revealed Resident #1 had a fall on 7/25/14. The facility concluded the "resident had a non-injury fall secondary to attempting to transfer self to bed from wheelchair." The facility determined appropriate care planning was in place and updated the care plan to include, "remind resident to use call light for assistance with transfers." According to the facility's investigation, Resident #1 was found on the floor of the bathroom on 9/5/14. The facility concluded the resident attempted self-transfer from the wheelchair to the toilet, fell and sustained a fracture of the right hand. On 10/14/14 at 3:06 p.m., during an interview, the licensed nurse (Staff B) confirmed Resident #1 did not have an appropriate fall prevention care plan in place.

Based on interview and record review it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (#1) reviewed. This failure caused harm when Resident #1 was sent to the hospital with low oxygen saturation after not receiving prescribed medication to treat heart and lung disease. Findings include: Resident #1 admitted to the facility from the hospital on [DATE] at approximately 3:30 p.m., with multiple [DIAGNOSES REDACTED]. Day and night shift nurses on 7/2/14 and the day shift nurse on 7/3/14, failed to give Resident #1 prescribed medication. Review of the record revealed Resident #1 had physician orders [REDACTED]., carvedilol BID, prescribed to treat the resident's [MEDICAL CONDITION], [MEDICATION NAME], a diuretic, scheduled once a day in the morning to treat the residents [MEDICAL CONDITION] and [MEDICATION NAME] (antibiotic) prescribed to treat the residents aspiration pneumonia scheduled for 8:00 a.m. and 8 p.m. The Medication Administration Record [REDACTED]. On 7/2/14, the day the resident admitted to the facility, she did not receive two evening doses of [MEDICATION NAME] (dinner and hour of sleep), one evening dose each of [MEDICATION NAME] and carvedilol. On 7/3/14 the resident did not receive morning doses of [MEDICATION NAME], carvedilol, [MEDICATION NAME] or the 8:00 a.m. dose of [MEDICATION NAME]. According to a witness statement dated 7/3/14, the nursing assistant (Staff D) entered the resident's room on 7/3/14 at around 10:00 a.m., and took the resident's vital signs. The resident's "oxygen saturation was low, 60" and Staff D went to get the nurse, and shortly after the resident was transported to the hospital. According to the hospital records "summary of visit" dated 7/5/14, documented, while in the emergency room , Resident #1 was noted to be hypoxemic (low level of oxygen) with oxygen saturations in the 70's and 80's. The resident received a dose of [MEDICATION NAME] with improvement. The discharge [DIAGNOSES REDACTED]. On 8/28/14 at 3:21 p.m., during an interview, the licensed nurse (Staff C) stated she worked the morning the resident was transported to the hospital, and confirmed the morning medications were not given. On 8/28/14 at 3:45 p.m., during an interview, the licensed nurse (Staff B) stated the morning medication pass is ideally done by 10:00 a.m. Staff B stated the day shift nurse who did not give the medication on 7/2/14 would not provide a statement, and the night shift nurse who did not give the medication on 7/2/14 did not know some of the medication was in the emergency kit. Staff B stated the facility did not identify the day shift nurse who worked on 7/3/14 also failed to give the resident prescribed medications. Staff B confirmed Resident #1 did not receive prescribed medication on 7/2/14 and 7/3/14. On 8/28/14 at 3:50 p.m., the administrator (Staff A) was informed of the above findings.

Based on observation, interview and record review it was determined that the facility failed to ensure all measures to prevent weight loss were taken for 1 of 3 Sampled Residents (# 19) reviewed for nutrition of the 41 residents who were included in the Stage 2 review. This failure contributed to continued unplanned weight loss for Resident #19. Findings include: Resident #19 was admitted to the facility on [DATE] from a local hospital for wound healing. Observations on 4/15/13 during the noon meal revealed Resident #19 eating his/her lunch with milk and coffee. Resident #19 had a wound vac (device used to help heal wounds). Review of Resident #19's medical record indicated he/she was not on a planned weight loss diet. Further review of the record revealed a note from the hospital he/she transferred from dated 2/12/13 which identified him/her at "moderate" nutritional risk. Review of a dietary note dated 2/20/13 revealed Resident #19 weighed 161.3 lbs. (pounds) while in the hospital. Review of the weights recorded since returning from the hospital revealed: Hospital weight = 161.3lbs Facility 2/18/13 = 156.8lbs Facility 2/25/13 = 156.9lbs Facility 3/5/13 = 148.4lbs Facility 3/12/13 = 145lbs Facility 3/21/13- = 143.4lbs (after one month in facility weight has dropped 8.5% since the first facility weight). Resident #19's most recent weight listed in his/her record was on 4/17/13 at 138.4lbs (an 11.7% drop in 2 months, since the first facility weight). Further record review revealed a nutritional assessment dated [DATE] which identified recent weight loss and had a goal of weight maintenance. The dietician also recommended to add Prostat (a protein supplement designed specifically for wound healing) 30 milliliters (ml) every day to promote wound healing. Review of the March 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation to show Resident #19 received prostat in the month of March 2013. Review of the April 2013 MAR indicated [REDACTED]. Review of Resident #19's record revealed a physician's orders [REDACTED]. The order did not specify which protein supplement or how much should be given. Review of the March 2013 MAR indicated [REDACTED]. The directive did not indicate how much of the supplement should be given. The MAR indicated [REDACTED]. Review of the April 2013 MAR indicated [REDACTED]. The directive did not indicate what supplement or how much to give. The MAR indicated [REDACTED]. During an interview on 4/18/13 at 2:20 p.m., Staff H reported she administers 60 ml of Med Pass for the protein supplement. When asked how nurses were to know what supplement and how much, Staff H reported she knew to give the Med Pass because it was ordered for more than once per day and she asked another nurse how much to give. Review of package inserts for Med Pass and Prostat revealed either supplement can be given more than one time per day. During an interview on 4/24/13 at 9:25 a.m. Staff E reported the order for protein supplement with meals was not complete and staff should have called to clarify what supplement and how much. Staff E further reported whenever staff gives a protein supplement, they should document how much the resident drinks so staff can make an accurate assessment of the resident's nutritional status. Review of physician's orders [REDACTED].#19 had been receiving 60 ml three times daily). During an interview on 4/18/13 at 11:50 a.m. Resident #19 reported she does not drink all of the protein supplements, as she did not care for the taste of them. Labs drawn 3/4/13 indicated Resident #19's protein levels were low at 5.5 g/dl (normal range is 6.1-7.8g/dl). Additionally his/her [MEDICATION NAME] levels were low at 2.3g/dl (normal 3.3-4.8g/dl). A nutrition progress note dated 3/27/13 identified Resident #19 had undesirable weight loss over the last 5 weeks. The note also identified the lab levels and noted they could be indicative of moderately depleted protein stores. The dietician recommended adding an additional protein supplement, Med Pass 90 ml three times daily. Review of Resident #19's medical record revealed the recommendation made by the dietician was never carried over into an order. During an interview on 4/25/13 at 9:25 a.m., Staff E reviewed Resident #19's record and reported the recommendation should have been carried through to an order, but it had never been done. Failure to administer protein supplements as ordered by the physician and failure to carry out the recommendations of the dietician contributed to Resident #19's weight loss and placed the resident at potential risk for further weight loss and risk of delayed healing of his/her wounds. . RESIDENT #120 Record review revealed Resident #120 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #120's Minimum Data Set (MDS), an assessment tool, dated 3/5/13, indicated the resident had unclear speech but was able to make him/herself understood. The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was alert and oriented. The resident experienced weight loss of 5 percent or more in the last month or 6 percent or more in the last 6 months. Review of Nutrition Risk Data Collection and Assessments, dated 2/29/12, 6/13/12, 9/5/12, 12/7/12 and 3/6/13 revealed that Resident #120 had difficulty with chewing and swallowing. Resident #120 was on a pureed dysphagia diet. The record revealed that between 10/2/12 and 4/23/13, he/she experienced a net loss of 11.8 pounds (10/2/12: 142.0 pounds; 4/23/13: 130.2 pounds). The resident's ideal body weight was between 160 and 196 pounds. During an interview on 4/16/13 at 11:07 a.m., when asked if he/she had any chewing or eating problems, Resident #120 said, "Yes: no teeth." When asked why he/she did not wear his/her dentures the resident stated, "They hurt." The Resident Care Manager (Staff G) was unable to provide documentation to verify that the facility monitored whether the resident was wearing dentures, and if not, assessed the reason why. Record review revealed the Speech Therapy Treatment Note, dated 6/5/12, in which Staff V stated Resident #120 "is requesting diet to be upgraded to least restrictive diet." On 4/24/13 at 2:50 p.m., during an interview in the presence of 2 surveyors in the facility conference room, the speech therapist (Staff V) stated that when she provided speech therapy for Resident #120 in June/July 2012, the resident was very motivated to advance from a pureed diet to foods with a more solid texture. Staff V stated that if Resident #120 had dentures that fit properly and he/she was willing to wear them, it would warrant a reevaluation by speech therapy. When asked if having properly fitting dentures could increase Resident #120's potential for advancing to a more textured diet, Staff V said, "It would help." Failure to promptly evaluate and take action to ensure that Resident #120 had properly fitting dentures diminished the resident's potential for advancing to the least restrictive diet possible and placed the resident at risk for further weight loss. Refer to F-412 for further interviews and record reviews.

Based on observation, interview and record review it was determined that the facility failed to identify and repair an environmental hazard which led to an avoidable injury for 2 of 4 Sampled Residents (#'s 59, & 116) reviewed for accidents of the 41 residents who were included in the Stage 2 review. The hazardous area caused harm to Resident #59 when the resident fell over a raised cement area and suffered a laceration to his/her head . The facility's failure to repair an environmental hazard placed all residents, visitors, and staff at risk for further falls and injury. Findings include: RESIDENT #59 Resident #59 admitted to the facility on [DATE] from the hospital after having a fall at home. During an interview on 4/15/13 at 2:09 p.m., Staff J reported Resident #59 had fallen outside in the smoking area. Staff J further reported Resident #59 had abrasions to his right elbow and knee, and also lacerated his head, requiring staples. During an interview on 4/15/13 at 2:30 p.m. Resident #59 confirmed he had fallen in the smoking area. Resident #59 reported that some tree roots had come up breaking the cement sidewalk, and that was the reason he tripped and fell . Resident #59 further stated the area he had fallen in was an area that had been repaired before he fell , however, it remained uneven. He stated there had not been any repairs to the area since the fall. During an interview on 4/23/13 at 11:00 a.m. Resident #113 reported he had witnessed the incident and confirmed that Resident #59 had tripped over raised cement and fell . Review of the facility incident investigation dated 3/24/13 included both Resident #59's statement, and statements from staff who witnessed the incident. All statements in the investigation indicated Resident #59 was walking within the smoking area, when he tripped over an uneven area of cement/concrete in the sidewalk. The investigation had a section titled Environmental Circumstances which identified uneven surface as a contributing factor that was present at the time of the fall. The investigation further indicated Resident #59 was sent to the emergency room for a scan of his head, and received staples to his head. The investigation included a "Building Services Work Order Request." The request form dated 3/26/13 was directed to the Maintenance department and in the section titled repairs to be done was a written note "Evaluate uneven concrete in smoking section." Observations of the smoking area on 4/23/13 at 1:30 p.m. revealed several areas of the side walk where slabs of concrete had been raised, and was no longer even with the slab next to it. The previously repaired area that Resident #59 had described was raised higher than the edge of the concrete with the center dropped to a lower level. Observations with Staff D on 4/23/13 at 3:45 p.m. revealed more areas of the sidewalk which had been broken and raised higher than adjoining cement. Staff D confirmed there were areas raised as high as 2 inches above the surrounding cement. Review of the facility's incident report revealed a resident had fallen over uneven cement in the smoking area on 8/29/12. Review of the incident investigation revealed the resident (#116) reported he had tripped over a cement slab that was higher than the one next to it. During an interview on 4/23/13 at 4:15 p.m. Staff D reported the sidewalk had not been repaired in August following Resident #116's fall and had not been repaired since Resident #59 had fallen in March. During an interview on 4/23/13 at 1:45 p.m. Staff A reported the area where the cement is uneven is used by many residents, both smokers, and non-smokers. Staff A further reported all areas of the sidewalk are used by the residents, including the areas with damage to the cement. Staff A confirmed the sidewalk had not been repaired since either resident's fall. The facility had knowledge of tripping hazards related to broken and raised cement pieces since Resident #116 fell in August 2012. The facility did not repair the sidewalk which consequently led to Resident #59 falling in March 2013. Resident #59 suffered a laceration to his/her head from the fall, which caused harm to Resident #59, and required an emergency room visit with staples placed to close the laceration. RESIDENT #116 Resident #116 admitted to the facility with multiple [DIAGNOSES REDACTED]. On 4/23/13 review of the facility's incident accident report revealed Resident # 116 had a fall on 8/29/12. The nursing note dated 8/29/12 with the time of 7:00 p.m., documented, in part, resident alert and oriented to person place and event, resident had injury in resident smoking area, tripped and fell over cement slab, scratches and slight redness to right hip. Further review of the facility's incident report dated 8/29/12 revealed the resident stated, in part, that the end of his shoe got stuck on the edge of one of the cement slabs in the smoking area. Resident stated that they were shaped as long squares and they were not level and he tripped over one that was higher than the other and fell . The facility's "Summary of Investigation Findings" documented, in part, the slabs of cement that are out in the smoking area are of different heights. The "Summary of investigation Outcome" documented, in part, the resident tripped and was not paying attention to where his feet were or where he was stepping, and the "Summary of Corrective Action Taken" documented, "resident educated to watch where he is stepping especially when it is crowded, and maintenance to assess concrete for safety and risk for tripping and falling." Review of the witness statements from other residents who witnessed the fall revealed two residents documented the resident tripped over the wheelchair footrest, and another resident documented the resident tripped over the cement slab and the wheelchair pedals. The facility failed to investigate the discrepancy in statements, although Resident #116 had a BIMs score of 14 and was able to articulate what occurred. The facility also failed to investigate the crowded smoking area. Review of the facility's typed "Interdisciplinary Team (IDT)" note dated 8/30/12 documented, in part, resident was out in the smoking area on 8/29/12 and tripped on the edge of the cement slabs that are out there. The designs of the cement are squares of concrete laid down with wood separating them and some are not the same height. Maintenance was to evaluate safety of smoking area to see if it is necessary to smooth uneven edges of cement. On 4/23/13 review of the "Building Services Work Order Request" dated 9/4/12 under the section, work or repairs to be done documented, "please evaluate the cement in smoking area, slabs are uneven and are a trip hazard." On the same form, under the section, to be completed by building services, the undated documentation noted, "smoking area is safe, and residents must stay under the tent." The evaluation of the work area did not address the uneven slabs of cement. On 4/23/13 at approximately 4:00 p.m., the Maintenance Director (Staff D) reported he repaired a missing piece of cement in July of 2012 before the resident's fall in August 2012, and no other repairs had been made in the smoking area under the tent or the surrounding areas following the resident's fall. On 4/23/13 at approximately 3:45 p.m.-4:15 p.m., observation of the repaired cement with Staff D revealed the previously repaired cement was uneven and was part of the walkway that led to the smoking area under the tent. Further observations of the areas surrounding the designated smoking area revealed raised uneven cemented areas. Staff D confirmed the surrounding areas had raised uneven cement and confirmed the previously repaired area was also uneven. When asked, Staff D reported he did not know exactly where to check for the uneven cement, in relation to the resident's fall, because he was not told the location of where the resident tripped, but only told that it was in the smoking area. On 4/23/12 at approximately 4:15 p.m., during an interview, Staff D reported he was instructed to check under the tent (smoking area) for uneven cement where the residents are "supposed" to smoke. Staff D stated he did not evaluate the surrounding areas of the smoking area, and did not evaluate the walkway leading to the designated tented smoking area because the work order documented "smoking area," and stated the designated smoking area is under the tent. Staff D reported he concluded the cemented area under the tent was safe. When asked, Staff D reported no one reviewed his work, and he is to send all of his paperwork to corporate at the end of the year. On 4/23/13 at approximately 2:00 p.m., during an interview, the Administrator (Staff A) confirmed residents did not always stay under the designated tented smoking area, and residents would move the patio chairs around to sit where they choose. Review of the facility's incident accident report revealed Resident #116 who had a BIMS score of 14 reported he tripped on the uneven cement in the smoking area in August 2012. Observations on 4/23/13, eight months later, revealed there were several areas of uneven cement in the smoking area. Staff D confirmed that no repairs were done to the uneven cement after the residents fall in August 2012. The facility failed to ensure requested work orders were appropriately carried out. The facility failed to address a trip hazard that caused Resident #116 to fall and sustain an injury. The facility also failed to provide oversight and give clear instruction to staff designated to evaluate the area of the fall occurrence. These failures contributed to the facility from implementing appropriate interventions, and placed residents at risk for further falls and injury.

Based on observation & interview & record review the facility failed prevent pressure sores for one of two sample residents (#117) who entered the facility without pressure sores, and failed to ensure that the resident received necessary treatment and services to promote healing, prevent infection or prevent new sores from developing of 25 residents reviewed for care. This resulted in harm. Findings include: <Resident #117> Record review found that Resident #117 was admitted to the facility [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] and Care Area Assessment (CAA) dated [DATE] identified that resident conditions of incontinence, immobility, pain and [MEDICAL CONDITION] placed the resident at risk for skin breakdown. No behaviors of rejection or resistance to care were identified. The facility identified that on admission, Resident #117 had no skin breakdown or pressure ulcers. Resident #117's care plan (initiated [DATE] with updates) identified that the resident had an air mattress, and a Roho cushion (provides pressure relief while seated in wheelchair). Staff was to lift, not slide the resident across the bed (which can cause forces of friction or shear that rub or tear skin on or under the skin surface). The resident was on a turn schedule. Staff was to use assistive devices to facilitate movement such as turn sheets, overbed trapeze or resident lift. Observation during survey from [DATE] to [DATE] noted that pressure relief equipment was not used to its full benefit for Resident #117. Observation on [DATE] at 11:00 a.m. noted Resident #117 sleeping in bed propped on his left side. The air mattress motor at end of bed was quiet. There were no lights on and no noise indicating air flow through the mattress. Observation on [DATE] at 10:00 a.m. Resident #117 was again observed sleeping in bed propped on his left side. There was no light or noise indicating that the air mattress was working. On [DATE] at 10:00 a.m. Nursing Assistant Certified G (NAC G) acknowledged that the bed was not working and retrieved her supervisor, Resident Care Manger A (RCM A). The RCM discovered that the air mattress was not plugged into the wall. According to RCM A it didn't matter that the air bed was turned on because the mattress never totally deflates. Both staff stated that the air mattress was on the day before or that morning. Resident #117 said that he did not hear bed air movement today or yesterday. Observation on [DATE] at 10:10 a.m. noted an uncovered Roho cushion on Resident #117's wheelchair. Certified Nursing Assistant G stated "it (cover) is probably in the laundry". Resident #117 said "it was gone yesterday; I put a towel over it". Placing a towel on top of an inflated cushion diminishes the effectiveness of the cushion's pressure relief protection. Observation during survey from [DATE] to [DATE] noted that staff practice was subjecting residents to forces of friction and shear during repositioning. For example on [DATE] 9:30 a.m. staff was observed sliding another resident (#115) up in bed without lifting her off of the surface of the bed. On interview [DATE] RCM-A acknowledged that staff were unable to prevent friction and shear forces during repositioning residents, including Resident #117. The RCM stated that staff can't lift Resident #117 totally off bed due to his weight and the pain it causes. According to RCM A, Resident #117 can't assist by putting his feet on the bed and he is unable to use an overbed trapeze. The RCM repeated that there is going to be some part of the resident's body sliding against bed (which can cause tissue injury). The RCM stated that the facility typically only uses 2 staff to reposition the resident. On interview at [DATE] 2:25 p.m. Resident #117 stated "I have sore on by back. They drag me on the bed, the hard surface makes me bleed." Resident #117 stated that he could move around a little in his chair, demonstrating by moving his upper body side to side. The resident was unable to lift himself up off the surface of the chair or shift position for pressure relief. Record review found that on [DATE] staff discovered a Stage 2 pressure sore (partial thickness loss of skin presenting as a shallow open ulcer) on Resident #117 ' s right buttock just above the tailbone extending toward the right hip. Staff measured the ulcer as 3 centimeter (cm) by 15 cm (6 inch across) blanchable red with a 2 by 3 cm (,[DATE] x 1 ? inch) purple area. Facility records documented that by [DATE] this area developed into a Stage 3 pressure ulcer (full thickness tissue loss which may include undermining and tunneling.) Social Service and medical records document that Resident #117 was admitted to the hospital [DATE] with decreased mental status,[MEDICAL CONDITION] (systemic infection from the tailbone wound) and required surgical cleaning of his wound. Records documented that Resident #117 returned to the facility on [DATE]. On interview [DATE] Resident Care Manager A (RCM A) stated that when Resident #117 transferred to her unit from a different unit on [DATE], he already had a pressure sore, which became worse. According to RCM A the wound developed and became worse because Resident #117 only feels pain from muscle contractions, has limited mobility and can't change position without assistance. The RCM stated that Resident #117 does not allow perineal care and would not lay down. According to RCM A before Resident #117 was hospitalized on [DATE], " I kept telling him -You have potential for osteomylelits (infection clear to the bone from the wound). He kept saying "no, no, no, I've died 7 times, I'm OK" he would not listen, he became so sick, he was reaching for things, he was septic." Review of Resident #117's MDS assessments from [DATE] to [DATE] found no reevaluation of Resident #117's care needs after he developed the Stage III pressure sore. The facility did conduct Braden Risk Assessment (to evaluate risk of developing pressure sore) after the resident returned from the hospital on [DATE]. According to facility evaluation, Resident #117 was at minimal risk of developing pressure sores (the lowest level of risk) until [DATE] when the facility determined that the resident was at moderate risk of developing a pressure sore. On [DATE] the facility determined that Resident #117 was at high risk of developing a pressure sore (Braden Scale 12) after the resident developed further pressure sores. On interview [DATE] Resident Care Manager A stated that Resident #117 got the new pressure sores because Resident #117 sat forward in his chair, or leaned to side which was his way of thinking "I can be up in chair". The RCM said that this caused pressure in other areas of body. Facility wound documentation shows that on [DATE] the resident developed a 4.0 cm by 1.2 cm pressure sore under his left sit bone a 1.0 cm by 3.0 cm pressure sore on his lower tailbone. Review of Resident #117's care plan found an update [DATE] that the resident would allow peri care and would be up in his chair for 2 hours maximum at a time. According to RCM-A and Social Service Staff-A (SS-A) Resident #117 did not comply with this plan of care. Staff determined that Resident #117 did not believe that it was harmful to stay up in his chair for ,[DATE] hours at a time. There was no identification and evaluation of potential alternatives other than to repeatedly remind the resident that he was at risk of further skin breakdown. Refer to F250

Based on observation, interview and record review the facility failed to ensure that 1 of 3 residents (#47) reviewed for non-pressure related wounds received necessary services and care to prevent self-inflicted injury and wound erosion. This resulted in harm to Resident #47. Findings include: Facility records show that Resident #47 was admitted [DATE] with medically disabling conditions and Dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #47 had cognitive impairment and had no identified areas of concern related to skin or behavior. An undated photograph of Resident #47 in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical records show that this scab was diagnosed as a non-cancerous ulcer in 2009. According to the medical record, in 2010 Resident #47 started picking at the ulcer. A physician's orders [REDACTED]. Record review found the last wound measurement was dated 1/12/12 when staff described the ulcer as a dark red scab that measured 2.3 centimeter (cm) by 1.5 cm covering the left side of the nose and under the nose. (The largest diameter approximately one inch.) The resident care plan dated 2/2/12 did not document interventions to prevent worsening of the facial ulcer. Observations throughout the survey 6/19 to 6/27/12 noted that Resident #47 was intermittently picking at the ulcer on her face with her left index finger. Resident #47 had one quarter inch long rounded nails, with chipped pink polish on all the days of survey. When picking, Resident #47 removed some of the scab, dabbed at it with paper towels and at times caused the area to bleed as evidenced by crusted blood on her nose or brown material under her fingernails. On interview 6/22/12 Resident #47 stated that she did not know what the ulcer was or why she picked at it. "I automatically do it." On 6/27/12 at 4:25 p.m. observation noted that there was an approximately one quarter inch cleft in Resident #47's left nostril. None of the staff interviewed on 6/26 or 6/27/12 (Nursing Assistant Certified B, Director of Nursing, Licensed Practical Nurse F, Resident Care Manager C, and Resident Care Manager A) knew that the resident had developed a cleft in her nose. Review of the MAR found that staff was administering nasal spray to alternate nostrils daily. Even though nursing staff was administering nasal spray daily, none of the nurses identified that Resident #47 had a 0.6 cm by 0.2 cm cleft in her nose. Skin assessments signed by facility nursing staff on 6/7/12, 6/13/12, and 6/18/12 noted no new skin issues. On interview 6/27/12 Resident Care Manager A (RCM A) stated that Resident #47's nails could not be trimmed (to mitigate picking) because the resident would not let staff trim her nails. On interview 6/27/12, the Director of Nursing Services (DNS) stated that the cleft was due to Resident #47 applying repeated pressure to her nose. The DNS measured the cleft as 0.6 cm by 0.2 cm. According to the DON, no prevention measures were in place because they had failed in the past. .

Based on observation, interview and record review the facility failed to provide necessary care and services to attain or maintain the highest practicable well-being as evidenced by developed skin condition and hypoglycemic (low blood sugar) event. The facility failed to implement measures to prevent skin breakdown for 2 of 6 Sampled Residents (#s 1 & 2) identified at risk for skin breakdown. The facility failed to notify the physician of changes to the skin integrity or obtain an order to treat the wounds for Resident #1. The facility was aware of the unavailability of bariatric briefs and left the residents without incontinent protection resulting in skin breakdown. This constituted actual harm. The facility failed to implement measures to prevent episodes of [DIAGNOSES REDACTED] for 1 of 13 Sampled Residents (#7) known to be at risk for [DIAGNOSES REDACTED]. This failure resulted in harm as the resident suffered an additional episode of unresponsiveness related to [DIAGNOSES REDACTED] placing the resident at risk for permanent brain damage and ultimately death. Findings include: SKIN BREAKDOWN Resident #1 Resident #1 was diagnosed with [REDACTED]. Interview with Resident #1 on 11/30/11 at 1:55 p.m. revealed the facility was out of disposable briefs for her size. The resident reported the back of her legs had open sores due to sitting on a urine soaked pad. When asked what the resident was using if briefs were not available the resident replied "nothing". The resident then raised her dress revealing no brief or undergarments. The resident sat on a reusable incontinent bed pad with a pillow case covering the pad draped over the side of the resident's bed where the resident sat. The resident said another resident a few rooms down was also out of disposable briefs. Observation of the resident's skin on 11/30/11 at 2:20 p.m. revealed dried, scabbed area on the back of the resident ' s right leg located between the ischium (Area where buttocks and leg meets) and back of the knee. The area was approximately 4 x 6 cm with scabs and dried yellow skin flaking around the pink, scabbed area. The left leg had two dressings on the back of the leg. Staff A removed the first dressing revealing a reddened area with raised areas (welt-like). Upon removing the second dressing a blistered, reddened area was noted approximately 8 x 4 cm. The fluid drained from the blister leaving a thin layer of clear, wrinkled skin covering the area. During the observation Resident #1 reported the open areas on her skin occurred as a result of sitting in urine. After the observation Resident #1 reported the area was painful and requested the Complaint Investigator ask the nurse to bring her a pain pill. Observation of clean utility closet on 11/30/11 at 2:05 p.m. revealed numerous bags of 2XL, XL and large pull-ups but no briefs. Interview with Anonymous Staff on 11/30/11 at 2:05 p.m. revealed Resident #1 did not wear pull-ups and the facility was out of briefs that fit the resident. The anonymous staff was unable to say how long the resident was without briefs. Subsequent interview with Resident #1 revealed the 2XL pull-ups were too small for the resident. Record review revealed no evidence of notification to the physician of the open areas on the skin or order to treat the wounds that were covered with dressings. Staff A indicated the recapitulation of orders for Resident #1 revealed an order to "Cover left inner thigh with Island Dressing, may also cover with night inner thigh as needed per resident request." There was no order for treating wounds on the back of the legs. Resident #1 reported on 11/30/11 of a log being used in her room to track when care is provided. On 12/01/11 Staff A confirmed that staff used a log when providing care. Review of the resident ' s log from 11/23/11 at 11:20 a.m. through 11/30/11 at 2:35 p.m. revealed on: ? 11/23/11 the resident did not receive personal care for more than six hours from 5:38 p.m. to 11:45 p.m. ? 11/24/11 the resident did not receive personal care for four hours from 11:40 a.m. to 3:50 p.m. From 3:50 p.m. to 7:30 p.m. ? 11/25/11 the resident did not receive personal care for seven hours from 6:10 p.m. to 1:15 a.m. on 11/26/11. ? 11/26/11 the resident did not receive personal care for six hours from 11:15 a.m. to 5:08 p.m. ? 11/27/11 the resident did not receive personal care for 11 hours from 1:20 p.m. to 12:30 a.m. ? 11/28/11 the resident did not receive personal care for 11 hours from 7:10 a.m. to 6:15 p.m. ? 11/29/11 the resident did not receive personal care for over eight hours from 5:00 a.m. to 1:45 p.m. RESIDENT #2 Resident #2 was diagnosed with [REDACTED]. Observation of personal care for Resident #2 on 11/30/11 at 2:45 p.m. revealed an open area on the resident's coccyx approximately 3 x 0.5 cm, open area on left ischium approximately 0.5 x 0.5 cm, open area on left hip area approximately 0.5 x 0.5 cm. The resident was without a brief with a draw sheet under her buttocks and a towel between her legs. There was no brief or other incontinent pad to wick away moisture leaving the resident lying in her own moisture on the sheet. Interview with Resident #2 0 11/30/11 at 2:45 p.m. revealed the facility ran out of her size of brief. The resident reported she was not wearing anything because the briefs and pads were not available. Resident #2 said, "They had me wearing the little briefs that were cutting into my skin. The nurse suggested I wear nothing." During the same interview the resident stated she used the bedpan while awake but was always incontinent when she slept. The resident said she usually wore attends with a pad under her. Interview with Anonymous Staff on 11/30/11 at 2:50 p.m. revealed Resident #2 usually wore a disposable brief and used a disposable pad when in bed. Interview with Staff B on 11/30/11 3:00 p.m. revealed the open areas on the resident resulted from briefs being "bunched" beneath the resident. Staff B said usually three briefs were laid open side by side under the resident with the middle brief pulled up between her legs because the resident was incontinent of urine when she slept or napped. The briefs became bunched under her buttocks causing skin breakdown. Review of the care delivery guide for Resident #2 revealed no guidance to staff for use of briefs. A note attached to the care delivery guide dated 10/28/11 instructed staff to use a draw sheet only instead of briefs to prevent skin breakdown since the resident was continent and used the bedpan. [DIAGNOSES REDACTED] Resident #7 was diagnosed with [REDACTED]. Record review of Resident #7 revealed the resident had an episode of [DIAGNOSES REDACTED] on 10/05/11 at 3:00 p.m. The resident was found unresponsive by Staff C and reported the incident to a nurse. Upon assessment the resident's blood glucose was 35 mg/dl. (blood sugars significantly low). Numerous interventions were used to raise the blood glucose to 66 mg/dl. Interview with Staff D on 12/01/11 at 6:00p.m. revealed the intervention implemented to prevent reoccurrence was to increase frequency the staff checked on the resident. Interview with Family Member on 12/02/11 at 11:30 a.m. revealed the day after the episode of [DIAGNOSES REDACTED] (10/06/11) she wanted to remove the resident from the facility because she did not feel the resident was checked enough. The facility agreed to check on the resident every hour and initiated a sign-in book. Record review revealed a grievance from the family member of Resident #7 dated 10/06/11 related to the resident not being checked enough. The action taken on the grievance form indicated increase in frequency of checking on the resident and initiation of care book. During the same interview the family member reported Staff C informed her Resident #7 had his lunch tray in front of him when Staff C entered his room. The family member said she found the resident received his insulin even though he did not eat his meal. Record review revealed on 10/09/11 Resident #7 suffered an episode of unresponsiveness related to [DIAGNOSES REDACTED]. The resident's blood glucose was 40 mg/dl. The resident's family was visiting when the incident occurred enabling the facility to respond immediately. The facility obtained an order to decreased the resident's insulin. Interview with Staff D on 12/01/11 at 6:00 p.m. revealed the incidents of [DIAGNOSES REDACTED] were not investigated.

Based on observation and interview the facility failed to provide care, and treat residents with dignity and respect by not providing bariatric briefs for 6 of 6 Sampled Residents (#s 1, 2, 3, 4, 5 & 6) and caused residents distress. This failure resulted in psychological harm as residents felt anguish and embarrassment related to lack of disposable briefs in their size and they remained without incontinent protection. This failure constituted actual harm. Findings include: RESIDENT #1 MDS assessment dated [DATE] indicated Resident #1 required extensive assistance with toileting. Resident had urinary incontinence. During an interview with Resident #1 on 11/30/11 at 1:55 p.m. a persistent foul urinary odor was noted. Resident #1 said the facility did not have disposable briefs to fit her. The resident stated she has been without briefs for what felt like two weeks. The resident also stated she was angry and felt stressed related to not having briefs and having to sit in the same spot on her bed to prevent from leaking urine. Refer to F309 Resident #1 related to resident's skin condition. RESIDENT #2 According to MDS (Minimum Data Set, an assessment tool used by the facility) dated 9/3/11 revealed Resident #2 was immobile, required extensive assistance with dressing, and toilet use. Resident had urinary incontinence (involuntary leakage of urine.) During an interview with Resident #2 on 11/30/11 at 2:45 p.m. the resident said "they are out of my size brief; I know my size is available they were able to get them in the hospital. They don't even have pads, I'm not wearing anything. It's embarrassing for me to not have a brief and lay here with a towel between my legs." Observation of personal care for Resident #2 revealed the resident only had a sheet beneath her buttocks and a towel between her legs. The resident had ointment on her buttocks area smeared on the sheet she lied upon. During the observation the resident stated she was able to use the bedpan while awake but she was incontinent while she slept or napped which is why she had the towel between her legs. RESIDENT #6 MDS assessment dated [DATE] indicated Resident #6 required extensive assistance with dressing, toilet use and daily hygiene tasks. This resident had urinary incontinence. Interview with Resident #6 on 12/01/11 at 4:55 p.m. revealed she was in bed for two days because the facility did not have briefs to fit her. The resident said it was frustrating because there was nothing she could do. The resident said the facility cut open the sides of pull-ups and then laid the pull-ups beneath her while she was in bed. Resident #6 said she was uncomfortable about moving in her bed due to the possibility of leaking urine. RESIDENT #5 MDS dated [DATE] indicated Resident #5 was immobile and required extensive assistance with toileting, personal hygiene and getting dressed. Resident #5 had urinary incontinence. Interview with Resident #5 on 12/01/11 at 1:30 p.m. revealed two nights earlier the facility ran out of briefs in her size and she had to use a pad. The resident stated she wore two sometimes three briefs because she voids heavily. The resident stated she worries about wetting her bed when she is not wearing the correct size brief. She said she usually waits until she has voided twice before she turns on her call light to notify the staff. She was afraid to go twice because she could wet her bed since the briefs were too small. RESIDENT #3 MDS dated [DATE] revealed Resident #3 was immobile, and always incontinent of urine . Resident required extensive assistance with dressing, personal hygiene and toilet use. Resident #3 stated on 11/30/11 at 2:20 p.m. the facility was out of briefs in her size. The facility provided her with pull-ups to use; however, the largest pull-ups the facility provided were too small. RESIDENT #4 MDS dated [DATE] revealed Resident #4 was totally depended on staff for mobility and required extensive assistance with toilet use, personal hygiene, and dressing. Resident was incontinent of urine. Resident #4 [DIAGNOSES REDACTED]. Interview with Resident #4 on 11/30/11 at 3:30 p.m. revealed the resident always wore briefs. The resident stated he had a brief on. Observation during the same interview revealed the resident lied in bed with his sweat pants pulled down revealing the resident was not wearing a brief. Interview with Anonymous Staff on 11/30/11 at 3:35 p.m. revealed the resident was to wear disposable briefs. Interview with Staff F on 11/30/11 at 5:00 p.m. revealed the facility ordered five cases of briefs of all sizes on 11/17/11. Staff F said the utility rooms were stocked daily and if the staff ran out of a particular size of brief they would inform her and she would get briefs from the storage room. If the facility ran out of a particular size they would get the briefs from a named sister facility. Interview with Staff G (central supply at the named sister facility) on 12/01/11 at 9:30 a.m. revealed no one from the facility contacted her for bariatric briefs. Staff E stated on 12/01/11 at 6:00 p.m. that the larger briefs were being used by residents as pads to put their feet on, to cover a table or wiping spills. The briefs were too expensive to be used for other than its intended purpose. Staff E mentioned the amount of money spent on disposable briefs. All six residents were morbidly obese requiring bariatric size briefs. The facility did not have a system of ensuring the correct size brief was available causing residents to not have incontinent supplies available and were left using pillowcases, towels and pads. Residents complained of embarrassment and anger related to not having briefs available or having to wear briefs too small for them. .

Based on interview and record review the facility failed to provide adequate medical services for 1 of 8 Sampled Residents (#1). This failure resulted in harm to the resident due to failure to follow orders to provide dressing changes as ordered by the surgeon and physician and failed to aggressively follow-up with physician when infection was noted. Findings include: Interview with Resident #1's Surgeon on 01/24/11 at 3:18 p.m. revealed Resident #1 arrived at an appointment on 01/21/11 disheveled and "filthy". The resident's stump was "in terrible shape, smelly and infected with no compression or ace wrap on the resident's stump." The need for compression to aid in the healing process of the stump was emphasized by the surgeon. The surgeon admitted the resident to the hospital on the same day to schedule him for surgery related to infection of the stump. Record review of surgical report dated 01/24/11 indicated Resident received revision of left BKA. Infected, necrotic (dead) tissue was removed, necrotic skin edges excised and the tibia (leg bone) shortened in order to close the skin. During the same interview on 01/24/11 the surgeon stated Resident #1 received a BKA on 12/16/10 without complications. He saw the resident again on 01/12/11 for removal of staples to the stump; the resident arrived from the facility without a dressing and with no compression to the stump as ordered. When the resident arrived at his subsequent appointment with the surgeon on 1/21/11 he was again not wearing compression on the stump. Interview with Family Member on 02/02/11 at 11:20 a.m. revealed she observed wound care on Resident #1 several times and never observed compression being applied to the stump, "They washed it off with a clear liquid then applied a band aid. The prosthesis guy brought in the compression bandage. He changed it then showed them how to wrap the leg. By then it was too late the leg was already infected. I don't think they knew how to take care of the leg". The family member reported the facility did not encourage the resident to elevate his leg until after the resident was seen at the hospital on [DATE]. Then the facility encouraged elevation and use of slide board. Interview with Prosthetist on 02/02/11 at 12:40 p.m. revealed on 01/18/11 the wound was observed open with steri strips in place and copious amount of drainage. There was no compression on the stump. There was an ace wrap loosely placed and not in the correct position so no actual compression was applied to the stump. The Prosthetist took pictures and forwarded them to the surgeon's office to prepare them for when the resident arrived for his scheduled appointment three days later. The Prosthetist returned to the facility the following two days to show the nursing staff how to properly wrap the resident's stump with compression. Record review revealed admission order dated 12/21/11 instructed staff to (1) change wound dressing to left BKA with [MEDICATION NAME] (stockinette) QOD (every other day) (2) order stump shrinker for left BKA. The order from the primary physician for the stump dressing change dated 12/23/10 indicated Kerlix with ace wraps with stockinette everyday until stump shrinker available. Review of TAR (treatment administration record) indicated on 12/23/10 (admission day) the treatment was changed to "change wound dressing to left BKA with Island Dressing ([MEDICATION NAME] surrounded by tape)." No evidence of a physician ordering the Island Dressing was located. No compression dressing for the stump was indicated on the TAR. According to Lippincott Manual of Nursing Practice 7th edition copyright 2001, compression is necessary to a new amputation to prevent [MEDICAL CONDITION], support circulation and promote healing, minimizes pain, reshapes the limb and permits the attachment of a prosthetic attachment. An article from Orthotics and Prosthesis Journal Volume 6 number 2 indicated compression is necessary to control [MEDICAL CONDITION] which is "inevitable in a postoperative limb" The inability to control [MEDICAL CONDITION] delays the rehabilitation process. Although there are many systems to control [MEDICAL CONDITION] the most common system for controlling [MEDICAL CONDITION] is with use of the elastic wrap bandage. Record review revealed on 01/12/11 the surgeon ordered (1) Keflex 500 mg tid (three times daily) (2) dressing changes on the [MEDICAL CONDITION] stump as follows: gently cleanse with saline, apply ABD dressings, soft cast padding role, and a six inch ace bandage. (3) as soon as this can be available, a compression sleeve should be applied to the left [MEDICAL CONDITION]. (4) Followup examination in one week. Record review of TAR for January 2011 revealed no evidence of any treatment to the wound stump for the month of January until 01/15/11, three days after the surgeon ordered the treatment. The facility was unable to provide evidence of any treatment routinely applied as ordered prior to 01/15/11. On 01/26/11 interviewed Staff D regarding Resident #1 receiving treatment to stump during the first two weeks of January. Staff D was unable to find evidence of the resident receiving wound treatment from 01/01/11 to 01/14/11. Interview with Resident #1 (resident was alert and oriented) on 01/25/11 at 8:15 a.m. revealed the facility did not provide daily treatment to his stump wound and he did not receive compression to his stump daily. Interview with Staff A on 01/26/11 at 1:30 p.m. revealed the resident's wound on his stump dehisced (opening of surgical wound). Staff A was able to describe the dressing applied to the wound after the resident was seen by the surgeon on 01/12/11. Resident #1 entered the facility after a BKA to receive rehabilitation and treatment to his wound. The facility changed the order for the treatment without notifying the physician. The new treatment order did not include compression to the stump. Witnesses indicated no observation of compression to the stump and the staff providing care to the wound had to be educated on the application of the compression. There was no consistent documentation of any treatment being applied to the stump during the first two weeks of January; a critical time since the resident presented with an infection.

Based on interview and record review the facility failed to provide consistent and thorough oral care for 1 of 9 Sampled Residents (#1) requiring assistance with ADLs (activities of daily living) and failed to provide a system for monitoring the delivery and refusal of oral care. This failure resulted in harm due to significant decline in oral hygiene and potential for pneumonia. Findings include: LACK OF PROVISION OF ORAL CARE Interview with Hospital Staff on 10/7/10 at 1:45 p.m. revealed Resident #1 admitted to the hospital on [DATE] with neglected oral care. The resident's teeth were described as "brown and black. The lower front teeth were covered with brown slime." The hospital staff provided oral care four or five times upon admission resulting in an improvement to the appearance of the resident's teeth. Observation of hospital photos of Resident #1's mouth revealed black and brown debris hanging from the upper teeth and stuck to the lower teeth, brown slime surrounded the lower teeth with significant tooth decay throughout the resident's mouth. The resident's lips contained dried film and skin peeling from the interior aspect of lips. The photos indicated the resident had not received regular oral care in the facility. Physical examination from the primary care physician dated 07/18/09 (one month after admission to the facility) indicated the resident presented with "fairly good oral hygiene." Confirming decline in condition of the resident's teeth. Hospital Social Work Assessment and Recommendations notes dated 9/24/10 revealed the resident's spouse reported the resident had not received oral care in weeks because "the girls are too busy." The resident's spouse reported the resident entered the facility with white teeth and he wondered why her teeth kept darkening. Record review of dentist progress note dated 9/16/10 revealed the dentist recommended the resident's teeth be brushed three to four times daily with a soft toothbrush and floss after each brushing. The resident's care plan updated 9/13 (no year indicated) directed staff to use toothettes for mouth care. On 9/16 (no year indicated) the care was updated to "encourage oral care 3-4 x day reapproach if res refused r/t pain." The same instructions were on the resident's care directive, no instructions for use of a toothbrush. Interview with Staff C on 10/08/10 at 2:20 p.m. revealed Resident #1's husband usually provided oral care for the resident as indicated by the husband asking for toothettes. Staff C reported using BMX (mouth numbing solution) then a toothette to clean the resident's teeth indicating no use of a toothbrush as ordered by the dentist. LACK OF MONITORING ORAL CARE Interview with Staff B on 10/08/10 at 2:40 p.m. reported the staff attempted to brush the teeth of Resident #1 using a soft toothbrush but the resident complained of mouth pain. Review of progress notes from 8/21/10 to 9/24/10 revealed only one documented note of the resident getting her teeth brushed dated 9/23/10; the documentation indicated the resident was found to have two loose teeth. The note also indicated the husband reported the teeth were loose for three or four months. No indication the facility was aware of the loose teeth prior to 9/23/10 although the husband was aware for several months. During same interview Staff B revealed the staff provided oral care using toothettes (single-use sponges swabs). Toothettes remove obvious debris from teeth but does not remove plaque and toothpaste is not used with toothettes. Without toothpaste the toothette is unable to remove oral bacteria due to the surface tension of the bacteria and unable to provide remineralization of teeth increasing the potential for cavities. During same interview Staff B stated the husband usually asked for toothettes and provided the oral care for the resident. However, no documentation of the resident refusing oral care from staff or of the husband providing oral care to the resident. Staff B indicated the nursing assistants documented care on the Care Tracker system (computer system). However, the care tracker system does not list oral care as a separate category and does not allow for narrative documentation. Ultimately there was no documentation of the resident refusing oral care. Interview with the resident's dentist on 10/07/10 at 1:30 p.m. revealed Resident #1 was there for a checkup on 9/16/10 but the resident refused to open her mouth and moved her head repeatedly preventing x-rays from being taken so an examination of her teeth was not conducted. The dentist said the last time the resident was seen was two years ago and there was no concern about the resident's teeth then. Review of progress notes indicated the resident complained of mouth pain on 9/10/10. The facility obtained on order for BMX (mouth numbing solution) before meals. There was no documentation of attempted oral hygiene after applying the solution. POTENTIAL PNEUMONIA RELATED TO LACK OF ORAL CARE Hospital Consultation note dated 9/25/10 indicated the resident presented with poor mouth care. The plan from the physician included "speech therapy eval and treat. Oral care. Take measures to avoid recurrent aspiration." Record review of hospital records dated 9/25/10 indicated Resident #1 admitted to the hospital with [REDACTED]. The Journal of the American Dental Association published an article (2006) indicating poor oral hygiene contributed to pneumonia due to the colonization of respiratory pathogens on the plaque of teeth. Literature from American Journal of Critical Care dated 12/2003 indicated poor oral care was associated with increase in [MEDICAL CONDITION] disease and cardiovascular diseases due to colonization of bacteria in the oral cavity. The same article indicated toothbrushes were more effective in plaque removal than toothettes. Documentation indicated the resident admitted to the facility with good oral health on 06/10/09. On 09/25/10 documentation from the hospital indicated the resident presented with "non-existent oral care." After Resident #1 complained of mouth pain a dental exam was scheduled. The resident's care plan and care directive did not instruct staff to use a toothbrush to clean the resident's teeth as instructed by the dentist. There was no documentation of any refusals of oral care by the resident. Photographs from the hospital revealed obvious neglect of oral care. The resident was hospitalized with pneumonia; literature supported an association between pneumonia and poor oral hygiene.

Based on interview and record review the facility failed to provide prompt and adequate pain relief for 1 of 9 Sampled Residents (#6). This failure resulted in harm due to lack of follow up of undelivered pain medication and notification to physician of severe pain resulting in hospitalization of resident related to pain. Findings include: Interview with IP1 (Interested Party) on 9/27/10 at 9:45 a.m. revealed Resident #1 admitted to the facility on [DATE] at 1:20 p.m. The resident underwent [REDACTED]. The resident brought a prescription for [MEDICATION NAME] (narcotic pain medication) with her to the facility. At 3:00 a.m., 14 hours after arriving in the facility, the resident was in extreme pain and requested [MEDICATION NAME]. The medication was not yet available. The resident called her POA (power of attorney) reporting severe pain then called an ambulance. IP1 stated the resident reported she experienced the most excruciating pain, 10 /10 on the pain scale (0= no pain, 10= most severe pain). The resident returned to the hospital for IV (intravenous) pain medication to control the pain. The resident did not return to the facility. Record review of progress notes indicated the resident complained of abdominal pain at 1:20 p.m. when she arrived in the facility but the facility had not received an authorization code for narcotic pain medication. No pain medication was provided. Record review of post acute care orders revealed Resident #6 received routine [MEDICATION NAME] sulfate (narcotic pain medication) for chronic pain. Progress note dated 9/18/10 11:00 p.m. indicated the facility had not received the resident's medication. Subsequent progress note at 2:00 a.m. revealed all medications arrived except for the resident's pain medication ([MEDICATION NAME] and [MEDICATION NAME]). Review of (MAR) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Progress note dated 9/19/10 at 4:00 a.m. revealed the resident was found sitting on the side of her bed at 3:00 a.m. crying. The nurse offered [MEDICATION NAME] only. At 3:35 a.m. the medics and interested party arrived to escort the resident to the emergency room for uncontrolled pain. Interview with IP1 on 9/27/10 at 9:45 a.m. revealed the resident called 911 due to the severity of her pain and IP1 coincidently arrived at the facility the same time as the ambulance. Interview with Staff A on 9/27/10 at 2:45 p.m. revealed the staff had difficulty filling the order for the narcotic pain medication due to problems such as quantity not being indicated and a requirement for the physician to call the pharmacy. Record review revealed the prescription had the quantity listed in addition to the physician's DEA (drug enforcement administration) number. The fax receipt indicated the prescription was faxed on 9/18/10 at 4:16 p.m., three hours after Resident #6 arrived at the facility. Progress notes did not indicate any follow-up with the pharmacy for the medication until 3:00 a.m. when the resident was crying from the pain. The progress notes did not indicate any intervention was taken to include notifying the physician. During interview on 9/27/10 at 2:45 p.m. Staff A stated the resident was given [MEDICATION NAME] earlier for pain; since the [MEDICATION NAME] was effective for pain relief the facility was not in a hurry for the narcotic pain medication. Record review revealed the resident received [MEDICATION NAME] on 9/18/10 at 5:45 p.m. for abdominal pain with a pain level of 8/10. There was no documentation of the effectiveness of the [MEDICATION NAME].