Every finding on record at Bridge Crest Post Acute

Based on interview and record review, the facility failed to ensure wound care treatments were provided as ordered for 1 of 4 sampled residents (Resident 1) reviewed for pressure ulcers [injuries to skin and underlying tissue resulting from prolonged pressure on the skin]. Resident 1 did not have wound care treatments for a left heel pressure ulcer completed for 5 days although signed off as completed by nursing staff. This failure placed residents at risk of infection, pain and poor clinical outcomes.Findings included. Review of the facility policy titled, Skin at Risk/Skin Breakdown, revised 09/2024, showed, It is the policy of this center that a resident who enters the center without pressure ulcer/injury does not develop pressure ulcer/injury unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure ulcer/injury receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident 1 was admitted to the facility on [DATE] with multiple diagnoses to include congestive heart failure (heart unable to pump blood efficiently], chronic kidney disease [kidneys are unable to filter blood efficiently], diabetes mellitus type II [too much sugar in the blood], atrial fibrillation [a common heart rhyme disorder], and multiple sclerosis [ a long term disease of the brain and spinal cord. According to the admission Minimum Data Set [MDS-an assessment tool] assessment dated [DATE], the resident had mild cognitive impairment. Record review of Resident 1's hospital discharge notes and physician order, dated 07/15/2026, showed an order reading, Wound Location; bilateral heels Topical Wound Care:Recommend using povidone iodine to wound(s) as anantibacterial and a desiccant to keep wounds dry. Additional Recommendations:Offloading Devices: Foam offloading boot(s) Record review of Resident 1's facility admission notes and physicians order, dated 07/15/2026, showed an order reading, Wound Location: bilateral heels. Recommend using povidone iodine to wound(s) as an antibacterial and a desiccant to keep wounds dry. Offloading Devices: Foam offloading boot(s) Record review of Resident 1's physician's order, date 07/19/2026, showed and order reading, WOUND CARE: LEFT HEEL1) Cleanse with wound cleanser unless eschar, [a dry dark leathery patch of skin that falls off or is removed from healthy tissue] becomes soft then use vashe, [a skin neutral, professional wound cleansing liquid)2) Apply skin prep to peri wound3) Paint eschar with betadine4) Place ABD [army battle dressing] pad and wrap in Kerlix5) Sign and Date Bandage Record review of Resident 1's Treatment Administration Record [TAR] for 07/19/2026, 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/24/2026, 07/25/206, 07/26/2026, and 07/27/2026 showed licensed nurse signatures for the completion of wound care for the left heel. Record review of Resident 1's initial wound assessment for the left heel, dated 07/21/2026, at 6:15 PM, completed by Collateral Contact (CC) 1, Physician's Assistant, showed, Wound: 1Location: Left HeelPrimary Etiology: Pressure Injury/UlcerSeverity: UnstageableGoal of Care: wound healingSize: 6 x 6 x 0 Wound area is 36. Wound volume is 0Wound Base: All escharExposed Tissues: NonePeriwound: Intact without signs of infectionExudate: No wound drainageWound Odor: none Record review of Resident 1's secondary wound assessment for left heel, dated 07/28/2026, at 4:36 PM, completed by CC 1, Physician's Assistant, showed,Wound: 1Left heel unstageable pressure injury is deteriorating with the softening or the eschar and mild separation from the wound bed. The wound dressing has not been consistently changed this week. Will continue Betadine with ABD pad and rolled gauze along with strict heel offloading. Continued pressure reduction and close monitoring for eschar instability remain important. Record review of Resident 1's progress notes on 07/28/2026 at 3:06 PM shows Staff E, Registered Nurse (RN) and Resident Care Manager (RCM) documented, During wound rounding it was noted that wound had not been completed on residents left heel since 7/22/2026 eve nurse. Wound provider assessed wound and determined minor deterioration noted to the wound. Photo obtained for weekly assessment and wound care provider per providers recommendations. Assistant Director of Nursing (ADON) and Director of Nursing (DON) made aware and will discuss with nurses involved, in-house provider made aware as well. In an interview on 08/12/2026 at 2:00 PM, Staff G, RN, said the evening of 07/27/2026 had been very busy and she accidentally signed off on the treatment and didn't complete it. In an interview on 08/12/2026 at 2:25 PM, Staff H, RN, said the treatment orders were misleading. She had worked a double shift that day and had completed wound care on the day shift and thought she was done with wound care for Resident 1. Staff H said she brought this to the attention of RCM and ADON. In an interview on 08/12/2026 at 3:02 PM, Staff E, RN, said she was present when the team did wound rounds on 07/28/2026 and found Resident 1's left heel dressing with a date of 07/22/2026. Nurses who had signed that treatment had been completed were re-educated and counseled. In an interview on 08/12/2026 at 03:45 PM, Staff F, Licensed Practical Nurse (LPN), said she and Staff E were doing wound rounds with the wound care provider on 07/28/2026 when they found Resident 1's left heel dressing with a date of 07/22/2026. The provider asked why the treatment hadn't been completed. In an interview on 08/12/2026, Staff A, Administrator, said he had anticipated a citation regarding this issue and processes had been put in place to prevent further incidents. Reference WAC 388-97-1060[3][b].

Based on interview and record review, the facility failed to ensure medications were provided to meet the immediate needs of 1 of 3 sampled residents (Resident 1) reviewed for pharmacy services when the resident's prescribed pain medication was unavailable following admission. The facility failed to utilize available medication access procedures or contact the provider for an alternative medication order. This failure placed the resident at risk for untreated pain and delayed medication administration.Resident 1 was admitted to the facility on [DATE] with diagnoses including intervertebral disc degeneration with back pain and lower extremity pain (degeneration of the discs between the bones of the spine that can cause back and leg pain).Resident 1's medication administration record (MAR) documented an order for oxycodone-acetaminophen 10/325 mg, one tablet every 8 hours as needed for pain related to intervertebral disc degeneration with back pain and lower extremity pain. The MAR documented this medication was not administered during Resident 1's stay on 7/11/2026 and 7/12/2026. A progress note dated 7/11/2026 at 11:21 PM documented Resident 1 reported severe neck pain due to spinal compression (pressure on the spinal cord or nerves). The note documented the pharmacy was contacted to request an estimated time of arrival for the medication and staff were advised the medication was expected to arrive around 12:00 AM. On 07/21/2026 at 12:00 PM, Collateral Contact A (CCA) stated Resident 1 had a prescription for oxycodone-acetaminophen for pain and did not receive the medication during her stay. CCA stated nursing staff advised there was an issue obtaining the medication from the pharmacy. CCA stated Resident 1 was in significant pain and was crying. CCA stated the family removed Resident 1 from the facility AMA approximately 24 hours after admission due to concerns regarding the resident's care, including Resident 1 not receiving the prescribed oxycodone-acetaminophen. On 07/23/2026 at 11:00 AM, Staff A, Registered Nurse/Director of Nursing Services (DNS), stated medications ordered for newly admitted residents are sent to the pharmacy for dispensing and delivery to the facility. Staff A stated that when an ordered medication is needed before delivery, nursing can contact the pharmacy to obtain a code to access available medications from the facility's automated medication dispensing system. Staff A stated nursing may also request immediate medication delivery from the pharmacy. On 07/23/2026 at 12:35 PM, Staff B, Registered Nurse, stated she provided care to Resident 1 during the evening shift on 07/11/2026. Staff B stated Resident 1 reported severe neck pain and the prescribed pain medication was not available. Staff B stated she contacted the pharmacy and was advised the medication was expected to arrive around midnight. Staff B stated she was unaware that narcotic pain medication could be accessed through the facility's automated medication dispensing system and was also unaware that she could contact the provider to obtain an alternative pain medication order when the prescribed medication was unavailable. Staff B stated she believed Resident 1's prescribed pain medication could not be administered until it arrived from the pharmacy. On 07/23/2026 at 1:40 PM, Staff A stated the medication was delivered to the facility shortly after Resident 1 had discharged AMA. Staff A stated that when the ordered medication was not available, the nurse could have contacted the pharmacy to obtain a code to access available medications from the facility's automated medication dispensing system. Staff A stated the ordered oxycodone-acetaminophen 10/325 mg was not available in the automated medication dispensing system; however, immediate-release oxycodone 5 mg and 10 mg were available. Staff A stated the nurse could have contacted the provider for an alternative order, including an order for available oxycodone with acetaminophen administered separately. Staff A stated this would have allowed Resident 1 to receive an alternative pain medication while awaiting delivery of the originally ordered medication. Reference WAC 388-97-1300

.Based on interview, and record review, the facility failed to ensure services provided met professional standards for 2 of 3 residents [Residents 1 and 2] when reviewed for quality of care. The facility failed to follow or document physician orders as indicated, and only sign for tasks completed. These failures placed residents at risk for unmet care needs, medical complications, inaccurate medical record, and a diminished quality of life. < Resident 1>Resident 1 was admitted to the facility 02/26/2026. The Minimum Data Set (MDS, an assessment tool), dated 03/05/2026, showed Resident 1 admitted with diagnoses that included Type 2 diabetes mellitus with neuropathy and left foot ulcer. The MDS documented Resident 1 was cognitively impaired and required assistance with activities of daily living. Prior to admission Resident 1 had undergone a first ray amputation, (a surgical procedure that removes the big toe and it's connecting long bone) to the left foot. A record review of the physician's orders, dated 04/24/2026, included an order for wound care to the left foot. The order read to change the dressing and reapply wound vac every Monday and Friday morning. A record review of a facility incident report, dated 05/18/2026, documented Resident attended podiatry appointment on 5/13/26. On the morning of 5/16/26, it was identified that the wound vac had not been reattached following the appointment and remained off the resident. Review indicated wound vac treatment had been documented as completed on 5/15/26. Wound vac was reapplied on 5/16/26 in am. A record review of the Treatment Administration Records (TAR) for May 15th, 2026, showed Staff F, Licensed Practical Nurse (LPN) signed for the administration of wound vac to Resident 1's left foot. In an Interview on 07/14/2026 at 3:25 PM, Staff D, RN, said Staff F, LPN, charted they applied the wound vac to Resident 1's foot on 05/14/2026. When Resident 1's wife came to visit on the weekend she found it was not on and notified the charge nurse. In an interview on 07/14/2026 at 4:30 PM, Staff B, RN/DNS said Staff F was given a final warning and placed on a performance improvement plan on 05/18/2026 for not applying wound vac on Resident 1 and documenting it had been completed. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The MDS, dated [DATE], documented Resident 2 was cognitively intact and required assistance with activities of daily living. A record review of the physician's orders, dated 04/21/2026, documented:Wound care: Bilateral Nephrostomy drain sites (tubes inserted into the kidney to drain urine). Cleanse with wound cleanser. Pat dry. Cover it with slit gauze. Flush Bilateral Nephrostomy tubes with 10cc Normal Saline.Empty bilateral nephrostomy drains every shift for Drain maintenance. Document amount of drainage. Record review of TAR, dated 04/24/2026 and 04/25/2026 for both day and evening shifts, showed Staff F's initial indicating emptying of nephrostomy tube. In the box requiring an amount for drainage there was a slash. Record review of facility Grievance/Concern Form for resident problem identification and follow up, dated 04/28/2026, documented Resident 2 reported nephrostomy tubes were not being drained routinely. In an interview on 07/14/2026 at 12:58 PM, Staff E, LPN, said that one of the reasons Staff F, LPN, was terminated was for charting treatments had been completed prior to completion of them. An example of this was for the treatments for Resident 2. Staff F was working a double shift and had signed that nephrostomy drains had been drained but in the space for the amount of drainage there was a dash, not an amount. When Staff E asked about this Staff F said they were working a double shift and would document the amount of drainage when they got the chance. In an interview on 07/14/2026 at 4:30 PM, Staff B, RN/DNS said Staff F was given a final warning and placed on a performance improvement plan on 05/18/2026 for not applying wound vac on Resident 1 and documenting it had been completed. Counseling, re-education, and scheduled audits for medication and treatment documentation were initiated. Initially there was noted improvement but as audits continued there was a decline in performance. Staff F, LPN's employment was terminated on 06/24/2026. Past noncompliance - the facility corrected the deficient practice prior to initiating the abbreviated survey on 06/24/2026. Reference WAC 388-97-1620 (2)(b)(I)(II)(6)(b)(I).

Based on interview and record review, the facility failed to notify the resident's legal guardian of the discovery of a medication omission and failed to notify the resident's legal guardian of the resident's transfer to the emergency department on 6/20/2026 for 1 of 3 sampled residents (Resident 1) reviewed for resident representative notification requirements. This failure placed residents at risk of their legal representatives being unable to participate in decisions regarding the resident's care and treatment.Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (condition that can cause persistent sadness), anxiety disorder (condition that causes excessive worry or fear) and history of cerebral infarction with residual deficits (blockage of blood flow to the brain that resulted in ongoing impairments). The Minimum Data Set, an assessment tool, dated 5/05/2026, documented the resident had moderate cognitive impairment. Review of an Interdisciplinary Team (IDT) note, dated 06/19/2026 at 11:50 AM, documented Provider inadvertently discontinued Resident 1's sertraline (medication for treatment of anxiety and depression) 5/26/2026.Restarted 6/18/2026. Monitoring for adverse side effects.On 07/14/2026 at 3:00 PM, Collateral Contact A (CCA) stated the facility did not notify them when Resident 1 did not receive sertraline for a period of several weeks and was not notified when Resident 1 was transported to the emergency department on 06/20/2026. CCA stated the facility had not notified her of Resident 1's transfer. CCA stated she attempted to contact the facility for additional information but did not receive a return call. On 07/15/2026 at 1:56 PM, Staff A, Registered Nurse/Director of Nursing Services, stated he did not notify Resident 1's guardian when he discovered Resident 1 had been without sertraline for approximately three weeks. Staff A stated he did not notify Resident 1's guardian when sertraline was restarted. Staff A stated he was unaware whether Resident 1's guardian had been notified regarding the emergency department visit on 06/20/2026.On 07/15/2026 at 2:05 PM, Staff B, Charge Nurse, confirmed that she had not contacted Resident 1's guardian and there was no documentation indicating Resident 1's guardian had been notified regarding the discontinuation of, the restart of sertraline, or the AV's transfer to the emergency department on 6/20/26.On 07/15/2026 at 3:00 PM, Staff A stated Resident 1's guardian should have been notified when the facility discovered that Resident 1 had been without sertraline for approximately three weeks and restarted the medication. DNS stated Resident 1's guardian should also have been notified when Resident 1 was transferred to the hospital on [DATE].Reference WAC 388-97-0320

.Based on observation, interview and record review, the facility failed to ensure staff provided meal service according to the facility's posted meal service schedule for 4 out of 4 meals [Breakfast served on 05/30/2026 and breakfast, lunch, and dinner meals served on 06/13/2026] reviewed for meal service. These failures placed residents at risk for not receiving their meals as scheduled, medical complications, and diminished quality of life. Findings included.Record review of a facility policy, titled, Mealtimes, undateed, showed Policy Interpretation and Implementation documented meals times were as follows: Breakfast 7:45-8:45Lunch 12:45-1:45Dinner 5:45-6:45 An observation on 06/11/2026 of the facility postings on bulletin boards on [NAME] Hall and Post Acute documented mealtimes as follows: Breakfast7:45 am to 8:45 am7:45 am Sunrise Dining Room8:00 am Transitional Care Unit Hall 18:15 am Transitional Care Unit Hall 28:30 am Expressions8:45 am [NAME] Cart Lunch12:45 pm to 1:45 pm12:45 pm Sunrise Dining Room1:00 pm Transitional Care Unit Hall 11:15 pm Transitional Care Unit Hall 21: 30 pm Expressions Hall and Dining Room1:45 pm [NAME] Hall Dinner5:45 pm to 6:45 pm5:45 pm Sunshine Dining Room6:00 pm Transitional Care Unit Hall 16:15 pm Transitional Care Unit Hall 26:30 pm Expressions Hall and Dining Room6:45 pm [NAME] Hall Review of department records showed on 06/01/2026 a reported concern was received alleging several residents had voiced concerns that on Saturday, 05/30/2026, breakfast had been two hours late. In an interview on 06/14/2026 at 2:30 PM, Staff C, Dietary Staff, said all the meal carts for Saturday, 06/13/2026, had come out late that day. Staff C explained breakfast had been prepared by the Dietary Manager. Staff C came in at 12:00 PM. The Dietary Manager was there for some of the day but in and out of the facility. The first lunch meal carts did not go out until 1:45 PM. The last lunch meal cart did not go out until 2:30 PM. Dinner carts started coming out at about 7:30 PM with last cart coming out after 8:00 PM. In addition, Staff C said that due to being short staffed and being rushed for time the tray line food temperatures were not taken. RESIDENT INTERVIEWSIn an interview on 06/11/2026 at 1:00 PM, Resident 1 said meals were late except when Staff D, Dietary Staff, was working. Resident 1 said they had talked with management. In an interview on 06/14/2026 at 2:00 PM, Resident 2 said lunch came out on 06/13/2026 at around 2:00 PM. They ae supposed to get their lunch at 1:00 PM. Dinner came out between 6:45 PM and 7:00 PM. Resident 2 emphasized, That's too late. We're all tired by then. In an interview on 06/14/2026 at 2:05 PM, Resident 3 said meals came out late on 06/13/2026. Lunch didn't come out until nearly 2:00 PM. Dinner didn't come out until 7:00 PM. In an interview on 06/14/2026 at 2:18 pm, Resident 4 said on 06/13/2026 breakfast came about 9:20 am to 9:30 am. Lunch came out about 2:30 PM to 3:00 PM. Dinner came out between 8:00 PM and 8:30 PM. Resident 4 said the mealtimes were too late. Especially dinner. Resident 4 explained they need time to digest their food before they go to bed otherwise it can upset their stomach. Resident 4 also expressed concerns with meals being on time for diabetic patients as blood sugars could run low. Resident 4 said this also affects medication administration times. In an interview on 06/14/2026 at 3:51 pm, Resident 5 said on 06/13/2026 breakfast came at about 9:30 AM, Lunch about 2:30 PM, and Dinner between 8:00 PM and 8:30 PM. STAFF INTERVIEWSIn an interview on 06/11/2026 at 2:30 PM, Collateral Contact 1, facility staff, said that over the past few weeks the timing of meal carts had gotten better, however initially it was not uncommon to have carts come out at least half an hour late.In an interview on 06/12/2026 at 11:25 AM, Collateral Contact 2, facility staff, said on 05/30/2026 they remembered the breakfast trays being late and residents being upset.In an interview on 06/12/2026 at 11:39 AM, Collateral Contact 3, facility staff, said they remembered breakfast being very late on 05/30/2026. This was the morning no one showed up in the kitchen. The management team had gotten together and started on breakfast. A cook showed up and took over.In an interview on 06/12/2026 at 12:30 PM, Collateral Contact 4, facility staff, said they remembered the breakfast trays on 05/30/2026 coming out very late. Collateral Contact 4 said there have been many complaints about food times, not just on 05/30/2026.In an interview on 06/12/2026 at 12:35 PM, Collateral Contact 5, facility staff, said they remembered breakfast being late on 05/30/2026 but doesn't think it was two hours.In an interview on 06/14/2026 at 12:35 PM, Collateral Contact 6, facility staff, said that on Saturday 06/13/2026 meal trays had come out late all day. The lunch trays for Transitional Care Unit due at 12:45 PM had not come out until 1:45 PM. This meant the residents on the other side of the facility didn't get their lunch until after 2:00 PM. This was difficult because lunch was coming out at change of shift when residents needed toileting and report out to the oncoming shift was supposed to start.In an interview on 06/18/2026 at 12:00 PM, Staff B, Dietary Manger, said the kitchen was very dated and it was a challenge to get meal trays out on time due to the lack of space in the kitchen for preparation. Staff B said the department was short-staffed and they were in the process of hiring additional staff.In an interview on 06/18/2026 at 1:30 PM, Staff A, Administrator, said they had been working on the dietary process and had several meetings. Staff A felt the timing of meal preparation and delivery was getting better. Staff A said they were in the process of hiring dietary staff, which had been challenging. Staff A said the facility was utilizing agency dietary staff during the process of recruitment and onboarding. Reference WAC 338-97-1120.

.Based on interview and record review the facility failed to ensure safe food preparation by not documenting food temperatures for 8 out of 18 meals reviewed for food safety. This failure placed residents at risk for food borne illness and decreased quality of life. Findings included. Findings included. Review of the facility's policy, titled, Food Borne Illness Prevention, dated August 2024, showed, POLICY: Dietary employees follow policy and procedures and best practices to prevent foodborne illnesses, prevent cross contamination, and maintain their establishment in a clean condition and in good repair. In an interview on 06/14/2026 at 2:30 PM, Staff C, Dietary Staff, when asked to provide tray-line temperature logs for timing as to when meals were served on 06/13/2026 said We usually check the temps [temperature], but I didn't do them yesterday due to lack of help and time. Record review on 06/14/2026 of tray line temperature logs, dated 06/08/2026 through 06/14/2026, documented there were no temperatures taken for breakfast and lunch meals on 06/13/2026, and no temperatures taken for evening meals on 06/08/2026, 06/09/2026, 06/10/2026, 06/11/2026., 06/12/2026, and 06/12/206. Record review on 06/16/2026 of tray line temperature logs submitted by Staff A on 06/16/ 2026, dated 06/08/2026 through 06/14/2026, showed documented temperatures for breakfast and lunch meals on 06/13/2026, and documented temperatures for evening meals on 06/08/2026, 06/09/2026, 06/10/2026, 06/11/2026, 06/12/2026, and 06/13/206. In an interview on 06/18/2026 at 11:45 PM, Staff A, Administrator, said that Staff B, Dietary Manager, had submitted the temperature logs to him on 06/16/2026. In an interview on 06/18/2026, at 12:00 PM, Staff B, Dietary Manager, when asked about the discrepancy of temperatures logged on Tray-line logs copied on 06/14/2026 and logs submitted on 06/16/2026 said, I was the one who recorded them. Staff B said he'd had paper all over the place with food temperatures on them and had transcribed them to the log when asked to submit them to Staff A. When asked if he could produce papers, he said, No they could be at home, but they are not here. In an interview with on 06/18/2026, at 1:30 PM, Staff A, Administrator, said when shown the temperature tray-line log copied on 06/14/2026 compared with the log submitted by Staff B on 06/16/2026, It appears the temperatures had not been taken. Reference WAC 388-97-1100[3].

Based on interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided for dependent residents for 3 of 4 sampled residents (Resident 8, 30 & 50) reviewed for ADL care. This failure placed residents at risk for poor hygiene, health complications and a diminished quality of life.Findings included .Resident 8 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set, (MDS, an assessment tool), dated 11/10/2025, documented Resident 8 was alert and oriented. Record review of Resident 8's bathing record, dated 10/30/2025 to 12/09/2025, documented one shower was provided on 11/18/2025, eighteen days after being admitted . Record review of Resident 8's Electronic Health Record (EHR), did not document a shower refusal or a reason for a shower not being offered. during this period. During an interview on 12/09/2025 at 10:32 AM, Resident 8 said he did not remember the last time he received a shower. Resident 30 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 30 was alert and oriented. Record review of Resident 30's EHR, dated 11/10/2025 to 12/09/2025, documented no showers were provided during this time period. Record review of Resident 30's EHR, did not document a shower refusal or a reason for a shower not being offered during this period. During an interview on 12/08/2025, Resident 30 said she had only received four showers since being admitted . Resident 30 stated, They make a plan for a shower, then I don't get one. Resident 50 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 50 was moderately cognitively impaired. Record review of Resident 50's EHR, dated 11/22/2025 to 12/09/2025, documented one shower administered on 12/01/2025. Record review of Resident 50's EHR, did not document a shower refusal or a reason for a shower not being offered during this period. During an interview on 12/09/2025 at 8:50 AM, Resident 50 said it had been a while since she showered and would like a shower. During an interview on 12/11/2025 at 10:15 AM, Staff O, Certified Nursing Assistant, said residents were offered a shower twice a week. Staff O stated if residents refused showers, we try to reapproach, and track the refusals. Staff O was unable to confirm the last time residents 8, 30 and 50 showered.During an interview on 12/11/2025 at 1:22 PM, Staff B, Director of Nursing Services/Registered Nurse said residents were offered showers during their allotted time. Staff B was unable to produce documentation showing completed showers, and/or refusals. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 4 of 16 sampled residents (Resident 1, 73, 3, & 6) reviewed for bed rails, pressure ulcer/injury, unnecessary medications, dental, and communication/sensory needs. This failure placed residents at risk for risk of injury, unmet care needs, and a diminished quality of life. Findings included. Bed rails Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 11/14/2025, showed Resident 1 was cognitively intact. In an observation and interview on 12/09/2025 at 9:20 AM, Resident 1's bed was observed with a one quarter length bed rail on the upper left side of bed. Resident 1 said he did not remember anyone talking to him about the bed rail. In an observation on 12/09/2025 at 2:05 PM, Resident 1 was observed lying in bed with a one quarter length bed rail on the upper left side of the bed. In an observation on 12/10/2025 at 9:15 AM, Resident 's 1 bed was observed with a one quarter length bed rail on the upper left side of the bed. In an interview on 12/10/2025 at 10:34 AM, Resident 1 said no one talked to him about putting a bed rail on his bed. Resident 1 said the bed rail was on the bed when he was admitted . Record Review of Resident 1's Comprehensive Care Plans, initiation dated 11/10/2025, did not show a Focus, Goal, or Intervention related to a bed rail. In an interview on 12/10/2025 at 11:14 AM, Staff F, Nurse Manager/Registered Nurse (RN) said if a resident had rails on their bed, they needed to have a care plan for the bed rails. Staff F said there was not a care plan for Resident 1's bed rail and there should have been. In an interview on 12/10/2025 at 1:18 PM, Staff B, Director of Nursing/RN, said the bed rail on Resident 1's bed should have been on his care plan. Pressure Ulcer/Injury Resident 73 was admitted to the facility on [DATE] with multiple diagnosis to include pressure ulcer (skin/tissue damage caused by prolonged pressure) of right buttock. The admission MDS, dated [DATE], showed Resident 73 was moderately cognitively impaired and had a pressure ulcer present on admission. Record review of Resident 73's NURSING - ADMISSION/readmission EVALUATION/ASSESSMENT, dated 11/29/2025, showed Resident 73 had a right buttock pressure skin issue. Record review of Resident 73's December 2025 Electronic Treatment Administration Record (ETAR) showed Resident 73 was receiving wound care to the right gluteal (buttock) pressure injury/ulcer daily and as needed. Record Review of Resident 73's Comprehensive Care Plans, initiation dated 12/01/2025, did not show a Focus, Goal, or Intervention related to skin and/or a pressure ulcer and/or injury. In an interview on 12/10/2025 at 10:55 AM, Staff M, Certified Nursing Assistant (CNA), said to get information for the care needs of a resident such as skin or wound care, assistance needed, and mobility, they used the Kardex (a nursing documentation system used to provide a summary of resident care needs). In an interview on 12/10/2025 at 10:59 AM, Staff F said after a resident admitted , the nurse would start the baseline care plan and the nurse managers would finish the comprehensive care plan making sure all the resident's diagnosis were covered. Staff F said the care plan populated the information on the Kardex for the CNAs. Staff F said if a resident had a skin concern or pressure wound, there would be a care plan addressing the skin. After looking at Resident 73's Electronic Health Record (EHR), Staff F said there was not a skin and/or pressure injury care plan and there should have been. In an interview on 12/10/2025 at 1:18 PM, Staff B said it was his expectation a care plan was in place for residents with a pressure injury. Unnecessary Medications Resident 3 was admitted to the facility on [DATE] with multiple diagnoses to include depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and lupus anticoagulant syndrome (an antibody [protein in your body made by your immune system] that makes you prone to blood clots). The admission MDS, dated [DATE], showed Resident 3 was cognitively intact and was taking antipsychotic (drugs used primarily to treat symptoms such as hallucinations and delusions), antidepressant, and anticoagulant (drugs that slow down the blood clotting process) medications. Record review of Resident 3's physician orders, dated 11/17/2025, showed Resident 3 was prescribed Lurasidone (an antipsychotic medication) 20 mg (milligrams) daily. Further review of Resident 3's physician orders showed the Lurasidone increased to 40 mg daily on 11/26/2025 and decreased back to 20 mg daily on 12/03/2025. The November 2025 and December 2025 Electronic Medication Administration Record (EMAR) showed Resident 3 was receiving Lurasidone daily. Record review of Resident 3's physician orders, dated 11/17/2025, documented Resident 3 was prescribed Apixaban (an anticoagulant) 5 mg twice daily. The November 2025 and December 2025 EMAR showed Resident 3 was receiving Apixaban twice daily. Record review of Resident 3's Electronic Health Record (EHR) provider notes, dated 12/03/2025, documented an additional diagnosis, .Generalized anxiety disorder [a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things] | Active | 12/03/2025. Record review of Resident 3's physician orders, dated 12/03/2025, documented Resident 3 was prescribed Clonazepam (a medication used to treat anxiety) 0.5 mg (milligrams) every 12 hours as needed. The December Electronic Medication Administration Record (EMAR) showed Resident 3 received Clonazepam on 12/06/2025 and 12/09/2025. Record review of Resident 3's physician orders, dated 12/04/2025, documented Resident 3 was prescribed Fluoxetine (a medication used to treat depression) 10 mg daily. The December 2025 Electronic EMAR showed Resident 3 received Fluoxetine 10 mg daily beginning 12/05/2025. Record Review of Resident 3's Comprehensive Care Plans, initiation dated 11/18/2025, did not show a Focus, Goal, or Intervention related to psychotropic medication (medications that affect the mind, emotions, and behavior) use. Record Review of Resident 3's Comprehensive Care Plans, initiation dated 11/10/2025, did not show a Focus, Goal, or Intervention related to Anxiety and/or anxiety diagnosis. Record Review of Resident 3's Comprehensive Care Plans, initiation dated 11/18/2025, did not show a Focus, Goal, or Intervention related to lupus anticoagulant syndrome and/or anticoagulant medication use. In an interview on 12/11/2025 at 3:05 PM, Staff F said there should be a care plan in place for residents taking anticoagulant medication and psychotropic medications, like an antidepressant, antianxiety, and antipsychotic. After looking at Resident 3's EHR, Staff F said she did not see any care plan addressing psychotropic medication use and there should have been. Staff F further said there was not a care plan for Resident 3's diagnosis of anxiety and there should have been. Staff said she did not see a care plan related to anticoagulation medication use and indicated there should have been. In an interview on 12/11/2025 at 4:09 PM, Staff B said it was his expectation residents on psychotropic medications had a care plan in place addressing the medication use and a diagnosis of anxiety. Staff B further said he expected there was a care plan in place for anticoagulation medication use. Dental/Communication Resident 6 was admitted to the facility on [DATE]. The Quarterly MDS dated , 11/23/2025, indicated Resident 6 was alert and oriented. In an interview on 12/08/2025 at 3:18 PM, Resident 6 indicated he had a partial upper denture plate and natural lower teeth. Record review of Resident 6's Electronic Health Record (EHR) showed no care plan indicating Resident 6 had a removable upper denture plate. In an interview on 12/09/2025 at 11:15 AM, Staff G, Nursing Assistant, said that the Kardex would show items such as dentures/partials. Staff G was unable to locate information on the Kardex for Resident 6 indicating that he had a removable upper denture plate. Staff G said she was not aware that Resident 6 had partial teeth. In an interview on 12/11/2025 at 10:02 AM, Staff H, Registered Nurse and MDS Nurse said they completed the resident assessments on each resident, and the Resident Care Manager (RCM) was responsible to care plan anything specific to the residents. Staff H said she was not required to care plan findings from her assessments. In an interview on 12/11/2025 at 11:25 AM, Staff B said he would expect the care plan to indicate if patients had dentures or partial teeth. Communication In an interview on 12/08/2025 at 3:18 PM, Resident 6 indicated that he was hard of hearing (HOH) and asked for the speaker to come around to the left side of the bed so that he could hear better. Resident 6 said he had nerve damage to both ears from work around jet engines. Resident 6 stated that he had hearing aids at home but had not brought them into the facility. Record review of Resident 6's EHR showed no care plan indicating he was HOH or used any type of assistive device for communication. In an interview on 12/09/2025 at 11:15 AM, Staff G said the Kardex would show items such as hearing aids or devices. Staff G was unable to locate information on the Kardex for Resident 6 indicating a hearing deficiency or use of any type of communication device. Staff G said she thought that Resident 6 had trouble hearing because of the oxygen machine in his room. In an interview on 12/11/2025 at 10:02 AM, Staff H said they completed the resident assessments on each resident, and the RCM was responsible to care plan anything specific to the residents. Staff said she was not required to care plan findings from her assessments. In an interview on 12/11/2025 at 11:25 AM Staff B said he would expect the care plan to reflect hearing deficiencies and devices used for communication. Reference WAC 388-97-1020(1)(2)

Based on interviews and record review, the facility failed to initiate bowel interventions for 1 of 7 residents (Resident 30) reviewed for bowel management and failed to obtain accurate weights for 3 of 9 residents (Resident 12, 41 & 50). This failure placed residents at risk for discomfort, experiencing health complications and a diminished quality of life.Findings included . Record review of the facility policy, titled, Bowel Protocol, revised February 2019, documented: At the beginning of each shift, the Licensed Nurse will pull the Resident Bowel Management Report and identify residents that have not had a BM [bowel movement] for 3 days. The Licensed Nurse will review the residents' MAR (Medication Administration Record) to determine if the PRN [as needed] Bowel Protocol had been initiated by the previous shift. Bowel movements are charted every shift by the CNA. - Residents who have not had a bowel movement in three days, will be given Milk of Magnesia [laxative, a medication to help produce a bowel movement]. - If no bowel movement by the following shift, a Dulcolax suppository [laxative] is given. - If resident continues without a bowel movement by the next shift, a Fleets enema [laxative] will be given. Bowel Management Resident 30 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 11/10/2025, documented Resident 30 was alert and oriented. Record review of Resident 30's Bowel Movement (BM) task sheet, dated November- December 2025, showed documentation of Resident 30's BM activity on 11/11/2025 at 1:40 PM. Resident 30's next BM was documented on 11/18/2025 at 9:45 AM, approximately 164 hours since the last BM. Record review of Resident 30's BM task sheet, dated November- December 2025, showed documentation of Resident 30's BM activity on 11/18/2025 at 9:45 AM. Resident 30's next BM was documented on 11/22/2025 at 7:29 AM, approximately 93 hours since the last BM. Record review of Resident 30's BM task sheet, dated November- December 2025, showed documentation of Resident 30's BM activity on 11/23/2025 at 4:48 PM. Resident 30's next BM was documented on 12/03/2025 at 8:55 AM, approximately 243 hours since the last BM. Record review of Resident 30's Electronic Health Record (EHR), dated November- December 2025, did not show documentation of bowel interventions from 11/18/2025- 12/12/2025. In an interview on 12/11/2025 at 2:36 PM, Staff P, Registered Nurse, stated, Our expectation is to administer something on day 3. If not working, then Milk of Magnesia is the second choice. Staff P said the administration is then documented in the MAR. Staff P stated, this was not done. During an interview on 12/11/2025 at 1:22 PM, Staff B, Director of Nursing Services (DNS)/Registered Nurse said it was his expectation for staff to follow the Bowel Protocol per facility policy. Staff B was unable to produce documentation of successful bowel interventions for Resident 30. Weights Record review of the facility policy, entitled Weight monitoring and Documentation revision date 03/2025 documented: Weekly weights will be documented for a minimum of 4 weeks following admission and for residents at nutrition risk as determined by the dietitian and nutrition risk review. Resident 12 was admitted to the facility on [DATE] with multiple diagnoses to include Congestive Heart Failure (condition where the heart can't pump enough blood to meet the body's needs). The 5-day admission MDS, dated [DATE] indicated Resident 12 was moderately cognitively impaired. Record Review of Resident 12's EHR documented the following physician's order, dated 11/27/2025: One time a day for weights related to UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE (I50.20) for 4 Weeks. Record Review of Resident 12's EHR, showed 1 weight recorded since admission, on 11/28/2025. Resident 12's EHR did not show any additional documentation of weights being taken as ordered. Resident 50 was admitted to the facility on [DATE], with multiple diagnoses to include Congestive Heart Failure. The Quarterly MDS, dated [DATE], documented Resident 50 was mildly cognitively impaired. Record Review of Resident 50's EHR documented the following physician's orders, dated 09/12/2025: One time a day for weights related to UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE (I50.20) for 4 Weeks. Record Review of Resident 50's EHR documented the following physician's orders, dated 12/3/2025: Check weight daily and report to provider for > [greater than] 3lb [pounds] weight gain in 2 days or 5lb weight gain in 1 week. Record Review of Resident 50's EHR, showed one weight recorded since admission, on 11/24/2025. Resident 50's EHR did not show any additional documentation of weights being taken as ordered. In an interview on 12/10/2025 at 10:37 AM, Staff Q, Certified Nursing Assistant (CNA), said the Nursing Assistants do the weights. Staff Q stated, after we weigh, we put in the weight into the chart. In an interview on 12/10/2025 at 1:52 PM, Staff G, CNA, said the CNA's view a physical list of residents needing to be weighed. Staff G stated, We weigh the residents and put the number into the chart. During an interview on 12/11/2025 at 1:22 PM, Staff B, DNS, said it was his expectation for staff to weigh and document residents' weights as ordered. Resident 41 was admitted to the facility on [DATE] for rehabilitation services and wound care. The 5-day MDS, dated [DATE], indicated Resident 41 was alert and oriented. Record review of Resident 41's EHR showed one weight recorded on 11/19/2025. Record review of Resident 41's EHR showed a nutrition assessment dated [DATE], which documented Resident 41 was underweight and had a documented pressure ulcer. In an interview on 12/11/2025 at 2:30 PM with Staff J, Dietician, said she reviewed weights weekly at a nutrition at risk meeting they attend in person. Staff J said she would give the facility a list of weights needed on a flowsheet. Staff J said she would wait for the weights to be done and sent back to her. Staff J said she was only able to locate one weight in Resident 41's EHR. Staff J said that Resident 41 should have been weighed weekly since admission. Staff J said she did not have a flowsheet indicating the need for a weight to be obtained by staff from the weekly nutrition at risk meetings. In an interview on 12/11/2025 at 1:22 PM, Staff B said it was his expectation for staff to weigh and document residents' weights as ordered. WAC 388-97-1060(1)

Based on observation, interview, and record review the facility failed to accurately assess oral care status and communication needs for 1 of 20 residents (Resident 6) reviewed for accuracy of assessments. This failure placed residents at risk of having unmet needs, ineffective communication and a diminished quality of life. Findings included .Resident 6 was admitted to the facility on [DATE] after a hospitalization. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/23/2025, indicated Resident 6 was alert and oriented and had no oral care devices or concerns; and indicated no hearing impairment or devices.In an interview on 12/08/2025 at 3:18 PM, Resident 6 indicated he had an upper partial denture plate that needed repair. Resident 6 said he had natural lower teeth.In an interview on 12/11/2025 at 10:02 AM, Staff H, Registered Nurse/MDS Nurse, said she did not think Resident 6 had teeth. Staff H said she does a face-to-face interview with the residents during their assessment. Staff H said she had completed the assessment and incorrectly coded the MDS.Communication In an interview on 12/08/2025 at 3:18 PM, Resident 6 indicated that he was hard of hearing (HOH) and asked for the speaker to come around to the left side of the bed so that he could hear better. Resident 6 said he had nerve damage to both ears from work around jet engines. Resident 6 stated he had hearing aids at home but had not brought them into the facility. Record review of Resident 6's electronic health record, dated 05/20/2025, showed a diagnosis of hearing loss in both ears.In an interview on 12/11/2025 at 10:02 AM, Staff H said she did not think Resident 6 had a hearing deficiency. Staff H said she tended to talk loud and maybe did not notice the hearing deficiency. Staff H said they were aware Resident 6 used a hearing amplifier device at times to communicate. Staff H said she had completed the assessment and incorrectly coded the MDS.In an interview on 12/11/2025 at 11:25 AM Staff B, Director of Nursing/Registered Nurse, said he would expect the MDS assessment to be accurate and reflect the specific needs of the residents. Reference WAC 388-97-1000(1)(b)

.Based on observations, interviews, and record reviews, the facility failed to ensure adequate living space was available for 1 of 3 residents (Resident 41) reviewed for accommodation of needs/preferences. This failure placed residents at risk of restricted mobility and potential for a decreased quality of life.Findings included.Resident 41 was admitted to the facility on [DATE] for rehabilitation services. The 5-day Minimum Data Set, an assessment tool, dated 11/18/2025, indicated Resident 41 was cognitively intact.In an interview on 12/08/2025 at 11:16 AM, Resident 69 said that he gets tired of his roommate (Resident 41) backing his wheelchair into his bed when trying to open the room door to leave. Resident 69 said that the room is too small for 3 patients in wheelchairs.During an observation on 12/08/2025 at 11:35 AM, Resident 41 was attempting to transfer from his bed into his wheelchair. Resident 41 was unable to move the wheelchair closer to his bed due to his tray table obstructing the path. Resident 41 turned on his call light to have staff move the table so he could transfer into the wheelchair. Resident 41 then demonstrated how difficult it was to get out of his room. Resident 41 backed his wheelchair into the room's door to close it. Resident 41 was then able to roll out from between the bed and the wall which was obstructed by the open door. Resident 41 said it is extremely difficult to navigate the room because of how the room is arranged.In an observation and interview, on 12/11/2025 at 11:15AM, Staff B, Director of Nursing, looked at Resident 41's room and said it did look cramped and probably could be set up better. WAC 388-97-0860(2)

Based on interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for 1 of 20 residents (Resident 30) whose care plans were reviewed. These failures placed residents at risk for unidentified/ unmet care needs and a diminished quality of life.Findings included .Resident 30 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 11/10/2025, documented Resident 30 was alert and oriented. Review of Resident 30's physician's order, dated 09/17/2025, documented Resident 30 was using a BiPAP [Bilevel Positive Airway Pressure, Non-invasive ventilation used for breathing support]. Review of Resident 30's comprehensive care plan, initiated 09/17/2025, showed no care plan was developed to address Resident 30's BiPap. During an interview on 12/12/2025 at 12:22 PM, Staff R, Resident Care Manage/Registered Nurse, said residents can bring their own medical equipment, which was assessed for residents' use and care planned. Staff R stated, Her care plan was never changed from cPAP [Continuous Positive Airway Pressure, Non-invasive ventilation used for breathing support] to BiPap. That would not be best practice. During an interview on 12/12/2025 at 1:22 PM, Staff B, Director of Nursing Services/ Registered Nurse said Resident 30's biPap should have been care planned. Reference WAC 388-97-1020(2)(c)(d)

Based on interview and record review, the facility failed to provide resident centered activities incorporating the resident's preferences for 3 of 3 sampled resident (Resident 7, 14 & 62) reviewed for activities. This failure placed residents at risk of unmet needs and a decreased quality of life.Findings included.Record review of facility's policy, titled, Activity Programs, revised June 2018, documented, .2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.Record review of facility's activities calendars from September 2024 through December 2025 did not show any resident bus outings.Resident 7Resident 7 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/14/2025, documented Resident 7 was alert and oriented.In an interview on 12/08/2025 at 11:35 AM, when asked about activities she enjoyed, Resident 7 stated, there is a bus, and they don't use it. Would be nice to just get out. Resident 7 said the facility had not offered opportunities to go out into the community. Resident 14Resident 14 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 14 was alert and oriented. Record review of Resident 14's care plan, dated 09/10/2025, documented, .Activities: Resident 14 enjoys Bingo, reading on her tablet, cards, family visits, word-search and crossword puzzles, listening to Old Country music, pet visits, trips/outings, walking and watching Old Shows and action on TV. Alert and orient .In an interview on 12/08/2025 at 3:21 PM, when asked what activities the facility offered, Resident 14 stated we used to get a bus ride to the park, but it has been a year. Resident 62Resident 62 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 62 was alert and oriented.In an interview on 12/10/2025 at 9:15 AM, Resident 62 stated, we used to go for outings, sometimes to the lake but not anymore. In an interview on 12/11/2025 at 10:20 AM, when asked if the facility offered and/or provided residents opportunity to go out into the community, Staff N, Activities Director, said there had not been outings on the activities calendar since September 2024. Staff N said that after the new company took over, the bus previously used was being used by the Oregon facilities. In an interview on 12/11/2025 at 3:59 PM, Staff A, Administrator said the bus that was in use under the previous facility owner was being used by sister facility in Portland.Reference WAC 388-97-0940(1)(2)

Based on observation, interview, and record review, the facility failed to obtain a Bed Rail/Bed Enabler and Device Consent and Evaluation for 1 of 4 sampled residents (Resident 1) reviewed for accidents. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life.Findings included. Record review of the facility's policy, titled, Physical Restraints and Enablers/Devices, date revised July 2023, documented, .a. Devices may include but are not limited to the following: i. Bed rails (quarter, 1/2, 3/4 full) .5. The resident and/or resident representative is provided risks/benefits of restraint use or enabler/device use, and consent obtained prior to implementation of the device.6. The care plan is updated for the device use with the goal for the least restrictive measures. The Kardex is updated to identify restraint or enabler use and identifies other interventions put into place addressing the medical symptoms, environmental, safety, and psychosocial concerns. Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (an assessment tool), dated 11/14/2025, showed Resident 1 was cognitively intact. In an observation and interview on 12/09/2025 at 9:20 AM, Resident 1's bed was observed with a one quarter length bed rail on the upper left side of bed. Resident 1 said he did not remember anyone talking to him about the bed rail. In an observation on 12/09/2025 at 2:05 PM, Resident 1 was observed lying in bed with a one quarter length bed rail on the upper left side of the bed. In an observation on 12/10/2025 at 9:15 AM, Resident 's 1 bed was observed with a one quarter length bed rail on the upper left side of the bed. In an interview on 12/10/2025 at 10:34 AM, Resident 1 said no one talked to him about putting a bed rail on his bed. Resident 1 said the bed rail was on the bed when he was admitted . Review of Resident 1's Electronic Health Record (EHR) showed no Bed Rail/Bed Enabler and Device Consent and Evaluation related to bed rails was completed. Record Review of Resident 1's Comprehensive Care Plans, initiation dated 11/10/2025, did not show a Focus, Goal, or Intervention related to a bed rail. In an interview on 12/10/2025 at 11:14 AM, Staff F, Nurse Manager/Registered Nurse (RN), said for residents that used assistive devices like bed rails, they needed to have an evaluation and consent, and care plan in place. After looking at Resident 1's EHR, Staff F said she did not see an evaluation, consent, or a care plan for Resident 1's bed rail and there should have been. In an interview on 12/10/2025 at 1:18 PM, Staff B, Director of Nursing/RN, said it was his expectation an evaluation, consent, order, and care plan was in place for bed rails on a resident's bed. Reference WAC 388-97-0260

Based on interview and record review, the facility failed to ensure routine pain medication was acquired timely for 1 of 6 residents (Resident 53) reviewed for pain management. This failure placed residents at risk for increased pain and diminished quality of life. Findings included .Resident 53 was admitted to the facility on [DATE] with diagnosis including chronic pain. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/12/2025, documented Resident 53 was alert and oriented and was almost constantly in pain which occasionally interfered with her day-to-day activities.Record review of Resident 53's physician order, dated 10/02/2025, showed Buprenorphine Transdermal Patch [pain medication] Weekly 20 MCG/HR [micrograms/hour] (Buprenorphine) Apply 1 patch transdermally in the evening every Thu [Thursday] for chronic pain and remove per schedule.Record review of Resident 53's electronic medication administration record (EMAR) did not show Buprenorphine transdermal patch was administered on Thursday December 4th, 2025, as scheduled. In an interview on 12/09/2025 at 10:02 AM, Resident 53 said she did not receive her Buprenorphine pain patch the previous week (12/04/2025) and had not received it since. Resident 53 rated her pain at 10/10 at the time of the interview. In an interview on 12/10/2025 at 2:44, Staff L, Registered Nurse (RN), said if a medication was not available in the cart, the nurse would pull it out of Omnicell (medication dispenser) or call the pharmacy to have it delivered immediately. Staff L said the missed medication would be documented in the EMAR and the oncoming nurse would be made aware to follow-up on its delivery. In an interview on 12/10/2025 at 3:14 PM, Staff B, Director of Nursing/RN, reviewed Resident 53's 12/04/2025 EMAR and said Buprenorphine was not signed off as administered. Staff B said it was his expectation that if a medication was not available, the EMAR was signed off, the provider notified and staff coordinated with pharmacy to have the medication delivered. Reference WAC 388-97-1300(1)(a)

Based on interview and record review, the facility failed to administer medications as directed by the physician's orders for 2 of 5 residents (Resident 4 & 32) reviewed for unnecessary medications. This failure placed residents at risk for increased side effects and a diminished quality of life.Findings included. Resident 4 Resident 4 was admitted to the facility on [DATE], with multiple diagnoses to include Type 2 Diabetes Mellitus with Hyperglycemia (condition where the body either doesn't make enough insulin or can't use insulin properly). The Quarterly Minimum Data Set (MDS, an assessment tool), dated 09/19/2025, showed Resident 4 was alert and oriented. Record Review of Resident 4's physician order, dated 11/13/2025, showed Insulin Glargine Subcutaneous Solution 100 UNIT/ML [milliliter] (Insulin Glargine) Inject 17 unit subcutaneously in the morning related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) HOLD FOR BG< [blood glucose less than] 100. Record review of Resident 4's December 2025 electronic medication administration record (EMAR) showed Resident 4 received Insulin glargine on 12/07/2025 with 82 BG,12/08/2025 with 82 BG, and 12/09/2025 with 86 BG. In an interview on 12/11/2025 at 3:26 PM, Staff B, Director of Nursing and Registered Nurse (RN), Reviewed Resident 4's insulin order and December 2025 EMAR and said insulin was administered on 12/07/2025, 12/08/2025 and 12/09/2025 outside the order parameters to hold the medication. Staff B said it was his expectation that staff held the medication and notified the provider. Resident 32 Resident 32 was admitted to the facility on [DATE] after hospitalization. The Quarterly MDS, dated [DATE], indicated Resident 32 was alert and oriented. Record review of Resident 32's EHR showed a physician order, dated, 07/30/2025, for oxycodone (narcotic pain medication) to be administered between the hours of 9:00 PM and 6:00 AM for pain not relieved by scheduled medication. Resident 32's Medication Administration Record (MAR) showed oxycodone given on 12/01/2025 at 10:48 AM, 12/08/2025 at 2:25 PM, and 12/09/2025 at 12:53 PM which was outside of the physician's time parameters. In an interview on 12/11/2025 at 3:45 PM, Staff I, Registered Nurse/Resident Care Manager said the order indicated oxycodone should only be administered between the hours permitted in the order. Staff I said the nurses must not have been reading the entire order for the directions. In an interview on 12/12/2025 at 11:34 AM with Staff B said he was not aware of the medication administration discrepancy in Resident 32's MAR. Staff B said he would expect the nurses to follow the physicians' orders. Reference WAC 388-97-1060(3)(k)(i)

Based on interview and record review the facility failed to provide a written bed hold notice (a way for the resident to reserve their bed when away from the facility) at the time of transfer or within 24 hours for 1 of 1 sampled residents (Resident 77) reviewed for hospitalization. This failure placed the residents at risk for not being informed of their right to hold their bed while in the hospital, protection of resident rights during transfer, and decreased quality of life.Findings included .Record Review of the facility's Bed Hold Policy and Procedure, dated 08/01/2024, documented, The resident and/or resident representative is informed of this policy in writing upon admission, transfer or leave of absence. If unable to provide at the time of transfer or leave of absence, the policy is provided within 24 hours. It also said, . If nursing is unable to provide notification at time of transfer or discharge the Social Services Director or designee contacts the resident and/or resident representative to notify them of facility policy and obtain a decision.Record review of Resident 77's admission Minimum Data Set (MDS- an assessment tool), dated 08/18/2025, documented Resident 77 was admitted on [DATE] and assessed as alert and oriented.Record review of Resident 77's Progress Notes, dated 09/22/2025, stated, .Due to decreased O2 stats [oxygen saturation] and no orders for breathing treatments res [resident] sent out via 911 EMTs. 0210 [by emergency transport at 2:10 am].Record Review of Resident 77's Electronic Medical Records showed no documentation of a written Bed Hold Notice at the time of transfer or within 24 hours.Record Review of Resident 77's Nursing Home Discharge MDS, dated [DATE], documented Resident 77 had an unplanned discharge on [DATE] with return anticipated.In an email correspondence on 12/10/2025 at 4:15 PM, Staff A, Administrator, stated, As for [Resident 77's] bed hold, we looked but it appears that one was missed.In a joint interview on 12/12/2025 at 11:15 AM, Staff B, Director of Nursing/Registered Nurse (RN) and Staff F, Nurse Manger/RN, said when a resident was transferred to the hospital they should be sent with a bed hold form that included the cost to hold their bed and the resident's decision. Staff B and Staff F said if a resident was transferred to the hospital emergently, the manager and/or Social Services would take care of the bed hold form the next day. Reference WAC 388-97-0120 (4)

Based on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 2 of 5 sampled residents (Resident 3 & 4) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life.Findings included. Review of the facility's policy titled, Psychotropic Medications [drugs that affect a person's thoughts, emotions, and behaviors] – AIMS, revised March 2019, documented, .1. Licensed staff will assess all residents receiving antipsychotic medications and Reglan [a medication that carries a risk of developing severe movement disorders] at a minimum: On admission Prior to initiation of a new antipsychotic or Reglan Every 6 months while receiving the medication . Resident 3 was admitted to the facility on [DATE] with multiple diagnoses to include depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission MDS (Minimum Data Set, an assessment tool), dated 11/24/2025, showed Resident 3 was cognitively intact and was taking antipsychotic medication. Record review of Resident 3's physician orders, dated 11/17/2025, showed Resident 3 was prescribed Lurasidone (an antipsychotic medication) 20 mg (milligrams) daily. Further review of Resident 3's physician orders showed the Lurasidone increased to 40 mg daily on 11/26/2025 and decreased back to 20 mg daily on 12/03/2025. The November 2025 and December 2025 Electronic Medication Administration Record (EMAR) showed Resident 3 was receiving Lurasidone daily. Review of Resident 3's Electronic Health Record (EHR) did not show documentation of an AIMS test completed for the administration of Lurasidone. In an email (electronic mail) on 12/11/2025 at 2:19 PM, Staff A, Administrator, said it did not appear there was an AIMS test completed for Resident 3. In an interview on 12/11/2025 at 3:05 PM, Staff F, Nurse Manager/Registered Nurse (RN), said an AIMS test was not done prior to the administration of Resident 3's Lurasidone and there should have been. Staff F said she just learned about the AIMS test and did not know it was supposed to be done. In an interview on 12/11/2025 at 4:09 PM, Staff B, Director of Nursing/RN, said it was his expectation an AIMS test was completed for residents taking antipsychotic medications. Resident 4 Resident 4 was admitted to the facility on [DATE], with multiple diagnoses to include borderline personality disorder (a mental health condition). The Quarterly MDS, dated [DATE], showed Resident 4 was alert and oriented. Record review of Resident 4's physician's order for psychotropic medication, dated 12/18/2024, showed Cariprazine HCl [hydrochloride salt] Oral Capsule 3 MG [milligram]. Give 3 mg by mouth at bedtime for clear thoughts. related to BORDERLINE PERSONALITY DISORDER (F60.3). Record review of Resident 4's EHR shows an AIMS test titled B. ABNORMAL INVOLUNTARY MOVEMENT SCALE (AIMS) - V 2.1 completion date of 03/28/2025, 6 months after cariprazine was started. In an interview on 12/11/2025 at 3:26 PM, Staff B said AIMS tests were completed for residents on antipsychotics on admission and every 6 months. When asked if an AIMS test was completed for Resident 4, Staff B reviewed Resident 4's EHR and said the first documented AIMS test was completed on 03/28/2025. Staff B said the AIMS test was not done on admission, and it should have been. Reference WAC 388-97-1060(3)(k)(i)

Based on observation and interview, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure the Electronic Health Record (EHR) for 1 of 4 medication cart computers (Number Two medication cart) reviewed for privacy and confidentiality. This failure placed residents at risk for loss of confidential medical information and a diminished quality of life.Findings included.In an observation and interview on 12/10/2025 at 2:43 PM, in the Expressions dining room, the Number Two medication cart computer screen was observed open and unlocked displaying the Point Click Care (PCC, a healthcare software platform, offering an EHR to manage clinical, financial, and operational aspects) access page logged in. No nursing and/or facility staff were observed within view of the medication cart and computer. A resident was observed sitting alone in the dining room six feet away from the medication cart and computer. A visitor was observed to walk into the Expressions dining room while the computer was unlocked, and no staff were present. After 1 minute, Staff D, Licensed Practical Nurse, and Staff E, Registered Nurse (RN), entered the Expressions dining room. When asked about the computer on top of the Number Two medication cart open and unlocked to PCC access without staff in view, Staff E said the computer should have been locked. Staff D nodded his head yes and said the computer should have been locked. Staff E stepped over and locked the computer screen. In an interview on 12/10/2025 at 2:50 PM, Staff C, Director of Clinical Services/RN, said it was her expectation computer screens were covered, minimized, or locked when no staff were present so no one could access resident's medical records. In an interview on 12/10/2025 at 2:55 PM, Staff B, Director of Nursing/RN, said a computer screen should be locked when no nurse was present.Reference WAC 388-97-0360 (1) (2)

Based on interview and record review, the facility failed to obtain written consent prior to administering psychotropic medications (medications that affect the mind, emotions, and behavior) for 2 of 5 residents (Residents 3 & 4) reviewed for unnecessary medications. This failure placed residents at risk of not being informed of psychotropic medication risks and benefits and a decreased quality of life.Findings included . Record review of the facility's policy titled, Psychoactive Medications, undated, documented, 2. On admission the resident's medication regimen is reviewed for psychoactive medication orders. a. Prior to the administration of psychotropic medication, consent is obtained from the resident or resident representative. 4. The risks/benefits of the drug use and informed consent is obtained from resident/resident representative prior to administration of any psychoactive medication initiation or dose increase. Resident 3 was admitted to the facility on [DATE] with multiple diagnoses to include depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission MDS (Minimum Data Set, an assessment tool), dated 11/24/2025, showed Resident 3 was cognitively intact and was taking antidepressant medication. Record review of Resident 3's Electronic Health Record (EHR) provider notes, dated 12/03/2025, documented an additional diagnosis, .Generalized anxiety disorder [a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things] | Active | 12/03/2025. Record review of Resident 3's physician orders, dated 12/03/2025, documented Resident 3 was prescribed Clonazepam (a medication used to treat anxiety) 0.5 mg (milligrams) every 12 hours as needed. The December 2025 Electronic Medication Administration Record (EMAR) showed Resident 3 received Clonazepam on 12/06/2025 and 12/09/2025. Review of Resident 3's EHR did not show documentation of an informed consent completed for the administration of Clonazepam. Record review of Resident 3's physician orders, dated 12/04/2025, documented Resident 3 was prescribed Fluoxetine (a medication used to treat depression) 10 mg daily. The December 2025 Electronic EMAR showed Resident 3 received Fluoxetine 10 mg daily beginning 12/05/2025. Review of Resident 3's EHR INFORMED CONSENT - Psychoactive Medication, dated 12/09/2025, showed Resident 3 gave consent for Fluoxetine on 12/09/2025, four days after the medication was started. In an interview on 12/11/2025 at 3:05 PM, Staff F, Nurse Manager/Registered Nurse (RN), said an informed consent was needed prior to a resident starting a psychotropic medication. Staff F said Resident 3 did not have a consent for Fluoxetine completed when it started on 12/05/2025. Staff F said Resident 3 should have signed consent before he started taking the Fluoxetine. In an interview on 12/11/2025 at 4:09 PM, Staff B, Director of Nursing/RN, said it was his expectation residents on psychotropic medications have consents signed prior to administration of the medication. In an interview on 12/12/2025 at 9:22 AM, Staff B said a consent was not completed for Resident 3's Clonazepam and there should have been. Resident 4 Resident 4 was admitted to the facility on [DATE], with multiple diagnoses to include borderline personality disorder (a mental health condition). The Quarterly MDS, dated [DATE], showed Resident 4 was alert and oriented. Record review of Resident 4's physician's order for psychotropic medication, dated 12/18/2024, showed Cariprazine HCl [hydrochloride salt] Oral Capsule 3 MG [milligram]. Give 3 mg by mouth at bedtime for clear thoughts. related to BORDERLINE PERSONALITY DISORDER (F60.3). Record review of Resident 4's EHR did not show a psychotropic medication informed consent form completed prior to administration of cariprazine. Record review of Resident 4's EHR showed a signed consent form titled, *INFORMED CONSENT - Psychoactive Medication - V 4.0, dated 06/23/2025, 6 months after cariprazine was initiated. In an interview on 12/11/2025 at 3:26 PM, when asked if Resident 4 had a signed consent for cariprazine, Staff B reviewed Resident 4's EHR but was unable to locate an informed consent for when the cariprazine was started on 12/18/2025. Staff B said it was the expectation that an informed consent for the psychotropic medication was signed prior to the medication being administered. Reference WAC 388-97-0260

Based on interview and record review, the facility failed to consistently assess, monitor, and provide wound care treatments as ordered to existing pressure ulcers for 1 of 3 residents [Resident 1] reviewed for pressure ulcers. Resident 1 experienced harm when the residents left heel wound became malodorous, excessive fluid discharge, developed a maggot (fly larvae) infestation that required hospitalization and antibiotic treatment and placed the resident at risk of decreased quality of life. Findings included.Record review of the National Library of Medicine article, titled, Maggot Infestation: Various Treatment Modalities, dated 03/30/2018, showed the invasion of the skin and subcutaneous (under the skin) tissue by larvae (maggot) was known as maggot infestation. Maggot infestation was a condition in which fly maggots feed off and develop in the tissues of a living person or animal. This results from flies laying eggs in or on the tissue. 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) within eight to 12 hours. Infestation can cause infection, pain, and psychological distress associated with having a maggot infestation. Record review of the facility policy, titled, Skin at Risk/Skin Breakdown, dated June 2025, documented, Within 8 hours of admission a licensed nurse examines resident's entire body to determine if skin impairment is present. Upon admission, skin at risk and any actual skin impairment is identified and interventions are considered to prevent further breakdown.Resident 1 was admitted to the facility on [DATE] at 3:45 PM with diagnoses to include osteomyelitis [an infection of the bone occurring when bacteria or other microorganisms enter the bone tissue and cause inflammation and damage], chronic ulcers [wound or sore] to both heels, and vascular dementia [confusion due to reduced blood flow to the brain]. Review of the admission Minimum Data Set [MDS-an assessment tool] assessment, dated 09/06/2025, showed Resident 1 was cognitively impaired. Record review of a Resident 1's hospital note, dated 08/25/2025, showed Resident 1 had the following diagnoses: Acute on Chronic Bilateral Lower Extremity Heel Ulcerations with Osteomyelitis, Bilateral Lower Extremity Venous Insufficiency, Left heel was Unstageable and right heel was stage 3. Under the Musculoskeletal section, it showed Resident 1 had tenderness to bilateral heels with unstageable pressure injury of the left heel, and stage 3 on the right heel. Record review Resident 1's admission orders, dated 08/30/2025, showed Resident 1 admitted with no orders for antibiotics. Record review of Resident 1's admission assessment and skin evaluation, dated 08/30/2025 at 11:43 PM, and completed by Staff C, Licensed Practical Nurse (LPN), showed, Pressure wounds to the right and left heels. In section 1e. of the skin assessment, meant for description of wounds, Staff C's documentation showed, Dressings changed by [the hospital] on 08/30/25. Record Review of Resident 1's physicians orders, dated 08/31/2025, showed an order reading, Wound Care: Bilateral Heels; Every morning. Change dressings every morning. Use betadine [an antibacterial solution used to kill germs to prevent infection] moistened gauze and cover with a dry dressing daily. Keep heels offloaded [positioning to alleviate pressure] at all times. This order was to be completed once a day on the day shift until 09/03/2025 when it was switched to once a day on the evening shift. Record review of Resident 1's Treatment Administration Record [TAR], dated 08/31/2025, showed no signature for the administration of treatment to right and left heel wounds were completed. Record review of Resident 1's TAR, dated 09/04/2025, showed a nurse signature with code 2 indicating Resident 1's refusal of treatment to bilateral heels. Record review of Resident 1's TAR, dated 09/05/2025, showed a signature for Staff D, Registered Nurse (RN), for the administration of treatment to right and left heel wounds. Record review of Resident 1's progress notes, dated 09/07/2025 at 4:13 PM, showed Staff E, RN, documented, This LN found maggots on left heel pressure ulcer during dressing change, foul odor present, no c/o [complaint of] pain. On call provider notified, order to send out to hospital for evaluation. Picked up by ambulance at 4:24 pm, Resident Care Manager and family notified.Record review of Resident 1's hospital notes, dated 09/07/2025, showed Resident 1 admitted to the hospital due to chronic lower extremity wounds with concerns for maggots in the bilateral feet wounds. According to the emergency room provider, they had to remove maggots from Resident 1 upon arrival to the emergency department. While in the hospital, Resident 1 was prescribed oral and IV (intravenous) antibiotics for their bilateral lower extremity heel wounds with osteomyelitis.Record review of Resident 1's re-admission hospital notes titled Active Issues dated 09/08/2025, showed the following:Acute on Chronic Bilateral Lower Extremity Heel Ulcerations, Osteomyelitis, Bilateral Lower Extremity Venous Insufficiency .Patient was hospitalized 08/25[/2025] through 8/30[/2025] .Patient was discharged to SNF [Skilled Nursing Facility] .Patient returned to ED [emergency department] with worsening bilateral foot wounds. Wounds appeared not to have been cared for and were full of maggots .Large bilat[eral] heel wounds with drainage, necrotic [dead tissue] appearing tissue. Multiple wounds over bilat[eral] LE [lower extremity's] Record review of Resident 1's investigation surrounding the finding of maggots to the left heel wound, dated 09/16/2025, showed conclusion documentation from Staff B, RN/Director of Nursing Services, as follows:Missed opportunity to take wound pictures. Missed opportunity to complete wound evaluation. Missed opportunity to round daily and ensure wound care was being completed according to standards. Missed opportunity to ensure transition into Skilled Nursing Facility was successful and that wound care standards were upheld. In an interview on 09/10/2025 at 10:50 AM, Collateral Contact 1 (CC1), Resident 1's daughter, said her mother's cognitive status had declined with all that had happened. Her mother had only been at the nursing facility for a little over a week when she was sent back to the hospital. On 09/06/2025 when she arrived to visit her mother there was a putrid smell. At one point she saw a fly land on her bedding. The next day she received a call from the facility informing her they were sending her mother to the hospital because they had found maggots in her wound. In an interview on 09/19/2025 at 4:00 PM, Staff F, Licensed Practical Nurse (LPN) and Resident Care Manager (RCM), said that upon admission the nurse would complete an admissions assessment including a skin assessment and document findings. Staff F said the process had recently been refined. When a resident was admitted on an evening shift or during the weekend, the RCM would follow up with initial photographs and measurements of the wounds, weekly photographs and measurements of wounds, make sure wound orders were documented correctly, and treatments were being completed. Staff F explained the nurses on the evenings and weekend shifts did not have access to the camera used to take photographs and measurements of wounds. When asked if measurements and/or photographs had been completed for Resident 1 during their stay at the facility, Staff F said no, they had not. In an interview on 09/21/2025 at 2:36 PM, Staff E, RN, said she had been off for three days, had come back to work on Sunday 09/07/2025, went to complete the treatment for Resident 1 around 2:30 PM and found maggots in the left heel wound. Staff E said she had last changed Resident 1's dressing on 09/03/2025 and there had been no signs of maggots. Staff E said she remembered a therapist requesting Resident 1's dressing to be changed as it was weeping (wound with excessive fluid discharge). In an interview on 09/21/2025 at 4:22 PM, Staff G, Nursing Assistant Certified (NAC), said she only worked at the facility two days per week. Staff G stated, When she [Resident 1] admitted the week before she was okay. Alert and a little confused but perky. When I saw her the next Sunday (09/07/2025), I knew something was off. She wasn't perky and there was an odor. Her roommate commented on it, and I checked her to see if she'd had a BM [bowel movement]. She hadn't. I knew something was up. I thought it was her wound. I told the nurse, and she went in and did the treatment and found maggots. In an interview on 09/22/2025 at 1:05 PM, Staff H, Physical Therapist (PT), said she had seen Resident 1 twice on Wednesday 09/03/2025. In the morning the bandages to Resident 1's heels had been soaked as were the moon boots (therapeutic boots utilized to offload pressure to heels). Staff H requested the bandages be changed by the nurse and sent the moon boots to the laundry. When Staff H went back in the afternoon that bandages had been changed. Staff H said the bandages to bilateral heels were frequently soaked and the odor was very bad. In an interview on 09/22/2025 at 1:23 PM, Staff I, PT, said she cared for Resident 1 on 09/04/ 2025. Staff I said Resident 1's bandages were always soaked. It was as if the nurse would change them and they immediately became soaked again. When asked what type of dressing covered the wounds, Staff I said gauze was wrapped around the dressings placed on the wounds. Staff I said the smell was terrible. In an interview on 09/23/2025 at 3:29 PM, Staff D, RN, said she had been at the facility the evening of 09/05/2025 and was doing admissions. She left at approximately 8:00 PM. A nurse had called off and there were three nurses to pass medications and complete treatments. Staff D said she signed for all of the treatments for Cart 4 but did not do them. She informed the three nurses at the facility she had signed off on them so it was one less thing they had to do but they would need to pitch in together to help get the treatments completed. In an interview on 09/25/2025 at 1:30 PM, Resident 1 said the staff at the facility did not change the dressings on her feet very often. She said there were flies there. In an interview on 09/25/2025 at 1:35 pm, Collateral Contact 2, (CC2) Resident 1's son, said that on 09/01/2025 Resident 1 called him to bring in a fly swatter because there were many flies. CC2 added that on 09/06/2025, the day before Resident 1 was sent back to the hospital, his sister came and brought an air freshener and applied Mentholatum [ointment with a strong menthol smell] beneath her nose because the odor was so bad. In an interview on 10/17/2025 at 12:51 pm, Staff C, LPN, said he remembered the evening of 09/06/2025. Staff F had been doing admissions. There had been a nurse who called off sick. Staff F informed Staff C she had signed off for and completed all the treatments on his wing. Staff C said he had been grateful because they were short staffed. Staff C said he did not change the dressings for Resident 1 that evening. Later he learned that Resident 1 was found with maggots in her left heel wound.In an Interview on 11/07/2025 at 12:25 pm, Staff C stated, When [Resident 1] first admitted there was not an odor. This developed over time.In an interview on 10/27/2025 at 3:45 pm, Staff B, RN/Director of Nursing Services, said it was his expectation that when a resident was admitted to the facility, a total body assessment was to be completed, and this would include a skin assessment. The purpose was to know what the resident was coming in with and therefore the needs of the resident so they could be monitored and treated accordingly. Reference WAC 388-97-1060 [3][b]

Based on interview and record review, the facility failed to address a new skin pressure injury, timely notify the provider, and timely implement wound treatment orders for 1 of 1 sampled residents (Resident 1) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Resident 1 experienced harm when they developed a facility acquired pressure ulcer which deteriorated prior to staff obtaining timely orders for wound treatment and pressure reduction modalities. This failure placed residents at risk for development and/or worsening of wounds, medical complications, and a diminished quality of life. Findings included . Review of the facilities policy entitled, Skin at Risk/Skin Breakdown, revised 09/2020, showed procedure #5: Upon discovery of newly identified skin impairment (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound, etc.), the licensed nurse will: Notify the physician and obtain a treatment order if needed, document on the Treatment Administration Record (TAR) after implementation. The policy section entitled, Treatment/Management, showed #1: The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and applications of topical ointments. Resident 1 was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes with diabetic polyneuropathy (too much sugar in the blood causing loss of feeling), and hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side (stroke that caused loss of movement). The annual Minimum Data Set assessment, dated 01/12/2025, showed Resident 1 required assistance with activities of daily living and required substantial to maximum assistance with turning and repositioning in bed. Review of a nurse progress note, dated 03/13/2025, documented Resident 1 had an open wound on their right buttock measuring 2 centimeters (cm) X 4 cm and another purple area that looked like it was going to open up laterally to it measuring 10 cm x 1 cm. Resident 1's right heel was black on the outside approximately 6 cm X 6 cm, the skin on the outside of her shin going up from the heel was warm and red. The writer noted they cleaned the wound on Resident 1's bottom and put a border dressing on it, but they [wounds] need to be assessed, and wound orders put in. Review of a nurse progress note, dated 03/14/2025, documented, Photo taken and placed in chart. Wound care also done at this time. Review of a nurse progress note, dated 04/01/2025 and referred to as a late entry from 03/17/2025, documented, Showed wound care physician resident's right foot and sacral area. We were placing a foam 6x6 on sacral area and zinc. Heels to be floated. The sacral area continue to treat with a cover and zinc. No written order was completed until 04/01/2025. Review of Electronic Medical Record (EHR) physician orders showed no orders were written for wound treatment or pressure reduction mattress until 04/01/2024, 20 days after wounds were identified. Review of EHR progress notes showed no notes were written for wounds identified on 03/13/2025 until 04/01/2025, 20 days after wounds were identified. Review of March 2025 and April 2025 Treatment Administration Record (TAR), from 03/13/2025 to 04/02/2025, showed no treatment was signed for until 04/01/2025, 20 days after wounds were identified. On 04/08/2025 at 3:00 PM, Staff C, Registered Nurse (RN), said if nurses identified a wound, it was their responsibility to make sure providers were notified, an order was received and noted, and residents were placed on alert status. On 04/23/2025 at 11:01 AM, Staff D, Licensed Practical Nurse (LPN), said the nursing assistants reported Resident 1's skin condition to her and she took measurements and made a progress note. Staff D said they did not notify the provider, obtain an order, or make a note on the TAR. Staff D said this was the responsibility of the wound nurse or Resident Care Manager (RCM). At 11:57 AM, Staff F, LPN, RCM, said they learned of Resident 1's wound by accident when the facility wound nurse and wound care provider were doing rounds. They had been asked to assist and note orders. The therapeutic mattress was ordered at that time. Staff F said the wounds were unstageable (dark black tissue indicative of loss of blood flow) at that time. At 1:20 PM, Staff F, LPN and Wound Nurse, said they had not written or noted orders. Staff F said they used house standing orders and completed treatments when on duty. At 2:15 PM, Staff B, DNS, said it was her expectation when licensed staff identified a wound, they reported it up the ladder, so the entire health care team was aware of the issue. The expectation was to make a progress note, place residents on alert status, and obtain an order for treatment and pressure reduction as applicable. On 04/25/2025 at 12:33 PM, Staff G, LPN, said she had completed measurements and a progress note for Resident 1. Staff G said the progress note, called a tiger text, sent a message to the healthcare team consisting of the RCM, Director of Nursing (DNS), and the provider. Staff G said she did not receive an order but placed a dressing on the wounds per nursing judgment. Staff G said she did not place Resident 1 on alert status. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 1 sampled residents (Resident 1) reviewed for significant medication errors. Resident 1 experienced harm when they received two doses, of 10 times the ordered amount, of a blood thinner medication that resulted in hospitalization with three hematomas (bleeding within a muscle group) and transfusion of one unit of packed red blood cells. This failure placed residents at risk for a significant medication error, medication side effects and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis affecting one side of the body) and transient ischemic attach (temporary interruption of blood flow to the brain). A review of the hospital discharge orders, dated 01/24/2025, showed Resident 1 to receive Enoxaparin (also called Lovenox, an injectable blood thinner that prevents and treats blood clots) 30 milligram (mg)/0.3 milliliter (ml) syringe give 0.3 ml subcutaneously (sq--under the skin) once daily in the evening for deep vein thrombosis (clot) prevention. Resident 1's January 2025 Medication Administration Record (MAR), dated 01/24/2025, showed the resident was to receive Enoxaparin Sodium Injection Solution 300mg/3ml inject 3ml sq in the evening for deep vein thrombosis prevention. The MAR showed Resident 1 was administered 3ml (10 times the amount ordered) of Enoxparin Sodium Injection Solution subcutaneously on 01/25/2025 and 01/26/2025. A review of the hospital records, dated 01/27/2025, documented Resident 1 received 10 times the dose of Lovenox on 01/25/2025 and 01/26/2025. Resident 1 had a right gluteal (buttock) IM (intramuscular) hematoma (bleeding within a muscle group) 12 x 4.5 cm with extension across right hemipelvis (half of the pelvis), right posterior chest wall IM hematoma 5.3 x 2.4 cm and left posterior (toward the back of the body) wall IM hematoma 9.1 x 2.9 cm. Resident 1 had gradual anemia (body losing blood cells) requiring 1 unit of packed red blood cells. On 02/24/2025 at 1:25 PM, Staff A, Director of Nursing Services, said the order from the hospital showed to give 0.3ml of Lovenox sq, but the order was entered in by medical records as 3ml of Lovenox sq. Staff A stated, It [med error] was missed by everyone, including pharmacy. Medical records missed it. The nurse checking the orders, after they were put in, missed it. The Resident Care Manager (RCM) missed it. And then two nurses ended up giving it before it was discovered by another nurse coming in . Pharmacy sent a multi dose vial and the nurses drew up 3ml instead of 0.3ml syringes of Lovenox. On 03/06/2025 at 12:56 PM, Staff B, Medical Records, said when placing Hospital orders into the computer, she goes down the list of medication orders and enters them into the facility system. If she has any questions or concerns regarding any of the orders, she will not put those orders in and will place a note for nursing. Staff B said she was familiar with some common medications and dosages, but was not familiar with Lovenox. Staff B said she could not tell that 3ml, as opposed to 0.3ml, of Lovenox was an uncommon dosage so she did not leave a note for nursing to review. At 12:56 PM, Staff C, Licensed Practical Nurse, said normally she would check the ordered one by one and check it with the orders from the hospital. Staff C stated, I was really busy that day. I messed up and I just activated all the orders. At 3:24 PM, Staff D, RCM, said he was still in training and had no experience as an RCM. Staff D said he did not believe he had checked the orders until the day they had already found the medication error. Reference WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to ensure timely laboratory services were provided for 1 of 1 sampled residents (1) reviewed for laboratory services. Resident 1 experienced a critically elevated white blood cell (WBC) count and was sent to the emergency department with increased swelling and discomfort in both lower legs and left arm. This failure placed residents at risk for delay in treatment and a diminished quality of life. Findings included . Resident 1 was readmitted to the facility on [DATE] with diagnoses including Chronic Myelomonocytic Leukemia, a rare blood cancer originating in the bone marrow and is characterized by an overproduction of white blood cells. The Minimum Data Set assessment, dated 12/26/2024, showed resident was cognitively aware and required moderate assistance with activities of daily living. The hospital discharge orders, dated 12/20/2024, documented, Future lab orders at Skilled Nursing Facility [SNF]. Complete by 12/27/2024, Completed Blood Count, [CBC], and Basic Metabolic Panel [BMP]. A review of Resident 1's electronic medical record showed the hospital discharge orders had not been noted and the lab draw had not been completed by 12/27/2024. A physician order, dated 12/31/2024 at 7:15 AM, showed Resident 1 was to have a lab draw for a CBC and BMP to be completed for three consecutive days, on 12/31/2024, on 01/01/2025, and on 01/02 2025. Resident 1's December 2024 and January 2025 Medication Administration Record (MAR) showed the lab draw, ordered on 12/31/2024, was signed as completed on 12/31/2024 only. The results of the 12/31/2024 lab draw were not located in Resident 1's medical record. Resident 1's medical record showed a lab draw for CBC and BMP was completed on 01/03/2025 at 10:48 AM. A laboratory report showing the lab draw results, dated 01/03/2025 at 12:55 PM, identified abnormal values including a critically elevated WBC count of 47.4. (a normal WBC count range is 3.8-10.1.) The report for Resident 1 documented to repeat analysis with a new blood sample. The January 2025 MAR showed Resident 1 did not have any orders for the lab draws to repeat analysis of CBC and BMP on 01/04/2025 and 01/05/2025. A physician order, dated 01/06/2025 at 11:15 AM, was written for a lab draw for a CBC to be completed for three consecutive days on 01/06/2025, on 01/07/2025 and on 01/08/2025. The January 2025 MAR showed the lab draw was signed as completed on 01/06/2025. A lab report, dated 01/07/2025 at 8:15 PM, identified Resident 1 had abnormal values including a critically elevated WBC count of 55.0. A nursing progress note, dated 01/07/2025 at 2:50 PM, Resident 1 was sent to the emergency department the morning of 01/07/2025 with increased swelling and discomfort to both lower legs and left arm. Resident 1's medical record showed the resident did not return to the facility. On 01/23/2025 at 2:42 PM, when asked about the facility's process for implementing lab orders upon admission, Staff C, Licensed Practical Nurse (LPN), said it was sometimes the nurse who helped with admissions, or sometimes medical records, but usually it was the floor nurses who initiated lab orders when a resident was admitted from hospital. Staff C said the nurses review the hospital orders for labs, verify orders with the provider, and activate the orders in the electronic medical record (EMR). On 01/28/205 at 3:38 PM, when asked who oversees noting lab orders for new admissions, Staff D, LPN, said the nurse on duty would enter the lab order into EMR for the specified time. Then the Resident Care Manager (RCM) would review the orders and make sure they were noted and faxed to the lab and the order was placed in the lab book. Staff D said the expectation was for the floor nurses to know if there was a lab due on their shift. If so, they signed for this on the MAR when the lab was completed. Staff D said if the lab did not show up to complete the lab, they either called them or reported this to the RCM for further action. At 4:07 PM, Staff D, Registered Nurse (RN) and Previous Admissions Nurse, said the lab orders went in with the medication orders in EMR, and the nurses also had a copy of the admissions orders. Staff D said it was up to the floor nurses to get the lab orders into the lab app (place to document lab orders that can be seen by the facility nurses and the lab). If they were not able to get the orders into the app, they could also call the orders into the lab. Staff D said the nurses were responsible to communicate to others if the lab could not be drawn, resident refused, or the resident went to the hospital. On 02/05/2025 at 3:00 PM, Staff B, Interim Director of Nursing Services and RN, said she had not been at the facility at the time of Resident 1's admission and discharge. However, she had inquired with staff if they knew anything about missed lab work for Resident 1. Staff B said a staff member informed her that during a morning clinical meeting Resident 1's labs were discussed, and it was realized they had been missed. The labs were reordered and then missed again. Staff B this was brought to the attention of the previous Director of Nursing Services and the Resident Care Manager for Resident 1. Staff B said she had implemented a system where labs were discussed each morning; and verification of orders, completion of lab draws, and lab results were brought forward for review by herself and the interdisciplinary team. Reference WAC 388-97-1620 (2)(b)(i)(ii)(6)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to ensure there was a comprehensive and safe system in place for residents dependent on emergency respiratory equipment in a power failure including the proper emergency equipment at the bedside, a written emergency plan for residents dependent on life sustaining equipment and staff who specialized in respiratory care equipment and were knowledgeable in respiratory care for 1 of 1 sampled resident (Resident 10) reviewed for respiratory services. This facility failure, to have a necessary respiratory care system placed residents at risk of death in an emergency situation and was determined to be a Immediate Jeopardy. This failure placed residents at risk for serious adverse outcomes in the event of an emergency and a diminished quality of life. An Immediate Jeopardy (IJ) was called on 11/07/2023 at 3:00 PM when the facility failed to have emergency equipment at the bedside, a respiratory care related emergency plan and adequately trained respiratory service staff when the facility was providing care to a resident who was a ventilator assisted individual. This IJ was determined to have started on 03/21/2023 when the Resident 10 required the use for life support/non-invasive mechanical ventilation equipment when the facility did not have the respiratory program in place. The immediacy was removed on 11/09/2023 at 12:06 PM after the Resident 10, dependent on mechanical ventilation life support respiratory services, was discharged from the facility and staff training had been initiated. Findings included . Facility policy entitled Respiratory Treatment, revised 06/22/2022, did not include information for management of Trilogy Ventilators (brand name of a respiratory ventilator that provides breathing) or other life sustaining respiratory equipment. Facility Assessment, dated 11/23/2021 to 11/22/2022, showed the facility population had a rating of high for Asthma, COPD (Chronic Obstructive Pulmonary Disease, affects your ability to breathe), or Chronic Lung Disease (respiratory diseases which cause difficulty breathing) and very high for Respiratory Failure (when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide). The facility assessment documented, We cannot also provide Invasive Mechanical Ventilator services at our facility. We do have a goal to potentially take Tracheostomies in the future. Before we are to ever accept a resident with this treatment need, we would ensure Overall Staffing was sufficient in this area with proper education, hands-on training with appropriate oversight, monitoring and follow-up, but for now this category does not apply. The assessment noted they could provide services for Non-Invasive Mechanical Ventilator Equipment; the BiPap and CPap, respiratory equipment that provides ventilation. The assessment did not include the Trilogy ventilator(brand name of respiratory equipment) including the MPV (mouthpiece ventilator) as Non-Invasive Mechanical Ventilator Equipment Services they could provide. Resident 10 was admitted to the facility on [DATE] with diagnoses including muscular dystrophy (a group of muscle diseases which cause progressive muscle weakness which can affect the muscles required for breathing and movement) and quadriplegia (unable to move the body from neck area down). The quarterly Minimum Data Set (MDS), an assessment tool, dated 08/19/2023, showed Resident 10 was cognitively intact and totally dependent on staff for daily care needs where the staff provided all the effort to complete an activity. The MDS showed Resident 10 was receiving non-invasive ventilation and oxygen therapy. The MDS did not show documentation of respiratory therapy minutes. Resident 10's respiratory care plan, revised 03/14/2023, showed, Uses nocturnal [nighttime] ventilation with BiPAP and daytime ventilation with Trilogy and MPV. [Resident 10] uses the mouthpiece ventilator full time and requires it for life support. A provider order, dated 03/21/2023, documented Trilogy ventilator settings for pressure support (volume of air with pressure to inflate the lungs) with a backup rate (minimum rate for breaths per minute). On 11/07/2023 at 9:07 AM, a BiPAP mask (soft mask used by machines that blow oxygen/air for assistance in breathing) was observed laying across the top of respiratory equipment on Resident 10's bedside table. Resident 10 said she wore it last night. Resident 10 was utilizing a moveable mouthpiece with a straw like hard tube that delivered a breath on demand. Observation of the respiratory equipment showed the mask and a humidification device were dated 10/11 (year was not included). A filter on the Trilogy ventilator was dated, 11/06/2023. When asked about the maintenance and cleaning of the respiratory equipment, Resident 10 said her family member changed the Trilogy filter yesterday. There was no emergency respiratory equipment observed at the bedside or in the room. There was no red outlet (used during a power outage for emergency power) in the room. The Trilogy ventilator was plugged into an outlet (with an unknown emergency power connection to the back up generator) with a plug divider holding nine total cords. At 9:13 AM, Staff D, Registered Nurse (RN), said she had one resident (Resident 10) requiring staff assistance to use a BiPAP. Staff D said the care aides were trained to take it off. Staff D described the process of removing the BiPAP which included changing the settings. Staff D said she had never seen Resident 10's apparatus before. Staff D said Resident 10 was new to her as she had recently moved rooms. Staff D said Resident 10's family member took care of her, and stated, Basically what we do is medicate her. [Resident 10's family member] provides most of her care, washes her and stuff. At 9:55 AM, Resident 10 said she took a breath a few times every few minutes. Resident 10 said she could not be without it (Trilogy) for too long as her carbon dioxide was too high. Resident 10 stated, It was necessary [equipment]. Resident 10 said she had to direct some staff on how to change her from the mask to the straw like mouthpiece. Resident 10 said a company came to change the settings. Nurses did not change the settings. Resident 10 said she could not go without the ventilator for more than 10 minutes. When asked what would happen if the power went out, Resident 10 stated, I would be in trouble. At 12:06 PM, Staff E, Nursing Assistant Registered, said she did not know the duration of the battery power for the Trilogy ventilator. Staff E said when Resident 10 had gone out of the facility, the medics hooked her to their ventilator. Staff E said respiratory emergency equipment including the ambu-bag (respiratory emergency equipment that gives breaths manually) was kept on the crash cart, not in resident rooms. Staff E said she changed Resident 10 from her mouthpiece to the mask when working night shift. Staff E said she was taught to complete the task by another night shift care staff. Staff E said Resident 10 and her family member showed staff how to complete the task as well. Staff E said if Resident 10 did not take a breath or fell asleep, the Trilogy beeped. Staff E said when staff heard the beep, they would go in and tell Resident 10 to take a breath or offer her to wear the mask. At 12:07 PM, Staff K, Certified Nursing Assistant (CNA), said she refilled the water for Resident 10's equipment. Staff K said the Trilogy helped Resident 10 breathe. Staff K said she was not sure where the ambu-bag was located. At 12:07 PM, Staff F, CNA, said she did not recall having training on the Trilogy ventilator. Staff F said she did not care for Resident 10 but did assist moving her mouthpiece closer one time. When asked where the emergency respiratory equipment was located, Staff F said probably on the crash cart. At 12:13 PM, Staff G, Licensed Practical Nurse (LPN), said she had not received any training on the Trilogy ventilator or BiPAPs. Staff G said she did not know what would happen if the power went out. Staff G said if the Trilogy broke, she would call the number on the machine. At 12:15 PM, Staff H, LPN, said the crash carts contained the ambu bag, located in the dining rooms. Staff H described her training for the Trilogy ventilator as being told not to touch the settings; and if there was an issue, contact the Director of Nursing Services or a Resident Care Manager. Staff H said if the power went out, residents on machines like Resident 10's, should be plugged into red outlets and staff should apply oxygen from a tank. At 12:18 PM, Staff I, Resident Care Manager, RN and acting Director of Nursing Services, said the Trilogy was usually plugged into a backup electricity red plug and she was unsure of the battery life. Staff I said she was unsure if the Trilogy battery was currently charged. Staff I said the emergency respiratory supplies were kept in Central Supply or on the rescue carts, at the nurses' station. Staff I said each nurse, who had Resident 10 as a patient, was educated on the use of the Trilogy. Staff I said Resident 10 was the best teacher on the machine. Resident 10 walked staff through using her machine. Staff I said training was not normally documented on a training sheet. They just made sure staff were trained on use of the Trilogy. At 12:25 PM, Staff J, LPN, said she had not received any training on a BiPAP or similar machines. Staff J said she was not very comfortable with them. Staff J said she did not really have to mess with them, because the CNAs changed Resident 10's connections. Staff J said she was Resident 10's current nurse and there was no Respiratory Therapy staff available. When asked if anyone trained her on Resident 10's respiratory care, Staff J said Resident 10's family member had written out directions. Staff J said the machine beeped to remind Resident 10 to breath. Staff J said she did not know how long Resident 10 could go without the machine assisting with breaths. Staff J said if the power went out they would move Resident 10 to a room with a red outlet. Staff J said the power had gone out before, and Resident 10 was moved temporarily to a room with electricity. Staff J said if the Trilogy stopped working, she would get help, call the machine's 800 number and facetime Resident 10's family member. At 3:00 PM, the [NAME] State Fire Marshal said the facility was unable to determine if the outlet in Resident 10's room, which the Trilogy was plugged into, was connected to a backup generator. The Fire Marshal said the facility was not able to determine which facility outlets were attached to which generator and there was no evidence of a Type 1 electrical system (required for use of life supporting/life sustaining equipment). See F-906 Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation and interview, the facility failed to ensure the required Type 1 essential electrical system (EES) and generator was in place and operational prior to accepting a ventilator assisted resident where an emergency electrical power system would be needed to maintain life support equipment in the event of a power outage for 1 of 1 sampled residents (10) reviewed for respiratory services. This was determined to be an Immediate Jeopardy to not have the necessary Type 1 EES system and placed residents at risk of death if an emergency occurred. This failure placed residents at risk in case of a power outage and needing respiratory support. An Immediate Jeopardy (IJ) was called on 11/07/2023 at 3:00 PM when the facility failed to have a Type 1 electrical system when the facility was providing care to a resident who was a ventilator assisted individual. The IJ was determined to have started in 03/21/2023 when Resident 10 was ordered a non-invasive mechanical device for life sustaining equipment. The immediacy was removed on 11/09/2023 at 12:06 PM after Resident 10, dependent on mechanical ventilation life support respiratory services, was discharged from the facility. Findings included . Resident 10 was admitted to the facility on [DATE] with diagnoses including muscular dystrophy (a group of muscle diseases which cause progressive muscle weakness which can affect the muscles required for breathing and movement) and quadriplegia (unable to move the body from neck area down). The quarterly Minimum Data Set (MDS), an assessment tool, dated 08/19/2023, showed Resident 10 was cognitively intact and totally dependent on staff for daily care needs where the staff provided all the effort to complete an activity. The MDS showed Resident 10 was receiving non-invasive ventilation and oxygen therapy. The MDS did not show any documentation of respiratory therapy minutes. The Respiratory care plan, revised 03/14/2023, showed, Uses nocturnal [nighttime] ventilation with BiPAP (a respiratory equipment that provides ventilation) and also daytime ventilation with Trilogy (brand name of a respirator equipment) and MPV (mouthpiece ventilator). The care plan showed Resident 10 used the mouthpiece ventilator full time and required it for life support. A Provider order, dated 03/21/2023, documented the Trilogy ventilator settings for pressure support (volume of air with pressure to inflate the lungs) with a backup rate (minimum rate for breaths per minute), required elements for use of a ventilator. On 11/07/2023 at 9:07 AM, Resident 10 was observed utilizing a mouthpiece ventilator. There were no red outlets observed in her room showing where to have the ventilator plugged in for back up generator during a power outage. Resident 10's Trilogy ventilator was plugged into a cream colored outlet (with no emergency power) with a multiple plug divider. One of the plugs was attached to a multiple outlet surge protector. In total the outlet had nine cords attached/plugged in. At 9:55 AM, Resident 10 said she took a breath a few times every few minutes. Resident 10 said she could not be without it (Trilogy) for too long as her carbon dioxide was too high. It was necessary. Resident 10 said she could not go without the ventilator for more than 10 minutes. When asked what would happen if the power went out, Resident 10 stated, I would be in trouble. At 12:06 PM, Staff E, Nursing Assistant Registered, said she did not know the duration of the battery power for the Trilogy ventilator. At 12:13 PM, Staff G, Licensed Practical Nurse (LPN), said she did not know what would happen if the power went out. At 12:15 PM, Staff H, LPN, said if the power went out, residents on machines like Resident 10, should be plugged into red outlets. At 12:18 PM, Staff I, Resident Care Manager and Registered Nurse (acting Director of Nursing Services), said the Trilogy was usually plugged into a backup electricity red plug and was unsure of the battery life on the Trilogy. Staff I said she was unsure if the Trilogy battery was currently charged. At 12:25 PM, Staff J, LPN, said she did not know how long Resident 10 could go without the machine assisting with breaths. Staff J said if the power went out they would move Resident 10 to a room with a red outlet. Staff J said the power had gone out before, and they temporarily moved Resident 10 to a room with electricity. At 3:00 PM, the [NAME] State Fire Marshal said the facility had two backup generators, but neither was a Type 1 system. The Fire Marshal said the facility was unable to determine if the outlet in Resident 10's room, which the Trilogy was plugged into, was on a backup generator. The Fire Marshal said the facility was not able to determine which facility outlets were attached to which generator. The Fire Marshal said the facility could not provide evidence of a Type 1 electrical system in the building. Reference WAC 388-97-2200

Based on observation, interview and record review, the facility failed to prevent significant weight loss when a resident was removed from weight monitoring, was not consistently assisted with meals, and was not provide the requested supplement for 1 of 1 sampled residents (36) reviewed for nutrition. This caused harm to Resident 36 when he experienced a significant weight loss of 30.18 percent (%) in five months and four days. This failure placed residents at risk for weight loss, a lack of nutrition and a diminished quality of care. Findings included . Resident 36 was admitted to the facility on [DATE] with diagnoses including stroke. The quarterly Minimum Data Set (MDS), an assessment tool, dated 08/17/2023, showed Resident 36 was moderately cognitively impaired, could make needs known, required set up assistance for eating and was identified as a resident with unplanned weight loss. The MDS documented Resident 36's weight as 150 pounds. The care plan for unplanned/unexpected weight loss related to eating less than body requirements, dated 08/07/2023, showed the goal was to have Resident 36's weight return to baseline. Staff were to give Resident 36 supplements as ordered, alert nurse/ dietitian if not consuming on a routine basis and if weight decline persists contact physician and dietician immediately. The Nutrition At Risk (NAR) assessment, dated 08/10/2023, documented, Resident has sporadic eating, taking about 50% of supplements offered. The assessment documented the weights were off and Resident 36's weight was stable. The assessment showed the facility did not have concerns for continued weight loss and stopped reviewing Resident 36, and was moved to As Needed basis for further reviews. This was the last available facility interdisciplinary team NAR Assessment for Resident 36. The Nutrition/Dietician Assessment, date 08/16/2023, documented, [Resident 36] weight is down a severe amount since his admit and recently his weight has started to decrease more. The assessment documented Resident 36 had varied meal intake and was not accepting the ordered supplement well. The assessment showed concerns for continued weight loss and need for different interventions to prevent further loss including requesting strawberry flavored supplement. The assessment documented Resident 36 said he was not offered the supplements. The weight list for admission, dated 05/12/2023, showed Resident 36 weighed 194.2 lbs. A Provider order, dated 05/16/2023, documented Ensure Plus (dietary supplement) two times a day. (This order was discontinued on 11/06/2023 and changed to a strawberry supplement to be given three times a day.) The weight list, dated 09/06/2023, showed Resident 36 weighed 146.1 pounds, a 24.77 % weight loss since admission. The weight list, dated 10/14/2023, showed Resident 36 weighed 135.6 pounds, a 7.19 % weight loss since 09/06/2023 and a total weight loss of 30.18% since admission. A Provider order, dated 11/06/2023, documented Ensure Plus three times a day, Strawberry if available, three months after this intervention was noted in the 08/16/2023 Nutrition/Dietician Assessment. On 11/06/2023 at 1:00 PM, Resident 36 was observed during the lunch meal. The resident was not provided a lunch tray or assistance. There were several drinks on the resident's bedside table which had been there since the morning of 11/06/2023. Resident 36 appeared thin and frail with eyes and cheeks sunken in. On 11/07/2023 at 8:00 AM to 3:45 PM, during intermittent observations, Resident 36 was in bed and did not go to the dining room for breakfast or lunch. Resident 36 was observed in the same position in bed with little to no interactions with his environment. Resident 36 appeared thin and frail. On 11/08/2023 at 8:40 AM, Staff D, Registered Nurse, said she sent Resident 36 to the hospital that morning at 6:30 AM because he was refusing to eat or drink for the last two days. At 9:39 AM, Staff I, Resident Care Manager and Registered Nurse (covering for the Director of Nursing Services while she was out of the building), said Resident 36 had diminished eating and was sent to hospital that morning. Staff I said Resident 36 was just not taking food in. The resident was refusing the last couple days and his eating had decreased over time. Staff I said the interventions to encourage Resident 36 to eat included completing a risk benefits form and educating him about the need to eat, telling Resident 36 to eat the protein if not eating the whole meal. Staff I said Resident 36 generally ate 0-50% of meals. Staff I said they had implemented Ensure supplements but he was not willing to take it. Staff I said Resident 36 was followed in NAR meetings. Staff I said the NAR meetings were every Thursday. When asked when the last NAR for Resident 36 was, Staff I said 08/10/2023. After reviewing Resident 36's weight record, Staff I said Resident 36 gained for a while so they probably took him off the NAR meetings. Staff I said the weight on 10/14/2023 was an error. Staff I said Resident 36 was on monthly weights because he was over here (on the 100 hall, long term side of the building). At 11:11 AM, Staff L, Physician Assistant, said his treatment plan would have changed if he knew Resident 36 was not getting out of bed and refusing meals. Staff were to offer the resident encouragement to eat. Staff L said the plan was to get Resident 36 out of bed and moving. Staff L said he was not notified of the weight loss (as directed in the care plan). Hospital Progress Note, dated 11/15/2023 at 3:56 PM, showed Resident 36 returned from the hospital, and the resident's weight was 123 pounds, an additional 7 pounds from 10/14/2023. Reference WAC 388-97-1060 (3)(h)

Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for 1 of 3 sampled residents (Resident1) reviewed for pressure ulcers. This caused harm to Resident 1 when a pressure ulcer developed under a neck brace that was not looked at for 26 days after being admitted to the facility. This failure placed residents at risk for worsening skin impairment, a change in health status and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set, a comprehensive assessment tool, dated 08/28/2023, documented the resident required one-person limited to extensive assistance and documented Activity itself did not occur for bathing in the seven day look back period. Resident 1's skin assessment, dated 08/23/2023, documented no wounds. Resident 1's Braden scale (assessment tool used for assessing pressure ulcer risk), dated 08/23/2023, showed a score of 17 indicating the resident was at risk for pressure wound development. Resident 1's medical record documented the resident had an initial skin assessment, an assessment on 08/23/2023 and on 09/09/2023. Resident 1's medical record, dated 09/18/2023 at 12:00 PM, documented Resident 1 had a Stage 4 pressure injury (pressure related skin injury that extends into muscle, tendon or bone) to his left clavicle (collar bone) measuring 4 centimeters (cm) x 5 cm x 0.5 cm. On 09/21/2023 at 11:50 AM, Staff A, Director of Nursing Services, said Resident 1's skin had not been assessed under his cervical collar (neck brace) due to orders from neurology not to take off the cervical collar (C-collar). The wound was discovered during Resident 1's shower and brought to the attention of Staff B, Licensed Practical Nurse. At 12:00 PM, Resident 1 was observed to have a pressure injury under his C-collar to his left collar bone. On 09/28/2023 at 12:38 PM, Staff B said nurses did a weekly skin check for their residents. Typically, this was done when residents were getting done with their showers or getting dressed. Staff B said the skin check involved thoroughly looking over residents' skin to note any changes of condition and to identify compromised skin. Staff B said when Resident 1 admitted to facility, nurses were instructed by their manager not to remove Resident 1's C-collar so Staff B did not remove Resident 1's C-collar to assess his skin underneath. Staff B said when giving Resident 1 a shower, CNAs placed a plastic wrap over the C-collar to protect it, but do not remove it. Staff B said on 09/18/2023 (26 days after admission) Staff B instructed the CNA on duty to remove the C-collar during Resident 1's shower because his neck/shoulder area was beginning to smell. Staff B said she observed Resident 1 had a pressure wound under his C-collar. Staff B said she never saw any orders directing staff to not look under Resident 1's C-collar to assess the condition of his skin. At 1:00 PM, Staff A said the nurses should have looked under the C-collar to assess the skin underneath to check for tissue breakdown. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to provide necessary care, services and treatment in accordance with professional standards of practice, when the facility failed to assess and monitor adequate oral intake of a resident with diabetes for 1 of 3 sampled residents (#1) reviewed for quality of care. This failure placed residents at risk for medical complications [REDACTED]. This failure caused harm to Resident #1. Findings include . Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 12/16/18, documented the resident was cognitively intact and required supervision with eating. A review of Resident #1's admitting physician orders, signed on 01/19/19, documented the following insulin orders: -Insulin NPH-insulin regular (70-30) 100 unit/milliliter (70-30) injection-Inject 114 units into skin every morning and 100 units into skin every night. (NPH 70-30 insulin is a man-made insulin which is a mixture of 70% intermediate-acting and 30% short-acting insulin, which is used to control blood sugars. NPH 70-30 insulin starts to work within 10 to 20 minutes after injection, peaks in 2 hours and keeps working for up to 24 hrs.) -Lancets blood glucose strips-use as directed to test blood sugars twice daily or as directed. A nurses progress note, dated 01/20/19 at 10:20 PM, documented at 7:15 PM Resident #1 was found to look pale, skin was clammy and was sweating through her clothing. Blood sugar was checked and it was 32. The progress note noted, Resident was groggy and answering questions. Gave 120cc OJ (orange juice) and apple sauce with sugar packets. Rechecked CBG (capillary blood glucose) was 34, Gave Insta-Glucose 31g. Resident unresponsive at this time. Rechecked blood sugar 38, gave [MEDICATION NAME] injection to left thigh. Rechecked it was 84. Resident not responding to stimuli or sternum rub. Noted foaming at mouth, trouble swallowing loss of consciousness labored breathing. Blood sugar 61. Documentation showed the physician was notified and the resident was sent to the emergency room . Resident #1 continued to be unresponsive when emergency medical transport arrived at the facility. Documentation did not show an assessment was completed by the Registered Nurse. A review of Resident #1's hospital records showed the resident arrived at the hospital on [DATE] at 9:03 PM. Resident #1's History and Physical, signed on 01/21/19 at 12:02 AM documented the following Assessment: -Neuro Acute [MEDICAL CONDITION]: Due to [DIAGNOSES REDACTED] +/- acute hypercarbic [MEDICAL CONDITION]. -Pulmonary (lungs)/Respiratory Acute [MEDICAL CONDITION] with hypercarbia; (MONTH) be due to hypoglycemic coma. A review of Resident#1's care plans, initiated 12/20/18 (from her prior admission) showed no comprehensive diabetic care plan was initiated. Resident#1's nutritional status care plan, initiated 12/20/18 (from her prior admission), did not address meal monitoring and insulin management. A review of Resident #1's oral intake, for 01/20/19, showed no documentation of how much the resident had eaten for breakfast and lunch. The dinner intake showed not taken and fluids taken was 340 ml for the day. A review of Resident #1's (MONTH) 2019 Medication Administration Record [REDACTED]. On 02/07/19 at 3:00 PM, Staff C, Licensed Practical Nurse (LPN), said on 01/20/19 at around 5:30 PM, before dinner, she administered 100 units of NPH 70-30 insulin to Resident #1. Staff C said she saw the resident's tray delivered to her room. Staff C said within an hour she checked on the resident. At that time she was told by Staff D, Certified Nursing Assistant (CNA), the resident did not eat dinner. On 02/11/19 at 3:25 PM, Staff E, LPN and Resident Care Manager (RCM), said it was her expectation for staff to document how much the resident ate. Staff E said there was no way of knowing how much Resident #1 ate for breakfast and lunch. Staff E said for a blood sugar of 101, she would not have given the insulin. She would have waited to see how much the resident would have eaten prior to administering such a hefty dose. Staff E said she would have instructed aides to monitor the resident's oral intake prior to administering. At 4:20 PM, Staff C, LPN, said she felt safe to administer the insulin for a blood sugar level of 101. At 5:05 PM Staff F, Registered Nurse and RCM, with Staff A present in the room, said she would have waited to see how much the resident would have eaten prior to giving the insulin, and stated, It's a lot of insulin. Staff F said she would have notified the physician when Resident #1 did not eat dinner. Staff A, Administrator, said she would not expect anything different to be done from what Staff F said. Staff A said they have counseled Staff C and provided education. Staff A did not provide documentation of Licensed Nurses competencies regarding diabetes education and/or insulin administration competencies for the past six (6) months. On 02/13/19 at 11:13 AM, Staff B, Director of Nursing Services, said the hypoglemic event that occurred for Resident #1 was secondary from the respiratory distress. Staff B said Staff C did the right thing to administer the 100 units of insulin. Staff B said she would have done the same thing, administer the 100 units of NPH 70-30 insulin. On 02/14/19 at 11:32 AM, Staff D, Nursing Assistant, said Resident #1 was tired and sleepy at the beginning of the evening shift. She had to wake the resident up several times to try to have the resident eat dinner. Staff D said Staff C attempted to wake the resident as well to eat dinner. Staff D said the resident did not eat her dinner. Staff D said she did not have to report to Staff C the resident did not eat because Staff C was aware the resident did not eat. Staff D said it was reported to her from the previous shift that Resident #1 had been sleepy most of the day, and stated, The resident had not been eating her meals. On 02/27/19 at 4:00 PM, Staff G, Regional Nurse Consultant, said it was expected for aides to document the percentage of what residents had eaten and how much fluids taken for each meal. Staff G said it was expected for aides to notify the nurses if a resident did not eat or had eaten less than usual. Staff G said it was expected for staff to notify physician if the resident was not feeling well, eating less than usual or not eating prior to giving insulin. Staff G stated, It is standards of practice. Staff G said if staff finds out the resident did not eat and had already administered insulin, they should be notifying the physician right away. On 03/01/19 at 2:00 PM, Staff H, Resident #1's Primary Physician, said it was his expectation for staff to notify the physician when the resident was not eating or ate less than usual prior to giving insulin. When asked about Resident #1, Staff H said it was expected for staff to have held the insulin and determine if the resident had adequate oral intake prior to insulin administration. Staff H indicated the expectation would be to follow standards of practice and wait to administer the insulin to see what Resident #1's dinner intake would have been. Record review showed Resident #1 was sent to the hospital, on 01/20/19, unresponsive, had low blood sugars and in respiratory distress, which in turn resulted into acute hypercapnic (too much carbon [MEDICATION NAME] in the blood) [MEDICAL CONDITION]. Reference (WAC) 388-97-1060 (1)

Based on interview and record review, the facility failed to develop and implement an appropriate and safe discharge plan including reducing factors with the potential to lead to preventable readmissions, medical complications [REDACTED]. This failure placed residents at risk for medical complications, hospitalization , failed discharge, ad a diminished quality of life. This caused harm to Resident #2 when he was hospitalized approximately 19 hours after discharge from the facility. Findings included . Resident #2 was admitted to the facility on [DATE] with multiple diagnoses. The Minimum Data Set, an assessment tool, dated 12/24/18, documented, the resident was cognitively intact; required two person physical assist with bed mobility, transfers and toileting; and had unsteady balance. A review of the 72 hour Notice D/C from Therapy, dated 01/04/19, documented equipment needs were front wheeled walker (a question mark was noted beside wheelchair). Resident #2's Physical Therapy Discharge Summary, dated 01/21/19, documented, the following; -Bed Mobility=Maximum Assist 70%-89% hands on assist required- comments: Due to patients medical condition, and overall weakness patient requires extensive assist with two persons. -Transfers= Maximum Assist 70%-89% hands on assist required; Transfers=2 person assist. -Supervision/Assist: 24 hour supervision/assist. The request for discharge orders, dated 01/21/19, showed no wound care services were requested for follow up. A nurses progress note, dated 01/28/19 at 3: 36 PM, documented, Resident #2 was discharged home on[DATE] at 2:00 PM with home health to follow up. Resident #2's hospital records showed the resident was readmitted to the hospital on [DATE] after being at home for approximately 19 hours. Resident #2 was unable to get out of bed, firefighters were called and the resident was taken to the emergency room . Resident #2's [DIAGNOSES REDACTED]. A Physical Therapy evaluation, dated 01/29/19, showed the resident could not bear weight and recommended 24 hour care. A review of Resident #2's facility medical records did not contain documentation of the following: discharge planning assessment, comprehensive discharge care plan, evaluation of residents discharge needs, responses to referrals made from home health and caregiver providers, discussion with the resident of other discharge options, and notification to the local Ombudsman. On 03/04/19 at 11:30 AM, Staff I, Resident Care Manager (RCM) and Registered Nurse (RN), said Resident #2 was discharged home alone with support from home health and caregivers. Staff I said the resident stayed in bed most of the time and required extensive assist in all his care needs. Staff I said at the time of discharge, nursing needs included wound care to right heel and left ankle. Staff I said she felt the resident could manage his own suprapubic catheter (empties bladder through an incision in the belly) as his had it for a long time. Staff I said it was her understanding social services had set up home health services for wound care as well as caregivers for when the resident discharged home. When asked about a comprehensive care plans including skin integrity and suprapubic catheter, Staff I said they were not done. Staff I stated, the facility just missed almost all his care plans. We now have a new system to fix that. At 12:30 PM, Staff J, Social Services Director, said discharge planning was discussed in morning meetings, during care conferences and in weekly skilled meeting. Staff J said, discharge needs were discussed with residents and the team upon admission, during care conferences and ongoing. Staff J said social services was responsible for coordinating discharges, discharge assessments, discharge care plans and care conferences. Staff J said for Resident #2's discharge plan, needs and options were discussed on multiple occasions with the resident. Staff J said home health RN, Physical Therapy (PT) and Occupational Therapy (OT) services were arranged prior to the resident discharging. Staff J said he assisted the resident to arrange privately paid caregivers and ordered a wheelchair. Staff J said the resident was planned to receive a total of eight (8) hours of care daily between home health and caregivers. Staff J was unable to provide documentation of the number of caregiver hours and the coordination of care with home health agency. When asked if a discharge assessment was completed and a comprehensive discharge care plan was initiated, Staff J, stated, No, I should have. Staff J was unable to provide documentation of responses for the referrals made to home health agency, local ombudsman, medical equipment and caregiver providers. Staff J said he felt the discharge was safe as Resident #2 had home health and caregivers arranged. At 2:55 PM, Staff B, Director of Nursing Services and RN and Staff G, Regional Nurse Consultant present, said it was expected the discharge planning process to start on day one of admission. Staff B said discharge planning was discussed daily in morning meetings, during care conferences and skilled meeting. Staff B said Resident #2 had arrangements made for home health for wound care needs and caregivers services privately paid and felt the discharge was safe. Staff B said the resident needed a wheelchair and no other discharge needs were identified. Staff G said if a discharge was felt to be unsafe, the facility would notify Adult Protective Services. On 03/06/19 at 12:10 PM, the facility identified the home health agency listed on the discharge summary, said the agency was not the provider of choice. At 12:19 PM, the home health agency requested by the resident, said no records were on file showing a referral for home health was requested by the facility. At 12:40 PM, the private Caregiver Provider (CG), Case Coordinator, said she visited the resident on 01/23/19 in the facility, and CG told Staff J the resident was not ready to discharge due to weight bearing concerns. CG said she was assured by Staff J the resident would be able to bear weight, stand and pivot to chair with one person by the time the resident discharged . CG said the initial visit was for four (4) hours on 01/28/19 and subsequent visits were planned for two (2) hours in the morning and two (2) hours in the evening for two (2) weeks. CG said Staff J was made aware of the caregiver hours they could provide. CG said on 01/29/19 at 8:00 AM, a caregiver attempted to get Resident #2 out of bed, the resident could not bear weight, was unable to get the resident out of bed and caregiver called firefighters to assist. CG said she felt the facility misinformed her of the resident's weight bearing status to be able to send the resident home. Hence, the resident failed at home and needed hospitalization . CG said it was her understanding the resident's discharge equipment (lift) needs included a hospital bed and a hoyer that were not in place by the time services were started. At 1:04 PM, Resident #2 said he laid in bed and did not get up from 6:00 PM on 01/28/19 to 8:00 AM on 01/29/19. Resident #2 said he was weak and unable to get out of bed with the caregiver's assistance and firefighters were called for assistance. Resident #2 said he was told by Staff J he needed to leave as his insurance had ended. Resident #2 said he did not insist on discharging from the facility and had not discussed Medicaid with the facility. Reference (WAC) 388-97-0080 (2)(a)(d)(e)(i)(ii)(iii)(iv)(g)(5)(6)(7)(a)(b)(c)

Based on observation, interview and record review, the facility failed to identify, evaluate and analyze accident hazard risks in the residents' environment for 11 ambulatory residents with access to the electrical room and for 3 of 16 sampled residents (#82, 61 & 116) when residents were observed routinely walking on wet floors. Failure to ensure residents were protected from hazardous areas placed resident at risk of falls and injury. This failure resulted in an immediate jeopardy on 4/3/17 (electrical room) and 4/5/17 (wet floors). Findings include: <Electrical Room> On 4/3/17 at 12:00 p.m., a key was observed to be attached to the wall at waist height outside a room marked electrical in the resident long term care hallway. The key easily opened the door. The room was very dark and the light switch was difficult to locate. Inside the electrical room there was a drop down to a concrete floor of one inch. The room was narrow. Waist high electrical panels with levers lined the right side of the room. The panels were floor to ceiling and stuck out 10 inches from the wall. On the left side of the room, at head height, there was a long metal panel with various colored wires which hung down 5-6 inches from the bottom. At 12:07 p.m., the Maintenance Director (DOM) stated the wires that hung down on the left were low voltage phone wires, part of the active phone system. He stated the various levers shut off power to different parts of the building. The lever on the far left was used to test the generator. The DOM indicated residents should not be in the electrical room. At 12:11 p.m., Licensed Nurse (LN) F stated the electrical room held phone lines and PUD stuff. LN F stated there were 4 breaker panels in the electrical room. I can go in and reset the breaker in case anything trips. It happens a lot in the summer when the air conditioning is on. <Sprinkler Room> On 4/3/17 at 12:15 p.m., the sprinkler room door was observed to be unlocked. The door opened into a small room which had a large hot water tank with copper colored pipes that were warm to the touch. A large red pipe came up from the floor in front of the doorway and went up to the ceiling and across the room. The room was difficult to move around in due to the small size of the room, the pipes coming up from the floor and across the room and the hot water tank. At 1:58 p.m., the administrator observed the open sprinkler room door and stated, It should be locked. Residents should not be able to get in there. <Wet Floors> On 4/4/17 at 2:01 p.m., Housekeeping Staff B (HS B) was observed mopping the floor of the Expressions Dining Room. Wet floor signs were placed at the entrances to the dining room. Resident #82 was observed to enter the dining room and ambulate across the visibly wet floor several times. Resident #61 was observed to enter the dining room and ambulate across the visibly wet floor several times. Other residents were seated in the dining room. Staff were observed near the medication cart in the dining room and did not redirect residents away from the potential danger of the wet floor. HS B did not redirect residents away from the wet floor. On 4/5/17 at 2:14 p.m., HS B was observed mopping the floor of the Expressions dining area. Wet floor signs were placed at the entrances to the dining room. Resident #61 was observed ambulating on the wet floor. Seven residents with the ability to ambulate were observed seated in the dining room when mopping began. Resident #61 was observed to be pacing back and forth on the wet floor. Resident #116 was observed ambulating on the wet floor. The surveyor's shoes slid easily on the wet floor. Licensed Nurse (LN) G and a nursing assistant were observed in the dining room and did not redirect residents away from the wet floor. A hallway, just outside the dining room and the full length of the dining room was observed to be carpeted and was not mopped. On 4/5/17 at 5:31 p.m., when asked about the procedure for mopping the Expressions Dining Room, LN G stated, There is never going to be a time that someone isn't in there, and indicated residents see the mopping and know to avoid the area. LN G stated, I have had more issues with the wet floor. LN G indicated staff redirect the flow of traffic when mopping is occurring. At 5:35 p.m., LN G provided a list of residents residing on the Expressions unit who were able to ambulate. Two residents were identified as being able to ambulate with staff assistance only. 14 residents were listed as being able to ambulate without staff assistance. At 6:04 p.m., the Director of Nursing Services (DNS) stated the housekeeping staff should mop one half of the dining room at a time and nursing staff was responsible to redirect residents to walk on the un-mopped side to enter and exit the dining room. Resident #82's care plan, dated 2/21/17, identified the resident had a history of [REDACTED]. The care plan directed staff to, monitor wandering and re-direct if unsafe. The care plan documented the resident had seven falls since admission to the facility. Resident #61's care plan, dated 3/30/17, identified the resident was at risk for falls and had a history of [REDACTED]. Resident #116's care plan, dated 3/9/17, identified the resident was at risk for falls and had a history of [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for 1 of 3 current sampled residents (#65) reviewed for dignity. This failure placed residents at risk for delay in care and services, diminished self-esteem and a decreased quality of life. Failure to provide timely care and services caused psychosocial harm to Resident #65. Findings include: Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 1/8/17, indicated the resident was able to make needs known, was alert and oritented, and was totally dependent on staff for bed mobility and toilet use and required extensive two person assistance for personal hygiene. On 4/4/17 at 9:11 a.m., Resident #65 was observed with tears falling down her cheek, and stated, Because I'm a two person assist with a hoyer lift they have to wait until they have two people and it can take an hour so I have to go in my brief. I don't like it. I feel like an animal. Why don't I get the same rights as other people? I feel really bad being (resident's age) and having to 'potty' on myself. On 4/10/17 at 4:15 p.m., when asked how often she was offered a bedpan, Resident #65 stated, They only offer when I ask for one. They just tell me a lot to go ahead and go and then they will clean me up. When asked how that made her feel, the resident stated, Like an animal. On 4/6/17 at 3:20 p.m., the resident's family member said a situation occured in November of 2016 and stated, My sons were visiting and my mom said she had to go to the bathroom and the call light was turned on. No one came in so they went to look for someone. My mom said she had to go to the bathroom and the nurse said, '(Resident #65), you don't go anymore. You can just go on yourself.' My mom was one of those people that dressed very nice and now she is unable to even participate in her own personal hygiene. That's really hard on her. Resident #65's bowel and bladder incontinence care plan, dated 4/4/17, initiated 10/21/16, documented interventions including offering bedpan upon rising, before/after meals, at bedtime and as requested. On 4/10/17 at 2:17 p.m., when asked how often the resident was placed on a bedpan, Nursing Assistant (NA) B stated, When we put her down for bed, she will usually want to sit on a bedpan before. On 4/10/17 at 3:46 p.m., when asked about the resident's use of a bedpan, Licensed Nurse (LN) H, stated, Sometimes she will use the bedpan if she is able to let them know. By the time she says something she has already been incontinent. The facility failure to provide timely assistance resulted in the resident feeling like an animal. This caused psychosocial harm to Resident #65.

Based on observation, interview and record review, it was determined the facility failed to ensure 1 of 3 sampled residents, Resident # 1 was free of a significant medication error when staff failed to administer medications as ordered. This avoidable failed practice caused harm, increased complications related low blood sugar, required the resident to receive injections to increase blood sugar and subsequently required the resident to be admitted to the hospital due to significant medication error. The facility also failed to educate staff on insulin administration to include failing to follow safe standards of medication delivery practice and ensure competency of licensed staff administering medications per MD orders and to identify signs and symptoms of complications related to [DIAGNOSES REDACTED]. This failure placed residents at risk and an immediate jeopardy was determined to exist. The facility was informed of the immediate jeopardy on 9/9/16. Findings include: Resident # 1 admitted to facility on 3/06/2016 with [DIAGNOSES REDACTED]. Medications and monitoring to treat this [DIAGNOSES REDACTED].>[MEDICATION NAME] 20 units injection twice a day. ([MEDICATION NAME] is a long acting, man-made insulin used to control high blood sugar. Long-acting insulin covers insulin needs for about one full day onset of 1-2 hours and peaking between 6-8 hours.) Blood sugars (CBG) to be tested before meals and at bedtime [MEDICATION NAME] sliding scale before meals and at bedtime as needed. ([MEDICATION NAME] is a rapid-acting insulin covers insulin needs for meals eaten at the same time as the injection and typically ordered as a sliding scale based on blood sugar levels onset of 10-20 minutes). An incident report dated 8/23/2016 documented by director of nursing (DNS) related, Received a call from administrator stating the resident received another resident ' s insulin by mistake. DNS gave instructions to notify MD immediately and monitor closely. LN on duty did notify MD and he gave instructions to monitor resident, check blood sugars every 15-20 minutes and give [MEDICATION NAME] {an injection to help increase blood sugar} for blood sugar less than 80. [MEDICATION NAME] was given x 2 on evening shift. Resident received 26 units of [MEDICATION NAME] R U500 units injected subcutaneously. ([MEDICATION NAME] R U-500 is highly concentrated and contains 5 times as much insulin in 1 mL as standard U-100 (100 units/mL) insulin. It is a rapid-acting insulin covers insulin needs for meals eaten at the same time as the injection and typically ordered as a sliding scale based on blood sugar levels onset of 10-20 minutes.) Resident was noted to be confused at times at the beginning of the shift, appeared weaker than baseline and sweating noted. Blood sugar was 57 mg at 2215 accepted orange juice/snacks and oral glucose. Blood sugar monitored every 15-20 minutes blood sugar at 2245 75 mg/dl MD notified regarding blood sugar result of 67 and 59 mg/dl around midnight, [MEDICATION NAME] 1 mg injection given X 2 as ordered, pharmacy notified for STAT delivery of medication, pharmacy suggested clarifying with MD for maximum [MEDICATION NAME] doses. MD was notified per on call phone note at 04:40 a.m. CBGS fluctuating from 50 ' s to 70 ' s they are now out of [MEDICATION NAME], recommend transport for further treatment for [REDACTED]. AMR (ambulance service) was called and resident was sent to the ER with a blood sugar of 38 mg/dl Hospital history and physical note by MD dated 8/24/16 at 10:49 a.m. documented by the time the EMS arrived the resident ' s CBG (blood glucose level) was 20 . The resident received D50% (concentrated sugar water given in critical hypoglycemic events) and was brought to the emergency room (ER). In the ER resident was sleepy and her blood sugar was still low in the 70 ' s every time they turned off the D10% ( [MEDICATION NAME] IV). The history and physical went on to say that the patient received Humilin RU-500 by mistake in addition to her usual dose [MEDICATION NAME] 20 units. The emergency room assessment documented Persistent [DIAGNOSES REDACTED] due to unintentional insulin overdose. Patient got more insulin than her usual dose by mistake. Resident was admitted to the hospital related to the significant medication error. On 9/7/2018 at 3:00 p.m. When asked what was done after identifying the medication error, the DNS stated, Medication audits on all nurses, then monthly, and brought to the nurses meeting We moved the nurse to Expressions where it is not as busy and no insulin is given. Documentation of audits completed on nurses submitted 9/08/2016 at 11:47 AM revealed Medication Pass observation reports were completed on only 8 of 18 current nurses employed at the facility. In cross referencing audits versus the employee list, there were 10 nurses that had no documentation that Medication Pass Observations were completed as indicated by DNS. The DNS indicated that nursing staff need to, follow the 5 rights of medications, if a resident refuses they throw it away and reprocess it, and immediately the nurse has to do an intervention and put on alert and do an incident report, and we review the next morning. When asked how much [MEDICATION NAME] the facility stocked, the DNS stated, I would have to go look, I know we have it in the E-Kits and they are replaced weekly when we call. DNS returned and stated, We have 4 doses of [MEDICATION NAME] in the facility. ( ICD-10 [DIAGNOSES REDACTED].) During the 9/7/16 3:00 pm interview with the DNS, the investigator inquired about staff educations regarding hypoglycemic episodes. The DNS stated, I will start education tomorrow morning. On 9/08/2016 at 11:47 AM an email from the administrator indicated an In-service had been conducted and 12 signatures submitted with education types and causes of medication errors from a nurse ' s viewpoint. A copy of an invoice for 5 doses of [MEDICATION NAME] that had been delivered to facility on 9/7/16 was included. On 9/9/16 at 12:10 p.m. the Administrator related that the licensed nurse who had administered the incorrect insulin received coaching. The coaching plan was done on 8/31/16 and we decided to move her to Expressions. Expressions is a wing of the facility that generally consists of residents with cognitive loss/ dementia diagnoses. At 1:45p.m. LN 1 ' s education and performance improvement plan was reviewed. It documented 8/31/2016 LN would follow the 5 rights of medication administration. Do not draw up a second syringe of insulin when you have another un-administered, you must destroy all medications not given immediately prior to moving on to another resident. Resources and support provided documented insulin administration and review of the 5 rights and to be reviewed on or before 9/30/16. On 9/9/2016 at 2:10 p.m. LN 1 was asked if there was anyone on the Expressions unit who received CBG testing or insulin, LN 1 stated, Yes we have two residents who have insulin. When asked if she had given insulin to those two residents she stated, Yes. In review of the medications for the two residents that require insulin administration, it was noted LN 1 had administered insulin on 8/27/16 and 8/28/16. At 2:10 p.m. When asked if there are diabetics on the Expressions unit administrator stated, DNS is getting that information for you . ICD-10 [DIAGNOSES REDACTED]. In review of the medication sheets for the two residents that required insulin administration, it was noted LN 1 had administered insulin on 8/27/16 and 8/28/16 to these residents. LN 1 did not receive coaching, education or counseling prior to returning to the facility after the incident on 8/23/16. LN 1 had administered medications to the 2 residents requiring insulin on that unit on 8/27 and 8/28/16. An actual Medication Pass Observation of LN 1 was not completed until 9/3/16 as documented on her Medication Pass Observation audit. In further discussion with the administrator and DNS on date 9/09/2016 it was determined that LN1 had drawn up the [MEDICATION NAME]for another resident who refused to take the insulin at that time. LN1 placed that syringe on the cart with the residents name on it and proceeded to prepare insulin for Resident #1. LN 1 laid both syringes of insulin on the cart and when she was ready to administer Resident #1 ' s insulin she picked up the wrong syringe of insulin and administered the [MEDICATION NAME]to Resident #1 instead of Resident # 6s. The practice of placing 2 syringes of insulin for two different residents on top of the medication cart was also a violation of medication standards of practice. Please refer to F 281 Standards of Practice for further information. By completion of the complaint survey on 9/15/16, the facility had alleged they had taken steps to remove the immediate jeopardy. The complaint investigator verified the facility had taken sufficient action to remove the jeopardy situation.

Based on interview, observation and record review, the facility failed to ensure 1 of 3 current sampled residents (Resident #1) received services that are provided according to accepted standards of clinical practice. This failure caused harm to Resident #1 that received another resident ' s insulin resulting in extremely low blood sugar and subsequent hospitalization . This placed residents at risk due to actions outside the standard of care. Findings include: Per Incident report dated 8/23/2016 Licensed Nurse (LN) 1 gave Resident # 1 Resident # 6 ' s insulin. Letter submitted by facility on 9/12/16 documented: The Licensed Nurse (LN 1) had prepared Resident # 6 ' s insulin injection. However Resident # 6 had refused to take the medication at that time. LN1 then proceeded to label the insulin syringe with the Resident # 6 ' s name. LN 1 then drew up Resident # 1 ' s insulin. The nurse now had two drawn up insulin syringes on top of her cart. LN1 then accidently picked up the wrong insulin and gave it to Resident # 1. After injecting the insulin, LN 1 noted it had Resident # 6 ' s name on it. Progress note dated, 8/23/2016 at 22:12 (10:22 p.m.) by LN 1 documented the following regarding Resident # 1; Res with [DIAGNOSES REDACTED] required [MEDICATION NAME] injections x 2 last CBG (blood sugar test) 93. Res remained asymptomatic, alert, oriented. Continue to monitor CBG until midnight. Progress note dated 8/24/2016 at 16:32 (4:32 p.m.) by LN 1 documented a late note entry for 8/23.2016 evening shift. This LN gave insulin U 500 25 units to resident by mistake. MD was immediately notified new order received to check CBG every 20 minutes to inject resident with [MEDICATION NAME] if blood sugar was below 80. On call phone note from Family Medicine included in the documentation contained in the Incident Report investigation submitted by the facility dated 8/24/2016 at 4:40 a.m. documented, CBGS fluctuating from 50-70 ' s they are now out of [MEDICATION NAME]. Plan to transport to hospital for further treatment for [REDACTED]. Progress notes did not indicate the MD was informed of resident having signs and symptoms of [DIAGNOSES REDACTED] as indicated in LN 2 ' s progress note. Progress notes dated 8/24/2016 at 05:50 a.m. by LN # 2 documented, Resident confused at times at the beginning of the shift, appears weaker than baseline, sweating noted, CBG 37 mg @ 22:15. On 9/14/2016 at 3:30 p.m. Review of physician order [REDACTED].# 2 obtained an order for [REDACTED]. No order was found written by LN # 1 regarding giving [MEDICATION NAME] to Resident # 1 ' s in the medical record or Electronic Physician orders, or on the Electronic Medical Record to document the obtaining of the [MEDICATION NAME] order or the administration of [MEDICATION NAME] by LN 1. Hospital history and physical note by MD dated 8/24/16 at 10:49 a.m. documented by the time the EMS arrived the resident's CBG (blood glucose level) was 20. The resident received D50% (concentrated sugar water given in critical hypoglycemic events) and was brought to the emergency room (ER). In the ER resident was sleepy and her blood sugar was still low in the 70 ' s every time they turned off the D10% ( [MEDICATION NAME] IV). The history and physical went on to say that the patient received Humilin RU-500 by mistake in addition to her usual dose [MEDICATION NAME] 20 units. The emergency room assessment documented, Persistent [DIAGNOSES REDACTED] due to unintentional insulin overdose. Patient got more insulin than her usual dose by mistake. Resident was admitted to the hospital related to the significant medication error.

Based on interview and record review, it was determined the facility failed to aggressively identify and advocate for the needs of 1 of 8 residents (#3) when they failed to ensure the resident received necessary care and services for the highest well being. This failure caused harm to the resident when the facility allowed the resident's Power of Attorney (POA) to direct the care of the resident in opposition to recommendations of the physician and staff. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 6/4/14, the resident rarely understood communication, had short and long term memory problems and had severe cognitive impairment. The resident was assessed as being moderately depressed. The resident required extensive staff assistance with activities of daily living and was always incontinent of bowel and bladder. The resident had experienced an overall gradual decline in physical function during the 2 year stay at the facility, which was not unexpected, because of her age and medical conditions. During July 2014, according to the "Resident Behavior Report Sheet", on 7/1, 7/5, 7/6, 7/7, 7/8, 7/9, 7/12, 7/17, 7/18, 7/21, 7/23, 7/25, 7/26, 7/27 and 7/28 (or 15 days during a 30 day period) the resident had frequent behaviors of "Hallucinations, delusional thoughts/comments, anxiety, calling/yelling out for 'help' and physical aggression toward staff." Possible staff interventions to reduce symptoms, included, "Quiet environment, re-direct resident, re-assure resident, offer toileting." On each of the above mentioned days, the answer to the question of whether the intervention was effective in decreasing the resident distress was recorded as "No" or "Nothing worked". According to documents in the medical record, the resident had two involved daughters. One had been appointed as Durable Power of Attorney for Resident #3 effective 1/24/05. The other daughter was not a POA, but visited frequently and did the resident's laundry. The record reflected unresolved conflict between the daughters regarding what was best for the resident. On 7/15/14 a chart note indicated the "POA very concerned about her sister who is taking clothes home to wash them with 'fragrance' and that the resident is quite sensitive to this. This has been an on-going battle between the sisters for quite a while. POA feels the fragrance is the cause of her mother's behaviors." On 7/15/14, a chart note indicated "Discussed resident's current psychotropic medications at the psychotropic meeting and the daughter's request for medication changes. MD {physician} feels Risperdal (a medication to decrease delusions and hallucinations) is benefiting resident and her (POA) request of giving Trazodone (an anti-depressant) throughout the day/eve is contraindicated for a patient of this age. IDT {Interdisciplinary team} agrees with MD decision and maybe the POA should look for alternative placement." On 7/15/14, the Risperdal 0.25 mg twice a day was "Discontinued per daughter no longer consenting to the use of this medication." On 7/30/14, at 1:00 p.m., the Administrator stated "We have had a lot of problems with the resident's {#3} behavior. The POA wanted the resident off the Risperdal and wanted the Trazodone increased. The Physician did not want to increase the Trazodone, but did discontinue the Risperdal. The physician didn't want to act without the POA's direction. When the family couldn't get what they wanted, they changed doctors to get the orders changed. The resident has new orders for Seroquel (a mood stabilizer) today. The resident yells a lot but seems stable. The resident was taken off the Risperdal several days ago and the resident has been screaming for 5 to 8 hours a shift. I have tried to tell the POA that sometimes the medications just stop working, but she does not want to relinquish control . I don't know if the resident is distressed, but the screaming is difficult for staff and other residents. The family is highly involved in the resident's care. I have asked the Ombudsman to get involved, but she really doesn't want to because she is familiar with the family history. The resident really needs an advocate." When asked who might be the best advocate for the resident, the Administrator stated "I don't know who might be the best advocate for the resident. We have thought about having a guardian ad litem appointed, but we have not done that." At 01:50 p.m., Licensed Nurse (LN) B, who works full time on the evening shift stated "The resident is constantly yelling at the top of her lungs. She really ramps up on my shift. No matter what you do, it doesn't work. She has gotten worse in the past 2 years. We have given up trying to contacting the physician because the doctor would give us orders, then the family would refuse to have the orders implemented. The POA (Power of Attorney) changes her mind every few minutes. The resident screams and assaults the aides anytime they try to provide care. Everyone's hands are pretty much tied by the POA. The POA gets totally involved in her mother's care, and then will disappear for months at a time." At 2:10 p.m., Licensed Nurse (LN) A stated "I've been here for a year and the whole time I have seen the resident's family fighting with each other. They put us in the middle. It has gotten so bad we are hardly able to do anything for the resident." .

Based on observation, interview and record review, it was determined the facility failed to provide necessary care and services to attain or maintain the highest level of well-being for 1 of 8 residents (#3) when they failed to assess whether frequently exhibited behaviors of screaming, resistance to care, hallucinations and delusions was attributable to organic causes such as pain, urinary tract infection, advancing [MEDICAL CONDITION] or other causes. This failure caused harm to the resident's well-being when she experienced almost daily behaviors unrelieved and unaffected by staff interventions. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 6/4/14, the resident rarely understood communication, had short and long term memory problems and was severely cognitively impaired. The resident's cognitive status remained unchanged since the original admission assessment completed on 5/8/12. On the original admission assessment, the resident exhibited no signs/symptoms of depression. However, at the end of 2013, the resident began to exhibit occasional signs of depression. Upon return from the second hospitalization , the MDS dated [DATE], the resident showed 9 signs of depression. An assessment completed on 6/4/14 showed the resident with 12 signs of depression, or moderate depression. The resident required extensive staff assistance with activities of daily living and was always incontinent of bowel and bladder. She resident had experienced an overall gradual decline in physical function during the 2 year stay at the facility, which was not unexpected. On 6/9/14 a "Psychoactive Drug Review" completed by the facility showed the resident was "Physically aggressive with personal care at times, Screaming at times during care." No changes were made in the medical regime. The review was completed by nurse managers, social services, and the consultant pharmacist. The report was then sent to the physician for review where no changes were made. No assessment of possible organic causes was found, no information related to the increasing signs/symptoms of depression was located. On 7/14/14 a "Psychoactive Drug Review" was completed again by the nurse managers, social services, the consultant pharmacist and was sent to the physician for review. It was noted the resident was "Yelling out at times, unable to console almost daily." No changes were made in the medication regime. No assessment of possible organic causes was found, again the resident's increasing signs of depression was not addressed. The resident had physician orders [REDACTED]. According to the manufacturer's information, [MEDICATION NAME] is a mood stabilizing anti-psychotic medication that can decrease mood and behavior symptoms. The drug can take up to 2 weeks to become effective and it's effects can last up to 6 weeks. The goal of treatment is to decrease delusions and hallucinations. When the POA refused to give consent for the [MEDICATION NAME], the resident was placed on alert charting to evaluate the response to the change, but it was not clear if additional alternatives were considered. The resident had physician's orders [REDACTED]. On 7/17/14, the dosage on the medication was decreased to 10 mg daily following an appointment at the physician office. No information was found regarding whether the resident's documented increase in depression symptoms were considered prior to the anti-depressant dosage being reduced. The resident also had orders for [MEDICATION NAME] (an antidepressant) 50 mg to be given at bedtime and for 25 mg to be given as needed. On 7/17/14 the order was changed to [MEDICATION NAME] 12.5 mg at 12:30 p.m., [MEDICATION NAME] 25 mg at 3:00 p.m. and [MEDICATION NAME] 75 mg at bedtime. According to the manufacturer's instructions, [MEDICATION NAME] is an antidepressant that begins working in 1-2 weeks and can take 2-4 weeks to be effective. The desired outcome would be for resolution of depression and an increased sense of well-being and interest in surroundings. On 7/02/14, a nursing note reflected "PRN (as needed) [MEDICATION NAME] administered at 4 p.m. with little to no effect, as Resident continued screaming and fighting care until [MEDICATION NAME] (pain medication) admin (administered) at 2000 (8:00 p.m.)." On 7/15/14, a nursing note reflected "First bedtime without [MEDICATION NAME] administration . Resident very combative this shift, hitting CNAs, screaming & yelling, trying to get out of bed several times, PRN [MEDICATION NAME] had no effect." On 7/16/14, nursing notes reflected "Resident yelling out multiple times this shift, cannot verbalize her needs per baseline confusion. Combative with care and swinging at staff when attempting to provide care." On 7/17/14, nursing notes indicated "Resident continued with baseline confusion and experienced multiple calling out and yelling episodes." On 7/18/14, a nursing note reflected "No increase in behaviors since dc (discontinuation) of risperdone ([MEDICATION NAME]) noted. c/t (continues to) be resistive to cares, including hollering." On 7/19/14, a nursing note reflected "Resident at baseline confusion and spent approx. (approximately) 3 hours calling out for various past family members, all of which have passed away. Resident appeared to settle down after the arrival of daughter." On 7/20/14, a nursing note indicated "Screaming, slapping upper thigh. Attempts to redirect unsuccessful." On 7/21/14,chart notes reflected "Resident yelling resident having hallucinations. Grabbing at things in the air above her head. Slapping own right thigh hard enough to he heard from down hallway. This (nurse) went immediately, numerous times, to find her doing this then screaming, in a very high pitch tone 'You are hurting me, stop it!' There was no one else in room. Pulling pillows out and throwing onto floor. Unable to redirect or console. Energy, agitation & screaming escalated during shift." On 7/22/14, chart notes indicated "Behaviors continue, yelling out. Redirection fails. MD notified of increasing behaviors." The physician ordererd for lab work to be done. On 7/23/14, chart notes stated "Screaming at beginning of shift." On 7/24/14, nursing notes indicated "Screams 'Help me.' 'Help me.' Behaviors continue." On 7/25/14, nursing notes reflected "Resident was screaming in high pitch tone and shouting 'Stop pulling my hair' with no one in room. (The POA) came into the facility at 21:45 and was very aggressive and stating she didn't need to be to up all night dealing with this (the resident screaming)." On 7/28/14, nursing notes reflected "Resident continued to call out for prolonged periods of time, despite staff's attempts at reassurance and reorientation, bathroom breaks, snacks, etc. Resident's daughter called to inform (the nurse) to be on the look out for a [MEDICATION NAME] (an anti-psychotic medication) order from the doctor's office." On 7/29/14, nursing notes reflected "Resident started on [MEDICATION NAME] today, too early to determine effectiveness, resident continued at baseline with prolonged periods of calling out." On 7/30/14 at 12:30 p.m., the Social Services Director (SSD) stated "The resident returned from the hospital in May with medication order changes. The POA was unhappy with the physician not wanting to make additional order changes The POA thinks the [MEDICATION NAME] is the only thing that helps. I am pretty sure the POA used the medication at home to just keep the resident quiet. The resident yells a lot, but seems stable. " At 2:15 p.m., the resident was observed to be lying in bed and appeared to be resting comfortably. The resident was unable to communicate verbally or to understand verbal communication at that time. On 7/31/14 at 5:15 p.m., Licensed Nurse (LN) B was asked if the resident might be having pain. LN B stated "The resident is not on any routine pain pills. She has orders for [MEDICATION NAME] (a pain medication) but we usually don't give it because both daughters are adamant that the resident shouldn't have any. The resident was given [MEDICATION NAME] on 7/25/14, 7/26/14 and 7/27/14 in the evening. The resident wouldn't be able to ask for pain medication, but I don't see her wincing or having abnormal vital signs that might indicate pain." It appeared the facility had grown accustomed to the resident's on-going screaming and other behaviors and had failed to evaluate possible organic causes for her lack of well-being. Physician notification and physician visits were driven by the family when the facility failed to take action. Possible pain or discomfort related to the resident's age and recent [MEDICAL CONDITION], and her inability to communicate did not appear to be taken into consideration as possible causes of her continued screaming.

Based on observation, interview and record review, the facility failed to prevent serious medication errors for 1 of 7 residents (#1) when 2 nurses erroneously gave Resident #1 another resident's medications. This failure resulted in harm to Resident #1 who sustained respiratory distress, change in level of consciousness and who required emergent transport and hospitalization following the error. Findings include: On 06/25/12 at 10:45 p.m., Resident #1 was mistakenly given [MEDICATION NAME] 10mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 875/125, [MEDICATION NAME] 300 mg, [MEDICATION NAME] powder, and [MEDICATION NAME] 300 mg which were intended for administration to another resident. Several of these medications can cause respiratory depression and a change in level of consciousness. The medications (with the exception of the [MEDICATION NAME]) were not ordered for Resident #1. According to facility reports, Licensed Nurse (LN) C prepared the medications for another resident, then handed the medications to LN D who administered the medications to Resident #1 in error. The medications were intended for another resident. The physician was notified and the night nurse was informed. Facility nursing notes dated 06/26 show the Resident was checked every 15 minutes after the error. At 01:45 a.m., the Resident became "Unable to arouse, color became pale, spO2 {Oxygen levels, normally expected to be between 95-100%} dropped to 74-79% on room air. O2 {oxygen}immediately applied to res. {Resident} via mask and spO2 rose to 96%. Still unable to arouse res {Resident}, even with sternal rub, 911 was called by other nurse while this writer stayed with res {Resident}." Hospital records dated 06/26 reflect the Resident was admitted to Intensive Care and required Bi-pap (mechanical assistance) for breathing. The Resident was transferred to the general unit after about 24 hours of critical monitoring. The Resident was able to return to the facility on ,[DATE] in the early afternoon. On 06/27/12 at 09:55 a.m., the Director of Nursing stated. "{LN D} is a new nurse. She just started a few weeks ago. She got behind in her med pass and {LN C} came out to help her. One nurse pulled the medications from the cart and the other nurse passed the medications. They gave the wrong medications to {Resident #1}. It is our policy that residents are free of any significant medication errors. Unfortunately, this error was significant." On 06/27/12 at 04:30 p.m., Resident #1 stated "I am happy to be home. I went to the hospital because I had trouble breathing. I had to have Oxygen." The Resident was not able to comprehend the cause and effect of the medication administration error. Refer to F 157 and F 281

Based on observation, interview and record review, the facility failed to ensure professional standards for medication administration when 2 nurses were involved in providing the wrong medications to 1 of 7 residents (#1). This failure led to Resident #1 sustaining respiratory distress and a change in level of consciousness that required emergent transport and hospitalization . Findings include: According to the Lippincott Fundamentals of Nursing 3rd Edition 1997, page 608 "The five rights help to ensure accuracy in medication administration: right medication, right client, right dosage, right route and right time." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was alert to self and able to communicate with staff, but did not have the capability to make health care decisions. According to the Minimum Data Set (MDS), an assessment tool dated 04/08/12, the Resident required extensive assistance of most activities of daily living (ADLs) but was able to feed self. On 06/25/12 at 10:45 p.m., Resident #1 was mistakenly given the medications intended for another resident. The medications given in error were: [MEDICATION NAME] 10mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 875/125, [MEDICATION NAME] 300 mg, [MEDICATION NAME] powder, and [MEDICATION NAME] 300 mg. [MEDICATION NAME] is used to treat anxiety, is rapidly absorbed and can cause respiratory difficulty and sedation; [MEDICATION NAME] is a mood stabilizer, is rapidly absorbed and can cause respiratory difficulty and sedation; [MEDICATION NAME] is an antibiotic; [MEDICATION NAME] is used to treat depression, is rapidly absorbed and can cause respiratory difficulty and sedation; [MEDICATION NAME] is a laxative; and [MEDICATION NAME] is used to treat certain kinds of pain and mood problems, is rapidly absorbed and can cause respiratory difficulty. The Resident did not have orders for any of the medications except the [MEDICATION NAME] On 06/26/12 at 01:45 a.m., about 3 hours after receiving the wrong medications, the Resident had a change in the level of consciousness and difficulty in breathing. 911 was summoned and the Resident required emergent transport to the hospital. The Resident was admitted to intensive care and required mechanical assistance with breathing. On 06/27/12 at 11:05 a.m., Licensed Nurse (LN) D stated "I was behind in my med pass on 06/25. A nurse from another unit came over to help me. We decided she would pull the medications and I would pass them. She looked at my list and saw I had highlighted everyone I had already passed medications to. I had not yet passed the medications for {Resident #1}. The other nurse and I talked about that. Theother nurse {LN C} said she was pulling the medications for another resident. I was still thinking about {Resident #1} when I went into the room and that's when I gave the wrong medications to {Resident #1}. I didn't realize what I had done until I came back to the medication cart and {LN C} handed me medications for {Resident #1}. {Resident #1} would not have known if the medications were correct or not. We looked at the Resident's allergies [REDACTED]. The Resident was placed on alert for monitoring and we told the night nurse what had happened. I know the "5 rights" from school, even though I am a new nurse. I had receivied orientation from another nurse, but I was really stressed out because of how late I was running." At 11:30 a.m., LN C stated "She {LN D} came to me between 8:00 and 9:00 p.m. on 06/25 and said she was really swamped. I came over to help her when I finished my work. We decided I would pull the medications and she would pass them. I know better than to pass meds that way, but we were in a hurry and trying to take short cuts." On 06/27/12 at 4:20 p.m., the Director of Nursing stated "I expect our nurses to administer medications using the right medication, patient, dose, route and time. That is our policy and that is basic nursing practice." Refer to F 157 and F 333

Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Former Resident #1) was provided necessary care to maintain the highest practicable level of physical well-being. This failure resulted in harm to the Resident who developed skin breakdown of his right foot when his weight and blood sugars were not managed and led to the necessity of his right leg amputation. Findings include: Resident #1 was admitted to the facility on [DATE] with [MEDICAL CONDITION], heart failure, diabetes, [MEDICAL CONDITIONS] and a [MEDICAL CONDITION] of his left leg. The Resident was alert and oriented and was able to use his electric wheel chair for mobility within the facility/community. Resident #1's left foot and leg had been amputated because of poor circulation and complications from diabetes about one year before his admission to the facility. He had a prior amputation of a toe from the right foot, but did not have impaired skin at the time of admission to the facility. He used a diabetic shoe to protect the skin of his right foot from developing skin breakdown. The Resident enjoyed working with physical and occupational therapy and was looking forward to being discharged to an apartment at the end of May. He was at high risk for skin breakdown because of his co-morbidities On 02/09/11, physician notes reflected the Resident was hospitalized for [REDACTED]." When Resident #1 was readmitted to the facility on [DATE], physician orders [REDACTED]. Resident #1 was not consistently weighed and weights were not consistently reported to the physician during the period between 02/14/11 and 06/10/11. Weight records show the Resident gained in excess of 2 pounds overnight at least 11 times (3/5, 3/13, 3/16, 3/24, 4/18, 4/23, 4/25, 4/27, 5/13, 5/16, and 5/20), but the physician was notified only once on 03/16/11. Weights were not recorded on 49 of the 117 days between 02/14 and 06/10, so it was not known if a weight gain occurred. On 05/21/11, a skin breakdown area was found on the Resident's right heel. Nursing notes reflected "4 cm (centimeter) Stage II open area right heel". The investigation report showed an area of skin breakdown was caused by "the diabetic shoe fitting too tightly because of the 10 pound weight gain.". The Resident had gained 10 pounds between 04/21/11 and 05/21/11 with no notification to the physician. The physician was notified of the weight gain on 05/25/11 and orders were initiated to increase a medication ([MEDICATION NAME]) to help eliminate fluid from the body. On 05/22/11, nursing notes reflected "Resident is making arrangements for fitting of new boot for right foot." It was not clear from the record whether the Resident was informed or understood about continuing risk of wearing the tight shoe. On 06/01/11, a Social Service note stated "Faxed catalog page that therapy provided re: need for podus boot." It was not clear whether if the Resident was wearing the tight diabetic shoe or no footwear between 05/21/11 and 06/01/11, The Resident's blood sugar levels were identified by the physician as being poorly controlled in April of 2011 and Insulin orders were adjusted twice that month by the Resident's Endocrinologist. The Resident's blood sugar levels were checked 4 times per day, and were found to be excessively high, ranging between 200-559 mg/dL (normal being 75-125 mg/dL). Nursing notes reflected several statements of "CBGs (blood sugar) controlled with scheduled insulin", despite the lowest recorded blood sugar being greater than 200 mg/dL. The Endocrinologist or the Primary Care Physician was not notified about high blood sugar levels between the end of April and 05/27/11 when the right foot wounds developed a "foul odor". No lab work or vascular studies were completed. On 05/26/11, a nutritional risk review (committee consisting of nurse managers, dietitian, and dietary manager) stated "resident with noted right heel Stage II pressure area approx 4 cm circumference. Plan: treatment order in place, Keflex to prevent infection x 2 week with follow up with wound nurse". No mention was made of weight fluctuations, uncontrolled blood sugars or Residents understanding of dietary compliance. On 06/02/11, the nutritional risk committee again discussed the resident and noted "Resident continues with noted right heel Stage II pressure sore 4cm x 4 cm. He has weight fluctuations, [MEDICATION NAME] recently increased. He has no recent PAB (pre-[MEDICATION NAME]) or [MEDICATION NAME], he eats well likely meeting protein needs. Plan: Treatment order in place, Keflex to prevent infection x 2 weeks. Wound clinic to follow up next visit. Request a multivitamin with minerals". No mention was made of uncontrolled blood sugars or Resident's understanding of dietary compliance. On 06/02/11, the Resident requested to see his Primary Care Physician and arrangements were made for an appointment on 06/03/11. On 06/07/11, the Resident was seen again at the wound clinic and appointments were scheduled for 06/09, 06/10, 06/20, 06/21 for vascular imaging appointments of the right foot. . Nursing notes reflected the Resident was cooperative with therapy. Social Service notes on 06/09/11 reflected the Resident was planning to discharge home as soon as arrangements were made, and that the Resident felt he was "going through a lot with the wounds and his wife filing for divorce". On 06/10/1, the Resident left the facility to go to a scheduled appointment. Later that day, nursing notes reflected "received call from Resident at hospital stating they are going to keep him there and do more tests and angiogram next week to improve leg and choose method of care." During interview on 07/11/11, the RCM stated the resident underwent [REDACTED]. The RCM stated the Resident was "always leaving the facility and eating cookies. I don't know how his blood sugar could be in control." During interview on 07/11/11, the Director of Nursing stated "The Resident gave up after he developed skin breakdown on his right foot. We talked with him a lot about what he could be doing differently, like being more compliant with his diet and elevating his leg, but I guess we didn't document that". See also F 157

Based on interview and record review the facility failed to report to the primary care physician when one of five sampled residents (Former Resident #1) experienced weight gain which led to swelling of his lower leg. The facility also failed to report the continuing poorly controlled blood sugar readings for one of five sampled residents (Resident #1). This failure caused the resident to develop non-healing skin breakdown from his shoes fitting too tightly and from the continuing high blood sugar levels and led to the necessity of an amputation of his remaining foot and leg. Findings include: Resident #1 was admitted to the facility on [DATE] from the hospital. His admitting [DIAGNOSES REDACTED]. According to the MDS (Minimum Data Set, an assessment tool), he was alert and oriented and mobile in the facility/community via his electric wheelchair. He required extensive assistance with his activities of daily living. <Physician notification, weight changes> On 02/09/11, physician progress notes [REDACTED]. He was given medications at the hospital to help remove some of the fluid and was readmitted to the facility on [DATE] with orders to weigh daily and notify the physician of weight increase by 2 pounds overnight or 3-5 pounds per week. On 03/16/11, the physician was notified of a weight gain >8 pounds and orders were given to add a new medication to help remove fluid from the body. On 05/21/11, an open area was found on the Resident ' s right heel. An investigation revealed the skin breakdown was caused by the diabetic shoe being too tight because the Resident "had a 10 pound weight gain this month." The physician was not notified until 05/25/11, when there was a weight gain of 3 pounds over night. New orders were given to increase a currently ordered medication. Of the 117 days between 02/14/11 and 06/10/11, weights were not recorded 49 times. The weights that were recorded reflected 11 times (03/05, 03/13, 03/16, 03/24, 04/18, 04/23, 04/25, 04/27, 05/13, 05/16, 05/20) where the fluctuations in weight met criteria for physician notification (2 pounds over night or 3-5 pounds per week), but the physician was only notified once on 03/16. It was not known if the Resident met the criteria for physician notification of weight gains on the days when the weights were not recorded. On 07/11/11, during interview, the Resident Care Manager (RCM) was not aware of the weights had not been recorded and was not aware the physician had not been notified as ordered. On 07/11/11, during interview, the Director of Nursing (DNS) was not aware of how daily weights were recorded or communicated to staff. She stated the weights should be taken by the Restorative Aide. <Physician notification, blood sugars> On 04/06/11, physician visit notes reflected Resident #1 was experiencing blood sugars in the 150-350 mg/dL range. (Normal range for random blood sugar checks would be 75-125 mg/dL.) The physician stated "Poorly controlled type 2 Diabetes" and gave orders on 04/06 to increase bedtime insulin and to return to the clinic in 2 months. According to Diabetic Records and nursing notes, the Resident continued to have blood sugars in the 200-300 range. Despite the blood sugars being out of control as often as 4 times daily, several entries in the nursing notes stated " CBGs (blood sugar checks) are controlled with scheduled insulin orders " . On 04/20/11, a nursing note reflected the physician was asked about increasing the insulin dose to lower the blood glucose, and insulin orders were changed on that day. Medication Administration Records (MARs) reflected the Resident ' s blood sugars continued to be documented four times per day and were consistently in excess of 200mg/dL and often up to 559mg/dL during May and June, until the time of the Resident's discharge on 06/10/11. The attending physician was not notified of the continued high blood sugar results between 04/20/11 until 05/27/11. When the Resident developed skin breakdown with a foul odor on 05/27, the physician was "updated on right heel ulcer and bloodsugars." On 07/11/11, the Director of Nursing stated it would not be likely for a wound to heal if a resident ' s blood sugars were too high for a long period of time. She stated the physician should have been notified earlier. See F 309

Based on interview and record review the facility failed to ensure significant medication error did not occur for one sampled resident (#1) reviewed for medication error. This failure caused harm to Resident #1 and placed other residents at risk for experiencing adverse effects of medications. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented. According to the facility's Medication Error Report dated 9/17/10 Licensed Nurse (LN) A administered an ear drop medication in Resident #1's eyes 9:35 p.m. The resident complained of pain in both eyes. The LN flushed the resident's eyes and notified the Director of Nursing Services (DNS) of the incident at 10:00 p.m. A nursing progress note dated 9/18/10 at 11:20 a.m. indicated the resident complained of "irritated eyes." An LN administered eye drops for the resident and noticed "redness to both eyes." A nursing entry at 9:15 p.m., the resident told an LN his daughter noticed his eyes were blue earlier that day. The resident said his vision was "blueish" and the symptom was new. The facility notified the resident's physician regarding the incident. The resident's physician ordered for the resident to be sent to the hospital for treatment. According to the facility's documentation, dated 9/19/10 the resident had a "corneal abrasion." On 9/21/10 an optometry note stated the resident had a "H/o (history of) conjunctival irritation/toxicity due to exposure to topical peroxide solution 9/17/10." On 9/28/10 at 3:10 p.m. during a phone interview with the resident's daughter, she stated she had visited her father on 9/18/10. She noticed her father's eyes were blue and told her father. On 9/30/10 approximately 10:00 a.m. the resident was sitting in his wheelchair in his room. The resident stated an LN had administered an ear drop medication in his eyes on the evening of 9/17/10. The resident said the moment the LN put the ear drop medication into his eyes it felt like "fire." The resident said he was transported to the hospital on the next day for a treatment and his eyes were better. At 10:12 a.m. LN B said she checked each medication for right route prior to administering a medication. At 11:40 a.m. the DNS said LN A was new to the facility and was working with a preceptor. The DNS stated the resident had medications ordered for his ears and eyes. The LN brought in both medications and set them next to each other. The DNS said the LN inadvertently took the ear drop medication and put in the resident's eyes. The DNS said the LN was expected to review each medication before administering them to the resident. The DNS said every LN had gone through an orientation period upon hire and had demonstrated safe medication administration. The DNS said she and/or the Resident Care Manager observed the LNs administered medications and reviewed the medication administration records to ensure significant medication error did not occur.