Every finding on record at Edmonds Post Acute

Based on interview and record review, the facility failed to provide an effective plan to control insects for 2 of 3 nursing units (Southeast Wing and Northeast Wing) and for 1 of 1 kitchen, reviewed for pest control. This failure placed the residents at risk for poor living conditions, emotional distress and a diminished quality of life.Findings included.SOUTHEAST WINGRESIDENT 1Review of the quarterly Minimum Data Set assessment (MDS-a required tool) showed the resident did not have problems with their thinking or memory.In an interview on 07/24/2026 at 12:36 PM, Resident 1 stated, there are insects that fly around the room, they usually come at least five times a week when the food comes out, they are annoying. I told staff about it, they all know.RESIDENT 2Review of the admission MDS dated [DATE] showed Resident 2 did not have problems with their thinking or memory.In an interview on 07/24/2026 at 12:42 PM, Resident 2 stated, I have seen little bugs flying around my food.RESIDENT 3Review of the quarterly MDS dated [DATE] showed the resident had intact thinking and memory.In an interview on 07/24/2026 at 12:51 PM, Resident 3 stated, they saw small bugs flying around the room, usually in the daytime, it has been happening a lot.NORTHWEST WINGRESIDENT 4Review of the admission MDS dated [DATE] showed Resident 4 had intact thinking and memory.In an interview on 07/24/2026 at 1 :51 PM, Resident 4 stated, there are a lot of bugs that fly around, all the time, but especially when the food comes out. I have also seen insects crawling on the floor, in the corners of the room.RESIDENT 5Review of the quarterly MDS dated [DATE] showed Resident 5 had no problems with their thinking or memory.In an interview on 07/24/2026 at 1:57 PM, Resident 5 stated, there are bugs that fly around in my room, around my food, I have also seen small bugs crawling on the floor in the corners and right by my bed I don't like any kind of bug, crawling or flying.KITCHENIn an interview on 07/24/2026 at 3:26 PM, Staff B, Maintenance Director, stated they had seen bugs crawling on the kitchen floor yesterday, and that they were aware of the flying insects. Staff B further stated they had put chemicals down the kitchen drain to try and get rid of the flying insects, then notified the pest control company.A review of the pest control invoice form dated 04/20/2026 showed they (pest control staff) checked in with Staff B. The invoice form further showed there were reports of insects in the kitchen and in the [staff] breakroom.A review of the pest control invoice form dated 06/05/2026 showed the facility had insects in a portion of the facility, but the facility was not financially covered to service those types of insects. The form further showed the pest control company could cover those types of insects if the facility wanted to renegotiate the contract to cover those types of insects.In an interview on 07/24/2026 at 5:09 PM, Staff A, Administrator, stated they needed to look into getting better pest control.Reference: (WAC) 388-97-3360 (1).

Based on observation, interview, and record review, the facility failed to ensure a clean, safe, and homelike environment for 1 of 3 residents (Resident 5), reviewed for environment. This failure placed the residents at risk of injury, a less than homelike environment, and a diminished quality of life.Findings included.Review of the facility's policy titled, Homelike Environment, revised in February 2021, showed that Residents are provided with a safe, clean, comfortable and homelike environment.Observation and interview on 06/23/2026 at 10:25 AM, showed an oxygen concentrator (a medical device used to deliver oxygen) and a bedside commode (a moveable toilet) on Resident 5's side of the curtain that belonged to their roommate (Resident 4). Further observation showed that the oxygen concentrator was near Resident 5's bed. Resident 5 stated, that [oxygen concentrator] is for [Resident 4] and it makes it cramped, hard to get into bed.Additional observations on 06/23/2026 at 2:45 PM, on 06/24/2026 at 11:35 AM and on 06/25/2026 at 9:56 AM, showed an oxygen concentrator and bedside commode on Resident 5's side of the curtain that belonged to their roommate (Resident 4).In an interview and joint observation on 06/25/2026 at 9:59 AM, Staff H, Certified Nursing Assistant, stated that they usually have a curtain in between [resident beds] so there would be space in-between them. Joint observation showed an oxygen concentrator and bedside commode on Resident 5's side of the curtain that belonged to their roommate (Resident 4). Staff H stated, this is the space we have for [Resident 5].In an interview and joint observation on 06/25/2026 at 10:11 AM, Staff I, Charge Nurse, stated that they expected residents to have their own belongings on their side of their room and not be in their roommates' space. Staff I stated that it included bedside commodes and oxygen concentrators. Staff I stated that the curtain between resident spaces divides the space and they would not expect one resident's bedside commode and oxygen concentrator to be on the other side of the curtain and in their roommate's space. Joint observation showed Resident 4's bedside commode and oxygen concentrator on Resident 5's side of the curtain. Staff I stated that the oxygen concentrator and bedside commode were on Resident 5's side and should be on Resident 4's side and it shouldn't [should not] be like that.In an interview on 06/25/2026 at 11:59 AM, Staff B, Director of Nursing, stated it's [it is] my expectation that every resident has their own space. Staff B stated that the room is divided by the curtain line between residents' beds. Staff B stated that the concentrator and bedside commode for Resident 4 should be on their side of the curtain, not on Resident 5's side. Staff B further stated, it's [it is] my expectation that every resident has their own space.Reference: WAC 388-97-0880 (1).

Based on interview and record review, the facility failed to ensure physician orders were implemented and followed in accordance with professional standards of practice for 1 of 1 resident (Resident 1), reviewed for quality of care. This failure placed residents at risk for not receiving necessary care services, unmet care needs, and a diminished quality of life.Findings included .Review of the facility's policy titled, Wound Care, revised in October 2021, showed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Review of the facility's policy titled, Medication and Treatment Orders, revised in July 2016, showed, Orders for medications and treatments will be consistent with principles of safe and effective order writing.Review of a face sheet printed on 06/11/2026 showed Resident 1 admitted to the facility on [DATE].Review of the hospital document titled, Discharge Summary, dated 05/14/2026, showed, Will need dressing changes of leg incisions every other day, under Outpatient Follow-up Issues.Review of the hospital document titled, Skilled Nursing Facility [SNF] Transfer Orders, dated 05/14/2026, showed Resident 1 had femoral-tibial bypass procedure on 05/06/2026 and right trans metatarsal amputation on 05/08/2026. The document further showed surgical care orders for:- Surgical wound care R (right) groin w (with)/ Medipore (a soft, breathable, and stretchable medical tape used to secure dressings and medical devices while minimizing skin irritation) until discontinued. comments: wrap right lower extremity with ACE wrap (an elastic bandage used to provide compression, support, and swelling control for injuries and rehabilitation). R groin w/ Medipore. change dressing. do not change-reinforce if saturated. 1st (first) change. by surgeon.- Surgical wound care right foot until discontinued. right foot. change dressing. do not change-reinforce if saturated.Review of the hospital document titled, Vascular Surgery, dated 05/13/2026, showed the following under Plan:- Elevate leg when not ambulating- Dressing change of leg incisions every other day- Wrap leg in ACE for the next week- OOB (Out of Bed) and on chair 2 (two) to 3 (three) times dailyReview of the May 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 05/14/2026 to 05/31/2026 showed no orders and/or documentation to indicate that Resident 1 had dressing changes to their leg incisions every other day and/or ACE wraps done to their right lower extremity.Review of June 2026 MAR/TAR showed no orders and/or documentation to indicate that Resident 1 had dressing changes to their leg incisions every other day and/or ACE wraps done to their right lower extremity.On 06/11/2026 at 2:38 PM, Resident 1 stated that their hospital discharge orders included changing their right leg incision dressings every other day, having their right leg wrapped with ACE wrap for one week, and to be out of bed 2 to 3 times a day. Resident 1 stated that these orders were not followed since they were admitted to the facility on [DATE]. Resident 1 stated that their right foot amputation dressing was changed on 06/03/2026 during their follow-up post-operative appointment outside the facility. Resident 1 further stated that the facility staff did not provide wound care to their right incisions and/or right leg since they admitted to the facility.In an interview and joint record review on 06/22/2026 at 3:27 PM, Staff C, Charge Nurse, stated that wound care for residents would be done following treatment orders. A joint record review of May 2026 and June 2026 MAR/TAR did not show that Resident 1 had a treatment order for their right leg incisions. Staff C stated that there were orders to not remove Resident 1's right groin wound dressing and right foot amputation dressing and to reinforce if soiled. A joint record review of the hospital Discharge summary dated [DATE] showed, will need dressing changes of leg incisions every other day. A joint record review of the hospital skilled nursing facility transfers orders showed, wrap right lower extremity with ACE wrap, under the right groin dressing orders. Staff C stated the orders should have been clarified with the hospital during admission, both treatment orders are not complete and are unclear. Staff C stated that there was no documentation to show that Resident 1 had right incision dressing changes or right leg ACE wrap treatments done since the resident was admitted to the facility on [DATE].In an interview and joint record review on 06/25/2026 at 12:46 PM, Staff B, Director of Nursing, stated that during the admission process the facility followed the skilled nursing transfer orders from the hospital as new admission orders. A joint record review of the hospital skilled nursing facility transfers orders showed, wrap right lower extremity with ACE wrap, under the right groin dressing orders. A joint record review of the hospital Discharge summary dated [DATE] showed, will need dressing changes of leg incisions every other day. Staff B stated that the facility used the hospital skilled nursing facility transfers orders as the official orders for new admits. A joint record review of May 2026 MAR/TAR and June 2026 MAR/TAR did not show documentation to indicate that Resident 1 received wound care/treatment to their right leg incisions or ACE wrap to their right leg. Staff B stated that the wound/treatment orders should have been clarified during Resident 1's admission time and that the hospital SNF transfer orders were the orders followed for newly admitted residents.Reference: (WAC) 388-97-1060 (1)(3)(b).

Based on interview and record review the facility failed to provide necessary/adequate supervision for 1 of 1 resident (Resident 2), reviewed for elopement. This failure allowed Resident 2 to exit the facility unnoticed and placed the resident at risk for serious injury and a diminished quality of life.Findings included .Review of the facility policy titled, Elopements, revised in April 2021, showed, Staff shall investigate and report all cases of missing residents.Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (a necessary) volunteer agencies i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area.Review of a face sheet printed on 06/16/2026 showed Resident 2 admitted to the facility on [DATE] with diagnoses that included dementia (a progressive condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life) and secondary parkinsonism (group of disorders that produce movement symptoms similar to Parkinson's disease [a condition where parts of the brain slowly stop working properly, causing movement and other body functions to become harder over time] such as tremor, slowness of movement, and rigidity, but arise from different underlying causes).Review of the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 05/19/2026 showed Resident 2 had severe cognitive impairment.Review of the elopement evaluation dated 05/14/2026, showed Resident 2 was disoriented all the time, agitated, ambulatory, independent with mobility, and was taking medications for verbal, physical, or emotional outbursts. Further review of the elopement evaluations showed that Resident 2 was at risk for elopement, wanders through facility.wanders into other rooms exit seeking.Review of the elopement care plan initiated on 05/26/2026 showed Resident 2 had a goal of, will not leave center unattended . Further review of the care plan showed an intervention for Assure resident is wearing their wander guard bracelet. distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. document wandering behavior and attempted diversional interventions.Review of another elopement care plan initiated on 05/14/2026 showed Resident 2 had a goal of, will not elope. Further review of the care plan showed an intervention for wander guard on right ankle.Review of the facility document titled, 15 Minute Check, dated 06/13/2026, showed Resident 2 was last seen in the dining room at 2:15 PM. Further review showed there was no documentation of 15 Minute Checks being completed between 2:30 PM and 9:45 PM (when resident returned from the Emergency Room) on 06/13/2026.Review of a police incident report dated 06/13/2026 showed that a report was received by the police on 06/13/2026 at 4:04 PM of Resident 2 walking and disoriented. Further review of the police report showed that the police were with Resident 2 at 4:05 PM near [NAME] dealership (on 212th SW and 99 interstate).Review of a google online map showed that the distance between facility and 212th & 99 interstate (where resident was found) was approximately 0.4 miles and that it took eight minutes walking to get there.Review of the investigation report dated 06/13/2026 showed Resident 2 was last seen in the facility on 06/13/2026 at 4:05 PM. Observation on 06/16/2026 at 3:33 PM showed Resident 2 was sitting on a chair next to the medication cart across their room. Further observation showed Resident 2 had a wander-guard on their right ankle.Observation on 06/16/2026 at 4:31 PM showed Resident 2 was sitting on a chair outside their room.In an interview on 06/16/2026 at 4:43 PM Resident 2's representative stated that Resident 2 had their wander guard on their right ankle after the resident was found outside the facility by local police on 06/13/2026.In an interview on 06/22/2026 at 2:17 PM, Staff E, Certified Nursing Assistant, stated they noticed Resident 2 was not in their room at around 2:40 PM. Staff E further stated that Resident 2 was not in the dining room. Staff E stated that Resident 2 walked independently and refused to use a walker. Staff E stated that they notified an unnamed nurse that Resident 2 was not in their room, and Staff E was told that Resident 2 was last seen in the dining room, then Staff E looked for Resident 2 in the dining and did not find them. Staff E stated that Resident 2 wore a wander guard on their leg.In an interview and joint record review on 06/22/2026 at 2:45 PM, Staff C, Charge Nurse, stated that they expected staff to check the facility when a resident was missing. Staff C stated they expected staff to look for a missing resident in the facility, call 911, notify resident's family, doctor, law enforcement, director of nursing, and administrator. Staff C stated that Resident 2 wandered around the hallways and dining room across the [NAME] nurse station. Staff C stated that Resident 2 was at risk for elopement and that they had a wander guard since admission. A joint record review of the elopements care plan showed that Resident 2 had the following goals: will not leave center unattended. will not elope. Staff C stated, well that did not happen, because [Resident 2] left the facility. A joint record review showed an elopement risk assessment dated [DATE] indicating that Resident 2 was disoriented all of the time; was agitated; was ambulatory; independent with mobility; was taking medications for verbal, physical, or emotional outbursts; wanders through facility.wanders into other rooms exit seeking. Staff C stated that Resident 2 wore a wander guard on their right ankle due to that they were exit seeking and wandered into other residents' rooms. A joint record review of a 15 Minute Check document dated 06/13/2026 showed that Resident 2 was seen in the dining room at 2:15 PM. Staff C stated, they documented seeing [Resident 2] in the dining room at that time, and then at 10:00 PM after [Resident 2] came back from the hospital. Staff C stated that there was no documentation of 15-minute checks on 06/13/2026 between 2:30 PM and 9:45 PM. Staff C further stated that Resident 2 should not have left the facility unattended.In an interview and joint record review on 06/25/2026 at 1:17 PM, Staff B, Director of Nursing, stated that residents at risk for elopement were evaluated during admission and that if they were exit seeking, a wander guard would be in place after a consent was obtained. Staff B stated that Resident 2 was pleasantly confused, wandered around, went into other residents' rooms, staff redirected them and that Resident 2 wore a wander guard. A joint record review of an elopement care plan showed Resident 2 would not leave the facility unattended. A joint record review of the elopement risk evaluation showed the resident was at risk for elopement due to exit seeking and wandering into other resident's rooms. Staff B stated that Resident 2 had a wander guard on their right ankle due to being at risk for elopement. A joint record review of the incident investigation dated 06/13/2026 showed Resident 2 was last seen in the facility on 06/13/2026 at 4:05 PM. A joint record review of the police report showed the resident was found by the police at 4:05 PM near [NAME] dealership (0.4 miles away from the facility), the same time the facility was reporting last seeing the resident. Staff B stated that Resident 2 should not have left the facility unattended.In an interview on 06/25/2026 at 2:40 PM, Staff A, Administrator, stated that Resident 2 should not have left the facility unattended. Staff A provided no further information.Reference WAC 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 2 of 7 residents (Residents 3 and 4), reviewed for medication administration. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the residents at risk for negative outcomes and a diminished quality of life. Findings included .Review of the facility policy titled, Pharmacy Services Overview, revised in April 2019, showed, the facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. the facility shall contact with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that supports the resident's needs, are consistent with current standards of practice. And meet state and federal requirements. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.Review of the manufacturer's recommendations titled, Biktarvy [Bictegravir-Emtricitab-Tenofov - an antiviral medication], revised in July 2025, showed, It is important to take Biktarvy on a regular dosing schedule with or without food and to avoid missing doses as it can result in development of resistance.Review of an online medication drug information titled, Medline Plus - Emtricitabine-Tenofovir Alafenamide Fumarate (an antiviral medication), revised on 07/15/2025, showed, Continue to take emtricitabine and tenofovir AF even if you feel well. Do not stop taking emtricitabine and tenofovir AF without talking to your doctor. If you stop taking emtricitabine and tenofovir AF even for a short time, or if you skip doses, the virus may become resistant to medications and may be harder to treat.<RESIDENT 3>Review of the face sheet showed Resident 3 admitted to the facility on [DATE] with diagnoses that included Human Immunodeficiency Virus (HIV-virus that attacks the body's immune system that can lead to Acquired Immunodeficiency Syndrome [AIDS - advance stage of HIV infection where the immune system is severely damaged making the body vulnerable to infections]).Review of the May 2026 Medication Administration Record (MAR) showed Resident 3 had an order for Emtricitabine-Tenofovir Alafenamide Fumarate (an antiviral medication) Oral Tablet 200-25 milligrams (MG- unit of measurement) Give 1 tablet by mouth in the morning for HIV. Further review of the May 2026 MAR showed Resident 3 did not receive their Emtricitabine-Tenofovir AF on the following dates: - 05/24/2026- 05/25/2026- 05/26/2026- 05/27/2026- 05/28/2026- 05/29/2026- 05/30/2026, and- 05/31/2026, a total of eight days for May 2026.Review of the June 2026 MAR showed Resident 3 had an order for Emtricitabine-Tenofovir AF Oral Tablet 200-25 MG. Give 1 tablet by mouth in the morning for HIV. Further review of the June 2026 MAR showed Resident 3 did not receive their Emtricitabine-Tenofovir AF on the following dates: - 06/01/2026- 06/02/2026- 06/03/2026- 06/04/2026- 06/05/2026- 06/07/2026- 06/08/2026- 06/10/2026, and- 06/11/2026, a total of nine days for June 2026.The June 2026 MAR also showed that Resident 3 had an order for Azithromycin (antibiotic - treats bacterial infections) tablet 500 mg. 1 tablet scheduled for 12:00 PM. Further review of the MAR showed Resident 3 did not receive their medication on 06/02/2026, as indicated by a blank on the MAR. On 06/16/2026 at 3:57 PM, Resident 3 stated that they had not received their Emtricitabine-Tenofovir AF since they admitted to the facility and were told that the pharmacy was not delivering the medication. Resident 3 stated they just started [taking the medication] last Friday [06/12/2026] or this week. Resident 3 stated that their doctor told them it was important for them to take both of their medications for HIV. Resident 3 stated they were afraid their illness would get worse or cause them to go back to the hospital.On 06/17/2026 at 10:59 AM, Resident 3 stated that they were discharging home today. Resident 3 showed their medication discharge orders included dolutegravir, bottle and Emtricitabine-Tenofovir AF bottle. Resident 3's medication order did not include the amount of tablets both of their medications had in each bottle. A joint record review and joint observation on 06/17/2026 at 11:14 AM with Staff J, Registered Nurse (RN), showed Resident 3's discharge medication orders showed dolutegravir, bottle and Emtricitabine-Tenofovir AF bottle. A joint observation of the dolutegravir bottle showed there were 11 tablets in it and the Emtricitabine-Tenofovir AF bottle had 24 tablets. Staff J stated that Resident 3's discharge medication orders should have included the number of tablets each bottle had.In an interview and joint record review on 06/22/2026 at 4:00 PM, Staff F, RN, stated that their medication administration process consisted of checking residents' orders, checking medication carts for the medications. Staff F stated that when medications were not available, staff would notify the provider and call the pharmacy until medications were obtained. A joint record review of May 2026 MAR and June 2026 MAR Resident 3's showed Resident 3 did not receive their Emtricitabine-Tenofovir AF on 05/24/2026, 05/25/2026, 05/26/2026, 05/27/2026, 05/28/2026, 05/29/2026, 05/30/2026, 05/31/2026, 06/01/2026, 06/02/2026, 06/03/2026, 06/04/2026, 06/05/2026, 06/07/2026, 06/08/2026, 06/10/2026, and 06/11/2026 a total of 17 days. Staff F stated that Resident 3's medication was not delivered by the pharmacy due to that their insurance did not cover it. Staff F further stated that Resident 3 was not provided with their medication from 05/31/2026 to 06/11/2026, for a total of 19 days. Staff F stated that the June 2026 MAR for 06/06/2026 and 06/09/2026 showing that Resident 3 was given their Emtricitabine-Tenofovir AF was documented by mistake, Staff F stated that on 06/11/2026 the pharmacy overnighted the medication and that Staff F provided Resident 3 their first dose on 06/12/2026. When asked Staff F if Resident 3 was not given their medication from 05/24/2026 to 06/11/2026 for a total of 19 days, Staff F stated Yes.In an interview on 06/23/2026 at 2:43 PM, Staff L, Pharmacist, stated that HIV medications should be administered as prescribed or following manufacturer's recommendations. Staff L further stated, residents should not be without their medications.In an interview and joint record review on 06/25/2026 at 11:39 AM, Staff D, Charge Nurse, stated they expected staff administered medications to residents as prescribed. A joint record review of May 2026 Mar and June 2026 MAR showed Resident 3 was not given their Emtricitabine-Tenofovir AF tablets on the above dates for a total of 17 days. Further review of the June 2026 MAR showed Resident 3 was not given their Azithromycin on 06/02/2026, it was blank. Staff D stated that Resident 3 should have been given their medications as prescribed and that if it was not documented it was not done.In an interview and joint record review on 06/25/2026 at 1:58 PM, Staff B, Director of Nursing, stated that medications for HIV were important. A joint record review of May 2026 MAR and June 2026 MAR showed Resident 3 was not given their Emtricitabine-Tenofovir AF and Azithromycin tablets on he above dates. Staff B stated that Resident 3 should have been given their medications as prescribed. <RESIDENT 4>Review of the face sheet showed Resident 4 admitted to the facility on [DATE] and was readmitted on [DATE]Review of May 2026 MAR showed Resident 4 had an order for Bictegravir-Emtricitab-Tenofov Oral Tablet 50-200-25 MG Give 1 tablet by mouth one time a day for HIV. Further review of the May 2026 MAR showed Resident 4 was not given this medication on 05/20/2026.Review of the June 2026 MAR showed Resident 4 was not given their Bictegravir-Emtricitab-Tenofov on the following dates:- 06/07/2026- 06/10/2026- 06/11/2026- 06/12/2026- 06/13/2026- 06/14/2026- 06/15/2026- 06/16/2026- 06/17/2026- 06/18/2026, and - 06/19/2026, for a total of 11 days.On 06/16/2026 at 3:31 PM, Resident 4 stated that they were told that their Biktarvy was not available and that their insurance did not cover it. Resident 4 stated, My doctor said I need to take my antiviral medication, I have been hospitalized for 6 [six] months, so it is important I get those medications, so I don't [do not] get too sick and go to the hospital again. An observation and joint record review on 06/17/2026 at 3:17 PM, showed Staff G was preparing Resident 4's medications that included Bictegravir. Staff G stated, let me check if this medication [Biktarvy] is here or not; I'm not sure. This medication is not available. Staff G stated that Resident 4 did not have this medication since last week. A joint observation of the June 2026 MAR showed Resident 4 was not given their Biktarvy from 06/10/2026 to 06/17/2026. Staff G stated, I think [Resident 4's] insurance hasn't [has not] covered it.A joint record review and interview on 06/22/2026 at 4:27 PM with Staff F showed the May 2026 MAR and June 2026 MAR indicated Resident 4 was not given their Biktarvy on 05/20/2026, 06/07/2026, 06/10/2026, 06/11/2026, 06/12/2026, 06/13/2026, 06/14/2026, 06/15/2026, 06/15/2026, 06/16/2026, 06/17/2026, 06/18/2026, and 06/19/2026, for a total of 11 days. Staff F stated that Resident 4's medication was not available in the facility pending pharmacy delivery. Staff F stated that Resident 4 should have been administered their medications as prescribed and the medications should have been available for Resident 4.In an interview on 06/23/2026 at 11:05 AM, Staff K, Medical Doctor, stated that they were aware Resident 3 & 4's medications for HIV were not available at the facility due to their medications not being covered by their insurance. Staff K stated that residents were being monitored. Staff K stated that HIV medications were important and that missing doses for prolonged time could cause flare ups of the disease symptoms. A joint record review and interview on 06/25/2026 at 11:39 AM with Staff D, showed May 2026 MAR and June 2026 MAR indicated that Resident 4 was not administered their Biktarvy on the above dates for a total of 11 days. Staff D stated that Resident 4 should have been administered their medications as prescribed. In an interview on 06/25/2026 at 1:58 PM, Staff B stated that Resident 4 should have been administered their Biktarvy as prescribed.In an interview on 06/25/2026 at 3:00 PM, Staff A, Administrator, stated that the facility should have had Resident 3 & 4's medications readily available.Reference: (WAC) 388-97-1300 (1)(b)(i-ii)(3)(a).

Based on observation, interview, and record review, the facility failed to ensure laundry was handled, stored and processed in a sanitary manner for 1 of 1 laundry room, reviewed for infection control. In addition, the facility failed to ensure Contact Enteric Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment and washing hands with soap and water when leaving the room) practices were followed for 1 of 7 staff (Staff JJ) and 1 of 1 resident (Resident 25), reviewed for transmission based precautions (measures put in place to prevent spread of infection by staff wearing Personal Protective Equipment [PPE-use of gown, gloves, mask and/or face shield] before entering a resident's room or environment). These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included. Review of the facility's policy titled, Policies and Practices-Infection Control, revised in October 2018, showed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. LAUNDRY ROOMIn an interview and joint observation on 03/02/2026 at 1:11 PM, Staff DD, Housekeeper, stated they were responsible for the laundry today. A joint observation showed three yellow bins of soiled laundry inside the laundry room next to a rack of clean linens. It showed that one yellow soiled bin was touching a bin of clean housekeeping rags. Staff E, Housekeeping Director, stated dirty items should not be touching clean items. When asked what they used for disinfecting the washing machines, Staff DD showed an unlabeled spray bottle with blue liquid in it. Staff E stated that every cleaner should be labeled and we're [we are] replacing these now, we can't [cannot] use them. Another joint observation showed a pile of wet clothes placed on top of a rolling cart that had dirty items, including dirty shoes on the bottom rack. Staff DD stated that yes the items on the bottom rack were dirty. Staff E stated that the wet clothes would need to be rewashed. In an interview on 03/03/2026 at 1:30 PM, Staff F, Infection Preventionist, stated that their expectations in the laundry room included, separating the dirty and clean areas, dirty laundry should not be touching clean items, and clean laundry should not be placed on a cart with dirty items on the bottom. Staff F stated that laundry should be transferred right from the washer to the dryer. Staff F further stated that laundry staff should not use unlabeled chemicals and that every chemical in the building should be labeled. In an interview on 03/04/2026 at 8:18 AM, Staff B, Director of Nursing, stated that their expectation in the laundry room was that the clean [should be] separate from dirty. Staff B stated that they expected laundry staff to transfer laundry directly from the washer to the dryer. Staff B further stated that all chemicals should be labeled. CONTACT ENTERIC PRECAUTIONSReview of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised in September 2022, showed that Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Review of the Centers for Disease Control Prevention (CDC) online article titled, Clinical Guidance for C. diff [Clostridium Difficile – is a highly contagious bacterial infection that can cause severe diarrhea] Infection Prevention in Acute Care Facilities, dated on 03/08/2024, showed, For patients [residents] with confirmed CDI [Clostridioides Difficile Infection], maintain contact precautions for at least 48 hours after diarrhea [loose, watery stools and urgent bowel movements] has resolved, or longer. STAFF JJObservation on 02/27/2026 at 11:53 AM, showed signage that room [ROOM NUMBER] was a contact enteric precautions room. It showed Staff JJ, Certified Nursing Assistant (CNA), put on a gown and gloves to enter room [ROOM NUMBER] to bring juice to Resident 25. Staff JJ took off their gown and gloves prior to leaving the room, used hand sanitizer, and did not use soap and water to wash their hands. At 12:20 PM, Staff JJ entered room [ROOM NUMBER] to take a meal tray to Resident 25. Staff JJ took off their gown and gloves prior to leaving the room, used hand sanitizer, and did not use soap and water to wash their hands. In an interview and joint observation on 02/27/2026 at 12:25 PM, Staff JJ stated that they knew what isolation precautions a resident was on by the sign at the door. Staff JJ stated that if a resident was on contact enteric precautions they would wear a gown and gloves and use hand sanitizer when leaving the resident's room. A joint observation of the signage at room [ROOM NUMBER]'s door showed to use soap and water upon leaving the room. Staff JJ stated that they did not use soap and water when leaving room [ROOM NUMBER] because there is no sink close by, it's [it is] all the way at the nurses station. In an interview on 03/03/2026 at 1:30 PM, Staff F stated that contact enteric precautions would be used if a resident was having diarrhea, three or four in a day or if a resident had C-diff. Staff F further stated that they expected staff to wash their hands with soap and water when leaving a contact enteric precautions room. In an interview on 03/04/2026 at 8:18 AM, Staff B stated that they expected staff to wash their hands with soap and water when leaving a contact enteric precautions room. RESIDENT 25Review of a face sheet printed on 02/25/2026 showed that Resident 25 readmitted to the facility on [DATE] with diagnoses that included diarrhea. Observation on 02/23/2026 at 10:31 AM, showed a contact enteric precaution signage outside Resident 25's door. In an interview on 02/23/2026 at 10:40 AM, Staff L, Registered Nurse, stated that Resident 25 was on contact enteric precaution for C-diff. On 02/23/2026 at 3:20 PM, Resident 25 stated that they were still having diarrhea. Observation on 02/25/2026 at 10:38 AM, showed an enhanced barrier precaution (EBP -to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections) signage outside Resident 25's door. On 02/25/2026 at 12:01 PM, Resident 25 stated that they still had diarrhea and that they had loose stools today, most of the night and morning. Review of Resident 15's Lab [laboratory] Results Report, dated 12/24/2025 showed that their stool sample was positive for C-diff. Review of Resident 25's February 2026 medication administration record showed an order for Rifaximin (antibiotic medication that treat infections) oral tablet give 550 milligrams (a unit of measurement) by mouth two times a day for C-diff for 10 days. Further review showed that Resident 25 completed their medication on 02/16/2026. Review of the Task: Bowel Movements from 02/13/2026 through 02/25/2026 showed that Resident 25 had loose/diarrhea from 02/13/2026 through 02/23/2026 and on 02/25/2026. In an interview on 02/26/2026 at 9:19 AM, Staff JJ stated that they changed Resident 25 today and that their bowel movement was loose. Staff JJ stated, It's [it is] always loose. In an interview on 02/26/2026 at 10:18 AM, Staff F stated that they followed CDC recommendations for infection control and prevention. Staff F stated that contact enteric precaution would be re-assessed once the resident had completed their antibiotics. Staff F stated that Resident 25 was admitted with C-diff and had a history of recurrent C-diff. Staff F stated their gastrointestinal doctor (specialist who focuses on the health of the digestive system and liver) would put them on antibiotics and that the resident would be placed on contact enteric precautions. When Resident 25 completed their antibiotics, they would be reassessed if they were still having diarrhea. If they continued to have diarrhea, they would continue to be placed on contact enteric precautions. Staff F stated that to get off contact enteric precaution, they need to have no diarrhea for 48 hours. Staff F stated that they had changed Resident 25's contact enteric precaution yesterday [02/25/2026] to EBP because Resident 25 had completed their antibiotics last week and that they had kept them on contact enteric precaution. Staff F stated that their provider thought that Resident 25 was colonized with C-diff and that Resident 25 was not tested for C-diff [after they had completed their antibiotics]. A joint record review of the Task: Bowel Movements from 02/13/2026 through 02/25/2026 showed that Resident 25 had loose/diarrhea except on 02/24/2025. Staff F stated that they changed Resident 25's precaution to EBP because they had completed their antibiotics, got an okay from the provider and that the provider believed they were colonized. A joint record review of Resident 25's Lab Results Report dated 12/24/2025 showed that Resident 25 was positive for C-diff. Staff F stated, technically we could have kept her on contact enteric precautions and that they should have tested them because they were sharing a room with two other residents. Staff F stated that they thought EBP would be appropriate at this point because they had done multiple education with the staff because of their recurrent diarrhea. In an interview on 03/04/2026 at 11:12 AM, Staff B stated that residents would be on contact enteric precautions for residents with any contact transmitted associated bacteria like C-diff. Staff B stated that residents could be colonized with C-diff and that they made sure that a laboratory test would be completed. If the test was negative, the resident could be taken off contact enteric precautions. If they continued to have loose stools and if they were colonized, they needed to have documentation. Staff B stated that if they continued to have new loose stools, they had to continue to be on contact enteric precautions. Staff B further stated that the provider felt it was unnecessary to test Resident 25 for C-diff and that they believed Resident 25 was colonized with C-diff. Cross Reference: F908.Reference: (WAC) 388-97-1320(1)(a)(c)(3).

Based on observation, interview, and record review, the facility failed to ensure an effective pest control system was in place for 1 of 1 kitchen and 1 of 29 residents (Resident 140), reviewed for pest control. This failure placed the residents at risk for unsafe living conditions, emotional distress, and a diminished quality of life.Findings included . Review of the facility's policy titled, Pest Control, revised in May 2008, showed, Our facility shall maintain an effective pest control program. The policy further showed, This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. KITCHENObservation on 02/23/2026 at 8:58 AM, showed two small black flies flying around the ceiling of the dish washing area and by the back entrance door. Further observation showed 50 small black flies that were stationary on the ceiling, wall and cabinet doors by the back entrance door. Observation on 02/24/2026 at 3:34 PM, showed one small black fly flying around by the back entrance door of the kitchen. Further observation showed 75 small black flies that were stationary on the ceiling, wall and cabinet doors by the back entrance door. In an interview and joint observation on 02/24/2026 at 3:37 PM, Staff Q, Dietary Aide, stated that they would put a request on TELS (a tool used to create, track and complete works orders) if they saw flies or rodents in the kitchen and would let Staff C, Dietary Manager, know. Staff Q stated that Staff C knew about the bugs flying around and that they were trying to get it taken care of. A joint observation showed small black flies on the ceiling. Staff Q stated that they were fruit flies and that they're [they are] too much and they're everywhere. Staff R, Cook, stated that they had this problem for at least two months, maybe a little less and that suddenly they're everywhere. In an interview on 02/27/2026 at 2:02 PM, Staff C stated that if there were a pest problem, staff would need to let them know and that they would let maintenance know. Staff C stated that they were aware of the flies and that they've [they have-maintenance and pest control staff] been putting stuff, some kind of chemical down the drain and spraying. Staff C further stated that it had been a couple weeks and that last week they started to congregate more by the back entrance. In an interview on 03/03/2026 at 10:40 AM, Staff D, Maintenance Director, stated that their expectation was for staff to put in a TELS request if they observed flies or rodents and that they would call their exterminator. When asked if they were aware of the flies in the kitchen, Staff D stated that Staff C had put in a work order last Wednesday [02/25/2026]. Staff D stated that once they got that request, they called their exterminator and that they came the next day. Staff D further stated they could not remember if it was Tuesday or Wednesday but that it was last week and that they had not received a maintenance work order prior to that. Review of the facility's maintenance log from September 2025 through February 2026 showed a work order for so many gnats (small flying insects) in the kitchen submitted on 02/24/2026 at 5:22 AM and was requested by Staff C. Further review did not show documentation that a work order was submitted prior to 02/24/2026. In an interview on 03/04/2026 at 11:44 AM, Staff A, Executive Director, stated that they expected staff to clean so that they don't [do not] attract flies and that if they noticed the flies, they should let them or maintenance know. RESIDENT 140Observation and interview on 02/23/2026 at 12:33 PM, showed six fruit flies on Resident 140's window curtain, one fruit fly on their bedside table, and one fruit fly on top of a sandwich bag. Resident 140 stated that the bugs bothered them a lot and that they had informed a nurse aide and a housekeeper two weeks ago and no action had been taken. A joint observation and interview on 02/25/2026 at 12:48 PM with Staff E, Housekeeping Director, showed fruit flies on Resident 140's window curtain and bedside table. Resident 140 stated the situation was grossing them out. Staff E was asked if a resident's room should have fruit flies and they stated, no. A joint observation and interview on 02/25/2026 at 12:52 PM with Staff F, Infection Preventionist, showed four fruit flies on Resident 140's window curtain and one fruit fly on top of a sandwich. Staff F was asked if the resident's room should have fruit flies and they stated, no. In an interview on 03/03/2026 at 11:22 AM, Staff B, Director of Nursing, stated that bugs should not be in resident's room. Reference: (WAC) 388-97-3360(1)

Based on interview and record review, the facility failed to provide written transfer/discharge notice to the residents and/or their representatives with the required information for 4 of 4 residents (Residents 30, 25, 52 & 14) and failed to provide a bed hold notice for 2 of 4 residents (Residents 52 & 14), reviewed for hospitalizations. These failures placed the residents at risk for not having opportunities to make informed decisions about transfer/discharge.Findings included. Review of the facility's policy titled, Transfer or Discharge Notice, revised in March 2021, showed that Residents and/or representatives are notified in writing, and in a language and format they understand. It showed that the resident and/or representative are notified of the specific reason for the transfer or discharge, date of the transfer or discharge, the location of where they are being transferred or discharged , and an explanation of the resident's rights to appeal the transfer or discharge. TRANSFER/DISCHARGE NOTICERESIDENT 30Review of the discharge Minimum Data Set (MDS-an assessment tool), dated 02/15/2026, showed that Resident 30 admitted to the facility on [DATE] and discharged to an acute hospital on [DATE]. Review of the Electronic Health Record (EHR-progress notes, assessments, and attachments) showed that Resident 30 was discharged from the facility on 02/15/2026. Further review of Resident 30's EHR showed no documentation that a written transfer/discharge notice was provided to Resident 30 and/or their representative. In an interview on 03/03/2026 at 9:05 AM, Staff I, Resident Care Manager (RCM), stated that when a resident discharged to the hospital they would usually call the family. Staff I further stated that they were unsure if a written transfer/discharge notice was provided to the resident and/or their representative. In an interview and joint record review on 03/04/2026 at 9:44 AM, Staff A, Executive Director, stated that we should be providing a written [transfer/discharge] notice. Staff A stated that Resident 30 went to the hospital. A joint record review of Resident 30's EHR showed no documentation that a written transfer/discharge notice was provided to Resident 30 and/or their representative. Staff A stated that I don't [do not] see anything, nothing like that for Resident 30. RESIDENT 25Review of the quarterly/discharge MDS dated [DATE] showed that Resident 25 was admitted to a Short-Term General Hospital. Review of the facility's Transfer Form dated 08/09/2025 showed that Resident 25 was transferred to the hospital related to abnormal laboratory results. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the EHR showed no documentation that a written transfer/discharge notice was provided to Resident 25 and/or their representative. RESIDENT 52Review of the discharge MDS dated [DATE] showed that Resident 52 was admitted to a Short-Term General Hospital. Review of the discharge MDS dated [DATE] showed that Resident 52 was admitted to a Short-Term General Hospital. Review of the discharge MDS dated [DATE] showed that Resident 52 was admitted to a Short-Term General Hospital. Review of the facility's Transfer Form dated 09/07/2025 showed that Resident 52 was transferred to the hospital for chest pain. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the facility's Transfer Form dated 10/31/2025 showed that Resident 52 was transferred to the hospital for uncontrolled pain. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the facility's Transfer Form dated 01/26/2026 showed that Resident 52 was transferred to the hospital for shortness of breath. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the EHR showed no documentation that a written transfer/discharge notice was provided to Resident 52 and/or their representative. RESIDENT 14Review of the discharge MDS dated [DATE] showed that Resident 14 was admitted to a Short-Term General Hospital. Review of the discharge MDS dated [DATE] showed that Resident 14 was admitted to a Short-Term General Hospital. Review of the discharge MDS dated [DATE] showed that Resident 14 was admitted to a Short-Term General Hospital. Review of the discharge MDS dated [DATE] showed that Resident 14 was admitted to a Short-Term General Hospital. Review of the discharge MDS dated [DATE] showed that Resident 14 was admitted to a Short-Term General Hospital. Review of the discharge MDS dated [DATE] showed that Resident 14 was admitted to a Short-Term General Hospital. Review of the facility's Transfer Form dated 06/09/2025 showed that Resident 14 was transferred to the hospital for surgery. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the facility's Transfer Form dated 08/08/2025 showed that Resident 14 was transferred to the hospital for abnormal vital signs (essential body functions) and no urinary [urine] output in their left nephrostomy (a thin plastic tube inserted through the back to drain urine directly from the kidney into a bag outside the body). Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the facility's Transfer Form dated 10/23/2025 showed that Resident 14 was transferred to the hospital for increase temperature and increase heart rate. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the facility's Transfer Form dated 11/17/2025 showed that Resident 14 was transferred to the hospital for increase temperature and increase heart rate. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the facility's Transfer Form dated 01/05/2026 showed that Resident 14 was transferred to the hospital for suspected kidney infection. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the facility's Transfer Form dated 02/02/2026 showed that Resident 14 was transferred to the hospital for unresponsiveness. Further review of the Transfer Form did not show that it included a statement of the resident's appeal rights and Ombudsman contact information as required. Review of the EHR showed no documentation that a written transfer/discharge notice was provided to Resident 14 and/or their representative. In an interview on 03/03/2026 at 9:18 AM, Staff L, Registered Nurse, stated that when a resident was transferred to the hospital, they completed the transfer form/packet and would make and give a copy to the resident. Staff L further stated that if the resident was alert, they would notify them of the bed hold, if they were not, they would notify their representative. In an interview and joint record review on 03/03/2026 at 3:10 PM, Staff I was asked if they provided the resident or their representative with a transfer/discharge notice that informed them of appeal rights/Ombudsman contact information when they were transferred to the hospital, Staff I stated that they have never done that. A joint record review of Resident 25's Transfer Form dated 08/09/2026, did no show that it contained appeal rights and Ombudsman contact information as required. Staff I stated that there were no appeal rights and Ombudsman contact information on the transfer form. Staff I stated that all the forms they completed when a resident transferred to the hospital was the transfer form, bed hold notice and paperwork that were provided to the paramedics. Staff I further stated that they did not provide any documents to the resident and/or their representative. In an interview on 03/04/2026 at 11:56 AM, Staff A stated that they expected residents and their representative to receive a written transfer/discharge notice. Staff A stated that the facility used the transfer form and that when they reviewed the form, it did not contain the appeal rights and ombudsman notification as required. When Staff A was requested to do a record review for Resident 52 and Resident 14, Staff A declined and stated, if it's [it is] not there, it's not there. BED HOLD NOTICEReview of the facility's policy titled, Bed-Holds and Returns, revised in October 2022, showed, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payor source, are provided written notice about these policies at least twice: a. notice 1 [one]: well in advance of any transfer (e.g. [example] in the admission packet; and b. notice 2 [two]: at the time of transfer (or if the transfer was an emergency, within 24 hours). RESIDENT 52Review of the discharge MDS dated [DATE] showed that Resident 52 was admitted to a Short-Term General Hospital. On 02/24/2026 at 10:54 AM, Resident 52 stated that they were not notified of a bed hold. Review of Resident 52's facility's undated document titled, Bed-Hold and Return Agreement, showed that it was not completed. Review of Resident 52's EHR did not show documentation that a bed hold notice was provided to the resident and/or their representative. In a joint record review and interview on 03/03/2026 at 11:27 AM, Staff Y, Medical Records Director, showed that Resident 52's undated Bed-Hold and Return Agreement, showed that it was not completed. Staff Y stated that it was loaded with nothing complete. Staff Y stated that staff should have followed up with a progress note that a bed hold notice was provided to Resident 52. A joint record review of Resident 52's progress notes showed no documentation that a bed hold notice was provided to the resident and/or their representative. Staff Y stated that they did not see a progress note. RESIDENT 14Review of the discharge MDS dated [DATE] showed that Resident 14 was admitted to a Short-Term General Hospital. On 02/27/2026 at 1:20 PM, Resident 14's representative stated that they were not notified of a bed hold. Review of Resident 14's EHR did not show documentation that a bed hold notice was provided to the resident and/or their representative. In an interview on 03/03/2026 at 9:18 AM, Staff L stated that if the resident was alert, they would notify them of the bed hold notice, and if they were not, they would notify their representative. In an interview on 03/03/2026 at 11:00 AM, Staff J, Social Service Director, stated that nursing would notify the resident of a bed hold and if they were unable to, Staff Z, Business Office Manager, would follow up and call the resident's representative. Staff J further stated that at a minimum [there] should be a progress note. In an interview on 03/03/2026 at 11:38 AM, Staff Z stated that if they were unable to provide a bed hold notice to the resident, they would follow up with the resident and/or their representative. Staff Z stated that they would document under progress notes. Staff Z stated that there was a bed hold form that would be provided to the resident. Staff Z stated that they would call the resident's representative and would write a progress note. Staff Z stated that they did not find a progress note that a bed hold notice was provided to Resident 52 and Resident 14 and/or their representative. Staff Z further stated that Resident 52 and Resident 14 and/or their representative should have been notified of a bed hold notice and that it should have been documented. In an interview on 03/04/2026 at 11:56 AM, Staff A stated that their expectation was for staff to offer a bed hold notice when a resident was discharged to the hospital and if they were unable to provide one, they would follow up as soon as possible if they want to do a bed hold. Staff A further stated that they expected it to be documented. Reference: (WAC) 388-97-0120(2)(a-d)(4).

Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately for 6 of 29 residents (Residents 4, 7, 103, 11,14, & 133), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were marked on the MDS regarding indwelling catheter (a flexible, hollow tube inserted into the bladder to continuously drain urine into an external collection bag), insulin injections (medication used to manage blood sugar levels), ostomy (surgically created opening on the abdomen that allows waste to leave the body), turning/repositioning program, hospice (specialized care for people with a terminal illness) and prognosis placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Further review of the RAI manual showed, The turning/repositioning program is specific as to the approaches for changing the resident's position and realigning the body. The program should specify the intervention (e.g. [for example], reposition on side, pillows between knees) and frequency (e.g., every 2 [two] hours). Progress notes, assessments, and other documentation (as dictated by facility policy) should support that the turning/repositioning program is monitored and reassessed to determine the effectiveness of the intervention. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period).INDWELLING CATHETERRESIDENT 4Observation and interview on 02/24/2026 at 10:38 AM, showed Resident 4 did not have an indwelling catheter. Resident 4 stated they did not have an indwelling catheter and that it was removed last year in July. Review of the quarterly MDS dated [DATE], showed Resident 4 was marked for indwelling catheter in Section H (Bladder and Bowel - under H0100A). Review of Resident 4's January 2026 progress notes and physician orders printed on 02/24/2026 showed Resident 4's indwelling catheter was discontinued on 07/24/2025. In an interview and joint record review on 03/03/2026 at 11:30 AM with Staff K, MDS Coordinator, stated that they follow the RAI manual for MDS accuracy. A joint record review of Resident 4's quarterly MDS dated [DATE] showed indwelling catheter was marked in Section H. Further joint record review of the January 2026 progress notes and physician orders showed Resident 4's indwelling catheter was discontinued on 07/24/2025. Staff K stated that Resident 4's indwelling catheter was discontinued before the quarterly MDS look back period, the MDS was not marked accurately, and the indwelling catheter should not have been marked. In an interview on 03/04/2026 at 9:08 AM, Staff B, Director of Nursing, stated that they expected MDS assessments to be completed accurately. Staff B further stated that Resident 4's quarterly MDS should not have been marked for indwelling catheter and that Resident 4's MDS was inaccurate. INSULINRESIDENT 7Review of Resident 7's admission MDS dated [DATE] showed that Resident 7 was marked seven days for injections in Section N (Medications – under N0300) and seven days for insulin injections in Section N (under N0350A). Review of Resident 7's January 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) printed on 03/04/2026 showed that Resident 7 was given insulin injection for two days (01/21/2026 and 01/23/2026) during the look back period. A joint record review and interview on 03/03/2026 at 11:30 AM with Staff K, showed Resident 7's admission MDS dated [DATE] was marked seven days for injections and seven days for insulin injections in Section N. Further joint record review of January 2026 MAR and TAR showed that Resident 7 was given insulin injections for two days (01/21/2026 and 01/23/2026) during the look back period. Staff K stated that Resident 7 was given insulin injections for two days, the MDS was not marked accurately, and the insulin injections should have been marked according to the days it was given during the look back period. RESIDENT 103Review of Resident 103's admission MDS dated [DATE] showed that Resident 103 was marked zero days of insulin injections in Section N (under N0350). Review of Resident 103's February MAR and TAR printed on 02/27/2026 showed that Resident 103 was given insulin injections for seven days (02/03/2026 through 02/09/2026) during the look back period. A joint record review and interview on 03/03/2026 at 11:30 AM with Staff K, showed Resident 103's admission MDS dated [DATE] was marked zero days for insulin injections in Section N. Further joint record review of the February 2026 MAR and TAR showed that Resident 103 was given insulin injection for seven days (02/03/2026 through 02/09/2026) during the look back period. Staff K stated that Resident 103 was given insulin injections for seven days and that the MDS was not marked accurately. In an interview on 03/04/2026 at 9:08 AM, Staff B stated that they expected MDS assessments to be completed accurately. Staff B further stated that Resident 7's and Resident 103's admission MDS were inaccurate and that the insulin injections should have been marked according to what was given during the look back period. OSTOMYRESIDENT 11Review of Resident 11's admission MDS dated [DATE] showed that Resident 11 was marked for ostomy in Section H (Bladder and Bowel – H0100C). Review of Resident 11's provider orders printed on 02/27/2026 showed no ostomy device. Review of Resident 11's December 2025 progress notes printed on 03/03/2026 showed no ostomy device. A joint record review and interview on 03/03/2026 at 11:30 AM with Staff K, showed Resident 11's admission MDS dated [DATE] was marked for ostomy in Section H. Staff K stated Resident 11 never had an ostomy. Further joint record review of the December 2025 progress notes and December 2025 MAR and TAR showed that Resident 11 did not have an ostomy. Staff K stated that Resident 11 did not have an ostomy and that the MDS was not marked accurately. In an interview on 03/04/2026 at 9:08 AM, Staff B stated that they expected MDS assessments to be completed accurately. Staff B further stated that Resident 11's admission MDS should not have been marked for ostomy and that Resident 11's MDS was inaccurate. TURNING/REPOSITIONING PROGRAMRESIDENT 14 Review of Resident 14's quarterly MDS dated [DATE] showed that Section M (Skin Conditions) was marked for Turning/repositioning program. Review of Resident 14's annual MDS dated [DATE], showed that Section M was marked for Turning/repositioning program. Review of Resident 14's comprehensive care plan printed on 02/25/2026 showed a care plan for Pressure ulcer [bed sore] of left buttock [bottom] and sacrum [tailbone] r/t [related to] Dermal [skin] Frailty, Decreased mobility, noncompliance with repositioning. Further review of the care plan did not show a turning/reposition intervention or a care plan to address a turning/repositioning program. Review of Resident 14's Electronic Health Record (EHR-progress notes, evaluations, miscellaneous files) showed no documentation to support that their turning/repositioning program was monitored and reassessed to determine the effectiveness of the program. In an interview and joint record review on 03/04/2026 at 10:15 AM, Staff K stated that they followed the RAI manual for MDS completion. Staff K stated that residents were placed on a turning/repositioning program if the resident could not do it themselves and that if it was care planned, it would be a program. Staff K stated that if a resident was on the turning/repositioning program, they would monitor and assess the program's effectiveness. A joint record review of Resident 14's quarterly MDS dated [DATE] and annual MDS dated [DATE] showed that Section M was marked for Turning/repositioning program. Staff K stated that Section M was marked for Turning/repositioning program. A joint record review of Resident 14's care plan showed an intervention to Offer to turn/reposition at least every two hours and as needed or requested with a resolved date of 03/07/2025. A joint record review of Resident 14's progress notes showed no documentation that Resident 14's turning/repositioning program was assessed and monitored to determine its effectiveness. Staff K stated that they did not see any documentations to support the turning/repositioning program marked for Section M on Resident 14's quarterly MDS dated [DATE] and annual MDS dated [DATE]. Staff K further stated that Section M was not accurate. In an interview on 03/04/2026 at 11:39 AM, Staff B stated that they expected MDS assessments to be completed accurately and timely. Staff B further stated that Resident 14's MDS should have been accurate. HOSPICE and PROGNOSISRESIDENT 133Review of Resident 133's EHR showed that Resident 133 was admitted to hospice services on 11/14/2025. Review of hospice physician note dated 11/14/2025, showed that the physician certifies that the patient's [Resident 133] prognosis is six months or less if the disease runs its normal course. Review of the admission MDS dated [DATE] showed that hospice care was not marked in Section O (Special Treatments, Procedures, and Programs). It further showed that Section J1400 (Prognosis) was marked no for the question Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 [six] months? In an interview and joint record review on 03/03/2026 at 3:04 PM, Staff K stated that they follow the RAI Manual for MDS accuracy. A joint record review of Resident 133's EHR showed they were admitted to hospice on 11/14/2025. A joint record review of the admission MDS dated [DATE], showed that hospice was not marked in Section O. Staff K stated that it should be. It further showed that that Section J1400 was marked no. Staff K stated that it should be marked yes. Staff K further stated that Resident 133's MDS was not accurate. In an interview on 03/04/2026 at 8:18 AM, Staff B stated that they expected the MDS to be accurate. Reference: (WAC) 388-97-1000 (1)(b) .

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 2 Refrigerators (Kitchen Walk-in Refrigerator), 1 of 1 Dry Storage Room, and 2 of 4 Staff (Staff GG & HH), reviewed for food services. The failure to label and discard food items past the use by date, perform hand hygiene and properly sanitized equipment, placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.Findings included.Review of the facility's policy titled, Food Receiving and Storage, revised in November 2022, showed, Dry foods and goods are handled and stored in a manner that maintains the integrity of the packing until they are ready to use. The policy showed, All foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date). The policy further showed, Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in August 2019, showed, The facility considers hand hygiene the primary means to prevent the spread of infections. The policy showed to use an alcohol-based hand rub or soap and water before donning (put on) sterile gloves, after removing gloves, before and after eating or handling food. The policy showed, Hand hygiene is the final step after removing and disposing of personal protective equipment [mask, gloves and gown]. It further showed, The use of gloves does not replace hand washing/hand hygiene. Integration of glove along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.KITCHEN WALK-IN REFRIGERATOR Observation of the Kitchen Walk-in Refrigerator on 02/23/2026 at 8:24 AM, showed the following food items:-one plastic container labeled Pineapple dated 2/20/26 [02/20/2026] with no use by date.-one metal container of chopped red onions with no label and use by date. In an interview and joint observation on 02/23/2026 at 8:47 AM, Staff C, Dietary Manager, stated that food items were to be labeled what it is and that it would be good for seven days. A joint observation showed one plastic container of Pineapple dated 2/20/26 with no use by date. Staff C stated that the pineapple was good for seven days. When asked if they expected staff to label it with the use by date, Staff C stated that they did not expect them to label with the use the by date because they can count. In another joint observation showed one metal container of chopped red onions with no label and use by date. Staff C stated that it should have been labeled with what it was and dated.In another observation on 02/27/2026 at 9:36 AM, showed one metal container labeled lettuce with use by date of 2/12 [02/12/2026].In a joint observation and interview on 02/27/2026 at 2:25 PM with Staff C, showed one metal container labeled lettuce with use by date of 2/12. Staff C stated that it should have been discarded. DRY STORAGE ROOMObservation of the Dry Storage Room on 02/23/2026 at 8:34 AM, showed one opened uncapped container of [NAME] Distilled Vinegar, dated 09/09/2025.In an interview and joint observation on 02/23/2026 at 8:55 AM, Staff C stated that they expected food items to be capped/covered. A joint observation showed one opened uncapped container of [NAME] Distilled Vinegar, dated 09/09/2025. Staff C stated that it should have had a cap.HAND HYGIENE/GLOVE USE/SANITIZATIONSTAFF GGObservation on 02/27/2026 at 8:57 AM, showed Staff GG, Cook, was at the sink in the dish washing area and were removing food scraps off a large tray with their bare hands. Staff GG washed their hands with water (no soap) and went to the preparation station and told an unknown male staff that had entered the kitchen with a machinery to go the other way as they were trying to pass through the kitchen. Staff GG went out of the kitchen with the unknown male staff. Staff GG entered the kitchen shortly after and went to the dishwashing area and proceeded to scrub the sink with their bare hands. Staff GG did not perform hand hygiene when they left and entered the kitchen.In another observation on 02/27/2026 at 9:14 AM, Staff GG entered the kitchen and went to the dishwashing area without performing hand hygiene. Staff GG were assisting Staff II, Dietary Aide, with the dishes. At 9:20 AM, Staff GG took a scrub from a plastic container with their bare hands and gave it to Staff II. Staff GG then took a clean dishware and stored them away. Staff GG stated that they took the scrub from the container with sanitizer water. The container with sanitizer water was murky and had used utensils, floating lids and food debris. Staff GG was asked if they considered their hands clean after getting the scrub from the container, Staff FF stated that it was sanitizer water. In an interview on 02/27/2026 at 12:23 PM, Staff GG stated that they would wash hand first, gloves second and that if they touched anything with bacteria or surface debris, they would perform hand hygiene. Staff GG stated that they would perform hand hygiene before entering the kitchen and stated, of course, that's [that is] mandatory. When asked if they would perform hand hygiene between dirty to clean task, Staff GG, stated, of course. Staff GG stated that the whole dishwashing area is dirty. When asked if the clean dishes would be considered dirty, Staff GG stated, no. Staff GG further stated that they should have performed hand hygiene when they were done cleaning the metal pan, when they went to put the clean dishes away, and after they took a scrub in the container with used utensils and food debris. STAFF HHObservation on 02/27/2026 at 9:14 AM, showed Staff HH, Cook, was in the preparation station preparing meatloaf and was working on top of a cutting board. Staff HH were touching raw meat with their gloves and then took a Grill & Griddle Cooking Spray that was on the table and sprayed a metal pan. Staff HH took the raw meat from a large tray and placed it onto a smaller metal tray. Staff HH removed their gloves and applied new gloves without performing hand hygiene. Staff HH applied mittens and took a tray out of the oven and placed it on top of the oven. Staff HH then placed it into a small metal pan, covered it with foil and placed it in the oven under the stove. Staff HH removed their gloves and applied new gloves without performing hand hygiene. Staff HH went back to the preparation station and covered a container of raw meat with foil. At 9:21 AM, Staff HH placed all the raw meat in a pan, removed their gloves (did not perform hand hygiene), and covered the pan with foil. Staff HH wore mittens and opened the top oven and placed the pan inside. Staff GG did not perform hand hygiene between glove use and touched the cooking spray with soiled gloves.Further observations on 02/27/2026 at 9:42 AM showed Staff GG pureeing food items in the preparation area with a cutting board on top of a white towel with raw meat drippings on the far left of the table. Staff GG placed trays on top of the cutting board as they mixed and covered the trays with foil. When they were done, they placed the trays in the oven. Staff GG cleaned the area they used to puree and left the area with the cutting board. Staff GG then took a metal container and sprayed the container with the Grill & Griddle Cooking Spray with bare hands, placed frozen vegetables in the tray and placed it on top of the oven. The Grill & Griddle Cooking Spray had red remnants from the raw meat on the bottle.In an interview and joint observation on 02/27/2026 at 10:05 AM, Staff GG stated that they would perform hand hygiene every time they changed their gloves/between glove use, when they entered the kitchen, and when they did a different task. Staff GG stated that they would clean the preparation area every time they were done, and when they get a chance, and that they cleaned it right away. Staff GG stated that they performed hand hygiene when they went out the kitchen and comes back inside, but when they were preparing food, they just change their gloves [did not perform hand hygiene between glove use]. A joint observation of the preparation station showed a cutting board on top of a white towel that had raw meat drippings. Staff GG stated that they used it to cut onions and that they would put it away. Staff GG touched the cooking spray that had remnants of raw meat with their bare hands, and they did not sanitize their preparation station after use.In an interview on 02/27/2026 at 1:58 PM, Staff C stated that they expected staff to perform hand hygiene before their shift, when they leave the kitchen, return to the kitchen, between glove use and from dirty to clean task. Staff C stated that Staff GG should have performed hand hygiene and that Staff HH should have performed hand hygiene between glove use, she needs to be washing her hands. Staff C further stated that Staff HH should not have handled the cooking spray with gloves with raw meat. Staff C further stated that they needed to get rid of the raw meat, clean the area and perform hand hygiene.In an interview on 03/03/2026 at 10:20 AM, Staff F, Infection Control, stated that they expected kitchen staff to perform hand hygiene before they started their shift, before handling food, before entering the kitchen, going from dirty to clean task and between glove use. Staff F stated that Staff GG should have performed hand hygiene and that Staff HH should have performed hand hygiene between gloves. Staff F further stated that Staff HH should not have touched the cooking spray with their gloves that they had used with raw meat.In an interview on 03/04/2026 at 11:44 AM, Staff A, Executive Director, stated that they expected food items to be stored and labeled correctly and that staff would follow proper hand hygiene practices. In a follow up interview at 1:41 PM, Staff A stated that if food items were past the use by date, they would expect staff to throw it out. Staff A further stated that they would expect staff to follow food safety procedures. Reference: (WAC) 388-97-1100 (3).

Based on observation, interview, and record review, the facility failed to ensure a homelike environment when medications were administered in the common area for 2 of 5 residents (Resident 47 &16), reviewed for medication administration. In addition, the facility failed to ensure a clean, safe, and homelike environment for 4 of 7 residents (23, 20, 27 & 65), reviewed for environment. These failures placed the residents at risk for injury, a less than homelike environment, and a diminished quality of life.Findings included. Review of the facility's policy titled, Maintenance Service, revised in December 2009, showed that Maintenance service shall be provided to all areas of the building, grounds, and equipment. Review of the facility's policy titled, Homelike Environment, revised in February 2021, showed that Residents are provided with a safe, clean, comfortable and homelike environment. MEDICATIONS GIVEN IN COMMON AREASRESIDENT 47Observation on 02/25/2026 at 11:31 AM, showed Staff PP, Licensed Practical Nurse (LPN), administered medication to Resident 47 in the common area in front of the [NAME] Nurse Station. In an interview on 02/25/2026 at 12:32 PM, Staff PP stated that they gave Resident 47 their morning medications in the common area in front of the [NAME] Nurse Station because she needed her morning meds and she was behind time. Staff PP further stated that we're [we are] not supposed to [give medications in common areas] for privacy reasons. RESIDENT 16Observation on 02/26/2026 at 9:28 AM, showed Staff QQ, LPN, administered medication to Resident 16 in the common area in front of the [NAME] Nurse Station. In an interview on 02/26/2026 at 9:36 AM, Staff QQ stated that as far as I know, it's [it is] ok to give pills outside the room. Staff QQ further stated that they gave Resident 16 their medications in the common area in front of the [NAME] Nurse Station. In an interview on 03/04/2026 at 8:18 AM, Staff B, Director of Nursing, stated that they did not expect medications to be administered to residents in common areas. BASEBOARD HEATERRESIDENT 23Observation on 02/24/2026 at 8:57 AM, showed the baseboard heater was coming away from the wall in Resident 23's room. Resident 23 stated it's [it has] been like that forever and stated that they had told staff about it. Observation on 02/25/2026 at 11:18 AM, showed the baseboard heater was coming away from the wall in Resident 23's room. In an interview and joint observation on 02/25/2026 at 12:05 PM, Staff JJ, Certified Nursing Assistant (CNA), stated that if they noticed something in disrepair in a resident's room, they would notify maintenance through an online software program. A joint observation of Resident 23's room showed the baseboard heater was coming away from the wall. Staff JJ stated that the baseboard heater was coming loose off the wall, you can see the nails or screws and that it needed to be reported to maintenance. A joint observation and interview on 02/25/2026 at 2:16 PM with Staff OO, Regional Maintenance, showed the baseboard heater was coming away from the wall in Resident 23's room. Staff OO stated that it's [it is] coming off [of the wall]. In an interview on 03/04/2026 at 9:44 AM, Staff A, Executive Director, stated that maintenance was responsible for maintaining resident rooms. Staff A stated that they expected staff to communicate to maintenance if they noticed anything in disrepair in a resident's room. Staff A further stated that they would not expect a baseboard heater to be coming away from the wall. RESIDENT 20On 02/24/2026 at 8:51 AM, Resident 20 stated that they were told by staff that they could not place anything inside the red marker that was placed around the baseboard heater. Resident 20 stated that they did not have anywhere to place their wheelchair and commode and that the only place they could place it was on the right side of their bed. Observation showed Resident 20's wheelchair was parked on the right side by the foot of the resident's bed, and their commode was by the wall. Resident 20's wheelchair and commode were inside the red marker by the baseboard heater. Observations on 02/27/2026 at 3:28 PM and on 03/02/2026 at 11:45 AM, showed Resident 20's wheelchair was parked by the foot of their bed on the right side, and their commode was by the wall. Resident 20's wheelchair and commode were inside the red marker by the baseboard heater. In an interview and joint observation on 03/03/2026 at 10:45 AM, Staff D, Maintenance Director, stated that the red marker by the baseboard heater was a reminder to keep things away from it. Staff D stated, nothing should be in that area and that if it was in that area, it had to be UL certified [Underwriters Laboratories- a critical standard for ensuring safety and reliability of fire protection products]. Staff D stated that they were potentially a fire risk because it's [it is] a heater. A joint observation showed Resident 20's wheelchair, commode and trash can were inside the red marker. Staff D stated that the garbage that was there would be a risk. A joint observation showed a wooden box by the wall on the left side of the baseboard heater. Staff D stated it was a risk but not an immediate risk and that technically should not be there. In an interview on 03/04/2026 at 11:53 AM, Staff A stated that they expected a safe home environment. Staff A further stated that staff had to ensure that resident equipment was outside the red marker for safety. BED LINENRESIDENT 27Observation on 02/23/2026 at 12:11 PM showed Resident 27's bed sheet had a medium round spot of brown dry stain on the left upper side and two streaks of parallel light greenish-yellowish stains on the right middle side. The bed was unkempt and not made. Resident 27 stated the bed had not been made for a whole week or even since admission, and had received several showers. Observation on 02/24/2026 at 9:38 AM showed the same brown stain on the left upper side and greenish-yellowish stain on the right middle side of the bed sheet. A joint observation and interview on 02/24/2026 at 9:43 AM with Staff LL, CNA, stated that there were brown and greenish-yellow stains on the bed sheet. Staff LL stated that the bed should be changed when visibly soiled, dirty, wet, or after the resident had a shower. Staff LL stated the bed should have been changed and it was not. In an interview on 03/03/2026 at 10:32 AM, Staff G, Resident Care Manager, stated that if a bed was visibly soiled or wet, staff were expected to change it. Staff G further stated that two staff members normally do rounds at the beginning and end of each shift to ensure residents were clean and dry, and they were expected to change the bed sheets after a shower. In an interview on 03/03/2026 at 11:15 AM, Staff B stated that it was their expectation that the residents' bed were clean, well-made, and remained dry every shift. BED FOOTBOARDRESIDENT 65Observations on 02/25/2026 at 1:10 PM, on 02/26/2026 at 12:15 PM, and on 02/27/2026 at 12:00 PM, showed a medium oval dark brownish red dry substance on the left inner side of Resident 65's bed footboard. Resident 65 stated that the staff needed to clean the footboard. In an interview and joint observation on 02/27/2026 at 2:25 PM, Staff S, Housekeeper, stated that housekeeping were responsible for cleaning the residents' headboard and footboard. A joint observation of Resident 65's footboard showed dark brownish red dry substance on the left inner side of the resident's bed footboard. Staff S stated that the dry substance looked like blood and that it should not be there. In a joint observation and interview on 02/27/2026 at 2:30 PM, Staff E, Housekeeper Director, showed a dark brownish red dry substance to Resident 65's footboard. Staff E stated that the dark brownish red dry substance looked like blood and that it should have been cleaned. In an interview on 03/03/2026 at 3:45 PM, Staff A stated that they expected staff to report any housekeeping needs and to clean them. Staff A further stated that they expected Resident 65's footboard to have been cleaned. Reference: (WAC) 388-97-0880 (1)(2) .

Based on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 2 of 6 residents (Residents 121 & 13), reviewed for ADLs. The failure to provide assistance with personal and oral hygiene placed the residents at risk for unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised in March 2018, showed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. RESIDENT 121Review of the admission Minimum Data Set (MDS-an assessment tool), dated 12/26/2025, showed that Resident 121 was dependent (helper does all the effort) for personal hygiene. Review of Resident 121's ADL care plan, revised on 12/19/2025, showed that Resident 121 requires one person staff total assist with personal hygiene. It further showed to clean and trim nails on bath day and as necessary. Trimming to be done by CNA [Certified Nursing Assistant]. Observations on 02/23/2026 at 10:29 AM, on 02/24/2026 at 10:42 AM, and on 02/25/2026 at 10:56 AM, showed Resident 121 with long fingernails and brown material underneath the fingernails on both hands. Additional observation on 02/25/2026 at 11:44 AM, showed Resident 121 with long fingernails and brown material underneath the fingernails on both hands. It further showed that a hospice shower aide had just finished giving Resident 121 a bed bath. In an interview and joint observation on 02/26/2026 at 1:12 PM, Staff BB, CNA, stated that Resident 121 needed help with ADLs and she can't [cannot] clean under her nails and could not trim their fingernails. A joint observation showed Resident 121 with long fingernails and brown material underneath the fingernails on both hands. Staff BB stated that Resident 121's fingernails need to be trimmed and looks like some food underneath the nails. Staff BB further stated that Resident 121's nails should have been cleaned and trimmed during the bed bath from the hospice shower aide yesterday [02/25/2026]. In an interview on 03/03/2026 at 9:05 AM, Staff I, Resident Care Manager (RCM), stated that CNAs were responsible for trimming/cleaning fingernails, unless the resident had diabetes (a disease where sugar in the blood is too high). Staff I further stated that Resident 121 needed help with ADLs including nail care and would expect CNAs to provide that for them. In an interview on 03/04/2026 at 8:18 AM, Staff B, Director of Nursing, stated that they expected staff to provide nail care for dependent residents. RESIDENT 13Review of Resident 13's quarterly MDS dated [DATE], showed Resident 13 needed substantial/maximal assistance (helper does more than half the effort) for nail care and oral care. Review of the care plan showed Resident 13 required assistance with oral care every morning, after meals, at bedtime, and as needed. Observation and interview on 02/26/2026 at 11:47 AM, showed Resident 13 had long nails with brown material underneath the nails on both hands. Resident 13 stated their nails were too long and dirty and they would like staff to trim them. Resident 13 stated they had asked staff for help, but staff were busy. Observation and interview on 02/26/2026 at 11:52 AM, showed Resident 13's teeth had yellow-brown crust deposits near the gum line. Resident 13 stated they had not brushed their teeth for nearly a week. Resident 13 further stated that staff were supposed to brush their teeth twice a day, in the morning and evening, but they had not received requested help. A joint observation and interview on 02/26/2026 at 11:55 AM with Staff LL, CNA, showed Resident 13's fingernails on both hands were long and unclean with brown material underneath. Staff LL stated that nail care was done during shower days, and aides would perform it unless the resident had diabetes, in which a nurse would perform the task. During a joint interview and observation on 02/26/2026 at 11:56 AM, Staff MM, Registered Nurse, stated Resident 13's fingernails were long and dirty, and the teeth had yellow food deposits and needed cleaning. Staff MM further stated that aides were responsible for nail care and oral hygiene, but the nurse would trim nails if the resident had diabetes. In an interview on 03/03/2026 at 10:48 AM, Staff G, RCM stated that Resident 13's fingernails should have been kept short and clean. Staff G stated that aides were responsible for providing nail care and oral hygiene and residents needing help should be offered assistance. In an interview on 03/03/2026 at 11:24 AM, Staff B stated that nursing staff and aides help with ADLs. Staff B stated if the resident had diabetes, the nurse would help with clipping nails and if not, the aides were responsible including providing help with oral care in the morning, night, and as needed. Reference: (WAC) 388-97-1060 (2)(c) .

Based on observation, interview, and record review, the facility failed to maintain resident dignity for 3 of 29 residents (Resident 106, 121 & 60), reviewed for dignity. This failure placed the residents at risk for diminished self-worth, potential embarrassment, and diminished quality of life.Findings included. Review of the facility's policy titled, Privacy, revised in February 2021, showed the residents are to be always treated with dignity and respect. Staff are expected to knock and request permission before entering residents' rooms and explain procedures before they are performed. Review of the facility's policy titled, Dignity, revised in February 2021, showed, When assisting with care, residents are supported in exercising their rights. For example, resident are .provided with a dignified dining experience. RESIDENT 106Observations on 02/27/2026 at 9:13 AM, at 9:19 AM, and at 9:23 AM, showed Staff KK, Licensed Practical Nurse, walked into Resident 106's room shared with one other resident without knocking at the resident's door, introducing themselves, or stating their intentions. In an interview on 02/27/2026 at 9:27 AM, Staff KK stated that it was expected that they knock at the door, introduce themselves, and tell the residents who they were and what they were going to do. Staff KK stated that they normally knock most of the time and could not remember if they knocked during these specific instances. In an interview on 03/03/2026 at 10:47 AM, Staff G, Resident Care Manager (RCM), stated that they expected staff to sanitize their hands, knock at the door, introduce themselves, and let the residents know what they were going to do. In an interview on 03/03/2026 11:23 AM, Staff B, Director of Nursing, stated that all staff should knock at the door, announce their name, use hand sanitizer, and tell the resident what they were going to do. RESIDENT 121Review of the admission MDS, dated [DATE], showed that Resident 121 was moderate cognitively impaired and was dependent (helper does all the effort) for personal hygiene. Review of Resident 121's comprehensive care plan, printed on 02/25/2026, showed no documentation of Resident 121's preference for facial hair. Observations on 02/23/2026 at 10:29 AM, on 02/24/2026 at 10:42 AM, on 02/25/2026 at 10:56 AM showed Resident 121 with many long whiskers on their chin. In an interview and joint observation on 02/26/2026 at 1:12 PM, Staff BB, Certified Nursing Assistant (CNA), stated that if they noticed that a female resident had facial hair they would ask the resident if they wanted them to shave it. Staff BB stated that if the resident was unable to communicate, they would help them shave. Staff BB stated that Resident 121 needed assistance with personal hygiene. A joint observation showed Resident 121 with many long whiskers on their chin. Staff BB stated, she has whiskers and that they would not expect that on a female resident. Staff BB stated, it should be trimmed and we can do [it] for her. In an interview on 03/03/2026 at 9:05 AM, Staff I, RCM, stated that the top priority was providing dignity to residents, and they would not expect a female resident to have facial hair unless they refused to have it shaved. Staff I further stated that they would not expect Resident 121 to have facial hair and that it was a dignity issue. In an interview and joint record review on 03/04/2026 at 8:18 AM, Staff B stated that they would not expect facial hair on women residents unless it was their preference, unless it was documented that they want it. A joint record review of Resident 121's comprehensive care plan showed no documentation that Resident 121 wanted facial hair. Staff B stated there was nothing about [Resident 121's] preference for facial hair. RESIDENT 60 Observation on 02/25/2026 at 12:50 PM, showed Staff M, CNA, standing on the left side of Resident 20's bed and was not eye level as they assisted them to eat their lunch. In an interview on 02/25/2026 at 12:58 PM, Staff M stated that Resident 60 was dependent with eating and that they encouraged/cued them to eat. Staff M stated that they knew that they should be sitting down while assisting Resident 60 to eat. Staff M stated that with Resident 60 you have to stand because there are other things around [in their room] and that they did not find it comfortable to sit down, but that I know I need to sit down. In an interview on 03/03/2026 at 9:10 AM, Staff L, Registered Nurse, stated that when CNAs were assisting residents who need one-to-one assistance with eating and that the expectation was for staff to sit down and be eye to eye when assisting the residents. In an interview on 03/03/2026 at 3:00 PM, Staff I stated that their expectation when assisting residents with their meals was for CNAs to sit down next to the resident, communicate with the resident, observe how the resident swallowed and to alternate between a bite and a drink. In an interview on 03/04/2026 at 11:11 AM, Staff B stated that they expected CNAs to sit down when assisting residents to eat their meals. Reference: (WAC) 388-97-0180 (2).

Based on observation, interview, and record review, the facility failed to develop and/or implement care plans for 2 of 29 residents (Residents 7 & 121), reviewed for comprehensive care plans. The failure to develop/implement care plans for anticoagulant (medications that helps prevent blood clots) usage and Activities of Daily Living (ADL) placed the residents at risk for unmet care needs and a diminished quality of life.Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. RESIDENT 7Review of Resident 7's physician orders showed an order for rivaroxaban (anticoagulant medication) 20 milligrams (mg – a unit of measurement) by mouth for deep vein thrombosis (DVT – blood clot that forms in a deep vein), started on 01/17/2026. Review of Resident 7's January 2026 and February 2026 Medication Administration Record (MAR) showed Resident 7 received rivaroxaban daily. Review of Resident 7's comprehensive care plan printed on 02/25/2026, showed no care plan for anticoagulant usage. In an interview and joint record review on 03/03/2026 at 11:30 AM, Staff G, Resident Care Manager (RCM), stated that when residents were receiving anticoagulants, they monitor them for bleeding and did labs. A joint observation of Resident 7's comprehensive care plan showed no care plan regarding anticoagulant usage. Staff G stated that there should be a care plan for anticoagulants. In an interview on 03/04/2026 at 9:08 AM, Staff B, Director of Nursing, stated that they would expect Resident 7 to have a care plan for anticoagulant. RESIDENT 121Review of the admission Minimum Data Set (an assessment tool), dated 12/26/2025, showed that Resident 121 was dependent (helper does all the effort) for personal hygiene. Review of Resident 121's ADL care plan, revised on 12/19/2025, showed that Resident 121 requires one person staff total assist with personal hygiene. It further showed to clean and trim nails on bath day and as necessary. Trimming to be done by CNA [Certified Nursing Assistant]. Observations on 02/23/2026 at 10:29 AM, on 02/24/2026 at 10:42 AM, on 02/25/2026 at 10:56 AM, and on 02/26/2026 at 11:34 AM, showed Resident 121 with long fingernails and brown material underneath the fingernails on both hands. In an interview and joint observation on 02/26/2026 at 1:12 PM, Staff BB, CNA, stated that Resident 121 needed help with ADLs and she can't [cannot] clean under her nails and could not trim their fingernails. A joint observation showed Resident 121 with long fingernails and brown material underneath the fingernails on both hands. Staff BB stated that Resident 121's fingernails need to be trimmed and looks like some food underneath the nails. In an interview and joint record review on 03/03/2026, Staff I, RCM, stated that they expected staff to follow the care plan/Kardex (care guide for CNAs) for residents. A joint record review of Resident 121's ADL care plan showed the intervention to clean and trim nails on bath day and as necessary. Trimming to be done by CNA. Staff I stated that they expected CNAs to follow the care plan/Kardex for Resident 121 and clean and trim their fingernails. In an interview on 03/04/2026 at 8:18 AM, Staff B stated that they expected staff to follow care plans and if it says to provide assistance with personal hygiene including nail care, then staff should be providing that. Reference: (WAC) 388-97-1020(1)(2)(a)(b) .

Based on observation, interview, and record review, the facility failed to ensure privacy and confidentiality of resident's medical information were maintained for 1 of 3 Unit Resident List/Document (Midwest [MW] 2 Unit), reviewed for confidentiality of records. This failure placed the residents at risk of having their medical and personal information compromised and a diminished quality of life.Findings included.Review of the facility's policy titled, Confidentiality of information and personal privacy, revised October 2017, showed, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. The policy further stated, access to resident personal and medical records will be limited to authorized staff and business associates.Observation on 02/27/2026 at 9:18 AM showed a paper document titled MW2 UNIT on top of the medication cart. The list contained residents' names and nursing notes regarding the medication pass (the process of preparing and administering medications) visible to anyone in the hallway.A joint observation and interview on 02/27/2026 at 9:24 AM with Staff KK, Licensed Practical Nurse (LPN), showed the MW2 Unit contained residents' Personal Health Information (PHI) and was placed on top of the medication cart, visible to people walking in the MW hallway. Staff KK stated that people walking in the hallway could see the PHI and stated the document should not have been left visible.In an interview on 03/03/2026 at 10:36 AM, Staff G, Resident Care Manager, stated that PHI should be kept private. Staff G further stated that if staff utilized a list, they should ensure the paper was flipped over to ensure information was not visible and placed in a shredder box at the end of the shift.In an interview on 03/03/2026 at 11:18 AM, Staff B, Director of Nursing, stated that resident documents should be kept in compliance with the Health Insurance Portability and Accountability Act (law protecting patient [resident] privacy by securing health data). Staff B further stated that documents should be flipped over, have a cover, or be appropriately stored to prevent exposure of resident information.Reference: (WAC) 388-97- 0360 (1)(b).

Based on interview and record review, the facility failed to ensure admission Minimum Data Set (MDS-an assessment tool) was completed timely for 1 of 21 residents (Resident 4), reviewed for comprehensive assessments. This failure placed the resident at risk for delayed and/or unmet care needs and a diminished quality of life.Findings included .Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.20.1, revised in October 2025, showed that the admission assessment must be completed by the end of day 14, counting the date of admission to the nursing home as day 1.Review of the facility's policy titled, MDS Assessment Coordinator, revised in November 2019, showed that the A Registered Nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment.The Resident Assessment Coordinator must date and sign each assessment to certify that the assessment has been completed.Review of Resident 4's admission Record printed on 02/23/2026 showed that Resident 4 was admitted to the facility on [DATE].Review of Resident 4's admission MDS dated [DATE], showed that it was completed on 08/05/2025 (12 days late).In an interview and joint record review on 03/03/2026 at 11:30 AM with Staff K, MDS Coordinator, stated that they followed the RAI manual for MDS completion. Staff K stated that an admission MDS was to be completed on day 14 of admission. A joint record review of Resident 4's admission MDS showed that it was completed on 08/05/2025. Staff K stated that the MDS was not completed timely and that it should have been completed by 07/28/2025.In an interview on 03/04/2026 at 9:08 AM, Staff B, Director of Nursing, stated that they expected Resident 4's admission MDS to have been completed timely.Reference: (WAC) 388-97-1000(1)(b)(3)(a)(5)(a).

Based on interview and record review, the facility failed to complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframe for 1 of 18 residents (Resident 25), reviewed for resident assessments. This failure placed the resident at risk for delayed care planning, unidentified care needs and services, and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument (RAI-instructional guidelines for MDS completion) 3.0 User's Manual Version 1.20.1, revised in October 2025, showed a Quarterly MDS was a non-comprehensive assessment used to track the resident's status between comprehensive assessments that ensured residents were monitored for critical indicators of a gradual change in a resident's status are monitored. The RAI further showed that the quarterly MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD-look back period).Review of Resident 25's quarterly/discharge MDS with an ARD of 08/09/2025, showed that it was completed on 05/25/2025 (three days late).In an interview and joint record review on 03/02/2026 at 1:12 PM, Staff K, MDS Coordinator, stated that they followed the RAI manual for MDS completion. Staff K stated that a quarterly MDS was due 14 days from the ARD. A joint record review of Resident 25's quarterly/discharge MDS with an ARD of 08/09/2025, showed it was completed on 05/25/2025. Staff C stated that it was completed late.In an interview on 03/04/2026 at 11:41 AM, Staff B, Director of Nursing, stated that they expected MDS assessments to be completed timely.Reference: (WAC) 388-97-1000 (4)(a).

Based on interview and record review, the facility failed to transmit the resident Minimum Data Set (MDS-an assessment tool) to the Centers for Medicare & Medicaid Service within the required timeframe for 1 of 29 residents (Resident 14), reviewed for resident assessments. This failure placed the resident at risk for unmet care needs and diminished quality of life. Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument [RAI-instructional guidelines for MDS completion] 3.0 User's Manual Version 1.20.1, revised in October 2025, showed that a discharge (non-comprehensive) MDS must be completed no later than 14 days after the Assessment Reference Date (ARD-look back period), and it must be submitted/transmitted within 14 days of the MDS completion date to the database as required.Review of Resident 14's discharge MDS with an ARD of 01/17/2025 showed that it was completed on 02/03/2025 (three days late).Review of Resident 14's discharge MDS with an ARD of 05/03/2025 showed that it was completed on 05/20/2025 (three days late).In an interview and joint record review on 03/02/2026 at 1:12 PM, Staff K, MDS Coordinator, stated that they followed the RAI manual. Staff K stated that the discharge assessment was due 14 days from the ARD. A joint record review of Resident 14's discharge MDS with an ARD of 01/17/2025 showed that it was three days late. In another joint record review of Resident 14's discharge MDS with an ARD of 05/03/20225 showed that it was three days late. Staff K stated that Resident 14's discharge MDS were late and should have been completed on time.In an interview on 03/04/2026 at 11:41 AM, Staff B, Director of Nursing, stated that they expected MDS assessments to be completed timely.Reference: (WAC) 388-97-1000(5)(a)(e)(i)(iii).

Based on interview and record review, the facility failed to initiate and resolve a grievance for 1 of 2 residents (Resident 52), reviewed for grievances. The failure to initiate, investigate, and resolve grievances for missing personal item placed the resident at risk for feelings of frustration, unmet care needs, and a diminished quality of life.Findings included .Review of the facility's policy titled, Grievance, dated in March 2025, showed, To assure that concerns are quickly and thoroughly evaluated and acted upon in order to resolve issues which affect the quality of life and care for residents in our facility. The policy further showed, When a concern is voiced to a facility employee, the resident, family, guest or fellow employee is directed to the appropriate department supervisor to evaluate and resolve the issue.Review of the quarterly Minimum Data Set (an assessment tool) dated 01/06/2026 showed that Resident 52 was readmitted to the facility on [DATE] and was cognitively intact.On 02/24/2026 at 10:52 AM, Resident 52 stated that their phone charger and documents were missing after their things were packed away when they were hospitalized . Resident 52 stated that the facility had not replaced their charger or found their documents. Resident 52 further stated that their representative spoke about it to Staff J, Social Service Director.Review of the facility's grievance log from September 2025 through February 2026 did not show that a grievance was logged for Resident 52's missing charger/documents, or that an investigation was completed.In an interview on 02/26/2026 at 11:40 AM, Staff J stated that they had grievance forms throughout the building that resident, family and staff had access to and could complete. Staff J stated that when residents or a resident's representative reported missing personal property, they would start a grievance and would investigate. Staff J stated that they were not aware of Resident 52's missing charger. Staff J stated that they had spoken to Resident 52's representative and that Resident 52's representative had spoken to Staff A, Executive Director, about a missing bag that Resident 52's representative had packed when Resident 52 was hospitalized . Staff J stated that they could not confirm what was in the bag and that the bag was probably thrown away. Staff J further stated that a grievance should have been filed for Resident 52's missing bag.In an interview on 02/27/2026 at 3:37 PM, Staff A stated that they expected a grievance form to be completed when residents or their representative reported a missing personal property and that they would expect it to be logged in the facility's grievance log. Staff A stated that Resident 52's representative informed them that they were missing a bag and that they had spoken to the housekeeper about it and that they could not find it. Staff A further stated that they should have filed a grievance, but I didn't [I did not].Reference: (WAC) 388-97-0460 (1)(2).

Based on interview and record review, the facility failed to facilitate quarterly care conferences or care plan meetings for 1 of 1 resident (Resident 25), reviewed for care planning. In addition, the facility failed to ensure care plans were revised timely and accurately to reflect shower preferences for 1 of 5 residents (Resident 6), reviewed for Activities of Daily Living. These failures placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life.Findings included .Review of the facility's policy titled, Care Planning-Interdisciplinary Team, revised in March 2022, showed, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. The policy showed, Care plan meetings are scheduled at the best time of the day for the resident and family when possible. The policy further showed, If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed, The resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences. The policy showed, If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. The policy further showed, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. RESIDENT 25Review of Resident 25's quarterly Minimum Data Set (MDS-an assessment tool) dated 02/05/2026, showed that they were admitted to the facility on [DATE] and that they were cognitively intact. On 02/23/2026 at 3:26 PM, Resident 25 stated that they did not remember attending a care conference meeting. Review of Resident 25's Electronic Health Record (MDS assessment, progress notes, evaluations, miscellaneous files) showed that a quarterly MDS was completed on 02/08/2025, 08/09/2025, 11/09/2025 and 02/05/2026. Further review showed no documentation that Resident 25 attended or was offered a care conference meeting and showed no documentation that Resident 25 declined to attend their care conference meeting. In an interview and joint record review on 02/26/2026 at 2:54 PM, Staff J, Social Service Director, stated that care plan meetings/care conference started on admission. When a resident was admitted to the facility, they meet with them within 48 hours, establish a baseline care plan and schedule their first care conference within the week. Staff J stated that care conference was offered quarterly and as needed, and that they would discuss the resident's plan of care. Staff J stated that they would document whether they had a care conference or if they declined under Social Services note in the progress note. A joint record review of Resident 25's progress notes showed no documentation that a care conference was offered or that Resident 25 had declined to attend. Staff J stated that Staff N, Social Service Assistant, did not document that they offered a care conference and whether Resident 25 accepted or not. Staff J further stated that Staff N should have offered Resident 25 a care conference meeting and that they should have documented whether they accepted or not. In an interview on 02/27/2026 at 3:41 PM, Staff A, Executive Director, stated they expected Social Services to invite residents to care conference quarterly and annually. Staff A stated that they would document that a care conference was offered and/or if they declined. Staff A further stated that they expected Resident 25 to have been offered a care conference and documentation if they or their representative declined to attend. RESIDENT 6On 02/26/2026 at 9:35 AM, Resident 6 stated that they preferred their shower on day shift and that they had told the shower aide about wanting to have two showers a week. Review of the Shower Sheet Check-Off dated 12/18/2025 and 01/15/2026, showed that Resident 6 preferred their shower in the mornings. Review of the Bathing/Shower task printed on 02/25/2026 showed, Shower schedule: Monday and Thursday evening and as needed.Review of Resident 6's comprehensive care plan printed on 02/25/2026, showed, BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannotbe tolerated.In an interview on 02/26/2026 at 1:27 PM, Staff O, CNA/Shower Aide, stated that they provided showers to the residents and followed a shower schedule. Staff O stated that they would try to accommodate shower preferences, that they would make sure to fit the residents in their schedule and let the Resident Care Manager (RCM) know. Staff O stated that the RCMs created the shower schedule. Staff O stated that when they first started working in the facility, the care plan matched what was on the shower schedule. Staff O stated that Resident 6 preferred their shower in the morning and that they were scheduled for an evening shower. In an interview on 02/26/2026 at 3:10 PM, Staff P, CNA/Shower Aide, stated that Resident 6 had told them that they wanted a shower on day shift and that they spoke to Staff O if they could give Resident 6 a shower in the morning. Staff P stated that they did not notify the RCM and that they had written it on the Shower Sheet Check-Off that they preferred morning showers. In an interview and joint record review on 03/04/2026 at 9:32 AM, Staff I, RCM, stated that residents' received two showers a week and as needed. Staff I stated that Staff F, Infection Control, initially did the shower schedule and that the RCMs can change it based on residents' request. Staff I stated that shower preferences would be care planned. A joint record review of the shower schedule showed that Resident 6 was scheduled for evening showers. A joint record review of the Bathing/Shower task showed, Shower Schedule: Monday and Thursday evening and as needed. A joint record review of Resident 6's comprehensive care plan showed no documentation that reflected Resident 6's shower preference. Staff I stated that Resident 6's care plan did not have documentation that they preferred morning showers and that their care plan should have been revised. In an interview on 03/04/2026 at 11:21 AM, Staff B, Director of Nursing, stated that shower preferences should be honored and that Resident 6's care plan should have been revised to reflect their shower preference. Reference: (WAC) 388-97-1020 (2)(e)(f)(5)(b).

Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 1) reviewed for falls received complete and timely assessments after a fall with a head injury. The facility had specific guidelines for monitoring residents' neurological status after a fall with head trauma yet did not follow these for Resident 1 who experienced harm with an unrecognized change in level of consciousness, potential pain, and delayed medical response. Findings included . Review of the Admission Evaluation form, dated [DATE], showed Resident 1 admitted to the facility on [DATE] with diagnoses that included recurrent falls and weakness. The Admission Evaluation form also showed the resident was a high risk for falls, required extensive assistance for mobility, and needed supervision for eating meals. Review of the Medication Administration Record dated [DATE] through [DATE] showed Resident 1 was receiving Aspirin (blood thinner) 81 milligrams every morning. Review of a fall investigation, dated [DATE], showed Resident 1 was found in the supine position (lying on back) on the floor of their room at 4:15 PM with a 4.0 centimeter (cm) x 5.0 cm bruise observed on the left side of the resident's forehead and face. Review of the neurological assessment (used to assess, check, and record signs/status following an injury in suspected or actual head trauma) flowsheet form dated [DATE] showed: This assessment should be completed at the following intervals for follow up on falls. A fall that is unwitnessed, or in which the head is struck requires neurological checks. Any change in resident condition requires a phone call to the primary care physician. The neurological assessment intervals listed on the form were to be performed every 15 minutes eight times, every 30 minutes four times, every 60 minutes four times, every four hours four times and every eight hours six times. The neurological assessment flowsheet consisted of two pages. The second page of the neurological assessment flowsheet assessed the level of consciousness (alert, drowsy, stuporous[unresponsive], comatose [unresponsive] and response [appropriate, inappropriate or no response] to pain. Review of the neurological assessment, dated [DATE], showed Resident 1 had an unwitnessed fall with a head injury. The second page of the neurological assessment form was not attached/completed and had no documentation that assessments for Resident 1's level of consciousness or response to pain were performed. On [DATE] at 2:00 PM, Resident Representative 1 (RR1), stated they visited Resident 1 on [DATE], when entering the room, Resident 1 was unresponsive, had food spilled on the floor, and the resident's legs were covered with milk. RR1 stated that they had to call for staff to come, and three unknown staff members came to Resident 1's room, at 5:58 PM, and one of the three unknown staff members asked the other unknown staff member, What is this [referring to the spilled food and milk]. RR1 said that the other staff member said that it was the resident's lunch tray and that bruises and a huge hematoma (a collection of blood or pooling of blood outside of a blood vessel caused by trauma were observed on the left side of the head and face of Resident 1. RR1 stated, the resident had bruises and had a huge hematoma on her head and supposedly that happened 24 hours prior to that. They should have called 911 right away and the firemen said the same thing. On [DATE] at 8:31 AM, Resident Representative 2 (RR2), stated if someone would have told me she fell on [DATE], the day she fell and hit her head, I would have said I want her sent to the hospital immediately. She might still be alive today if she would have been sent to the hospital the same day she fell . On [DATE] at 3:12 PM, a phone interview with Staff C, Registered Nurse, said they knew Resident 1 was a high risk for fall and they started the neurological checks 15 minutes after Resident 1 fell and saw the bruises and the hematoma on the left side of Resident 1's head and face. Staff C stated that a complete neurological check may show changes in the resident condition after a head injury or other injuries and that it was important to check if they were more confused, not responding at all to pain or anything else, especially with an unwitnessed fall and head injury. Staff C stated that the form they started was only one page long and Staff C stated that they did not see the second page of the neurological assessment form. On [DATE] at 3:19 PM, Staff H, Certified Nursing Assistant, said that residents that required supervision during mealtimes should be checked to see if they were okay or needed help with anything. Staff H also said Resident 1 ate meals independently in their room and required staff supervision. Staff H stated it would be unusual for Resident 1 to spill food and milk and that it would be a change for Resident 1 to do something like that. On [DATE] at 3:03 PM, Staff I, Licensed Practical Nurse, said that RR1 came to the facility on [DATE] around dinner time and found Resident 1 in their wheelchair with their lunch tray on the floor. Staff I also said there was food noted on the floor and that bruises and a hematoma on the left side of the head and face was from a fall that the Resident 1 had the previous day on [DATE]. Staff I said that they could not remember if the second page of the neurological assessment form were completed or not. Staff I then said that RR1 was the one who called 911 and the medics took Resident 1 to the hospital. On [DATE] at 4:01 PM, Staff B, Director of Nursing Services, said that the neurological assessment forms the facility used was two pages long and the second page was not completed for the fall incident that Resident 1 had on [DATE]. Staff B then said if the form had been completed it may have shown changes of condition or assisted staff to recognize a change of condition or injuries. Staff B also said that their expectation was for the nursing staff to complete the neurological assessment form completely if a resident had an unwitnessed fall and/or fell and hit their head. Review of hospital records, dated [DATE], showed Resident 1 admitted to the hospital with an altered mental status and a traumatic brain bleed, was placed on comfort care, and died in the hospital on [DATE]. Reference: (WAC) [DATE] (1)

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services to prevent the development and worsening of pressure injury for 2 of 4 residents (Resident 1 & 2) reviewed for pressure injuries (PI). Failure to complete on-going skin assessments and develop & implement a PI care plan with individualized interventions resulted in harm (wound deterioration) to both residents who developed pressure ulcers. Findings included . According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instruction manual, v1.17.1, a PI is defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Stage 2 (Partial thickness loss of skin presenting as a shallow open ulcer with a red, pink wound bed, without slough (a non-viable [dead] tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). Stage 3 Pressure Ulcer (Full-thickness skin loss) Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Eschar is dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Deep Tissue Pressure Injury (DTPI) Persistent non-blanchable deep red, maroon, or purple discoloration. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. Review of the undated facility policy titled, Pressure ulcer prevention/Treatment, undated and reviewed recommended that all residents were to be assessed on admission and weekly for four weeks, then quarterly, annually, and when there was significant change in condition using the Braden Risk Assessment (an assessment tool that predicts the risk for acquiring a skin pressure ulcer/injury), and Skin Integrity Assessment. RESIDENT 1 Resident 1 was initially admitted to the facility on [DATE] and was readmitted back to the facility on [DATE]. A review of the admission Minimum Data Set (MDS) assessment, dated 02/02/2022, revealed Resident 1 had impaired cognition, was unable to make his needs known, and required extensive assistance of two staff for bed mobility and transfers. An initial skin assessment on 01/20/2022 showed the resident had multiple bruises. One on the left arm and another on the left hand. After the fall on admission, an assessment showed that the resident had two skin tears on the inner side of the right arm. Review of the skin grid weekly evaluation [readmission skin assessment], dated 01/26/2022, showed Resident 1 had two surgical incisions, an open area, and three bruises. An open area was on the right elbow, measuring 1.5 centimeters (cm) length by 1.0 cm width. There was no documentation on the re-admission note to indicate resident had a PI. Record review of progress notes and skin grid weekly skin evaluation from 01/27/2022 to 02/18/2022 (3 weeks) showed no documented evidence of any skin assessments. Further review of records showed there was no individualized care plan and interventions for the pressure ulcer on the coccyx (tailbone area), or left and right heels prior to 02/18/2022. Further review of the nursing progress notes regarding the skin assessment, dated 02/18/2022 at 1:15 PM, showed Resident 1 had developed three new skin impairments (PI): Coccyx, measured 4.0 cm x 1.0 cm, Right heel, measured 1.0 cm x 1.0 cm, Left heel, measured 2.50 cm x 1.50 cm. Further review of the skin grid weekly skin evaluation dated 02/21/2022, showed a Stage 3 PI on the coccyx that measured 4.0 cm length x 1.0 cm width x 0.50 cm depth, and documented the coccyx PI was acquired in the facility. Review of the electronic medical record (EMR) daily task, 'Skin Observation,' assigned to nursing assistants from 01/31/2022 to 02/28/2022 showed that staff consistently documented No in response to the question Did you see a new skin problem? A review of an outside Wound Consultant report, dated 02/24/2022, showed Resident 1 had developed 3 PU wounds: Wound 1 Left heel PI, measuring 4.30 cm x 4.0 cm x 0.00 cm with 90 percent (%) epithelization (new skin-wound healing) and 10 % slough and was classified as Unstageable PI with an area of dry adherent slough. Wound 2 Right heel PI, measuring 1.90 cm x 2.70 cm x 0.00 cm with 100% epithelialization, and was classified as deep tissue injury. Wound 3 Sacral [coccyx] (tail bone area) PI, measuring 3.30 cm x 1.40 cmx 0.90 cm with 75% granulation (new skin tissue), and 25% slough was classified as Stage 3 PI with undermining (is the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface). Record review showed the facility was treating Wound 3 on the sacral area by cleansing with normal saline, gels honey, and to cover with boarder dressing. Wound 2 was being treated with skin protectant and continue offloading measures. Wound 1 was being treated with skin prep and leave open to air. A joint record review and interview on 03/01/2022 at 10:30 AM, Staff C, Residential Care Manager (RCM), Licensed Practical Nurse, (LPN) was asked what the facility's policy on skin assessment was. Staff C said that skin assessments were to be done on admission, weekly, quarterly, and when there was a significant change in condition. When asked where Resident 1 developed the 3 pressure injuries, Staff C said that Resident 1 developed the PI while in the facility. When asked if skin assessment was done from 01/27/2022 to 02/17/2022 and Staff C said, No, there was no skin assessment done for that period. Staff C Stated that skin assessment should have been done weekly during that period. RESIDENT 2 Resident 2 was initially admitted to the facility on [DATE], sent back to the hospital on 12/30/2021 and was readmitted back to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS showed Resident 2 was totally dependent with transfers, required extensive assist of two persons with bed mobility, and had one Stage 2 PI. On 02/07/2022 at 1:15 PM, Resident 2 was observed sitting up in his wheelchair with a pressure relieving cushion in place. The resident said sometimes he feels pain in his bottom when sitting in the chair for too long. Staff G, Registered Nurse, was asked how often Resident 2 was repositioned, Staff G said every 2 hours, and when needed. Review of the initial skin assessment on admitted d 12/20/2021 showed Resident 2 had multiple scattered skin discolorations/bruises to both lower extremities and the skin assessment did not identify other skin issues. Review of the wound nurse note [with a picture of the wound], at the hospital dated 12/31/2021, showed Resident 2 had a Stage 2 pressure ulcer [PI] on his right [left] buttock measuring 0.90 cm x 0.90 cm x 0.10 cm with partial thickness of 40% slough and 60% red tissue. Later observation on 03/01/2022 at 11:02 AM, showed that the wound was on the left buttock [and not on the right buttock]. A review of the skin grid skin evaluation completed by Staff F, RN, dated 01/04/2022, showed the resident had a Stage 2 PI on his left buttock measuring 2.10 cm x 1.20 cm with a Braden Risk Assessment score of 12 (an assessment tool that predicts the risk to acquire a skin pressure ulcer/injury) which indicated the resident was at a high risk of developing a PI. Review of the January 2022 Medication Administration Records (MAR) and Treatment Administration Records (TAR) showed that a treatment was written for the right buttock [instead of the left buttock] wound to be treated with NS [normal saline], pat dry and covered with foam dressing every shift and when needed from 01/06/2022 and was discontinued on 02/07/2022. Review of the care plan showed no documentation or intervention in the care plan for the resident's left buttock PI prior to 02/08/2022. Further review of Resident 2's clinical records from 01/06/2022 to 02/06/2022, showed no skin assessments were conducted during this period. Review of the progress note dated 02/07/2022 at 11:37AM, showed Resident 2's Right [left] buttocks wound has increased in size and measured 6.50 cm x 6.0 cm x 0.10 cm, but did not document what stage the PI was. Review of the skin grid weekly evaluation dated 02/10/2022 at 12:41 PM, showed the resident's left buttock PI had progressed to an Unstageable PI, measured 6.6 cm x 6.5 cm x 0.00 cm. Review of the Wound Consultant's report dated 02/10/2022 at 4:05 PM, showed Resident 2's left buttock wound was classified as Unstageable, measured 6.6 cm x 6.50 cm x 0.00 cm, and the wound base was 100% (covered with) slough. Review of the skin grid weekly evaluation completed by Staff C dated 02/07/2022 showed that the physician was notified of the right [left] buttock wound getting worst, and review of the MAR and TAR showed treatment was in place. Observation and interview on 03/01/2022 at 11:02 AM, showed Staff C performed a dressing change on Resident 2's left buttock PI. The resident was laying on his back with the head of the bed raised. The left buttock wound was covered with 100% slough, a mild brown color was visible on the left buttock's dressing and no odor was noted. The resident denied pain when treatment was provided. When Staff C was asked to describe the wound. Staff C said it was Unstageable with 100% slough, with a brown color discharge on the dressing, and measured 6.6 cm x 6.5 cm x 0.00 cm. On 02/14/2022 at 3:15 PM, Staff B, Interim Director of Nursing Services said that the left buttock PI was community acquired [started while the resident was outside the facility] and then worsened in the facility [it was a stage 2 that became unstageable PI]. Staff B stated that the wound was being treated by the wound consultant [writing orders and staff implementing]. Staff B was not able to find any skin assessments for Resident 2 from 01/06/2022 to 02/06/2022. Staff B responded via an email dated 02/15/2022 that Staff D, RCM, had not completed the skin grid assessment for Resident 2 between 01/06/2022 to 02/06/2022. Reference (WAC) 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to provide adequate supervision and/or implement interventions to prevent accidents for 4 of 6 residents (Residents 1, 3, 4, 5) reviewed for abuse or neglect. Failure to do so resulted in Resident 1 experiencing a fall with [CONDITION(S)], which was actual harm, and placed Resident 3 at risk for injury from future falls. In addition, failure to adequately supervise Residents 4 and 5 for unsafe smoking behaviors placed the residents at risk for potential burn injuries or environment safety hazards. Findings included . FALLS Resident 1 was admitted to the facility on [DATE], with multiple medical diagnoses, including [CONDITION(S)] (sensation of dizziness or loss of balance) and diabetes. The initial Minimum Data Set (MDS) assessment, dated 06/14/2021, showed the resident needed extensive assistance from 1 to 2 staff to complete the Activities of Daily Living (ADLs) such as transfers and toileting, was frequently incontinent of urine and occasionally incontinent of bowel, and that no toileting program was in place. The MDS noted the resident had experienced a fall with fracture prior to admission. On 07/21/2021 at 2:40 PM, Resident 1 was lying in bed in their room wearing a hospital gown. The right hip and upper thigh were bandaged with deep blue/black bruises extending out from under the bandages. When asked about the injury to the right hip, Resident stated, I miscalculated the steps when going up a flight of stairs. The resident was unable to recount the events leading to the [CONDITION(S)]. On 07/27/2021, at 3:00 PM, Resident 1 was lying in bed wearing a brief and hospital gown. The surgical incision was covered by bandages and deep-colored bruising was on the outer side of the right upper thigh. When asked about the injury and therapy, Resident 1 stated that she had not been up out of bed, was currently non-weightbearing, and was not able to stand yet. The Care Area Assessments (CAA) completed in conjunction with the MDS, dated [DATE], documented the resident was at risk for falls and indicated a care plan was implemented to lessen the risk of falls. The CAA summary noted the resident was able to use a front-wheeled walker to ambulate short distances and that the resident was occasionally incontinent of urine. The resident's care plan on admission did not identify the risk for falls or identify interventions to lessen the risk of a fall. The care plan for ADLs, initiated on 06/07/2021, indicated the resident was weight-bearing as tolerated with staff assist, and is not toileted. Review of the accident incident log between 06/01/2021 and 07/19/2021 showed Resident 1 had three falls on 06/11/2021, 07/03/2021 and 07/11/2021. The facility investigations of the three falls listed on the log, identified that each fall was associated with Resident 1 attempting to use the bathroom independently without assistance. Review of the investigation, dated 06/11/2021, documented Resident 1 was found on the floor in the resident's room. The resident reported she was trying to go to the bathroom. A progress note documented the fall occurred at 1:30 PM. The investigation concluded the fall was related to the resident being unfamiliar with the environment, as the resident was a new admit and was new to the facility. The investigation ruled out abuse and/or neglect. A care plan for fall prevention, initiated on 06/11/2021, identified the resident as a fall risk and a Goal of decreased incidence of falls. The interventions included the following: Keep call light in reach and encourage resident to use it for assistance as needed, Frequent checks due to recent fall and for safety, Keep needed items in reach, Provide safe environment, clean, dry floors free of clutter, adequate light, a working and reachable call light, and personal items in reach. A care directive was also initiated on the June 2021 Medication Administration Record (MAR) for licensed nursing staff to direct the Nursing Assistants (NA) to do safety checks on Resident 1 every two hours. According to the electronic medical record, the safety check task was consistently documented and completed. In addition, the care plan for ADLs was updated on 06/11/2021 to include the following: One care staff to assist with ALL ADL's. Review of a progress note, dated 06/30/2021, showed, resident was found on floor this morning. No additional information concerning this fall was found in the record. Initial review of the incident log did not show the 06/30/2021 fall. And there was no evidence the resident's care plan was reviewed by staff to determine the effectiveness of the interventions and/or updated related to this fall. The accident log did list a fall incident on 07/03/2021. The facility investigation documented that at 8:30 AM, Resident 1 told a Nursing Assistant (NA) that she had fallen during the night shift. The NA reported the incident and an investigation was initiated. The investigation documented the resident's statement, I fell last night close to my bed while trying to go to the bathroom and forgot to call for help at that time. Attached to the investigation was a fall check list and a document titled, 10 questions to answer at the time of resident fall, both were blank. A fall scene investigation was also attached, which noted the resident was alone and unattended at the time of the fall and was trying to use the bathroom. The fall scene investigation noted there was no injury, and a skin assessment indicated there were no new issues. A blood sugar level check was completed, and the resident was monitored for neurological changes. The investigation report documented falls could be prevented in the future by reminding Resident 1 to call for help. It indicated falls should be immediately reported, and that care planning for basic needs was in place. The report also indicated that as needed pain medication was administered. The investigation summary statement, completed by Staff B, Director of Nursing, indicated abuse and neglect was ruled out, and that the resident's care plan would be reviewed. Review of the care plan showed one change, initiated 07/08/2021, which was a care plan goal for decrease number of falls was added with a target date of 09/30/2021. The next fall investigation, dated 07/11/2021, showed that when an NA went to answer the call light at 5:30 AM, Resident 1 was found on the floor in the bathroom, lying next to a walker. The resident reported she was dizzy and was trying to sit on the toilet. The investigation documented there were no observed injuries and indicated the resident was wheelchair bound. The investigation summary statement, dated 07/14/2021, indicated x-rays were obtained on 07/12/2021 and found no injury. Due to the resident's continued complaints of pain, a second set of x-rays was completed on 07/14/2021. The x-ray results identified an acute femur fracture. Resident 1 was admitted for the surgical repair of the right [CONDITION(S)], and she was readmitted to the facility on [DATE]. The care plan was updated on 07/15/2021, with a new intervention to Cue/remind the resident to use call light for assist with transfers on each contact you have with her. And after readmission on 07/19/2021, the order for frequency of safety checks was increased to every hour. On 07/19/2021 at 2:30 PM, Staff B, Director of Nursing Services, stated that a resident should be accurately assessed for needs at the time of admission. The DNS acknowledged that a resident identified as continent should have a care plan on admission in regards to meeting the resident's toileting needs. On 07/21/2021 at 4:00 PM, Staff B indicated there were additional interventions, including assistive devices such as hip protectors, which could be implemented to reduce the risk of a fracture if a fall occurred. The care plan interventions for falls (implemented 06/11/2021) were not effective, as evidenced by the pattern of repetitive falls trying to get to the bathroom. No additional fall interventions were implemented on the care plan until 07/15/2021, after the fall with fracture occurred. In addition, the initial nursing assessment, dated 06/07/2021, identified the resident was continent of bowel and bladder, but no toileting plan was initiated. Not ensuring Resident 1 was provided with adequate supervision and/or assistive devices to lessen the risk of injury with falls, resulted in the resident sustaining a substantial injury, a [CONDITION(S)]. SUPERVISION DURING SHOWER Resident 3 Resident 3 was admitted to the facility on [DATE], with multiple medical diagnoses, chronic pain and diabetes requiring insulin management. The initial MDS assessment, dated 05/31/2021, documented the resident needed extensive assistance of 1 to 2 staff to complete ADLs such as transfers, dressing, grooming, toileting, and hygiene and needed supervision and stand by assistance to walk in the room and the facility. The assessment did not identify what assistance was needed with bathing, and noted no bathing services were provided during the 7 day assessment period. Observation on 07/21/2021 at 12:10 pm showed Resident 3 lying on her bed. The resident reported she had problems receiving an appropriate diet, in that she did not eat meals delivered the previous days due to the kitchen sending foods that were not appropriate for a diabetic diet. The resident also reported that on the previous day, she had been left alone in the shower room and had a hypoglycemic event. The resident stated she did not get the foods she requested for breakfast and lunch, and did not eat all of her meals which may have contributed to the event. Resident 3 stated she was mostly independent with ADLs. The resident said that during showers, she needed some assist with set up and supervision, and help washing her back. The resident said that the hypoglycemic (below normal blood sugar) event occurred while she was alone in the shower room (after set-up), she got weak and dizzy, and lowered herself to the floor. When the NA came back to check on the resident, the resident asked the NA to alert the nurse that she had low blood sugar. The resident said her blood sugar (BS) was 54. The nurse then directed the NA to get a glass of juice and added sugar to it before giving it to the resident to drink, to help bring bs back up to normal level. After drinking the juice, the resident requested to rest before transferring from the floor, and the staff again left the resident in the shower room. The NA returned and assisted the resident back into the shower chair and the shower was completed. When asked if she was usually left alone in the shower room, the resident stated she just needed a little help. When asked about the staff involved, the resident said those staff had not provided care on the unit (where she resided) and had never seen either of them before. Then at 12:40 PM, Staff D, RCM/RN, was asked if any concerns were reported by Resident 3. The staff explained he was aware of concerns about food items requested that were not provided, and stated the Dietary Manager had visited Resident 3 the previous day. Staff D stated he was not aware of any other reported concerns. When asked about the expectations for reporting and investigating falls, he clarified that even if the staff intervened and assisted with lowering a resident to the floor, an investigation should be initiated. On 07/21/2021 at 2:05 PM, Staff G, NA was asked about assisting Resident 3 with a shower. He stated the resident was left alone after providing set up in the shower room, and when he came back to check on Resident 3, she was found on the floor due to having low blood sugar. He stated the resident denied having a fall, and that the resident lowered herself to the floor. He stated the nurse who responded to the incident had said the resident's BS was 58 when checked. Staff G said the RN directed him to get a glass of juice and packets of sugar from the kitchen that then could be given to respond to the hypoglycemic event. Staff G stated it was okay to leave that resident in the shower room alone. Review of the clinical record, progress notes, July 2021 MAR, and blood sugar records between 07/20/2021 and 07/23/2021 did not have documentation regarding Resident 3 being found on the shower floor with a low BS level, administration of juice with sugar in response to a hypoglycemic event, physician notification or of any follow-up monitoring. On 07/21/2021, at 2:20 PM, Staff D, RCM/RN, responsible for supervising the resident's unit stated he was not aware of any hypoglycemic event. Staff D, then went to check with Staff I, a Licensed Practical Nurse (LPN) assigned to Resident 3's unit, and stated the resident had told Staff I that she had a fall, but was not aware of any report of hypoglycemic events. On 07/27/2021 at 2:05 PM, Staff H, RN, confirmed that he had responded to the request to check Resident 3's blood sugar while on the shower room floor. When asked if he documented the incident, he explained an entry should be in the progress notes. When asked if he could recall what the BS was when checked, Staff H said he could not recall exactly, but indicated that the resident's BS was below 60. When asked if he reported the incident to a physician, he stated he did not. On 07/27/2021 at 2:20 PM, Staff D, RCM/RN, was asked if Resident 3 was to be left alone in the shower room, he stated they were not. On 07/27/2021 at 3:45 pm, Staff B, DNS, stated all residents were provided with supervision in the shower room, even if they just needed set up. When asked for an investigation of the incident, Staff B stated an investigation was started, but had not yet been completed. (See F 610, for failure to conduct thorough investigations and taking action to prevent a similar occurrences.) SUPERVISION FOR SMOKING SAFETY On 07/19/2021 at 2:45 PM, Staff C, Resident Care Manager (RCM) stated the facility had a No-Smoking policy and said she was not aware of any residents in the facility who smoked. Resident 4 The resident was admitted to the facility on [DATE], with multiple medical diagnoses, including diabetes and below the knee amputation. The last annual MDS assessment, dated 06/18/2021, indicated the resident was alert and oriented, and needed extensive assistance from two staff to complete ADLs such as transfers, dressing, toileting, and used a wheelchair for locomotion. Observation on 07/27/2021 at 3:40 PM showed Resident 4 lying on his bed, however he declined an interview stating he was sleepy. A progress note, dated 07/13/2021 at 6:59 AM, documented, Last evening at around 9:30 resident was smoking in (her/his) room. The note indicated the RCM went to talk to the resident, and that the DNS and Social Worker were also notified. On 07/27/2021 at 3:45 PM, Staff B, DNS was asked about the progress note. Staff B stated that Resident 4 did not smoke in the facility. Staff B stated it was the roommate (Resident 5) who had been observed smoking in the room and said the progress note about Resident 4 was in error. Resident 5 The resident was admitted to the facility on [DATE] with multiple diagnoses including diabetes. Resident 5 then transferred to a hospital on 07/18/2021, and did not readmit to the facility. A progress note, dated 07/13/2021, showed the following, Resident [5] was smoking in his room with roommate [Resident 4] plus a stranger who brought the cigarettes through the window. The entry further explained the RCM talked to the resident and the person outside the window The note also documented the DNS and Social Worker were notified of the incident. Although the progress notes documented the smoking in the room incident had occurred, there was no documented monitoring of those residents for unsafe smoking behaviors afterwards. (Also refer to F 610 for Failure to Investigate.) . WAC Reference 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent catheter-associated injury or urinary tract infections for 2 of 5 residents (Residents 1 and 2) with an indwelling urinary catheter (tube for drainage of urine). The facility failure to provide adequate & timely assessment, close monitoring and timely reporting of condition changes, and interventions, such as checking for proper placement of a urinary catheter and/or consideration of all possible causes for reduced/obstructed urine flow through the catheter, contributed to harm for Resident 1 who developed an acute life threatening medical condition related to catheter placement/migration. Resident 1 was hospitalized due to the acute medical condition and required surgical intervention which constituted a situation of an Immediate Jeopardy (IJ). The failure to monitor for positioning of the urinary catheter drainage bag also placed Resident 2 at risk for catheter-associated Urinary Tract Infection (CAUTI) and catheter associated injury, as well as risk for diminished health and quality of life. An onsite visit was conducted on 4/9/2021 which showed the facility had removed the immediacy on 3/31/2021 by educating licensed staff on how often to change catheters, and checking catheter placement and for signs and symptoms of catheter-related injury. The removal education also included documentation/updating care plans, progress notes, provider notification, change in condition, as well as updating the Treatment Administration Record for residents with urinary catheters. Findings included . The National Institute of Health, NIH (https://www.ncbi.nlm.nih.gov) showed the following information regarding a medical condition Fournier's Gangrene: Fournier's gangrene is an acute, rapidly progressive, and potentially fatal condition that causes gangrene (Tissue necrosis caused by decreased blood flow) affecting the genital and surrounding areas, which more commonly affects men. In most cases, Fournier gangrene has an identifiable cause, such as injury from urethral catheterization (for men-insertion of a plastic tube from the opening at tip of penis through the urethra through to the bladder to help with urine drainage). Symptoms most commonly presented were penile/scrotal swelling, pain, foul odor and skin discoloration in those areas. Imaging studies such as Computed Tomography (CT) are used to diagnose the condition, and treatments include surgical debridement to remove damaged tissue) and antibiotics. Review of another article issued by the NIH titled Fournier's Gangrene following Urethral Necrosis by Indwelling Catheter indicated that in men, the inflated catheter balloon (which helps keep the tube in place in the bladder) can slip down into the urethra tube causing injury and produce necrosis (Tissue death) outwardly characterized by penile/scrotal swelling and redness. The NIH also indicated in a study titled, Urethral Erosion: a case for prevention, showed that adverse outcomes of long-term urethral catheterization can include urethral or penile erosion (tissue damage/wound from irritation and/or pressure from the catheter), and catheter-related necrosis of adjacent tissues. The study indicated outcomes associated with urethral and penile tip erosion could be prevented by properly securing the indwelling catheter(so it doesn't move/slip). Review of Foley Catheter information and instructions by manufacturer Bard Inc., showed that once the Foley catheter is inserted and urinary flow is observed, the catheter balloon should be inflated using entire 10 mL [milliliters] of sterile water provided in the prefilled syringe. Once the balloon is inflated, the instructions indicated to gently pull the catheter until the inflated balloon is snug against the bladder neck. This is done so as to ensure correct catheter balloon placement and prevent catheter injury such as urethral erosion. Review of an undated facility policy titled, Bowel and Bladder Program, Indwelling Catheters, provided on 03/19/2021, showed the following related to residents with indwelling urinary catheters: 1. Need for catheter, appropriateness of removing a catheter, initiating/updating care plan quarterly and for change of condition. The policy also included discussing goals with the resident and resident representative. Further review showed the need to review findings, interdisciplinary team (IDT) discussion. 2. Attempting to resolve factors identified in the assessment prior to catheter removal. Documentation of urine amounts, symptomatic infections, catheter size and orders to change catheter system due to blockage, leakage, and encrustation. Another facility policy was provided on 03/30/2021 and titled, Bowel and Bladder Program, Catheter-related Complications, dated 05/15/2019, which indicated the facility recognized an indwelling catheter may be associated with significant complications, including erosion of the urethra, bacteremia (infection), febrile (fever) episodes, bladder stones and fistula formation. The policy also showed staff were to: 1. Recognize and assess for complications, their causes and maintaining a record of any catheter-related problems. 2. Keep the catheter anchored to prevent excessive tension on the catheter which can lead to tears and dislodgement of the catheter. 3. In the absence of evidence indicating blockage, catheters need not to be changed routinely as long as monitoring is adequate. 4. Secure the catheter to facilitate flow of urine. RESIDENT 1 The resident admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, initiated and revised on 11/04/2020, identified the resident with a [CONDITION(S)] related to urinary catheter use. Interventions included: 1. Encourage adequate fluid intake. 2. Monitor/document/report to Medical Doctor (MD), signs and symptoms of [CONDITION(S)]. 3. Obtain lab/diagnostic work as ordered. The care plan, initiated on 09/04/2020 and revised on 11/11/2020, also identified the resident with an alteration in urinary elimination related to urethral catheter and urinary retention. Interventions were as follows: 1. Check catheter system every shift for patency and integrity. 2. Empty drainage bag every shift or as needed. Document amount of urine output per shift. The care plan did not include goals and interventions for potential catheter-related injuries or fluid output levels that were outside of set parameters. The care plan also did not include assessment, reporting, monitoring for signs and symptoms of catheter-related injury, such as swelling, bleeding or urethral erosion. The care plan did not indicate securing the urinary catheter to prevent catheter-related injury as instructed by the facility policy. The care plan was also not updated to include new goals and interventions related to penile/scrotal swelling (identified in progress notes on 03/16/2021). Lastly, the care plan did not indicate that staff should notify the resident's legal representative of any catheter-related problems. Review of the March 2021 Treatment Administration Record (TAR) showed instructions for staff to document urine output via Foley catheter every shift, and indicated staff were to report urine output amounts below 240 milliliters (ml) to the physician. Further review of the TAR showed the following documentation: On 03/02/21 and 03/04/21, the resident had a urine output of 200 ml for the day, evening, and night shifts. On 03/06/21, the resident had a urine output of 200 ml for the day shift. . Review of the progress notes for 3/2/21, 3/4/21, and 3/6/21 did not show that the low urine amounts were reported to a medical provider as instructed by the TAR. The progress notes did not show that an assessment was done for possible signs and symptoms of catheter injury or possible problems with the catheter. The notes also did not indicate the catheter was secured to prevent catheter-related injury. Further review of the March 2021 TAR showed the resident had a urine output of 200 ml for both the day and evening shifts of 03/15/2021. A progress note, dated 03/15/2021 at 1:05 PM, showed there was 200ml of urine in the resident's urinary bag. The urine was described as light yellow and cloudy with odor. The note showed the catheter was flushed with 60 ml and that staff would continue to monitor. The note did not show that the low urine amount was reported to the physician as directed by the TAR nor show that the possible [CONDITION(S)] symptoms, cloudy urine with odor, were reported to the physician as directed by the care plan. The note also did not show that the resident's legal representative was notified of the findings. There was no documented assessment for signs and symptoms of catheter-related injury or indication that the catheter and drainage tube were secured to prevent catheter-related injury. There was no further nursing documentation regarding monitoring description of the resident's urine and catheter until a nursing progress note, dated 03/16/2021 at 11:15 PM. The note showed that at approximately 9 PM, nursing assistants reported to the nurse that Resident 1 had a swollen penis and scrotum. The nurse documented the resident's Foley catheter was flushed with no fluid return. The old catheter was removed and a new catheter inserted. The new catheter then started to drain thick, [MEDICATION(S)]-like fluid with lots of sediment (particles/cloudiness). The nurse did not document an initial in-depth description regarding the amount of swelling and redness to the penis and scrotum area. The note only indicated that the swelling went down a little and the redness persisted [after the new catheter placement]. A medical provider was notified of the incident by phone and an order given to monitor. The note did not show that a post-insertion assessment was done to ensure appropriate catheter balloon placement after insertion, signs/symptoms for catheter-related injury or if the catheter was secured to prevent catheter related injury. The note did not state if the resident's legal representative was notified of the findings or if any attempt was made to find possible causes of the resident's penile/scrotal swelling. Another note on 03/17/2021 at 1:12 AM showed the resident still had swelling, but the swelling going down. It was not clear as to if this meant both penis & scrotal swelling or whether there was ongoing redness to the area(s). A progress note, dated 03/17/2021 at 9:12 AM (8 hours later), showed Resident 1 did not have any swelling of the scrotum, but the penis was slightly swollen with a blister on the tip. There was no approximate size of blister documented or whether there was ongoing redness to the area(s). The Foley catheter was flushed with no fluid return. The catheter was again changed and the new catheter immediately drained 1000ml of thick urine output with [MEDICATION(S)] sediment. The note did not show that a post-insertion assessment was made to ensure catheter balloon placement, presence of signs/symptoms for catheter related injury or if the catheter/drainage tube were secured to prevent catheter-related injury or if any attempt was made to find probable causes of the resident's penile swelling and blister on the penis tip. There was no indication that the resident's legal representative was notified of the findings. A note at 3:20 PM (6 hours later) showed the resident was doing much better, foley draining thick [MEDICATION(S)]-like sedimentation, flushed with output return. There was no description of the blister and/or whether there was still swelling or redness to the penis/scrotum. The note showed the resident was started on antibiotics for the penis blister and was to be monitored the rest of the shift. No other follow-up nurse monitoring notes were documented until the next day on 03/18/2021 at 12:17 PM (19 hours later). A late entry nurse practitioner's note on 03/18/2021, signed at 7:38 PM, showed the resident had an excessively swollen penis with a gray/white-colored lesion measuring 2 inches on the penile shaft with purulent drainage. The note indicated the penis was extremely tender to touch, the suprapubic region (lower abdomen) was reddened and inflamed, and the resident had a decreased urine output of 100 ml in the Foley catheter bag. The provider recommended the resident to be immediately sent to the hospital emergency room (ER) for further evaluation and treatment. The provider also documented that without immediate treatment, the patient was at high risk for further organ dysfunction and death. The resident was then transported to the ER for further evaluation. A nursing note on 03/18/2021 at 12:17 PM showed that the resident was sent out to the hospital at 12:00 noon to rule out bladder infection. Review of the hospital report, dated 03/18/2021 showed a CT scan was completed upon the resident's arrival to the ER. The resident was diagnosed with Fournier's Gangrene. The CT scan showed there was notable retraction of the Foley catheter into the distal penis with soft tissue infection (the catheter had pulled down/into the outer end of the penis). The note indicated the Fournier's Gangrene occurred post-traumatic from the catheter. A hospital progress note, dated 03/18/2021, showed the resident needed emergent surgical intervention. The report described the surgery as technically challenging given the amount of damage to the resident's genitalia. The report also showed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the hospital report, dated 03/24/2021showed a final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/01/2021 at 10:51 AM showed Resident 1 lying in bed with his eyes semi-closed. The resident's catheter bag was visible. When asked if he was aware of what happened, the resident did not respond clearly and could not articulate well. In an interview on 03/19/2021 at 1:07 PM, the resident's family member stated that Resident 1 was taken to the hospital due to a penile infection that needed surgical intervention. He stated that Resident 1 had been previously hospitalized for a catheter-related urinary tract infection (while residing at the facility). The family member stated that he believed the urinary catheter was the cause of the first [CONDITION(S)] and suspected that the resident had another infection from the same cause. On 03/26/2021 at 8:56 AM, the family member stated he had been told that the resident's final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/27/2021 at 10:45 AM, Staff A, Radiology Physician, stated that retraction of the Foley catheter into the distal penis meant that the tip of the Foley catheter, that usually was held in the bladder by an inflated balloon, had shifted or was placed into the resident's penile shaft and was most likely blocking blood flow to that area. He stated that in most cases, infection or gangrene could be the result if there was no intervention. When asked how this could be prevented, Staff A stated a urologist (specialist) would need to be consulted, but agreed that checking catheter placement could help prevent catheter injury and necrosis. On 03/29/2021 at 12:20 PM, Staff B, Licensed Practical Nurse (LPN), stated the reason she would change a catheter would be if the catheter was not draining due to blockage. When asked to describe steps to insert a catheter she stated she would wash hands, clean the resident's genital area, don sterile gloves, apply lubricant to the tube and insert the Foley until she got urine. Staff B stated she would then would inflate the balloon. When asked if there was anything else she would do, she stated she would provide ongoing monitoring to ensure the catheter was draining. When asked what she would do if a male resident, catheterized with a Foley catheter had a swollen penis or scrotum, she stated she would immediately speculate possible infection or if the catheter balloon was out of place, and call the doctor. She stated she would know if the catheter balloon was out place by resident having pain. On 03/29/2021 at 12:51 PM, Staff C, Registered Nurse (RN), stated the reason he would change a catheter would be if there was no urine drainage in the bag. When he was asked to describe how to insert a catheter he was able to describe sterile technique, but did not describe checking catheter placement once the catheter balloon was inflated. When asked what he would do if a male resident with a Foley catheter in place had a swollen penis, he stated he would send the resident to the ER. Staff C did not mention that he would do any initial and ongoing assessment to ensure catheter securement or assessment for catheter related injuries. On 03/29/2021 at 5:11 PM, Staff D, Registered Nurse (RN), was asked to describe how to insert a Foley catheter. Staff D stated she would clean the insertion site with antiseptic, insert the catheter and observe for urine flow. She stated the most important thing for her was to remember infection control; she did not further elaborate to include checking for catheter balloon placement. When Staff D was asked what she would do if a male resident catheterized with a Foley catheter had a swollen penis, she stated the first thing she would think of was urinary retention. When asked to further elaborate she stated she would report to the physician. Staff D did not mention she would do any initial and ongoing assessment to ensure catheter securement or assessment for catheter related injuries. On 03/29/2021 at 5:02 PM, DNS, Administrator, Staff E, Resident Care Manager were notified of an immediate jeopardy related to the resident's situation. All staff members were not aware of the situation or the severity of the resident's condition. On 04/01/2021 at 9:21 AM, Staff F, Attending Physician, stated the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He also acknowledged the resident was not fully aware of the severity of his condition probably due to his history of neuro [CONDITION(S)] disease. On 04/14/2021 at 11:11 AM, Staff I Director of Nursing, the facility Administrator, Staff J Corporate nurse, and Staff K Corporate nurse were asked if the resident's penile swelling should have been addressed in the care plan for goals and interventions. Staff K stated it was expected that nursing staff would only care plan if the resident's condition was chronic. She stated the resident's penile swelling was placed on alert charting. When asked if the risk for catheter-related injury should have been addressed in the care plan goals and interventions both the regional nurse, Staff I and Staff J stated it would not and stated they had never seen that in a care plan. When asked if notifying the resident's legal representative of the resident's penile swelling should have been documented by staff, Staff I stated notification should have been included in the care plan as well as the documentation. When asked what should have been included in the documentation for catheter insertion, Staff I stated documentation should have included how the catheter was inserted, such as using sterile technique, size of catheter used, resident's response to the insertion, and securing catheter placement. RESIDENT 2 Resident 2 admitted to the facility on [DATE]. A medical provider progress note, dated 06/26/2020, showed the resident admitted to the facility with a suprapubic urinary catheter. Review of the resident's admission Minimum Data Set (MDS), showed the resident had cognitive impairment and was not able to make her needs well known. Review of Resident 2's care plan, initiated on 08/21/2020, identified the resident with an Alteration in urinary elimination related to urethral catheter-Urinary retention that cannot be managed medically or surgically. Interventions were to keep catheter anchored to prevent tension or trauma. Review of March 2021 nursing progress notes and Treatment Administration Record (TAR) showed no documentation that nursing staff was monitoring the catheter placement or the placement of the drainage bag. During a joint observation and interview on 03/29/2021 at 1:09 PM with Staff E, the resident was lying in bed uncovered wearing an incontinent garment. A urinary catheter, unanchored and unsecured, lead to a urine drainage bag on the ground. The resident was restlessly moving her legs. Staff E stated the catheter bag should not be on the floor because it placed the resident at risk for infection and catheter injury from displacement of the catheter balloon. On 04/14/2021 at 10:26 AM, Staff I, Director of Nursing acknowledged the facility was not following the policies and procedures related to indwelling catheters and catheter related complications. Staff I also stated review of staff competencies had not been completed since 2018. (Refer to F726 Competent staffing) Reference (WAC) 388-97-1060(3)(c)

Based on observation, interview, and record review, the facility failed to ensure residents and staff were protected from COVID-19 (a contagious disease), and failed to ensure the all components of an effective infection control program were operationalized to provide a safe and sanitary environment to help prevent the development and spread of communicable diseases and infections. 1. The facility failed to ensure timely notification of COVID positive staff, and/or prevent staff with signs and symptoms (s/s) of COVID-19 from working on the floor/unit, and increased the likelihood for the spread of COVID-19 between residents and staff. 2. The facility failed to ensure staff followed infection control practices to prevent exposure to or spread of COVID-19 on proper use of Personal Protective Equipment (PPE), proper putting-on and removal of PPE, and appropriate hand hygiene when indicated. 3. The facility failed to ensure employees were fully screened for signs and symptoms of COVID-19. 4. The facility failed to consistently provide education on infection control including standard, contact and transmission-based precautions (TBP - contact, droplet, airborne, respiratory), and convey COVID-19 updates (s/s, how it is transmitted, screening, work exclusions, etc.) to all employees/staff. 5. The facility failed to provide a written respiratory program including a plan to fit-test employees for N95 respirator masks as necessary to protect residents and staff from COVID-19 infection. 6. The facility failed to ensure general and standard precaution for cleaning and disinfection were followed, and that dedicated environmental cleaning equipment were not prevented from leaving the COVID unit, potentially exposing other residents and staff on the other non-COVID unit/areas. 7. The facility failed to provide an effective infection control surveillance that includes early detection, management, laboratory testing, implementation of TBP, tracking, use of evidence-based surveillance criteria to define infection, use of data collection, and analysis and follow-up. 8. The facility failed to report a health care associated infection for Multi-Resistant Drug Organisms (MDRO - are common bacteria (germs) that have developed resistance to multiple types of antibiotics) to local/State Public Health Officials as required. These failures increased the likelihood of serious harm or death and constituted an immediate jeopardy. Findings included . DELAYED NOTIFICATION OF STAFF COVID POSITIVE TEST RESULTS During an interview on [DATE] at 5:30 PM, Staff A, Registered Nurse (RN), stated that she was tested for COVID on [DATE], and on [DATE] at 5:30 PM, she got a text message to call the DNS (Director of Nursing Services) ASAP (as soon as possible). Staff A stated she had worked day shift that day and missed the call/the message from the facility. However, Staff A stated that there was no other instruction(s) from the facility about her work schedule or about her work schedule for the following day being cancelled. Staff A, RN, then showed up for work on [DATE], and at 6:30 AM, she called the DNS to inquire about the message she received the evening before that day, but the DNS did not pick up her call. Staff A, RN, stated that she checked her work schedule for dayshift [DATE], and her name on the schedule was not crossed off. Staff A stated that Staff E, Licensed Practical Nurse (LPN), was the outgoing night-shift nurse who gave her the medication keys and informed her that she had been assigned to Cart 1 (Quarantine on East Unit). Staff A, RN, stated that she then worked on the floor and passed medications to her residents. Staff A, stated that a few hours later she saw the DNS and that was when she was notified that her COVID test was positive. She stated that she started feeling tired, dizzy and nauseated that day. Review of payroll hour's documentation, dated [DATE], showed Staff A had worked 7.6 hours at the facility that day. During an interview on [DATE] at 3:16 PM, Staff B, Human Resources (HR), Payroll, stated that Staff A worked on [DATE] for 7.6 hours. During an interview on [DATE] at 3:58 PM, Staff C, Medical Records (MR), stated that she called Staff A once on [DATE], but she did not leave any other instruction other than to call the DNS. Review of the [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed the following residents were among the residents who were exposed to Staff A, RN, while she worked on the cart and provided medications and/or treatments for residents assigned to her on [DATE]. Review of those residents' COVID test results showed they were positive for COVID-19 on the following dates: 1. Resident #1 - [DATE] 2. Resident #2 - [DATE] 3. Resident #3 - [DATE] 4. Resident #4 - [DATE] 5. Resident #5 - [DATE] 6. Resident #6 - [DATE] 7. Resident #7 - [DATE] 8. Resident #8 - [DATE] During an interview on [DATE] at 4:01 PM, the Administrator stated that Resident #8 was one of the residents who passed away due to COVID-19 infection. OTHER STAFF WITH DELAYED NOTIFICATION OF THEIR COVID POSITIVE TEST RESULTS 1. Review of the COVID positive test results for Staff H, LPN, showed that the laboratory released the results of Staff H's COVID test to the facility on [DATE]. 2. Staff D, Nursing Assistant Certified (NAC), was tested for COVID on [DATE], and records showed that the laboratory released the results to the facility on [DATE]. 3. Staff F, NAC, was tested for COVID on [DATE], and records showed that the laboratory released the results to the facility on [DATE]. 4. Staff G, NAC, was tested for COVID on [DATE], and records showed that the laboratory released the results to the facility on [DATE]. The facility was unable to provide documentation to support the above staff/employees were notified timely of their COVID test results. During an interview on [DATE] at 7:38 PM, Staff H, LPN, stated that he was tested for COVID on [DATE], and he worked on [DATE] to [DATE], and was off from [DATE] to [DATE]. Staff H stated that on [DATE] at 11:00 AM, the DNS texted him to call her back regarding his COVID test. Staff H called the DNS back, but she did not pick up his phone call, and still after a few hours he had not heard from her. Staff H then called the facility and was able to get a hold of the Administrator who let him know that he tested positive for COVID-19. Staff H stated that he had wondered why he was not immediately notified as soon as the facility received his COVID test result. He stated it made him upset because he got all of his family and immediate family sick and made trips to the emergency room twice because of COVID-19. During an interview on [DATE] at 4:29 PM, Staff I, RN, Resident Care Manager (RCM), stated that staff or residents who tested positive for COVID should be notified as soon as possible, and that staff who test positive should be notified before they showed up for work. During an interview on [DATE] at 3:58 PM, Staff C, MR, stated that staff should be notified right away when they tested positive for COVID, and the staff should be taken off the schedule. During an interview on [DATE] at 11:15 AM, Staff J, RN, Chief Nursing Officer (CNO), stated that staff should be notified as soon as the facility found out about staff with COVID positive test results. During an interview on [DATE] at 11:30 AM, the Administrator stated that Staff H, LPN, was notified of his positive COVID test result, but there was no documentation as to when he was notified. During another interview on [DATE] at 12:30 PM, Staff C, MR, stated that she did not report the COVID positive test results for Staff H, Staff D, Staff F, and Staff G, and stated that she did not have any documentation when the staff were notified of their COVID positive test results. Staff C stated that the DNS was responsible for calling the staff who had positive COVID test results for [DATE], and that she (Staff C) only took over that responsibility on [DATE]. STAFF DEVELOPED S/S DURING SHIFT During an interview on [DATE] at 7:14 PM, Staff K, RN, stated that when she came to work on [DATE], and she was assigned on the Quarantine Unit, she did not have COVID specific signs or symptoms (s/s). However, during the middle of her shift around 11:00 AM, Staff K stated that she started coughing, and notified her supervisor, but her supervisor told her to monitor herself. Staff K stated that she worked until about 3:30 PM that day because she needed to finish all of her work. Staff K stated that she was not aware of any specific instructions or protocol when s/s developed during her shift, other than to notify her supervisor which she did. Staff K stated the next day she developed fever, muscle aches, congestion, and dry cough, and then the day after that, she came back to the facility to be tested for COVID, and her results came back positive for COVID-19. Staff K stated that on [DATE], none of the residents were positive and/or had not received any positive COVID test results and that the facility did not have a COVID unit, but on [DATE] residents at the facility started to test positive for COVID-19. During an interview on [DATE] at 9:21 AM, Staff I, RN, RCM, stated that if staff developed s/s during their shift, the staff should be sent home. Staff I stated that Staff K notified her while they were in the unit that she was starting to cough during her shift, and did tell her to monitor herself or her cough. Staff I stated there were no clear instructions from the facility regarding staff who developed s/s during their shift, and she was not sure about their policy because there was no in-service about it. Staff I stated that Staff K should have been sent home. Review of payroll hour's documentation, dated [DATE], showed Staff K, RN, worked 8.63 hours at the facility that day. During an interview on [DATE] at 3:16 PM, Staff B, HR, Payroll, stated that Staff K, RN, was at the facility on [DATE], and worked for 8.63 hours. Staff B was asked about the facility's policy for staff who developed s/s during their shift, and Staff B stated, I don't know, that is nursing. Review of the [DATE] MAR and TAR showed the following residents were among the residents who were exposed to Staff K, RN who worked on the cart and provided medications and/or treatments provided for residents assigned to her on [DATE]. The residents' COVID test results showed positive for COVID-19 on the following dates: 1. Resident #2 - [DATE] 2. Resident #9 - [DATE] 3. Resident #10 - [DATE] 4. Resident #11- [DATE] 5. Resident #12 - [DATE] During another interview on [DATE] at 4:29 PM, Staff I, RN, RCM, stated that Staff K, RN, would have been assigned to Rooms ,[DATE] on their Quarantine Unit. During an interview on [DATE] at 11:15 AM, Staff J, RN, CNO, stated that if staff developed s/s during their shift, they should go home. During an interview on [DATE] at 4:01 PM, the Administrator stated that Resident #9 was one of the residents who passed away in the facility due to COVID-19 infection. PROPER USE OF FACE MASKS and FACE SHIELD Review of the facility's policy on COVID-19 Infection Prevention Control Measures, revised on [DATE], showed, Cloth face coverings for source control ARE NOT considered PPE. Staff should wear a facemask at all times when in the facility. Staff wear eye protection during any resident-care encounters or procedures. An observation on [DATE] at 1:05 PM showed Staff EE's, Facility Driver (FD), facemask slip down his face and came to rest under his nose. Another observation on [DATE] at 1:35 PM showed Staff EE was wearing his facemask under his nose. The DNS reminded him to put his facemask over his nose. An observation on [DATE] at 2:00 PM, Staff L, Laundry was wearing his surgical mask without a face shield or goggles. Staff L was delivering clothes to the residents to the non-COVID unit on the SW Hall. The DNS stopped him in the hallway and informed him that he needed to go home because he was wearing the wrong mask, and that he should be wearing a KN95 due to COVID-19 outbreak in the facility. Staff L stated that his N95 mask did not fit and was sliding off his face. The DNS stated that Staff L had been told several times about wearing his N95, and stated, He had to go home. An observation on [DATE] at 2:07 PM showed Staff M, Nursing Assistant Registered (NAR), was at the nurses' station, and she was wearing a KN95 over a cloth mask. The cloth mask was covering her nose, and her KN95 was partially covering her nose. The DNS was interviewed regarding the facility policy on appropriate use of facemasks when they were having a COVID-19 outbreak. The DNS stated that she was not sure, and that she would ask the Department of Health (DOH) about it. An observation on [DATE] at 3:10 PM, Staff JJ, NAR, while talking in the hallway on the East Hall COVID unit was observed pulling up his face shield and goggles to talk. Staff JJ stated that he puts down his face shield and goggles when giving care. He was asked about the facility's training on use of face shield and goggles, and responded he was not personally told what to do, and that his father worked at construction and his father told him what to do with face shield and goggles, and stated, I try to do the same. During an interview on [DATE] at 9:54 AM, the DNS stated that wearing a KN95 over cloth mask was unacceptable and that the NAR had been informed. During an interview on [DATE] at 4:29 PM, Staff I, RN, RCM, stated that staff should be wearing their facemasks and face shields and/or goggles when in the facility, and staff should leave them on at all times while working on the floor. HAND HYGIENE AND PROPER USE OF PPE According to CDC, the Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings include the recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (practices/procedures to prevent contamination from germs or microorganisms) or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. An observation on [DATE] at 2:10 PM showed Staff M, NAR, was at the nurse's station between the SW and NW Hall Unit, wearing her full PPE (gown, gloves, KN95 over her cloth mask and face shield), and was touching and typing on her phone with her gloved hand. Staff M then went in and out of the clean utility room, and entered the COVID Unit while wearing the same gloves. Staff M did not remove her soiled gloves prior to entering the COVID unit, did not do hand hygiene, and she put on a pair of gloves to her already gloved (soiled from touching her phone) hands. Staff M should have removed her soiled gloves, and perform hand hygiene prior to entering the COVID-unit. Observation on [DATE] at 2:15 PM showed Staff M, NAR, coming out of the COVID unit past the plastic zippered area, removed her soiled gloves, and disposed of her used gloves on the cart parked in the hallway by room [ROOM NUMBER] (a non-COVID unit/room with two residents, Resident #13 and Resident #22). Staff M then removed her soiled gown, and hung it on the hallway handrail close to the open entrance door of room [ROOM NUMBER]. The soiled gown was also touching a cart. On top of the cart were clean blue gowns, which were exposed to the soiled gown. Staff M stated that she hung her soiled gown on the rail so she could wear it again when she entered the COVID unit later. Further observation showed there was no hand hygiene station inside the plastic zippered area (between the COVID and non-COVID areas) where staff should do hand hygiene after removing their soiled gloves and gown. Staff M had to walk all the way to the non-COVID area, at the nurses' station, to wash her hands. The Administrator then walked into the hallway, and he was asked about the facility's process as to where staff should put on their PPE (gloves and gown) and where they can safely remove their used PPE. (Staff were already wearing their masks and face shields). The Administrator stated that staff should put on their PPE prior to entering the plastic zippered area, and staff should remove their PPE inside the plastic zippered area that separates the COVID unit from the non-COVID unit. At 2:35 PM, a joint observation with the Administrator and DNS showed the soiled gown was still hanging on the hallway rail by room [ROOM NUMBER]. They were informed that Staff M, NAR, had placed the soiled gown on the hallway rail after coming out of the COVID unit. The DNS stated, It was not acceptable. The DNS stated that the soiled gloves and gown should have been disposed while the NAR was inside the plastic zippered area (before coming out of the zippered area). The Administrator and the DNS were shown that there was no hygiene station or hand sanitizer available inside the plastic zippered area when staff removed their soiled PPE. During an interview on [DATE] at 4:29 PM, Staff I, RN, RCM, stated that staff should be doing hand hygiene (hand sanitizer should be available to the staff) after removing their soiled gloves even if their hands were not visibly soiled, followed by their soiled gown. Staff I stated that they were advised to dispose their soiled PPE in the COVID unit inside the plastic zippered area. HAND HYGIENE AND PPE USE ON THE NW HALL COVID UNIT An observation and interview on [DATE] at 3:00 PM showed Staff M, NAR, already wearing her full PPE, entering the COVID unit through the plastic zippered area. Inside the plastic zippered area, there was a computer for staff to chart. Staff M was touching/charting on the computer with her gloved hand. The call lights were on for room [ROOM NUMBER] (Resident #14), room [ROOM NUMBER] (Resident #15, #16), and room [ROOM NUMBER] (Resident #17, #23). The surveyor was in the hallway in the NW COVID unit, saw and heard Resident #16 say they needed help. The surveyor walked to the plastic zippered area and notified Staff M that Resident #16 was calling out for help. Staff M, walked into the COVID unit with the same gloves she was using on her computer, did not remove her soiled gloves and did not do hand hygiene, put on another pair of gloves (double gloving). Staff M knocked on the door and entered room [ROOM NUMBER]. Staff M then left room [ROOM NUMBER], and scratched her left wrist with her double-gloved right hand. Staff M then knocked and entered room [ROOM NUMBER] (Resident #18), then to room [ROOM NUMBER] (Resident #19, #20), touched the resident's personal items, and put away empty cups and applesauce containers from room [ROOM NUMBER]. Staff M then entered room [ROOM NUMBER] (Resident #14), and closed the door. Staff M then went to room [ROOM NUMBER] (Resident #17, #23). Resident #17 was in the bathroom and Staff M knocked on the door to answer the resident's call light. Resident #17 notified Staff M that she was not feeling well. Staff M let Resident #17 know she would notify her nurse. Staff M walked in the hallway toward the plastic zippered area, she unzipped it, and called out to the nurse that Resident #17 needed help. Staff M then touched the computer to chart with the same gloves she was using since she initially entered the COVID unit. In between these rooms in the COVID unit, Staff M did not do hand hygiene, and did not change her gloves in between these residents. When Staff M, NAR was asked about the facility's policy for hand hygiene and proper use of PPE, she was unable to explain the appropriate procedure, and stated that she was new to the facility. Then Staff M performed hand hygiene using the sanitizer on her gloved hands, removed her gown and disposed it in the hallway in the COVID unit, and then put on another pair of gloves to her already gloved hands, but she did not do hand hygiene prior to double gloving/putting on a new pair of gloves. During an interview on [DATE] at 3:27 PM, the DNS stated that staff were not expected to change their gown in between residents in the COVID unit unless their gown was soiled after resident care but staff should perform hand hygiene prior to entering the resident's room, put on a clean pair of gloves, and assist the resident. When done providing care, staff should remove their soiled gloves, and perform hand hygiene prior to leaving the resident's room. The DNS also stated that even if the staff was not providing direct care, performing hand hygiene and putting on a new pair of gloves was necessary because staff were touching the residents' call lights, doors, and personal belongings in their rooms. EMPLOYEE/STAFF SCREENING Review of the facility's policy on Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures for Screening, revised on [DATE], showed, Anyone entering the facility (including staff) is screened and triaged for s/s of and exposure to others with [DIAGNOSES REDACTED]-COV-2 infection. Review of the [DATE] and [DATE] Screening sheets showed the following staff/visiting staff did not fill out the s/s screening question, Have you had any respiratory symptoms such as difficulty breathing, sore throat, cough, congestion, nausea, vomiting, diarrhea, chills, fever, shortness of breath, muscle aches, malaise, change in ability to taste or smell, runny nose - Yes/No: [DATE] Staff FF, Occupational Therapy Registered [DATE] Staff N, LPN [DATE] Staff O, Dietary Aide [DATE] Staff P, NAC [DATE] Staff Q, NAC [DATE] DNS [DATE] Staff R, Laboratory [DATE] Staff S, NAR [DATE] Staff I, RN, RCM [DATE] Staff T, NAC Undated screening for Staff G, NAC [DATE] Staff U, NAC [DATE] Staff C, MR [DATE] Staff V, Housekeeping (HK) [DATE] Staff W, LPN [DATE] Staff I, RN, RCM [DATE] Staff X, Unknown Staff/Visitor [DATE] Staff M, NAR [DATE] Staff V, HK [DATE] Administrator [DATE] Staff Y, NAC [DATE] Staff Z, RN [DATE], [DATE], and [DATE], there were three unrecognizable names/staff that did not fill out the s/s. During an interview and joint record review on [DATE] at 10:44 AM, with Staff C, MR, stated that she was unable to read two of those names that entered the facility on [DATE] and [DATE], and for [DATE], Staff C did not recognize the third name of the staff/visitor that day. Staff C stated that employees were expected to fill out the screening questionnaire for s/s and if they were sick or not feeling well they should not be allowed to come to the facility. Staff C also stated they were notified about the screening, but she had not seen the policy, and was unsure about it. During an interview on [DATE] at 4: 29 PM, Staff I, RN, RCM, stated that staff should be screened for s/s, and employees needed to fill out the screening questions before coming in the facility. STAFF EDUCATION In interview on [DATE] at 1:15 PM, the DNS was asked how she conveyed updates on COVID-19 and infection control education to all staff. The DNS showed a training log sign in sheet dated [DATE], the program content of the training showed, Will consist of reinforcement of current policies & procedures, proper documentation expectations of professionalism, COVID-19 updates, & upcoming visitations. However, the objectives written on the program content had no clear and direct information regarding COVID-19 updates. In addition, there were no NAC attendees, and that was one of the two written copies of an inservice provided by the facility regarding COVID-19 updates during that day's onsite visit. On [DATE] at 10:46 AM, the Administrator and the DNS were sent an email request to provide any additional staff education or inservices regarding infection control including standard, contact, transmission-based precautions (TBP), and any COVID-19 updates from [DATE] to [DATE]. The facility then provided a copy of the [DATE] staff training/education. On [DATE] at 9:04 AM, the Administrator provided a copy of staff education, dated [DATE], for hand washing, donning and doffing PPE. Review of the facility's documented sign-in sheet for staff education showed no other inservices were done except the ones that the facility provided for [DATE] and [DATE]. During an interview on [DATE] at 11:15 AM, Staff J, RN, CNO, stated the facility had no set schedule for staff inservices/education, however, education should be on going all the time, a few times a month, especially during the COVID-19 pandemic. Staff J also stated that annual training should be happening. Staff J was informed there were only two staff trainings provided by the facility ([DATE], [DATE]). Staff J stated she would check for their staff education records from previous months and resend staff trainings. However, no other records of training/staff education was provided. ON ISOLATION WITHOUT SIGNAGE Review of the facility's policy on Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures under PPE revised on [DATE] showed, Signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (e.g. outside of a resident's room, wing, or facility wide). An observation and interview on [DATE] at 2:05 PM showed Resident #21 had an isolation cart outside of his room (room [ROOM NUMBER]), but there was no signage of the type of transmission-based precaution, and/or no signage of what type of PPE should be used when entering the room. An observation of the isolation cart showed a gown on top of the cart, an abdominal pad in drawer #1, garbage bags in drawer #2, and red bags in drawer #3. The DNS stated that normally they would have gowns, gloves, and eye protection in isolation carts. The DNS showed gloves were available in rooms and resting on a rail in the SW hallway (a non-COVID unit). The DNS was asked why the resident was on isolation as there was no signage on Resident #21's door. The DNS stated she was unsure why the resident was on isolation. Staff AA, NAC, then was asked why there was an isolation cart by Resident #21's room, Staff AA then stated that she did not know why, and would ask another staff about it. Staff AA called for another staff, and Staff DD, Restorative Aide, NAC, stated that Resident #21 was on droplet precautions because his roommate was positive and that he had been exposed. Review of COVID test result for Resident #21 on [DATE] showed positive for COVID-19. Review of the progress notes, dated [DATE] at 1:48 PM, showed the physician/nurse practitioner documentation that a nurse from the facility called to notify them that day that Resident #21 was found without a pulse at approximately 12:30 PM, and that CPR (cardiopulmonary resuscitation) was performed but he was declared death at 12:49 PM. During an interview on [DATE] at 4:01 PM, the Administrator confirmed that Resident #21 was one of the residents who passed away at the facility due to COVID-19 infection. RESPIRATORY PROGRAM and N95 FIT TESTING Review of the County DOH recommendations for COVID-19 Outbreak Guidance and Resources, dated [DATE] at 12:01 PM, showed the DOH provided the facility with strategies and recommendations for the COVID-19 outbreak, which included initiation of N95 fit testing as part of the facility's CMS (Center for Medicare Medicaid Services)-required respiratory program. Review of the facility's policy on Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures under Optimizing the Supply of PPE, dated [DATE], showed, Using N95 respirators only for HCP who need protection from both airborne and fluid hazards (e.g. splashes, sprays). If needed but unavailable, using face shield over standard N95 respirator. Providing training and assessing competency of staff utilizing PPE. Optimization strategies for training and fit testing N95 Respirators includes: Training HCP (Health Care Personnel) on indications and proper use of N95 respirators (fit, donning and doffing). Implementing just-in-time fit testing planning large scale evaluation, training, and fit testing of employees when necessary during a pandemic. During an interview on [DATE] at 1:15 PM, the DNS was asked to show their written respiratory protection program document, and was asked who was responsible for oversight of the program at the facility, the DNS stated, I don't know, not heard it called that. Review of the facility's policy and DOH's recommendations during the facility's COVID-19 outbreak did not show any indication that a respiratory program and fit testing of N95 respirators/masks for staff were initiated as of [DATE]. GENERAL AND STANDARD PRECAUTION FOR CLEANING/DISINFECTION Review of the facility's signage on Aerosol Precautions - for use with Novel respiratory viruses COVID-19 revised on [DATE], showed to use patient dedicated or disposable equipment and to clean and disinfect shared equipment including intravenous pumps, cell phone or pagers (if used in room), and other electronics, supplies, and other equipment prior to removing from patient's room. An observation and interview on [DATE] at 2:30 PM, with Staff BB, District Housekeeping (HK) Manager, showed Staff BB come out of the COVID unit and dispose her soiled gloves and gown while inside the plastic zippered area; however, there was no hand hygiene station/hand sanitizer inside the plastic zippered area. Staff BB brought with her from the COVID unit a spray bottle (Oxiver disinfectant), and a clear plastic bag with rags in it. Staff BB put the spray bottle and the plastic bag with rags in it on the floor so she could do hand hygiene using the hand sanitizer that was on the wall close to room [ROOM NUMBER] (a non-COVID unit/room). Staff BB then picked up the spray bottle and the bag of rags from the floor, and stated she would discard the bag because it was from the COVID unit, and would take the spray bottle to the office. A joint observation and interview on [DATE] at 2:35 PM, with the Administrator and DNS showed Staff CC, HK, coming out of the COVID unit with her yellow housekeeping cart. The cart had rags, mops, rolls of clear plastic bags, etc. Staff CC pushed the cart into the non-COVID unit by Rooms 27, 28 and 30 (a non-COVID unit/rooms). The Administrator then informed Staff CC that her yellow HK cart had to stay in the COVID unit, and Staff CC then pulled/pushed her cart back into the COVID unit. The DNS stated the COVID unit on the NW Hall with the zippered area had just very recently been put up, and they had not had a chance to train the staff yet on how to keep the COVID unit and the non-COVID unit supplies separate. INFECTION CONTROL SURVEILLANCE Review of the facility's policy on Surveillance for Infections revised on [DATE], showed, The Infection Preventionist will conduct ongoing surveillance for Healthcare Associated Infections (HAIs) and other epidemiologically significant infections (e.g. COVID-19, MDRO, UTI (Urinary Tract Infection-bladder infection), etc.) that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Facility records for infection (line list) surveillance was requested from the facility on [DATE] at 10:08 AM and on [DATE] at 10:32 AM. Review of the infection surveillance list for [DATE] to [DATE] showed tracking of infections was logged, but did not specifically show management of potentially infectious disease (COVID-19, MDRO, UTI, etc.) (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure residents were free from mental, physical, verbal abuse and/or neglect for four of four residents (14, 18, 75, 27). This failure resulted in verbal and emotional harm to Resident 14, neglect to provide timely care for Resident 27, and placed Residents 18, 75 at risk for mental/emotional compromise with diminished quality of life. Findings included . Review of the facility policy titled Prevention and Reporting: Resident Mistreatment, neglect, abuse including injuries of unknown source. The policy defined Abuse as the following: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or mental anguish. It also listed abuse as mental, physical, sexual, mistreatment, neglect, exploitation (manipulation, intimidation, threat or coercion). The policy also stated the resident's had the right to be free from abuse and neglect. It also stated all alleged violations should be reported immediately. The policy stated the center should provide for the immediate safety of the resident upon identification for potential abuse, neglect and mistreatment. RESIDENT 14 The resident admitted to the facility on [DATE] and was able to make her needs known. In a joint interview with Staff K, Medical Records on 09/06/19 at 3:49 PM, Resident 14 stated that she was told by the Administrator to not to tell (surveyors) that the facility was running short of supplies. During the interview, the resident appeared very upset (almost crying) and stated, It was killing me to have this knowledge. Staff 14 stated that she felt she had a responsibility to the other residents to report the lack of supplies, and feared retaliation from the Administrator. At 4:02 PM, the Regional Clinical Nurse was notified of the allegations made by Resident 14 about the Administrator. The regional clinical nurse stated that she would need to talk to her corporate people and get an investigation started. The regional Clinical Nurse stated a short time later that an investigation into the allegations about the Administrator was underway and said that the Administrator not in the building pending the results of the investigation. In a follow-up interview with Resident 14 at 4:46 PM, the resident was notified that her allegations had been reported. The resident broke down in tears stating, I have never been bullied like that before, and stated that now she felt safe to speak about all of her concerns without fear. RESIDENT 18 The resident admitted to the facility on [DATE] and was able to make her needs well known. During an interview on 09/10/19 at 12:11 PM, Resident 18 stated that the facility Administrator had threatened her. When asked how or why she felt threatened, the resident stated that the administrator had demanded that the resident write a check for money owed to the facility. During an interview on 09/10/19 at 2:02 PM, the Regional Executive Director was notified regarding Resident 18's allegations about the Administrator and the Regional Director stated that he would get an investigation started. Review of the facility investigation showed the resident expressed feeling bullied by the administrator. The investigation also showed the Administrator had gone to the resident four different times demanding money and had told Resident 18, I will evict you if you don't write me a check. I need you to write a check immediately. RESIDENT 75 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was able to make her needs known. However had very limited speech. Review of the resident's care plan initiated on 07/24/19 showed she was a one person assist for activities of daily living (ADL's). In an interview on 09/03/19 at 1:46 PM, the resident's family stated that Staff L, Certified Nursing Assistant (CNA) had been physically rough with her mother. The family member stated that her mother was 92, moved slowly and required a lot of patience and witnessed the incident. The family member stated that recently Staff L was transferring her mother from bed to chair. During the transfer, this CNA was impatient with her mother, as the family member watched the CNA picked up the resident's left leg with the surgical wound, shoved the left leg in to the wheelchair which caused pain to the resident. The family member then yelled at the CNA to be more gentle. She also stated that she had been texting the administrator regarding this CNA's behavior for at least 2 weeks regarding the alleged rough handling. The family member stated that the Administrator responded to her texts stating she would look into Staff L's abusive behavior. In a interview on 09/03/19 at 4:25 PM, the Administrator was notified about the allegations made by resident family member regarding Staff L's aggressive behavior towards Resident 75. The Administrator stated that she would start an investigation to look into the allegations right away. The administrator stated that she had no prior knowledge of the allegation, then stated, This is the first time I'm hearing of this and I'll call it in right away. The family member provided copies of her text messages to the Administrator with the Administrator's text responses for review. The texts messages showed the family member was at the bedside during and witnessed the incident had initially reported the alleged incident of Staff L's rough handling through texts to the Administrator on 08/31/19 with the Administrator texting back to the family member she would address and look into the matter. Further review of the text messages showed the family member had been in communication with the Administrator about Staff L's aggressive behavior for at least two weeks prior to the incident on 08/31/19. The texts messages showed the Administrator had prior knowledge of Staff L's rough handling, failed to report the incident and initiate an investigation. Review of the facility's incident log for (MONTH) 2019 to (MONTH) 3rd 2019 showed there were no allegations or incidents documented and no investigations regarding Resident 75 initiated during this period. Review of the facility staffing sheets for the month of (MONTH) showed Staff L had been assigned to provide direct care to Resident 75 on multiple days after the text messages were initiated by the family member. RESIDENT 27 Resident 27 was a long term care resident at the facility. The resident's [DIAGNOSES REDACTED]. According to the 06/27/19 quarterly Minimum Data Set, Resident 27 was cognitively intact, able to make her needs known, and required extensive two-person physical assistance for activities of daily living including toileting. A review of the toileting care plan dated, 09/27/18, stated alteration in bowel elimination r/t (related to) [MEDICAL CONDITIONS], adverse effects from medications, chronic diarrhea/constipation. The goal of the toileting care plan; resident will not develop skin breakdown related to incontinence. The care plan also identified the resident's was at risk for a pressure ulcer related to limited mobility. The care plan instructed staff to monitor, document, and report to the doctor any changes in skin status. In a review of the resident's skin sheet dated 07/15/19 showed no skin issues. The Medication Administration Record [REDACTED]. An observation on 09/04/19 at 1:45 PM showed the resident's call light was on in the hallway. Upon entering the room, Resident 27 stated that she had diarrhea and needed to be changed. Staff F, nursing assistant/NA entered the room approximately three minutes later. The resident requested that Staff F change her brief and reported she had diarrhea. Staff F stated that she had to find another NA to assist her due to the resident needing two person extensive assistance with toileting. Before Staff F left the resident's room, the resident agreed to have a state nurse be present during the brief change for a skin observation. Staff F turned off the resident's call light and went to find a second NA to assist. In an interview at 2:10 PM, approximately 25 minutes after answering the resident's call light, Staff F stated she was still unable to find any staff to assist with changing the resident's brief. The resident's call light was not turned back on. Staff F stated that she had changed the resident 30 minutes before she turned her light on at 1:45 PM. Staff F also stated the resident's skin was checked yesterday and that no skin issues were noted. Staff F then left the facility. Then at 2:30 PM, the resident turned her call light back on, and at 2:34 PM Staff G, RN, answered the call light. Staff G entered the resident's room, turned off the call light, and told the resident she would find someone to help her. Staff G then left the room, went down the hallway and back to the nurses station. An observation at a 2:50 PM; approximately one hour after the resident first requested assistance, showed Staff H, NA, enter the resident's room and start changing the resident's diarrhea-filled brief (alone). The resident's skin on her buttocks had unblanchable, beefy redness that covered both buttocks There were at least four red, moist areas on both buttocks that were macerated and open. The resident's coccyx also had an approximately 1.5 centimeter circular open area. Staff H stated, Those were not there a few days ago. During a joint observation of the resident's buttocks at 3:00 PM, the Director of Nursing Services (DNS) stated that the resident had a Stage II pressure ulcer and maceration on both her buttocks with open areas. The resident complained of pain and stated she had a pain level of 7. In an interview on 09/04/19 at 5:12 PM, the Administrator and the DNS were notified of the observations of staff neglecting to provide timely services to the resident in that the resident sat in a diarrhea-filled brief for over one hour, and had new skin breakdown (redness and open areas) on the buttocks with a Stage II pressure ulcer with pain at a level of 7. Reference (WAC) 388-97-0640 (1)

Based on observation, interview and record review, the facility failed to provide the necessary supervision for one of three residents (#1) who required 1:1 direct supervision per the resident's care plan. Failure to follow the plan of care and ensure adequate staffing for 1:1 supervision resulted in avoidable falls with harm for Resident 1. Findings include . RESIDENT 1 Resident 1 was a resident of the facility since (YEAR) with [DIAGNOSES REDACTED]. Resident 1's care plan, dated 5/2/19, showed that she required 1:1 supervision (of one resident by one staff) during the day and evening shift, and was to be on 30 minute checks at night time. The goal for the Plan of Care (P[NAME]) Problem for agitation, dated 06/24/2019, was to maintain safety with Resident 1's activities of daily living (ADLs), she will not cause injury to herself or others, and that she would remain on 24 hour 1:1 with staff for safety. The P[NAME] showed that Resident 1 was on 1:1 supervised care due to her behavior. A 07/05/19 nursing progress note showed that at around 9:45 AM, Resident 1 was calm and pleasant watching TV by the west nursing station under close supervision by nursing staff. The note showed Resident 1 slipped from her wheelchair to the floor and sustained an injury to her head (scratch). The plan of care was to continue with 1:1 supervision. Review of the facility's incident report for the fall, dated 07/05/19 at 1:39 PM, showed Resident 1 was under close supervision by nursing staff when she slipped from her wheelchair to the floor. The investigative report showed the main cause of the fall was Resident 1's significant dementia and that she had forgotten to lock her wheelchair brakes before she attempted to get up. The report showed Resident 1 had poor safety awareness and poor decision making. The plan to prevent reoccurrence was to make sure the wheelchair was locked when Resident 1 attempted to get up and to continue 1:1 care during both day and evening shifts. During an interview on 7/19/19 at 9:40 AM with Resident Care Manager (RCM A), a registered nurse, regarding Resident 1's fall out of the wheelchair on 07/05/19, RCM A stated that Resident 1 had been left unattended (no direct 1:1 supervision) when she got up and fell , sustaining a scratch to her forehead. Review of the actual staffing assignment for 07/5/19 with RCM A showed that there was no assigned staff to provide the 1:1 for Resident 1. RCM A stated that Resident 1's P[NAME] was not followed due to rearrangement of nursing assistant staff. RCM A stated that on 7/5/19 the NAC assisgned to provide 1:1 was removed from doing 1:1 for Resident 1 and put on Section 7 (west nursing unit) due to short staffing. RCM A stated that Resident 1's plan of care for direct 1:1 supervision was not done that shift, only visual 15 minute checks, which resulted in an avoidable fall with injury. Resident 1 had another fall on 07/14/19. A nursing note entry, dated 07/15/19 at 03:36 AM, showed a nursing assistant (NAC) had witnessed Resident 1's fall. The NAC witness statement showed that Resident 1 was outside when she lost her balance, fell on to the cement surface in the parking lot, and sustained skin tears on both palms of her hands. Resident 1 was provided Tylenol for pain. The facility investigative report for the 07/14/19 fall showed Resident 1 fell outside the facility in the parking lot and that an NAC was with the resident at the time of the fall. The report showed Resident 1 had lost her balance, fell on her left outstretched hand, and then onto her left hip. The NAC's written statement dated 7/14/2019 showed that Resident 1 lost her balance and fell on to her left side. The NAC, who had been assigned to provide 1:1 direct supervision of Resident 1 to ensure safety, did not write whether the resident was wearing a gait belt at the time of the fall. There was no documented information regarding the proximity of the the NAC to the resident when the resident fell or whether the NAC was holding the gaitbelt to help stabilize the resident while ambulating (prior to the fall). In addition, the investigation did not indicate whether the resident had exhibited any behaviors prior to the fall. A nursing progress note, dated 07/15/19, showed that Resident 1 guarded her left hip and stated ouch ouch when staff attempted to reposition her legs. Pain medication was administered and the physician was notified. The physician's note, dated 07/15/19, showed Resident 1 had experienced pain when being turned and was drowsy. A hip x-ray was obtained and showed a fracture to her left hip. The resident was sent to the hospital for further evaluation. A nursing note, dated 07/19/19, showed that Resident 1 was readmitted to the facility after surgical repair of the left hip. An observation on 7/19/2019 at 10:05 AM. showed Resident 1 in bed with oxygen in place. Resident 1 appeared groggy and did not response to verbal attempts to converse. Reference (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to consistently assess and implement timely pressure relief for one of three residents (Resident 3) with pressure sores. Failure to implement interventions for Resident 3 who was dependent on staff with risk factors for skin breakdown resulted in deterioration in skin condition and the developement of avoidable pressure ulcers. Findings include . A Stage 2 pressure ulcer- Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer and an unstagable pressure ulcer - Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. RESIDENT 3 Resident #3 was admitted to the facility on [DATE] with diagnosie of URI (upper respiratory infection), stroke with [MEDICAL CONDITION], and [MEDICAL CONDITION]. Resident 3 had three drainage devices. A urinary drainage device (nephrostomy tube), a urinary catheter and a drainage collection device (JP) to collect drainage from aspiration of a renal (kidney) abscess. Other [DIAGNOSES REDACTED]. The hospital discharge note dated 06/05/19 showed that Resident 3 had no skin breakdown, but was at risk for skin breakdown and had a dressing on the coccyx area for skin protection. The note showed Resident #3 had a nephrostomy tube (urine drainage device) and a JP drain for drainage collection from the abscess site. The admit skin assessment dated [DATE] showed that Resident 3 had excoriation on sacrum that measured 3 centimeter (cm) by 3 cm in size and had a urinary drainage catheter (foley), a nephrostomy (kidney) drainage tube and an JP drain tube in place from his kidney abcess. The nursing assessment under skin intergrity dated 06/05/19 showed Resident #3 has potential for a pressure ulcer, and that the goal was that pressure ulcer would show signs of healing and remain free from infection. No other interventions were checked off on the nursing assessment. The care plan for potential pressure ulcers related to catheter tubing, incontinence (bowel) and immobility dated 06/05/19 showed that 2 staff were to reposition Resident #3 at least every 2 hours. The admit Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #3 required two person assistance with bed mobility and toileting, was incontinent of stool (bowel), and had a urinary catheter and nephrostomy (kidney drainage bag). The MDS indicated Resident 3 was at risk for skin breakdown, had impairment of one side of his body, and was on a turning program. The next MDS (PPS) dated 06/22/19 showed that Resident #3 still required maximum assistance of 2 staff for bed positioning and toileting. The MDS showed that there were two new pressure ulcers: one Stage 2 and one unstagable ulcer. The next facility skin assessment form, dated 6/14/19, showed Resident #3 had four areas with excoriation (exc): - excoriation of the scrotum which was 1 centimeter (cm) by 1 cm in size, a 10 cm by 10 cm red area on left buttock with peeling skin, and the buttocks with two areas of excoriation, one that area measured 5 cm by 5 cm in size and another 2 cm by 1.5 cm in size. The Treatment Administration Record (TAR) for (MONTH) 2019 showed that there was no documentation regarding turning the resident every two hours or not using incontinent brief on Resident 3 until 06/16/2019. The TAR showed that Licensed Nurses (LN) were to ensure barrier cream was to be applied to prevent skin breakdown. The nursing progress notes from 06/05/19 to 06/12/19 showed there was excoriation on sacrum (06/08/19) and no skin impairment (06/12/19). A facility investigative report dated 06/14/19 was completed related to the new skin issues. The immediate action taken due to the skin breakdown was to educate the nursing assistants (NACs) regarding the importance of frequently repositioning Resident #3 who was at risk for skin breakdown and was dependent on staff for repositioning in bed. During an interview on 08/02/2019 at 4:30 PM, the MDS nurse stated Resident #3 developed pressure ulcers during his stay. The initial MDS showed no pressure areas, whereas the MDS dated [DATE] showed there were 2 pressure sores, a Stage 2 and one unstagable pressure ulcer. The MDS nurse stated there was no additional documentation to describe the pressure ulcers and the skin sheet assessment dated [DATE] showed excoriation of Resident 3's skin. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A nursing progress note entry, dated 06/25/19, showed Resident 3 was going out to a physician's appointment. The note showed that there was no new skin impairment. However, the last completed skin assessment form was on 06/14/19. There was no documented assessment of skin issues prior to going to physician visit (infectious disease-ID). The ID physician sent Resident 3 to the emergency room during the visit (06/25/19) due to his wounds (pressure ulcers) and elevation in temperature. The emergency room (ER) note, dated 06/25/29, showed Resident 3 had a sacral pressure ulcer and documented that when Resident 3 had been initially transferred to the nursing home on 06/05/19 without pressure ulcers. The hospital note, dated 06/25/19, showed Resident 3 was assessed to have a large sacral pressure ulcer and the wound base contained eschar (dead tissue): An unstageable sacral pressure ulcer measured 10 centimeters (cm) by 5 cm in size with black eschar and the surrounding border had yellow slough (dead tissue) and denuded skin. Bleeding was noted around edges of this pressure ulcer. Another pressure ulcer was noted on the resident's right sacral region and measured 3 cm by 2 cm in size and had drainage. The note documented that when wound care/treatment was performed, the resident exhibited pain (grimacing when the wounds were cleaned). The Treatment Administration Record for (MONTH) 2019 showed starting on 6/8/19, LNs were checking the dressing on the sacrum every shift for excoriation and a dressing application was started on 6/20/19. Lack of timely documented interventions for pressure relieve for Resident 3 who was dependent on staff resulted in an avoidable pressure ulcer with need for hositalization due to concern of an infected pressure ulcer. Reference WAC 388-97-1060 (3) (b)

Based on interview and record review, the facility failed to assess incision sites and follow physician's post-operative orders to promote incision healing and prevent possible complications for one of two residents (#1). Failure to consistently provide the necessary physician-ordered care, such as daily showers, resulted in harm for Resident 1 in that he required emergent drainage of the wound and hospitalization . Findings included . RESIDENT 1 Resident 1 was admitted to the facility on [DATE] following heart surgery, a Coronary bypass Graft (CABG). Resident 1 had two graft harvest (blood vessels used to create the bypass) sites, one on his left arm and the other on his left thigh (groin). The nursing admission assessment initiated on 12/4/18 and completed on 12/10/18 showed that Resident 1 had skin integrity concerns due to his multiple surgical incisions post(after) CABG. The nursing goal was that the incisions would heal and be free from infection. The nursing interventions included an assessment of the incision surgical wounds to include the status of the wound's surrounding area (perimeter), the wound bed, and healing progress, and to record and monitor wound healing weekly and PRN (as needed). The initial care plan was to monitor, document, and report to the physician any signs and symptoms of infection: increased drainage, foul odor redness and swelling, red lines coming from the wound, excessive pain, fever. The initial nursing assessment and interventions were signed as completed on 12/10/18. The admission skin assessment dated [DATE] showed that Resident 1 had six surgical incision sites: -Two chest incisions, one on the mid-sternal(breastbone) area that measured 24 centimeters (cm) in length, and another 5 cm surgical incision at the bottom of the mid-sternal incision area. -A 19 cm harvest surgical site on the left lower arm. -Three harvest sites on his left upper thigh: one measured 2 cm, second site 4 cm and the third site measured 3 cm in size. The admission skin assessment showed that Resident 1 had bruises on the front and back of his left thigh. The admit physician orders [REDACTED]. A nursing progress note entry dated 12/5/18 identified that Resident 1 had only three surgical incisions from his CABG. One incision was on his left forearm and measured 20 cm by 0.1 cm. The area was described as intact without drainage or sign or symptoms (s/s) of infection. The other incisions included the two sternal incisions; mid line chest that measured 22 cm by 0.1 cm. and another incision that was below the midline surgical incision to the chest and measured 0.1 by 6 cm. Both incisions were without any sign of infection. The nursing note showed no other skin issues (left upper thigh), and that nursing would continue to monitor surgical incisions every shift and continue to monitor for any new skin issues. A physician's note dated 12/5/18 showed that Resident 1 had a mid-chest incision that was healing well and had no signs of infection. The nursing plan was to provide wound care. The Treatment Administration Record (TAR) for (MONTH) (YEAR) showed that the Licensed nurses (LN) were monitoring the resident's left arm and left groin (thigh) for signs and symptoms of infection and the bruising on the back of thigh. Additionally, the TAR showed that wound/incision care included a shower daily. Review of the bath/shower report from 12/4/18 to 12/13/18 showed that Resident 1 only received a shower on three days (12/6, 12/10 and 12/13/18). During an interview and review of shower documentation records on 3/14/19 at 12:20 PM, with the Resident Care Manager (RCM A) regarding showers for Resident 1, she stated that the shower aides were the only staff who provided showers for Resident 1, and not the LNs. RCM A stated Resident 1 received only three showers, even though the physician had ordered daily showers to ensure the surgical incision areas were cleansed. During an interview on 3/14/19 at 3:14 PM Licensed Nurse (LN A), a Registered Nurse, stated Resident 1 had weekly skin assessments performed by RCM A, and that shower aides were the only staff who provided resident showers. During an interview on 3/14/19 at 3:28 PM, LN B, a Registered Nurse, stated that the unit had a shower aide who gave showers to the residents. The shower aide was to document the showers on the bath chart. LN B stated that the LNs did not shower residents. The next physician's visit note dated 12/10/18 showed that Resident 1's the mid-sternal (chest) incision was clean and dry; the left forearm incision had minimal [DIAGNOSES REDACTED] (redness), no drainage, dry and was intact; and that the incision on the medial left thigh shows some bruising hematoma incision C/D/I (clean, dry and intact). The care conference dated 12/12/18 showed that Resident 1's three surgical incisions were being monitored every shift for signs of infection and were healing well. The physician then saw Resident 1 the next day (12/13/18). The physician's note dated 12/13/18 showed that she was seeing Resident 1 due to redness and swelling on the left medial thigh for two days per nurse, and complaints of tenderness at incision site. The left groin/thigh site was noticed to be red with swelling, and the incision in left oozing pus, increased [DIAGNOSES REDACTED] proximal to incision, when I press more pus exudes from groin incision. The TAR showed no documented evidence that Resident 1's weekly skin assessment had been completed on 12/11/18 even though a LN informed the physician of redness and swelling in surgical area on the thigh. On 3/14/19 at 12:20 PM, RCM A stated there was no documented assessment or plan of care for Resident 1's surgical incisions. Resident 1 was transferred to the hospital on [DATE] for evaluation of the left groin area with redness and drainage of pus. The hospital's admit note dated 12/13/18 showed that Resident 1 had left medial thigh [MEDICAL CONDITION] (bacterial skin infection) at the CABG vein graft harvest site. The site had induration (a raised, hardened area) and redness. The Hospital's history and physical dated 12/13/18 showed that Resident 1's left thigh (graft site) had redness, swelling and discharge for three days prior to hospital transfer. [DIAGNOSES REDACTED]. The note showed that incision and drainage of pus was performed, and the resident required intravenous antibiotics. During an interview on 3/4/19 at 3:34 PM, Resident 1's family member stated that when the resident was admitted to the nursing home on 12/4/18, the physician and surgeon's discharge instruction was to have the surgical sites monitored and to make sure that Resident 1 received a daily shower. The family member stated Resident 1 did not receive daily showers. The family member stated that after Resident 1's shower on 12/13/18, the resident stated his leg hurt and there was pus and blood in the bed. The family member stated the nursing home physician saw the resident the same day, and Resident 1 was sent to the hospital because he had developed an abscess in the groin area. Reference : WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to provide adequate pain management for one of three residents (#3) reviewed for pain management. Failure to provide adequate pain management resulted in Resident 3 experiencing uncontrolled pain. Findings included The facility's pain management program dated (YEAR) stated that pain refers to any type of physical pain or discomfort in any part of the body. The pain management treatment goal is to decrease a resident's pain. RESIDENT 3 Resident 3 was admitted on [DATE] for rehabilitation following a pelvic fracture. The admit pain assessment dated [DATE] showed that Resident 3 had an order for [REDACTED]. The assessment noted that the resident wanted her pain managed by the use of pain medication. The nursing progress notes dated 3/14/19 and 3/15/19 showed that Resident 3 had requested her narcotic pain medication be administered prior to skilled therapy sessions (Physical Therapy, Occupational Therapy). The physician's visit on 3/15/19 showed that Resident 3 was alert, and that nursing was to monitor the resident's pain level. Other pain medications were ordered, such as Tylenol and [MEDICATION NAME], in addition to the [MEDICATION NAME]. On 3/20/19 at 9:43 AM, Resident 3 was observed in bed rubbing her groin and thigh area. The resident stated she was experiencing excruciating pain. She stated her pain was a 10 /10 (on a 0 (no pain) to 10 (worst pain) scale). When asked if the Licensed Nurse (LN) had given her any pain medication, she stated that she had requested a dose of her narcotic pain medication, prior to having a shower with skilled therapy (OT), as she was having horrible pain in her pelvic area. However, Resident 3 stated that LN C told her the narcotic medication was not available because it had run out. Resident 3 stated she did have the shower with therapy, but was in such pain during the shower. During interviews on 3/20/19 at 9:55 AM with Resident 3's medication nurse (LN C) and shower staff (Therapy Assistant-TA), LN C stated he had administered only the routine Tylenol for her sharp hip pain as there was no [MEDICATION NAME] available in the medication cart. LN C stated Resident 3 had informed him that the Tylenol did not do any good. Staff TA stated that when she took Resident 3 to the shower, the resident was having pelvic pain and that LN C gave the resident some Tylenol. During an interview on 3/20/19 at 10:22 AM, LN C stated that he had informed Resident 3 that there was no narcotic pain medication available for her pain. LN C stated Resident 3 described her pain as sharp in the left hip area and that the resident rated her pain as a 6 on a 0 to 10 pain scale (0-no pain and 10 worse pain). LN C stated no request for her narcotic medication ([MEDICATION NAME]) had been made to the pharmacy, therefore the resident's prescribed pain medication was not available to administered prior to her shower with OT. In another interview on 3/20/19 at 1:10 PM, Staff TA was asked about Resident 3's shower time and pain. The TA stated Resident 3 had pain before the shower, and the shower took some time to do as Staff TA had to help the resident because the resident said the Tylenol didn't work for her. The (MONTH) 2019 Medication Administration Record (MAR) showed that Resident 3 experienced pain during the night shift (3/19-3/20/19). The pain was documented as being an 8. There was no documented evidence that the [MEDICATION NAME] pain medication was ordered at this time or whether pain intervention occurred. The MAR and record was reviewed with the Resident Care Manager (RCM B) on 3/20/19 at 9:57 AM. The MAR showed that administration of the [MEDICATION NAME] had last occurred on 3/19/19. The record did not show that Resident 3's narcotic pain medication had been re-ordered. During an interview with RCM A on 3/20/19 at 10:15 AM, RCM A stated that LNs were to assess pain and document the resident's pain level on the MAR. RCM A also stated that if a resident received a PRN (as needed) pain medication, LNs were to follow-up with the resident by one hour after administration to assess the effectiveness of the pain medication, and then document whether pain relief was effective. RCM A stated that when the last dose of narcotic pain medication was administered, the LNs were to obtain an order and send the order to pharmacy to ensure pain management is maintained. Reference WAC 388-97-1060 (1)

Based on interview and record review the facility failed to meet toileting needs for 1 of 2 residents (72) reviewed for bowel and bladder. This failure placed the resident at risk for skin breakdown, infection but resulted in psychosocial harm associated with strong feelings of humiliation, positional discomfort from sitting in her feces for very long periods that further compromised the resident's quality of life. Findings included: The resident admitted to the facility in 2014 with a neuro muscular disease that had left her paralyzed in all extremities but had minimal use of her left hand. The resident was fully dependent on staff for toileting and personal hygiene but was able to make her needs known. Review of the resident's Minimum (MDS) data set [DATE] showed the resident was a total dependent, 2 person physical assist for toileting. Review of the facility policy titled Bowel Incontinence effective date (MONTH) (YEAR) stated The center strives to ensure that residents maintain their normal bowel elimination pattern and that residents who are incontinent of bowel receive appropriate treatment and services to restore as much normal bowel function as possible. The policy also stated Management of fecal incontinence was best managed by: 1. Scheduled and consistent toileting 2. Reducing or eliminating contributing factors. Review of the residents care plan dated 12/01/07 identified the resident with an alteration in bowel elimination. Interventions included Check resident every two hours and assist with toileting as needed. The care plan also identified the resident with actual/potential for moisture associated skin damage (MASD) related to bowel incontinence. Review of the Nurses Assistant care plan (Kardex) also stated the same interventions. Review of the Bowel activity flowsheets from 06/17/18 to 07/16/18 showed how often the resident was checked and changed as well as any episodes of bowel elimination. The sheets showed the resident had at least 2 bowel movements daily and some days up to 3 with diarrhea. However, multiple days reviewed showed the resident would have 10 hour periods without bowel care in the presence of fecal incontinence. In an interview on 07/09/18 at 9:28 AM, the resident stated she was bed bound, had pressure ulcers and stated they got worse when she had to sit in her feces. Resident 72 stated the last time she had to sit in her feces was for an hour and stated this happened a lot when they got short staffed. Resident 72 indicated she had told the aides who clean her up she hated sitting in her feces and stated Nothing ever gets better. In an interview on 07/16/18 at 2:42 PM, Staff BB Nurses Assistant (NA) stated the resident was a 2 person extensive assist and took 15-20 minutes to change her. She stated because of the extensive assist there were times when they could not get to the resident. In an interview on 07/16/18 at 2:55 PM, Staff B, Resident Care Manager (RN) was made aware of the resident's concern with sitting in her feces with staff taking a long time to respond. Staff B stated the resident was not care planned for how often staff should have been checking the resident with her paralysis. Staff B stated it should have been care planned for the resident to be checked every 2 hours and he would add it to the care plan for the resident to be checked every 2 hours. In a joint review of the daily bowel flow sheets Staff B was shown where there were multiple days when the resident had a bowel movement but was not checked or changed for up to 6-7 hours on those days reviewed. Staff B also stated the flowsheets reviewed were similar to flowsheets the NA's documented incontinent care. Summary During the initial interview with the surveyor, the resident voiced strong feelings of how much she hated sitting in her feces. Interviews conducted and records reviewed supported the resident's claim that ultimately resulted in psychosocial harm with her stating how much she hated sitting in her feces. The facility failed to follow the facility policy and care plan stated above. The resident's severe functional impairment (paralysis), left her fully dependent on staff for toileting needs that were not being met thus placed the resident at high risk for skin breakdown and infection. Coupled with the psychosocial compromise and the documented long periods of up to 10 hours with no incontinent care, greatly diminished the resident's quality of life. Reference (WAC) 988-97-1060 (3)(c)

Based on observation, interview and record review, the facility failed to consistently provide adequate supervision and implement the plan of care for 1 of 4 sample resident (1) who was known to be impulsive with a history of falls from a wheelchair (WC). Failure to ensure Resident 1 was adequately supervised when a new tilt in space WC was provided resulted in harm for Resident 1 who sustained a fracture. Findings included: RESIDENT 1: Resident 1 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 1 had severe cognitive impairments, impairment of his upper and lower left extremities, had behaviors and required 2 person assistance with transfers. Resident 1 was 6 feet 7 inches and weighed 157 pounds. The nursing progress notes from (MONTH) (YEAR) to (MONTH) (YEAR) showed that Resident 1 frequently attempted to get out of his tilt in space W/C while attempting to transfer himself to a normal chair. He also exhibited agitation, confusion and required 1:1 supervision of the staff due to behaviors and repeated attempts to get out of his WC in order to ensure his safety. The nursing progress notes showed Resident 1 had 2 falls on 04/8/18. The first fall was an unwitnessed fall in his room at 5:50 P.M., and the second fall occurred in the dining room at 6:30 P.M., when he slid from his WC to the floor. The facility's investigative reports for these two falls on 4/8/18 and the timeline documented that at 5:50 P.M., Resident 1 was assessed and brought outside of room for supervision and assistance with his meal. Forty minutes later, the second fall occurred when he slid out of his WC, his knees on ground in front of WC. Even though the facility documented Resident 1 was being provided supervision after the first fall at 5:50 P.M., he was brought to the dining room, and according to the nursing assistant he had attempted to transfer from his WC to a dining chair when the second fall occurred at 6:30 P.M. The third fall in (MONTH) (YEAR) occurred on 04/12/18. The nursing note showed that Resident 1 had a witnessed fall. Resident 1 stated he was trying to transfer himself from WC to a normal chair. The facility's investigation for the fall dated 4/12/18, documented that a visitor had observed Resident 1 falling from his wheelchair in the West TV room. The visitor tried to grab Resident 1 but his body was already down at the floor, and quickly grabbed his WC away from him to avoid him hitting his head on the WC, then she (visitor) made sure that the resident was alright to lay on the floor and she call the nursing assistants (NACs) to assist him. The report revealed Resident 1 stated he was trying to transfer himself into the regular chair. The facility's fall report for 4/12/18, indicated there were no staff who had witnessed the fall, and the contributing factors for Resident 1's fall was due to his poor safety awareness, poor decision making, and his habit of attempting to transfer himself. The plan was to ensure the resident was positioned properly while in the wheelchair to minimize falls. A Social Service (SS) note dated 04/13/18, documented, Resident 1 had a fall the prior afternoon, in the west lounge area, and the WC was partially tilted back when the fall happened. The nursing note dated 04/14/18 revealed Resident 1 was agitated, attempted to hit staff, was trying to get out of the WC and refused to be put to bed. A nursing note entry for 4/15/18, showed that Resident 1 had climbed onto the floor mattress next to his bed, and there was no documented evidence that the concave mattress had been initiated until 4/21/18. The fourth fall occurred on 4/18/18, Resident 1 was observed to self-propel in his tilt in space WC, and slid out of his WC when he attempted to stand on his own. The facility's investigative report for this fall indicated that the fall was due to his attempt to stand by himself, and the plan was to have staff check him every 30 minutes every shift, and PT to evaluate and treat the resident, related to fall out of tilt in space WC. The fifth fall occurred on 4/20/18. The unwitnessed fall occurred in Resident 1's room. The investigative report for the fall documented the resident was found in his room, on the floor and was laying on the tile floor in front of the floor mat. The report indicated the resident was confused, and he stated he hit his head. At this time the resident was placed on a concave mattress. Which was supposed to be implemented, per facility documentation on the facility investigation report dated. 4/8/18. The nursing note dated 04/21/28, documented resident now had concave mattress which was changed this evening and will monitor the resident. The nursing progress notes for 4/25/18, and 4/26/18, revealed that Resident 1 continued to be agitated, and would attempt to get out of his WC. A nursing note entry dated 4/27/18, revealed Resident 1 continued to roll onto the floor mat, and at one point, managed to move into the bathroom, where staff found him (sixth fall). The 4/27/18, the nursing progress notes for days and evening shifts documented Resident 1 attempted to crawl out of WC 4 times, was yelling with increased anxiety, and keeps attempting to get out of WC. On 5/3/18, the progress notes showed that Resident 1 continued to yell, and attempts to get up from bed. The staff provided 1:1 until he fell asleep, then checked on him every 30 minutes. On 5/15/18 the plan was to consider the appropriateness of the tilt in space WC due to Resident 1's repeated attempts to exit his WC by attempting to stand, and climb out of the WC. A PT note dated 05/18/18, showed Resident 1 required extensive assistance due to his confusion and decreased ability to follow commands, and was only alert x 2. The note indicated he was transitioned to standard WC, as he no longer required a tilt in space WC, and has demonstrated good head control when sitting in the Standard WC. The 5/19/18, a nursing note entry revealed at 1:15 P.M., the LN heard a thud. She observed Resident 1 on the floor, lying on his left side. Resident 1 stated he was trying to use his phone. The note documented the standard WC did not have leg rests in place as the NAC forgot to put them on. Resident 1 sustained a hematoma (swelling to left elbow). During the evening shift, the left elbow was still swollen and pain medication was administered. The physician ordered an x-ray which shower a fracture of Resident 1's elbow. In an observation on 05/24/18 at 11:20 A.M., Resident 1 was observed resting in bed. Resident 1's bed was in a low position, the left side of his bed was against the wall and a fall mattress was on the right side of his bed on the floor. A sling was on his left arm. When Resident 1 was asked about his sling and falls, he stated getting up and down from wheelchair, got out of my WC During an interview on 05/24/18 at 11:22 A.M. Staff A, Licensed Practical Nurse (LPN), stated, Resident 1 recently received a standard WC from Physical Therapy (PT). Staff A stated Resident 1 previously was using a tilt in space WC. (A Tilt in Space WC prevents the possibility of a resident from falling forward when in a sitting position with the chair in a tilted/reclined position.) On 5/24/18 at 1:30 P.M., Staff A was asked about the fall from the standard WC on 5/19/18. Staff A stated, Resident 1 had an unwitnessed fall out of the standard WC. She stated at the time of the fall, there was no footrest on the WC. During an interview on 05/24/18 at 2:00 P.M., with Staff B, PT stated Resident 1 was provided a standard WC on 5/18/19. Staff B stated Resident 1 had a history of [REDACTED]. PT stated in regard to the footrests, the use of only the left footrest was be necessary. However, there was no care plan initiated to ensure footrest use. During an interview on 6/4/18 at 12:40 P.M., Social Service, Staff C, stated Resident 1 would remove the arm rests of his WC, and the WC was positioned upright when he ate and adjusted to ensure comfort. Even though the facility had identified Resident 1 required supervision due to his impulsive behaviors of attempting to get out of his WC, when a standard WC was implemented there was no documented evidence in regard to how Resident 1's safety would be addressed when in the new WC on 5/18/18. Reference: (WAC) 388-97- 1060 (3) (g)

Based on interview and record review, the facility failed to thoroughly assess, consistently monitor and maintain skin integrity for 1 of 2 residents (1). Failure to consistently provide incontinent care and/or recognize a significant change in Resident 1's skin condition resulted in deterioration of skin condition with hospitalization and treatment for [REDACTED]. Findings included: The facility's procedure for bowel and Bladder Program updated 1/2017 read: Scheduled check and change program may be appropriate for residents who are unable to use a toilet. This program uses absorbent products to manage urinary incontinence. Residents are to be checked and changed based on accepted standards of practice. The facility's wound prevention and management procedure/policy indicated that weekly skin assessments were to be completed and recorded on the Treatment Administration Record (TAR). Skin impairment was to be monitored daily until healed. The procedure was to assess the skin condition and evaluate the progression of healing by documentation of the wound base, periwound (surrounding) condition, drainage, color, odor on the facility's assessment form. RESIDENT 1 Resident 1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 1 required 2 person assistance with toileting and hygiene, was incontinent of both urine and stool and had no skin issues. Review of Resident 1's care plan dated 08/1/17, showed a problem, actual / potential for moisture associated skin damage bilateral buttocks. The care plan directed staff to observe for signs/symptoms of MASD (inflammation, [DIAGNOSES REDACTED], erosions in skin folds or areas of skin exposed to moisture) and report to physician and nursing. It also directed staff to use barrier cream, after each incontinent episode, or after providing each episode of pericare, due to Resident 1's risk of developing a wound due to moisture and sweatiness. The care plan for alteration in bowel elimination/continence and diarrhea dated 10/24/17, directed staff to check the resident every 2 hours and provide pericare after each incontinent episode. The care plan dated 12/19/17 showed, due to Resident 1's incontinence, of both urine and stool, and with the potential/actual fungal rash to the perineal groin area, nursing was to apply an antifungal powder twice a day. The care plan dated 01/10/18 showed the resident had a history of [REDACTED]. The Care Guide used by the NACs, showed Resident 1 was on a scheduled check and change, every two hours and as needed for incontinence. It also directed staff to check for incontinence, wash, rinse and dry soiled area. A review of the skin risk prediction tool (Braden) dated 01/16/18 showed Resident 1 was constantly moist, had very limited mobility and was chair fast. The Bowel and Bladder assessments dated 01/23/18 revealed she was always incontinent of urine and bowel and that staff would provide a scheduled check and change. A review of the physician's orders [REDACTED]. --Remedy skin repair cream; apply topically to the area every shift. --Vitamin A and D ointment; apply topically to buttocks and sacrum area every shift. --Moist barrier ointment with aloe; apply topically to affected areas of buttock / peri area/thigh twice daily until resolved. -- EPC (ointment) with zinc oxide compounded with antifungal cream; apply to affected area of buttocks / peri area/ thigh twice daily. A review of the nursing progress notes from (MONTH) (YEAR) to (MONTH) (YEAR) showed, that Resident 1 had a history of [REDACTED]. Resident 1's clinical record revealed she had bouts of diarrhea and was receiving antibiotic medication [MEDICATION NAME] due to a history of a [MEDICAL CONDITION] infection (also known, as [DIAGNOSES REDACTED] is a bacterium that causes diarrhea). A physician's orders [REDACTED]. The physician documented that due to Resident 1's recurrent urinary infection, the use of estriol cream may lessen the frequency of the UTIs. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) documented the LNs only performed a skin assessment on 02/02/18 and 02/09/18 indicating there was no skin issues. There was no documented evidence a skin assessment was performed on the week of 02/16/18 or 02/23/18. The MD's assessment and plan dated 3/15/18, documented Resident 1 has history of recurrent urinary tract infections, she was recently started on extrace cream in effort to lessen frequency of recurrent urinary infections (UTIs). Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) documented a skin assessment was completed on 03/02/18. The 03/02/18 weekly skin assessment form documented redness to bilateral buttocks. The 3/10/18 weekly skin assessment form revealed Resident 1 had redness on her left buttock and a rash to the groin area. These skin assessments did not document the size of the redness or whether there was drainage or what were the relating factors for the redness. Review of the TARs for (MONTH) (YEAR) to (MONTH) (YEAR), revealed that LNs were documenting the application of the creams/ointments being applied to Resident 1's buttock every shift. Review of the Medication Administration Records (MARs) for (MONTH) (YEAR) revealed the vaginal cream was administered for only for 2 weeks, 1/13/18 to 1/26/18, and on 1/29/18. Review of the MARs for (MONTH) and (MONTH) (YEAR) revealed that the estriol cream was not administered to Resident 1 per physician's orders [REDACTED].>During an observation and interview on 4/20/18 at 1:40 PM, Resident 1 stated staff only changed her brief twice a day. She stated she was incontinent of urine and at times her diarrhea would be down her legs before the staff changed her. The bowel and bladder report forms from (MONTH) (YEAR) to 3/15/18 showed check and change was not documented as being performed, or documented as being performed for only 1 to 3 times a day for urinary incontinence and/or large bowel incontinence. The Bladder Report for (MONTH) and (MONTH) (YEAR) showed incontinent care was not provided by the NACs per the care plan: February (YEAR) Bladder Report documentation showed incontinent care was as follows: ---There was no documentation for incontinence care being performed on 2/2/18 or 2/16/18. --- Documentation for incontinence care being performed once in a 24 hours period was on 9 of 28 days. --- Documentation for incontinence care being performed twice in a 24 hours period was on 9 of 28 days. During (MONTH) of (YEAR), the bladder report documentation for incontinence care showed: -- Documentation for incontinence care was performed only once in 24 hours on 3/8 and 3/15/18. -- Documentation for incontinence care was performed only twice in 24 hours on 3/2, 3/3, 3/9 and 3/10/18 -- Documentation for incontinence care was performed once a shift on 3/1, 3/4, 3/5, 3/6, 3/7, 3/11, 3/12, 3/13, and 3/14/18. Resident 1 transferred to the hospital, due to an altered mental status, low blood pressure and oxygen saturation level on 3/15/18 and returned to the facility on [DATE] with a urinary catheter to keep the skin dry. The hospital's medical progress note dated 3/15/18 documented Resident 1 was admitted for an urinary tract infection and perinea [MEDICAL CONDITION] (A bacterial skin infection that often shows up as a rash, can spread rapidly, appears as a red, swollen skin rash that feels tender and hot; to prevent recurrent episodes of [MEDICAL CONDITION], keep the skin clean and well-moisturized). The hospital note documented Resident 1 had [MEDICAL CONDITION]/skin breakdown on the buttocks and perineal areas. These skin breakdown/wounds were assessed to be a mixture of MASD/IAD (moisture association skin [MEDICAL CONDITION]/incontinent associated [MEDICAL CONDITION]) and [MEDICAL CONDITION]. The hospital note went on to say the wound was described as a partial thickness wound of [MEDICAL CONDITION] and [MEDICAL CONDITION]. The wound bed was red and inflamed with moderated drainage. The hospital's progress note revealed that a urinary catheter was placed to keep the skin dry. An application of a medicated cream (antifungal) was applied to the buttocks and thigh area. An intravenous antifungal medication was given due to the severe fugal rash of her perineal area. During an interview on 4/20/18 at 2:25 P.M., Staff A, a licensed practical nurse (LPN), stated Resident 1 was unable to tell staff whether she was incontinent and was cognitively impaired. Staff A stated the facility used a protective cream to prevent skin issues and if the skin condition spreads or got worse in a 2 week period, then the LN would notify the physician and obtain an order to treatment the skin issue. During an interview on 4/20/18 at 1:35 P.M., Staff B, a nursing assistant (NAC) stated when a resident was to be checked and changed every 2 hours, the NAC checks the resident's brief and if the resident is soiled (incontinent of urine or stool), the NAC cleans the resident using wipes and then applies an ointment. Staff B stated if any skin breakdown (redness) was noticed the LN is notified. On 4/20/18 at 3:09 PM., Staff C, the Director of Nursing (DNS), confirmed that the MARs for (MONTH) and (MONTH) (YEAR), showed that LNs had not administered the prescribed vaginal cream as ordered by the physician on 1/9/18. Staff C also stated the documentation for the skin assessments in (MONTH) (YEAR), were not located, and the skin assessments performed by LNs on 3/2/18 and 3/10/18 were not thorough. On 4/25/18 at 8:52 A.M., Resident 1's bladder and bowel reporting sheets for (MONTH) and (MONTH) (YEAR) were reviewed with Staff C, the Director of Nursing. Staff C stated the documentation revealed incontinent care was not provided as directed on the care plan. Review of Resident 1's clinical record showed that even though Resident 1 was receiving various medicated ointments to the buttocks/groin area on all shifts, there was no documented evidence the LNs had thoroughly assessed or monitored the skin condition that deteriorated into cellulites requiring hospitalization , intravenous antibiotics, and placement of a urinary catheter. Not documenting the provision of incontinent care and treatment per plan of care resulted in recurrent urinary tract infections and decreased self-worth. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview and record review the facility failed to ensure timely assessments, supervision and implementation of measures to prevent reoccurrence and failed to follow the facility's policy regarding mechanical lift transfers for 2 of 3 residents (1 & 2). Failure to implement safety interventions, provide the necessary supervision and follow facility policy resulted in harm for Resident 1 who sustained a fracture and a skin tear for Resident 2. Findings included: RESIDENT 1 Resident 1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] revealed she had no cognitive deficits, did not exhibit behaviors and had no history of falls. According to the Resident Care Manager (RCM B) the resident was provided a bariatric bed with an air mattress with bolsters. The bariatric bed had half side rails at the head of the bed. RCM B stated the resident's upper body leaned to the side when she was in bed. The RCM B stated an assessment was completed on 7/18/17 when Resident 1 was provided the bariatric bed with bedrails due to a medical decline. The 7/18/17 Safety Device Data Collection and Assessment indicated the specialty (bariatric) bed and mattress was provided due to her obesity and to prevent skin breakdown and the use of the half bed rails at the top side of the bed was to increase independence with bed mobility. On 01/02/18 at 1:58 P.M., Resident 1 was observed resting in bed and the bed was positioned against the wall. A family member was visiting and stated she had fallen out of bed and broke her leg. The family member stated Resident 1 tended to list to side when in bed. On 01/04/18 Resident 1 was observed in bed. The bed was against the wall and the bed was in a low position and the bed rails at the top of her bed were parallel with the top of the mattress. A nursing progress note dated 11/25/17 documented Resident 1 was found by the side of her bed on the floor. Review of the facility's investigative report dated 11/25/17 documented Resident 1 likely fell out of bed due to the confusion related to her dementia and decline in health over the past several months. The report revealed she was on hospice as of 11/22/17 and exhibited increased confusion and continued to use a bariatric bed with side rails. Additional documentation from a staff (nursing assistant/NAC) regarding the 11/25/17 fall revealed the Resident 1 was found on the floor with her knees were pretzeled and her L (left) arm was stuck in guardrail. The documentation indicated the resident had been confused for the last few weeks and thinks her bedroom/house is somewhere else and has asked for help to get up and go upstairs or to her bedroom. The NAC indicated that she had been providing comfort and redirection for Resident 1. The investigative report for the 11/25/17 fall revealed that the plan was to revise the plan of care to include positioning the bed against the wall for left side lean? Try. Even though the facility's fall investigation documented the resident left arm was stuck in guardrail, there was no further assessment for continued use of the bedrails. After the 11/25/17 fall, the fall assessment completed on 11/30/17 did not assess the resident trunk balance even though Resident 1 was identified to lean in bed. Intervention was to include high/low bed. Due to Resident 1's medical decline, a significant MDS was completed on 11/29/17. The MDS showed that Resident 1 exhibited disorganized thinking, inattentiveness and required two person assistance with bed mobility. A safety device information assessment dated [DATE] indicated due to Resident 1's poor safety awareness her bed wound be against wall L (left) side. The nursing progress notes from 12/3/17 to 12/23/17 showed Resident 1 was confused, her judgement was impaired and she had repeatedly attempted to get out of bed (OOB) and was observed to be rocking in bed. A physician's note dated 12/12/17 late entry documented Resident 1's judgement and memory was impaired and had progressive dementia. Even though Resident 1 continued to exhibit confusion and lack of judgement and repeatedly attempted to get out of bed and required 2 person extensive assistance with positioning in bed, the facility did not consider the risk and benefit of her side rails. A nursing progress note dated 12/23/17 showed Resident 1 fell from bed and was found on the floor. The facility's investigative report dated 12/28/17 concluded Resident 1 had crawled out of bed, and fractured her ankle. The incident report showed Resident 1 was yelling and stated she crawled out to go to her other room and she was laying on left-side with head under bed and complained of pain in left hip/leg. The root cause analysis form documented that Resident 1's current interventions had included turning rails and a bariatric bed with bolsters. The investigative report showed that new interventions would include bed against the fall and fall matt. In a nursing progress note dated 12/27/17, showed that Resident 1 suffered a fall as she attempted to crawl out of bed and sustained a fracture. The note documented new intervention include putting her bed against the wall on her dominate side (right), a fall matt and that nursing identified her fall was in relationship to her increased confusion. Another progress note entry by social service (SSD) dated 12/27/17 revealed the family was informed regarding moving her bed against the wall and SSD documented on 12/28/17 the bed was moved against the wall yesterday afternoon with the goal of increasing her safety while in bed. A hospice note for 12/28/17, documented that the bed now against wall. Even though the facility documented the bed was to be against the wall after the initial fall on 11/25/17, documentation showed Resident 1's bed was not placed against the wall until after the second fall with injury on 12/27/17 when she sustained a fracture. On 01/04/18 at 2:45 P.M., RCM B stated only an initial assessment regarding the use of the bariatic bed and siderail use was completed on 7/18/17 and not after a change in condition. On 1/17/18, the administrator stated Resident 1's plan of care regarding the bed against the wall was not implemented until after the second fall on 12/23/17 which resulted in injury of a fracture. RESIDENT 2 Resident 2 was admitted on [DATE]. A physician's note dated 11/07/17 indicated Resident 2 had paresis (weakness) of his left side due to a spinal code injury (SCI) with [DIAGNOSES REDACTED]. The Care Plan dated 7/27/17 revealed the resident had limited mobility and was totally dependent on staff for repositioning in bed and required a hoyer lift with the assistance of 2 for transfers. Review of the facility's investigative report dated 11/17/17 documented a nursing assistant (NAC) observed the resident slipping out of his wheelchair, so to prevent the fall, the NAC got the hoyer (mechanical lift) and put resident in lift and transferred him to bed by herself. The investigative report concluded the NAC had transferred the residents contrary to care plan and normal safety procedures. The report documented the NAC self transferred a resident with a hoyer lift, who was a two person transfer. Resident also was found with a skin tear on the shin which facility has not been able to substantiate the skin tear was or was not due to the hoyer transfer of the resident. This transfer potentially placed the resident at risk for serious injury and was did not follow the plan of care. During an interview on 12/11/17, the Resident Care Manager (RCM B) stated the facility policy for a mechanical lift (hoyer) was to always have 2 staff members present when performing a transfer using the hoyer. On 12/11/17 at 10:55 A.M., Resident 2 was observed asleep in his bed and on 01/17/18 in bed being fed breakfast by a NAC. During an interview on 01/02/18 with Licensed Nurse (LNA), she stated Resident 2 was alert and dependent on staff, had no behavior issues and was a 2 person assist with transfers with the use of a mechanical lift. During an interview on 01/04/18 at 2:10 P.M., the Director of Nursing (DNS) stated Resident 2 had slipped down in his wheelchair and was stable enough to leave and get the hoyer lift and another staff to assist. The DNS stated a skin tear was noted after the hoyer lift and the NAC did not follow facility policy. Reference: (WAC) 388-97-1060 (g).

Based on observation, interview and record review, the facility failed to actively and consistently provide medically-related social services to attain the highest level of mental and psychosocial well-being for 1 of 1 residents (80) reviewed for social services and social services support. Failure to consistently identify, advocate, intervene, caused harm to Resident 80 as displayed by continued behaviors (crying, wailing) that were left untreated and without adequate interventions, and was left with untreated emotional distress that was not supported by the facility social services or staff. Resident 80 was also harmed when the facility failed to address her pattern of isolation and refusing assistance with Activities of Daily Living, even though there was a 7-month pattern of psychosocial behaviors. Findings include: RESIDENT 80 Appendix P defines Depressed mood (which does not necessarily constitute clinical depression) is indicated by negative statements; self-deprecation; sad facial expressions; crying and tearfulness; withdrawal from activities of interest; and/or reduced social interactions. The resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the resident's most recent Minimum Data Set ((MDS) dated [DATE], the resident was alert and oriented, scored a 15 on the Brief Interview for Mental Status (BIMS) and was able to make her needs known. Review of the resident's clinical record revealed the resident had behavioral, self-image/self-care issues as evidenced by observations, interviews with care staff and review of clinical documentation. Review of the resident's nursing care plan for Activities of Daily Living (ADL's) dated 07/23/17, showed the resident was identified with self-care performance deficit. Goals included the resident will be neat, clean and well-groomed daily. Interventions included discussing concerns related to loss of independence and decline in function. Goals and Interventions of the Nursing care plan reviewed did not include notification to a Physician, Nurse Practitioner or qualified professional for further evaluation and intervention if goals were not met. Review of the Social services care plan dated 07/19/17, identified the resident to have: History of crying loudly when upset, had bouts of tearfulness multiple times per week, refuses to take showers and change her clothes, poor ability to manage stress of daily life, poor personal and environment hygiene awareness, unwilling to have wig properly maintained or replaced. The care plan also identified the resident as having difficulty coping with daily activities and was frequently tearful due to her inability to cope with daily functions for her overall well-being. Goals and Interventions of the Social Services care plan reviewed, did not include notification to a qualified professional for further evaluation, monitoring and interventions for the resident's inability to maintain personal hygiene or behavioral stability. Review of the Social services and nursing progress notes from January to July 2017, showed the resident refused ADL care from care staff including showers, change of clothes, cleaning of room and wig care. Documentation showed the resident had multiple episodes of daily crying, tearfulness, yelling at staff when approached to have personal care implemented by care staff. Notes showed the resident's clothes were consistently stained from white face powder and hot chocolate stains. It was also documented the resident was extremely upset about losing her upper dentures and felt that nobody cared or was doing anything to replace them. Progress notes did not show any communication to a Physician, Nurse Practitioner or qualified professional regarding the resident's self-care and behavioral problems. Review of the resident's clinical chart showed a progress note from Psychiatry dated 2/10/16 where the resident was evaluated for depression and inability to handle stressors such as losing her dentures. No other Psychiatric follow up was done since then. In an observation on 07/24/17 at 2:58 PM, the resident had a white blouse on that was stained with black matter in her chest area. The resident was also wearing hospital socks that were heavily soiled stained with dark brown matter on the soles and a slight body odor was present when speaking with the resident. The resident also had on a lop-sided wig that was held in place by a purple scarf tied underneath her chin. In another observation on 07/26/17 at 1:23 PM, the resident was wearing tan colored pants stained with brown and black matter. The resident's blouse was stained with brown matter in her chest area. A slight body odor was present when speaking to the resident. The resident was also wearing a wig that was tied from her chin around her head to keep the wig in place. In an interview on 07/26/17 at 1:31 PM, Staff EE, Nurses Assistant (NA), stated the resident wore an unusual wig. When asked why the resident wore a scarf around her head, Staff EE stated the resident used it to keep the wig in place and whenever staff asked about it, the resident got upset and cried. Staff EE stated the resident refused to be bathed and insisted on washing herself in the sink. Staff EE also stated she was not sure when the last time the resident took a shower. Staff EE stated when the resident was asked about her soiled clothing she would frequently get upset and cry, so the staff eventually left her alone. Staff EE stated she had reported this to the nurses and was not sure what the long-term plan was for the resident's behavioral and self-care issues. In an interview on 07/27/17 at 07:45 AM, Staff O, NA stated the resident on multiple occasions had refused to take showers. Staff O stated the resident insisted on bathing herself and got offended or cried when asked to take a shower. Staff O stated she thought the resident was not doing a good job with bathing since there was an odor around the resident. Staff O also stated the resident got upset and sometimes cried when asked about her soiled clothing. Staff O stated nursing staff were aware but was not sure what the ongoing plan was at this time. In an interview on 08/01/17 at 12:34 PM, Staff GG, Nurse Practitioner (NP) stated the resident could have probably used more psychiatric intervention to address resident's self-care issues. Staff GG stated the documented psychiatry visit completed during the 2015-[AGE] year was not enough and stated the resident should have probably had frequent, ongoing counseling services. Staff GG stated the process she used was by placing a referral to the Psychiatric NP or Psychiatric doctor for further evaluation. Staff GG stated she was aware of the resident's self-care issues and would place a referral to the Psych Nurse Practitioner. At 1:09 PM Staff I Licensed Nurse (LN) stated the resident did not show any signs or symptoms to warrant any Psychiatric intervention. When asked if he thought nursing had done everything to address the resident's issues with ADL's and the resident's response to care, he stated maybe there was more they could have done to address the resident's self-care issues. After speaking with Staff I, he stated the resident would have ongoing Psychiatric evaluations. He also stated the resident's behavioral issues were not reported to a Psychiatric NP or doctor or brought to the attention of the facility interdisciplinary team (IDT). At 1:40 PM, When Staff P, Social Services Assistant (SSA) was asked what the long-term plan to address the resident's lack of ADL and behavioral care she stated we try to encourage the resident and right now, but we are at wits end of what else we can do and if you can think of something please let us know. She also stated when the resident gets distressed she wails so loud it disturbs other residents. At 4:26 PM, Staff Q, Social Services Director (SSD), stated the resident has had a history of [REDACTED]. Staff Q stated there were no signs and symptoms of depression and if there was a problem it would have come up sooner. She stated the resident has gotten really upset and was aware of her behavioral issues but was not sure if the issues were reported to a doctor or NP and nursing would have more info. In an interview on 08/02/17 at 9:53 AM, Staff I, LN stated there were no other psychiatric assessments or evaluations done since 02/10/16. Staff I stated Whatever is in the chart is all we have. Social Services failed to identify and provide emotional support for Resident 80 who would frequently cry, neglect self-care and had frequent emotional outbursts that would warrant evaluation, monitoring and ongoing follow up by a qualified professional to maintain the resident's emotional and overall well being. Refer to F248 for additional information of Resident 80 Reference: (WAC) 388-97-1620(2)(b)(i)(ii),(6)(b)(i)

Based on interview and record review the facility failed to follow the accepted standards of clinical practice in regard to assessment and monitoring of 1 of 3 residents (10) for neurological status after an unwitnessed fall and skin assessment after a cast removal. Failure to accurately assess the skin condition or neurological status placed Resident 10 at risk for poor health outcome and a delay in necessary services as the resident's condition deteriorated. Findings include: NEUROLOGICAL MONITORING Resident 10 was admitted to the facility on [DATE] following a partial right foot amputation. Other [DIAGNOSES REDACTED]. Review of a nursing progress note dated 6/26/17 at 2:36 p.m., showed Resident 10 had an unwitnessed fall. The post fall skin assessment showed that she sustained a bruise to her cheek. Review of the clinical record revealed there was no documented evidence regarding Resident 10's neurological status in order to evaluate for deterioration in condition after sustaining a head injury from an unwitnessed fall. An interview on 7/7/17, the Director of Nursing (DNS) said they were unable to locate/provide any documented neurological assessments. The facility failed to thoroughly assess, consistently monitor, and/or document Resident 10's neurological status following a head injury resulted in insufficient information to recognize any decline in Resident 10's status. SKIN ASSESSMENT & MONITORING The admit nursing skin assessment revealed Resident 10 had no pressure ulcers and had a cast on the right lower leg which covered her surgical site, a partial front foot amputation. The Care Plan for skin at risk dated 5/21/17, indicated staff would remove cast to inspect the skin for signs and symptoms of breakdown and Licensed Nurses (LNs) were to perform weekly skin assessments. On 7/12/17 at 3:30 p.m. during an interview with LN A, she stated she had performed the dressing change to the right foot on 6/23/17 after the vascular physician removed the cast. LN A stated the skin was dark red and appeared like bruising, dry, new blood and the surgical area sutures were noted. When asked about the heel, LN A stated she recalled the right (R) heel to slight red in color without bogginess. LN A stated she did not document the skin assessment of the right post-op surgical foot or R heel. The treatment administration record (TAR) for June 2017 revealed on June 23, 25 and 27th, the LNs documented the surgical site was cleansed with saline, then a Vaseline dressing was applied and covered with a non-adherent dressing and then wrapped with a bandage roll. The nursing notes and (TAR) from June 23 to June 27, 2017 revealed there was no documented assessments or monitoring in place to ensure Resident 10's surgical wound did not deteriorate or develop new skin breakdown due to her severe right foot ischemia. Even though the vascular physician had adjusted the cast and later (6/23/17) the surgical foot was to have a dressing change, there was no documented evidence that LNs had assessed or monitored the foot for complications due to the severe circulation of the foot. During an interview and review of the clinical record on 7/12/17, the Director of Nursing (DNS) stated LNs had not followed facility policy regarding weekly skin assessments and/or documented the assessment of Resident 10's right foot who had impaired circulation. Upon admission to the hospital for a schduled procedure, hospital staff felt the resident had a notible change in her neurological status which prevented the procedure and a brain bleed was discovered during testing. See F 281 and F 314 for additional information Reference: (WAC) 388-97-1620

Based on observation, interview, and record review, the facility failed to ensure ongoing assessment and monitoring were provided to identify and promote the healing of pressure ulcers (PUs) for 2 of 2 Residents (10, 151). Failure to consistently assess Resident 10 and 151's pressure ulcers to determine if there was healing and assess Resident 151's lower extremities due to medical condition or evaluate the impact of the current interventions resulted in deterioration of Resident 151's PUs on buttocks and the development of an unstageable PU on the heel and placed Resident 1 at risk of delayed healing. Findings include: The facility's skin policy revealed all residents are required to have weekly skin assessments and develop individualized interventions to manage pressure prevention. Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. RESIDENT 151 Resident 151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment for 3/1/17 documented no pressure ulcers. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 151 was 72 inches in height and weighed 398 pounds and required 2 person extensive assist with bed mobility. On 7/7/17 at 8:55 a.m., Resident 151 was observed in bed and stated he had a painful wound on his buttock. He stated the wound developed due to prolonged sitting in his wheelchair when waiting for ride to and from [MEDICAL TREATMENT] (renal) which is four times a week. On 7/18/17 at 10:25 a.m., Resident 151 was observed resting on a specialty air bed (LAL) with both heels resting on the mattress and wore compression bandage/stockinette ([MEDICATION NAME]) on both lower extremities. He stated his buttocks still hurt from prolonged periods of sitting and that his heels were not being floated off the mattress. Resident 151 required two separate transfers to the hospital due to changes in mental status and infection requiring antibiotics due to [MEDICAL CONDITION] (leg infection). The first transfer to the hospital was from 6/8/17 to 6/12/17 and the second transfer was 6/23/17 to 6/28/17. The facility's readmission skin assessment for 6/12/17 documented Resident 151 had an open area on the Left (L) buttock that measured 0.5 centimeter (cm) by 0.5 cm in size. There was no staging of the open area. The Treatment Administration Record (TAR) for June 2017 revealed Licensed Nurses (LN) were cleansing the open area with normal saline, and applying an ointment. There was no further skin assessment regarding whether the open area identified on the L buttocks had improved or declined between 6/13/17 - 6/21/17. The TAR for June 2017 documented that Resident 151 had a compression wrap (Unna boot) on both lower extremities (BLE) from June 1-8 and June 13 - 22. The next documented assessment of the L buttock open area was not until Resident 151 was seen at the wound clinic on 6/21/17. The wound clinic assessed Resident 151's wounds on 6/21/17. The note documented three areas of breakdown on the buttocks: L buttock, right (R) gluteal fold, and left gluteal fold. The wounds were to be cleansed daily or as needed (prn), apply ointment, and then a foam dressing. The wound center plan of care directed the facility to ensure off-loading to avoid pressure, and a foam cushion on the wheelchair. Other instructions included the use of bilateral lower leg compression wraps/[MEDICATION NAME]. On 6/23/17 (2nd hospital transfer), Resident 151 was sent to the hospital and he returned to the facility on [DATE]. The nursing assessment for 6/28/17 revealed [MEDICAL CONDITION] (swelling) of the lower extremities (ankles/feet), and that he required 2 person assist with bed mobility. The facility's readmission skin assessment (6/28/17) identified a 4 cm by 5 cm area as red, bleeding between both buttocks, and a 2 cm by 0.5 cm area within a 4 cm by 4 cm denuded/open area just below the R gluteal crease (denuded-loss of top layer (epidermis) of skin). There was no other description (key) regarding these wounds. The skin assessment revealed Resident 151 had no pressure ulcers to his heels upon readmit (6/28/17). The hospital transfer instructions for 6/28/17 re-admit instructed LNs to apply ointment and foam dressing to the buttock ulcerations, get off his buttocks more, change positions, sit on an air cushion or foam cushion, apply [MEDICATION NAME] (compression sockinette) to both LE and elevation. Further recommendations were to turn the resident every 2 hours with pillow on back for support, float heels and support all bony prominences. The physician note dated 6/29/17 documented that the use of [MEDICATION NAME] to both lower extremities (LE) with elevation until the specialty compression socks (juxtalite) were available. Review of the July 2017 TAR revealed no documented weekly skin assessments for 7/5/17 or 7/12/17. The next documented skin assessment was written by the wound clinic on 7/17/17. The 7/17/17 wound clinic assessment documented Resident 151 had significant decubitus ulcerations on his buttock and an unstageable new decubitus ulceration of the left heel. The wound clinic note for 7/17/17 documented Resident 151 had an unstageable ulcer on the lateral aspect of the heel and was described as a new dry, unstageable ulcer that measured 1.0 cm by 1.8 cm in size. The 7/17/17 clinic's assessment also documented a Stage 3 pressure ulcer on the R buttock (inferior gluteal fold) that measured 6 cm by 6.9 cm with a large amount of drainage. The L buttock (inferior gluteal fold) decubitus ulceration was described as a Stage 2 pressure ulcer which measured 0.1 cm by 0.1 cm in size. The wound clinic recommended that Resident 151's heels be floated at all times, continue [MEDICATION NAME] on LE for compression, turn every 2 hours, ambulate, and needed a low air loss alternating (LAL) pressure mattress. Review of Resident 151's [MEDICAL TREATMENT] communication forms contained no documented information regarding the need for pressure relief or off-loading during [MEDICAL TREATMENT] sessions. On 7/18/17 during an interview with the Director of Nursing (DNS), the DNS stated Resident 151's mattress was changed to a LAL mattress yesterday. During an interview with the resident care manager (RCM B) on 7/18/17, RCM B stated Licensed Nurses (LNs) did not perform weekly skin assessment per facility policy and/or ensure the care plan was updated to ensure pressure relieving interventions (LAL mattress, heel boots). RCM B stated the LNs did not thoroughly assess or document the skin for breakdown even though the LNs had been cleansing and applying ointment/dressing to Resident 151's buttock and applying/checking the compression wraps on his lower extremities. The Care plan dated 3/17 and 6/12/17 did not include pressure relieving device, offloading of heels/ buttock, and/or evidence of instructing Resident 2 to reposition self at 15-20 minute intervals. Although Resident 151 was identified as at risk for skin breakdown due to medical condition and prolonged periods of sitting due to [MEDICAL TREATMENT] sessions, the facility failed to consistently assess and implement or revise a plan of care to promote pressure relieving interventions. RESIDENT 10 Resident 10 was admitted to the facility on [DATE] following a partial right foot amputation. Other [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], revealed she required maximum assistance of two people for bed mobility and transfers and weighed 96 pounds. The admit nursing assessment revealed Resident 10 had no pressure ulcers on the buttock. Review of a nursing progress note dated 6/12/17 documented Resident 10 had a wound on her left (L) buttock which measured 0.5 centimeter (cm) by 0.5 cm in size. A new order was received to apply barrier cream twice a day and as needed. The note indicated the Care Plan was revised to ensure Resident 10 would be turned every two hours with offloading (pressure relief). The nursing notes and TAR for June 2017 revealed there was no documented evidence that weekly skin assessments were completed on 6/4/17 or 6/11/17 prior to the development of a wound on the left buttock (6/12/17). Additionally, even after the LN identified the wound on the left buttock area, there was no documented evidence weekly skin assessments were completed on 6/19/17 or 6/26/17. Resident 10 was transferred to the hospital on [DATE] for schedule surgery. The hospital's wound nurse assessed the L buttock and described the wound to be pressure vs MASD (moisture associated skin damage-moisture from incontinence) and was unable to determine the staging as the two wounds on the L buttock were scabbed over. The wound nurse ordered a cream to be applied to protect from incontinence (moisture). Review of Resident 10's clinical record revealed after identification of the open area on the L buttocks, there was no documented evidence as to whether the area deteriorated or improved once the barrier cream was initiated on 6/12/17. Reference: (WAC) 388-97-1060

Based on interview and record review the facility failed to follow the accepted standards of clinical practice in regard to assessment and monitoring of 1 of 3 residents (10) for neurological status after an unwitnessed fall and skin assessment after a cast removal. Failure to accurately assess the skin condition or neurological status placed Resident 10 at risk for poor health outcome and a delay in necessary services as the resident's condition deteriorated. Findings include: Nursing Standards of Practice according to Lippincott Manual Of Nursing Practice 10th Edition by Lippincott, Williams & Wilkins, indicate that following a head injury, assessment of neurological function should consist of Glascow coma scale (GCS) scoring, change in mental status, vital signs, pupil size and reactivity, personality changes, periorbital ecchymosis (bruising). These assessments are useful as a tool to monitor deterioration following head injury. According to the American Nurses Association, Scope and Standards of Practice, 2011, A licensed nurse (LN) shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the client's response to that care. Nurses assume a liability risk if they fail to monitor a patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. NEUROLOGICAL MONITORING Resident 10 was admitted to the facility on [DATE] following a partial right foot amputation. Other [DIAGNOSES REDACTED]. Review of a nursing progress note dated 06/26/17 at 2:36 p.m., showed Resident 10 had an unwitnessed fall. The post fall skin assessment showed that she sustained a bruise to her cheek. Review of the clinical record revealed there was no documented evidence regarding Resident 10's neurological status in order to evaluate for deterioration in condition after sustaining a head injury from an unwitnessed fall. An interview on 07/07/17, the Director of Nursing (DNS) said they were unable to locate/provide any documented neurological assessments. The facility failed to thoroughly assess, consistently monitor, and/or document Resident 10's neurological status following a head injury resulted in insufficient information to recognize any decline in Resident 10's status. SKIN ASSESSMENT & MONITORING The admit nursing skin assessment revealed Resident 10 had no pressure ulcers and had a cast on the right lower leg which covered her surgical site. The Care Plan for skin at risk dated 05/21/17, indicated staff would inspect the skin for signs and symptoms of breakdown and Licensed Nurses (LNs) were to perform weekly skin assessments. On 07/12/17 at 3:30 p.m. during an interview with LN A, she stated she had performed the dressing change to the right foot on 06/23/17 after the vascular physician removed the cast. LN A stated the skin was dark red and appeared like bruising, dry, new blood and the surgical area sutures were noted. When asked about the heel, LN A stated she recalled the right (R) heel to slight red in color without bogginess. LN A stated she did not document the skin assessment of the right post-op surgical foot or R heel. The treatment administration record (TAR) for June 2017 revealed on June 23, 25 and 27th, the LNs documented the surgical site was cleansed with saline, then a Vaseline dressing was applied and covered with a non-adherent dressing and then wrapped with a bandage roll. The nursing notes and TAR from June 23 to June 27, 2017 revealed there was no documented assessments or monitoring in place to ensure Resident 1's surgical wound did not deteriorate or develop new skin breakdown due to her severe right foot ischemia. Even though the vascular physician had adjusted the cast and later (06/23/17) the surgical foot was to have a dressing change, there was no documented evidence that LNs had assessed or monitored the foot for complications due to the severe circulation of the foot. During an interview and review of the clinical record on 07/12/17, the Director of Nursing (DNS) stated LNs had not followed facility policy regarding weekly skin assessments and/or documented the assessment of Resident 10's right foot who had impaired circulation. See F 309 and F 314 for additional information Reference: (WAC) 388-97-1620 (2)(b)(ii)

Based on interview and record review, the facility failed to contact a resident's physician when a medication was not available for 1 of 1 sample residents (36) reviewed for medications and an unplanned hospitalization . Failure to notify the resident's physician when the facility ran out of an antipsychotic medication prevented the resident from having a medical advocate causing harm to the resident which included a decline in mental stability and having an unneccessary admit to the hospital with emotional distress, anxiety and [MEDICAL CONDITION]. Findings include: Resident 36 admitted to the facility in February 2016 with [DIAGNOSES REDACTED]. Review of her Minimum Data Set assessment, dated 02/22/16, revealed she had no cognitive impairment. Review of Resident 36's physician's orders [REDACTED]. Review of the facility incident investigation documentation revealed the facility had run out of the [MEDICATION NAME] and did not administer the medication on 04/23/16, 04/24/16 and 04/25/16. Review of the facility incident investigation documentation revealed Resident 36 was admitted to a hospital on [DATE]. Review of the facility Medication Administration policy, dated July 2015, revealed it's not acceptable to omit a dose by indicating NA for Medication not Available from pharmacy. Remove a dose from Back-up Supply/Emergency Kit or contact pharmacy or on-call pharmacist and request medication to be sent as soon as possible. If the medication is not available, contact the physician, and/or medical director for further orders. In an interview on 05/16/16 at 5:10 AM, Staff A, Licensed Nurse, stated No, when asked if he had notified the resident's physician when he was unable to administer the [MEDICATION NAME] on 04/23/16 and 04/24/16. Review of a memorandum of a phone call from the facility Executive Director to the resident's physician, dated 04/27/16, revealed the physician verified no one had contacted him regarding the medication was not available or (to) ask for direction. Review of the facility incident investigation revealed the facility had not contacted the resident's physician until 04/26/16 when Resident 36 was requesting to be admitted to the hospital. Refer to CFR 483.25(m)(2); F-333 For significant medication error. Refer to CFR 483.60(a); F-425 Pharmacy services. .

Based on interview and record review, the facility failed to ensure 1 of 7 sample residents (36) whose medication regimes were reviewed remained free of significant medication errors. Failure to ensure an antipsychotic medication was available from the pharmacy caused harm to Resident 36 when she developed emotional distress and other psychiatric symptoms to include anxiety, sobbing and [MEDICAL CONDITION] which resulted in an unplanned hospitalization . Findings include: Resident 36 admitted to the facility in February 2016 with [DIAGNOSES REDACTED]. Review of her Minimum Data Set assessment, dated 02/22/16, revealed she had no cognitive impairment. Review of Resident 36's physician's orders [REDACTED]. Review of facility incident investigation documentation revealed the facility had run out of the [MEDICATION NAME] and did not administer it on 04/23/16, 04/24/16 and 04/25/16. Review of facility incident investigation documentation revealed Resident 36 was admitted to an acute care hospital on [DATE]. Review of the facility incident investigation revealed the facility had not contacted the resident's physician until 04/26/16. Review of [MEDICATION NAME] prescribing information revealed In the event of planned termination of [MEDICATION NAME] therapy, gradual dose reduction is recommended over a 1 - 2 week period. However, should a patient's medical condition require abrupt discontinuation (e.g, leukopenia), the patient should be carefully observed for the recurrence of psychotic symptoms . In an interview on 05/16/16 at 5:10 AM, Staff A, Licensed Nurse, (the nurse who didn't give the medication on 04/23/16 and 04/24/16) stated No, when asked if he had spoken with the resident's physician or the on-call pharmacist after he had not administered the medication for 2 days. Staff A stated he left a voicemail with the pharmacy when he did not get an answer. Review of the facility Medication Administration policy, dated July 2015, revealed it's not acceptable to omit a dose by indicating NA for Medication not Available from pharmacy. Remove a dose from Back-up Supply/Emergency Kit or contact pharmacy or on-call pharmacist and request medication to be sent as soon as possible. If the medication is not available, contact the physician, and/or medical director for further orders. Review of the facility incident investigation, dated 04/27/16, revealed: Nursing responsible for error, Type of error - missed dose, Explain results of error - resident had mental breakdown, and List precautions being taken to prevent a similar error - Inservice nursing staff and disciplinary action. Refer to CFR 483.10(b)(11)(i)(c); F-157 Notification of changes. Refer to CFR 483.60(a); F-425 Pharmacy services.

Based on interview and record review, the facility failed to ensure accurate medication procedures were utilized for 4 of 7 sample residents (36, 49, 124, 25) whose medication regimes were reviewed. Failure to acquire and administer required medications caused harm to Resident 36 when she did not receive an antipsychotic medication for 3 days which resulted in emotional distress, suicidal ideations and an unplanned hospitalization . Failure to: accurately transcribe physician medication orders, to accurately record when medications weren't administered, and failure to ensure the supply of pain medication was available in a timely manner placed residents at risk for less than optimal medication management. Findings include: RESIDENT 36 Resident 36 admitted to the facility in February 2016 with [DIAGNOSES REDACTED]. Review of her Minimum Data Set assessment, dated 02/22/16, revealed she had no cognitive impairment. Review of Resident 36's physician's orders [REDACTED]. She was to start at 12.5 milligrams (mg) for 3 days, then every 3 days the dose was to increase by 12.5 mg until the dose reached 200 mg. The first error that occurred was when the resident had completed 15 days of the medication and the new dose was to be 100 mg on 04/06/16. The facility incorrectly transcribed the Medication Administration Record [REDACTED]. Review of a facility Medication Error Report, dated 04/27/16 revealed this medication error was not discovered until 04/27/16. Review of a second Medication Error Report, also dated 04/27/16, revealed a second error related to the Clozapine occurred when the resident was supposed to receive Clozapine 162.5 mg on 04/23/16 and 175 mg on 04/24/16 and 04/25/16, but did not receive any medication on those days because the facility had run out of the medication. Review of a facility incident investigation revealed Resident 36 was admitted to the hospital on [DATE] due to emotional distress, anxiety and suicidal ideations. Review of Resident 36's April 2016 MARs revealed Staff A, Licensed Nurse (LN), had initialed the MAR indicated [REDACTED]. In an interview on 05/13/16 at 2:44 PM, the Director of Nursing Services stated he felt the facility had thoroughtly studied the root cause of the medication errors, had educated the nurses on proper facility practices, and had given disciplinary counseling to Staff A. RESIDENT 49 Resident 49 was readmitted to the facility in December 2015 with [DIAGNOSES REDACTED]. Review of the resident's February 2016 MARs and physician's orders [REDACTED]. The new orders were properly transcribed onto the February 2016 MARs. Review of the resident's March 2016 MARs revealed the new sliding scale insulin order, dated 02/24/16, did not get transcribed onto the March MARs. In March, the facility resumed the old sliding scale insulin coverage in effect prior to 02/24/16. The medication error was not discovered until 03/29/16. From 03/01/16 - 03/29/16 the resident received insulin coverage based upon the old sliding scale order. Review of a facility incident investigation report, dated 03/29/16, revealed the facility had determined the root cause of the error was the monthly recap had been completed the day prior to the new order and the nurse did not know the recaps had already been done. In an interview on 05/13/16 at 1:45 PM, the Director of Nursing Services stated the medication error had been made by Staff B, LN, who was to be inserviced on the facility's new process for performing the monthly medication recaps. RESIDENT 124 Resident 124 was admitted to the facility in March 2016 with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. On 05/17/16, review of the resident's MARs revealed the Spironolactone order had not been transcribed to the MARs and the resident had not yet received the medication. In an interview at 12:43 PM, Staff D, LN, stated I guess we have a medication error. Staff C went to the medication cart and returned with a full, unused medication card of Spironolactone labeled with Resident 124's name. RESIDENT 25 During an interview with Resident 25 on 05/13/16 at 10:35 AM, he stated nurses were not always giving his medications on time and verbalized an incident when he had to wait over 2 hours. He stated he was in distress to the point he almost called 911. Per record review, Resident 25 had [DIAGNOSES REDACTED]. Pain medications include morphine sulfate twice daily, acetaminophen 3 times daily, and oxycodone 15 mg every 6 hours if needed. Nursing documentation on 04/23/16, at 8:00 AM, states the nurse was unable to give oxycodone because they could not get an authorization number (when a resident's prescription for narcotics had run out, the facility must call the pharmacist to get an approval number to obtain the medication from the facility emergency supply kit). It was 10:10 AM before the authorization was obtained. The resident stated it was too late and it was not going to work and stated he was going to call 911. In an interview conducted with Staff F, LN at 11:34 AM regarding the process for handling controlled medications (those that require authorization to obtain from emergency supply kit) Staff F stated if a resident's supply of medication gets low, approximately 5 pills left, they contact the physician or pharmacy to assure there is a new prescription. She stated if they run out of medication they have to go through the authorization process which can result in a delay in giving medication to the resident. This process was not followed, which necessitated accessing the emergency supply kit. Refer to CFR 483.10(b)(11)(i)(c); F-157 Notification of changes. Refer to CFR 483.25(m)(2); F-333 For significant medication error.

Based on interview and record review, the facility failed to provide services according to the care plan for 1 of 4 residents reviewed, (Resident #1) when the facility staff transferred the resident from bed to wheelchair with one person assistance instead of two people assistance. This failure resulted in a fall and injury for Resident #1. --also see F323-- Findings include: Review of facility medical records on 12/29/15 revealed, Resident #1 resided in the facility for long term care since 2009. According to the facility Minimum Data Set assessment ((MDS) dated [DATE], Resident #1 had cognitive impairments, and needed extensive assistance from two people for transfers from bed. Review of the facility care plan dated 11/23/15 revealed, Resident #1 needed a gait belt for safe transfers, two people assistance for transfers, because he had poor safety awareness and a history of falls. Review of the facility investigation dated 12/23/15 revealed, Resident #1 fell in his room, in the morning, during a transfer from bed to wheelchair. He was being assisted by one person (Staff A) and fell to the floor, as he was guided to the floor by Staff A. In an interview on 12/29/15 at 2:33 p.m., Staff A, the caregiver present during the fall stated she did not know the plan of care for Resident #1. In addition, she did not follow the care plan, which directed staff to use two people and use a gait belt for the transfer from the bed to the chair on 12/23/15. Staff A also stated she lowered Resident #1 to the floor during the fall. In an interview on 12/29/15 at 2:25 p.m., the Director of Nursing (DNS) confirmed Staff A did not follow the care plan for Resident #1 at the time of the fall. The DNS further stated Staff A was educated by the DNS, upon hire, regarding how to follow the care plans. Due to the Staff A not following the care plan, Resident #1 was injured. See F 323 for further details about the fall and injury.

Based on interview and record review, the facility failed to prevent an accidental fall for 1 of 4 residents reviewed, (Resident #1), when a safety device, gait belt, was not used as assessed and care planned for the transfer from bed to chair for Resident #1. This failure resulted in a fall to the floor without the assistance of a safety device. Findings include: --see also F282-- Record review of the facility Resident Lifting, Transferring and Repositioning form dated 10/19/15 revealed, Resident #1 needed two people extensive assistance and a gait belt for transfers. Further review of the facility nursing quarterly assessment dated [DATE] revealed, Resident #1 needed extensive assistance from two people for transfers and was not steady to move from seated positions to standing. Review of the facility care plan dated 11/23/15 revealed, Resident #1 needed a gait belt for safe transfers and had poor safety awareness and a history of falls. Review of the facility incident log on 12/29/15 revealed, Resident #1 had a witnessed fall on 12/23/15 in his room. Review of the facility investigation dated 12/23/15 revealed, Resident #1 fell in his room in the morning during a transfer from bed to wheelchair while being assisted by one person (Staff A) and fell to the floor, as he was guided to the floor by Staff A. In an interview on 12/29/15 at 2:33 p.m., Staff A, the caregiver present with the fall for Resident #1 on 12/23/15, stated she did not use a gait belt for the transfer from bed to chair on 12/23/15 for Resident #1. Staff A also stated she lowered/guided Resident #1 to the floor during the fall, without using a gait belt and holding onto Resident #1's arm as she could not support his weight during the fall. In an interview on 12/29/15 at 2:25 p.m., the Director of Nursing (DNS) confirmed Staff A did not use the assessed safety device for transfer for Resident #1 on 12/23/15 at the time of the fall to the floor. The DNS further stated Staff A educated by the DNS regarding how to follow the care plan. Further review of the facility medical record for Resdient #1 revealed, the facility Progress Note and Communication Form dated 12/28/15: Resident #1 had swellling of the left lower leg from the knee down the calf and pain that was treated with Tylenol. Additional record review revealed, the facility Nursing Home to Hospital Transfer Form dated 12/29/15 noted Resdient #1 was sent to the emergency room for increased pain and swelling of the left leg early in the morning of 12/29/15. Review of the hospital records on 01/04/16 revealed, Resident #1 had a fractured left leg with displacement.

Based on interview and record review, it was determined the facility failed to follow their bed-hold policy for 1 of 3 sampled Residents (1). By not following the facility's bed-hold policy Resident 1 was left without placement following a scheduled hospitalization , which resulted in psychologic harm for the resident. Findings include: The facility's Bed-Hold Policy, dated 7/1/15, read: if you are hospitalized , you will be readmitted immedicately upon the first availability of a vacant bed in a semiprivate room. Record review revealed Resident 1 admitted to the facility on [DATE] and was transferred to a hospital on [DATE] for a scheduled surgery. On 9/22/15 at 12:01 p.m., an outside provider reported that the facility refused to take Resident 1 back from the hospital after her planned surgery. Initial record review revealed an undated Notice of Bed-Hold Policy and Rights was checked as hand delivered and dated 9/15/15 with Resident 1's name on the form. A nursing note entry, dated 9/15/15, documented resident wants to leave bed hold in the same room while in the hospital. On 10/13/15, Resident 1 was interviewed by telephone. When asked about the bed-hold policy notice, she stated the Licensed Nurse gave her the bedhold policy form. She verified she was told my bed would be held for 3 days. Resident 1 stated she was in the hospital for only 3 days, had anticipated to return to the faciltiy, felt upset and stated they did me wrong. On 10/9/15, during an interview with the Director of Nursing (DNS) she verified Resident 1 was not given a written discharge notice. A bed-hold policy form was in her chart, however facility administration had informed the hospital that the facility would not be readmitting Resident 1. Review of the admits and discharges for 9/15 and 10/15 indicated beds were available. There was no documented evidence provided to indicate the facility had followed up regarding the bed hold for Resident 1.

Based on observation, interview and record review, facility staff failed to follow the care plan and provide the necessary supervision to prevent injury to Resident 1. The resident fell out of bed while being dressed, and sustained a head injury including a laceration, requiring outside medical treatment. Findings include: Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 4/26/15, revealed he was dependent on 2 person assistance with bed mobility, transfers and dressing. The MDS indicated he had impairments of his left upper and lower extremity and weighed 173 pounds. On 7/15/15 at 10:40 a.m., Resident 1 was observed seated in his tilt back wheelchair. Both hands were contracted and his left arm and hand rested in the wheelchair trough device for support. A laceration was noted on his right side of his forehead. Review of the care plan and care delivery guide revealed the resident required 2 person assist with bed mobility and transfers. The facility's investigative report, dated 7/14/15 indicated during preparation to transfer the resident out of bed, one nursing assistant (NAC A) left NAC 2 with Resident 1 to obtain a sling for the mechanical lift. During this time, the other NAC 2 attempted to turn the resident in bed without the assistance of another staff member. The report also revealed that a 2 person assist was to be available for resident care and that NAC 1 was left with Resident 1 and was not attentive enough to resident's needs while providing care. On 7/15/15 at 11:50 a.m., the Resident Care Manager verified Resident 1 required 2 person assist with his bed mobility and transfers. On 7/15/15 the Director of Nursing verified the resident's Plan of Care was not followed and the resident sustained [REDACTED].

Based on interview and record review, the facility failed to monitor pressure sores and provide timely wound care for 1 of 3 residents (2). Failure to consistently assess Resident 2's pressure sores resulted in a delay in treatment and deterioration of the pressure sore. Findings include: The facility's policy for Admission Skin Assessment directed staff to complete a skin assessment form and a skin grid for each skin issue, to monitor skin impairment daily until healed and to document weekly skin assessments. RESIDENT 2: Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The hospital record revealed the resident had sustained a fall at home and was on the floor for several days after his fall and had developed pressure sores on his thigh, axilla (armpit), chest, shoulder and back due to his immobility after the fall. The facility's risk assessment for skin issues, dated 3/18/15, revealed Resident 2 was at risk for skin breakdown due to his bedfast state and limited mobility. This assessment form revealed the resident had over 20 skin issues which included abrasions, scabbed areas, blisters, and unstagable wounds. Even though numerous skin issues were identified on the inital admit skin assessment form, only 4 skin grid sheets were completed by Licenses Nurses (LNs) as follows: a) right posterior hip revealed a 10 centimeters (cm) by 3 cm area with center scab that measured 6.8 cm by 1.7 cm. (right buttock) b) left anterior chest revealed a skin issue that measured 1.2 cm by 9.0 cm in size with undetermined depth. c) Left axilla (armpit) area had a wound that measured 11 cm the 3.5 cm in size d) left posterior shoulder's wound measured 1.5 cm by 5.5 cm in size. After theses 4 initial skin grid documentation forms were completed, there was no documented evidence the other pressure sores (thigh, shoulder, chest) were measured to evaluate whether there was improvement or deterioration of these pressure sores. The nursing progress note, dated 4/4/15, documented the right buttock (posterior hip) pressure sore measured 8.5 cm by 1.5 cm in size, contained slough (dead tissue), had drainage that was foul smelling and the surrounding wound tissue (periwound) area measured 6 cm by 11 cm in size. Another nursing note entry revealed the physician was notified on 4/4/15 as the right buttock (posterior hip) wound was showing signs of infection and an order was received to obtain a wound culture. The note documented that on 4/5/15, the wound contained slough, had purulent drainage and the peri-wound area was angry red. At this time, the physician order [REDACTED]. The Treatment Administrative Record (TAR) for March 2015 revealed there was no documented evidence the pressure sore on the right buttock area was monitored or a treatment was initiated until 4/4/15. The TAR for April 2015 revealed that not until 4/4/15 (16 days) after admission an order was obtained for the right buttock wound. In addition to a delay in wound care treatment, there was no documented assessment with measurement on the facility's skin grid sheet for the right buttock (posterior hip) pressure sore until 4/5/15, 17 days after the initial measurement. Resident 2 was discharged home with home care on 4/6/15. A referral to a wound clinic was made as the LN documented he required daily wound care. During an interview on 4/4/15, the Director of Nursing (DNS) stated the wounds on admission for Resident 2 were related to pressure due to the his history of being immobile for several days after his fall at home. She verified the LNs had not followed the facility's policy for wound care. She stated the LN did not assess the pressure sores to determine whether the pressure sores were healing. She verified the Resident 2's right buttock (posterior hip) pressure sore had deteriorated.

Based on observation, interview and record review, the facility failed to ensure that the residents' environment remained free from accident hazards, and failed to ensure residents received adequate supervision and safety with assistive devices, for 3 of 4 residents sampled (Resident #1, 2, 3). This failure contributed to substantial injuries in 3 residents' falls, including a chin laceration, a head laceration, and a fractured hip. Findings include: ---Also see F225--- RESIDENT #1: FALL IN BATHROOM, CHIN LACERATION/SUTURES According to record review of facility medical records on 09/04/2014, Resident #1 was admitted to the facility for rehabilitation in July 2014. Review of the facility Minimum Data Set (MDS) assessment dated [DATE] revealed, Resident #1 needed extensive assistance for toileting from one staff, used a walker, and had a BIMS score of 13/15. Review of the facility Care Plan dated 07/19/2014 revealed, Resident #1 was to have one person assistance with transfers for fall risk. There was no device for a toilet riser listed on the Care Plan for Resident #1, including on the Care Delivery Guide for the caregivers. Review of the facility Progress Notes dated 08/01/2014 revealed, Resident #1 "fell from toilet riser at 7:45 a.m., and had pain to left knee and chin, laceration to chin, sent to ER". Record review of the facility Incident Investigation dated 08/01/2014 revealed, Resident #1 was found on the floor in her bathroom yelling for help on 08/01/2014 at 7:45 a.m., with a chin laceration, and right facial and knee pain which led to a hospital transfer and stitches for the laceration. Additional review of the facility investigation revealed, Resident #1 was alert and oriented times 4, sat on the toilet, the seat shifted from under her, and she fell . In addition, the investigation noted the equipment involved (toilet riser) was not attached to the toilet seat correctly. In an interview on 09/05/2014 at 11:15 a.m., Staff A, a caregiver assigned to Resident #1 at the time of the fall, stated she did rounds that morning at 6:10 a.m., however, she did not check the toilet riser or bathroom on her rounds at the beginning of the shift. Staff A also stated Resident #1 had moved to that room the day before. In an interview on 09/04/2014 at 2:00 p.m., Staff B, a caregiver who responded to Resident #1's calls for help on the day of the fall in the bathroom, stated when she entered the bathroom, Resident #1 was screaming, and the toilet riser was on the floor". In an interview on 09/04/2014 at 11:00 a.m., Staff C, a therapy department employee who also responded after the fall, stated if the toilet riser is correctly locked to the toilet, it will not come off when a resident sits down. Observation on 09/05/2014 at 11:15 a.m., revealed, in the bathroom for Resident #1 (private room, no other residents share the bathroom) where the fall took place, the toilet had a raised seat on top for Resident #1 to sit on, that was locked to the toilet seat, and did not move. Record review on 09/05/2014 revealed, there was still no intervention on the Care Plan/Care Delivery Guide for Resident #1 for the use of a raised toilet seat, over one month after the fall. Failure to ensure the environment was free of accident hazards, such as an unsecured toilet riser, and failure to ensure the safe use and adequate supervision of devices for Resident #1, contributed to substantial injury, laceration requiring stitches, and pain, after a fall from an unsecured device on the toilet. RESIDENT #2: FALL IN SHOWER ROOM, HEAD LACERATION/STAPLES Record review of facility medical records on 09/08/2014 revealed, Resident #2 was admitted to the facility in May 2014 for rehabilitation and wound care. According to the minimum data Set (MDS) assessment dated [DATE], Resident #1 had a BIMS score of 14/15, and needed extensive assistance for bathing, and all activities of daily living. Review of the facility Care Plan dated 07/23/2014 revealed, Resident #2 needed one person standby assistance with showering. Review of the facility Progress Notes dated 08/04/2014 revealed, Resident #2 fell in the shower at the facility and hit her head, had a laceration, and was sent to the ER, came back with staples on the back of the head, received narcotic for pain. Review of the facility Incident Report and Investigation dated 08/04/2014 revealed, Resident #2 asked for a washcloth, the caregiver "stepped away", and Resident #2 fell from the shower bench to the floor, sustained a laceration to the head with pain. The investigation also noted Resident #2 was alert and oriented during the shower. Further review revealed the paramedics stopped the bleeding at the facility, and Resident #2 went to the ER and received staples to the head laceration. Observation of the facility Shower Room and equipment on 09/08/2014 at 11:40 a.m. with Staff D revealed, a large shower room with multiple shower chairs lines up along the wall and a shower bench also in the room. The shower bench was observed to be about 4 to 5 feet long, with half of the bench with a back bar about 20 inches long, and half the bench without any back bar or other grab bar. In an interview during the Shower Room observation on 09/08/2014 at 11:40 a.m., Staff D stated the shower chairs and shower bench observed are stored in the shower room. Staff D also stated Resident #2's fall was "an unfortunate accident..she fell back and hit her head, there was no back support on the bench, called 911". In an interview on 09/08/2014 at 11:45 a.m., Resident #2 stated there was no back and no back bar on the shower bench when she fell backward and hit her head. Resident #2 also stated she did not know why she was on the bench, nor why she was sitting on the side of the bench with no back bar when she fell in the shower room and sustained a head laceration. Resident #2 further stated she lost her balance, fell backward when the facility staff went around the corner to get more towels, because sometimes she leans when she is sitting. Resident #2 stated she was afraid to go back to the shower room after the fall, and her head hurts all the time. Observation on 09/08/2014 at 11:50 a.m., revealed a golf ball sized bump on the back of Resident #2's head with discoloration. In an interview on 09/09/2014 at 11:25 a.m., Staff E, the caregiver present when Resident #2 fell in the shower, stated she (Staff E) stepped away from sight of Resident #2 when the resident fell in the shower room and hit her head. Staff E also stated Resident #2 was on a shower bench because Resident #2 "insisted" she wanted to use the bench. Staff E also confirmed Resident #2 was on the end of the bench that had no bar or back support because Staff E "thought it was okay". In an interview on 09/08/2014 at 12:10 p.m., Staff F, a nursing supervisor, stated the staff was always supposed to use the shower chair for Resident #2 because she leans, but the staff used the shower bench on the day Resident #2 fell off the bench and hit her head. Additional review of the facility medical record for Resident #2 on 09/08/2014 revealed, no documentation of a comprehensive assessment or plan of care for the use of the shower bench device (and without back bar or other bars on the device), for Resident #2. The facility did not ensure adequate safety for the the equipment and devices used for Resident #2 in the shower room, and did not ensure adequate supersion during the shower. This failure contributed to the substantial head injury for Resident #1 and pain. RESIDENT #3: FALL IN ROOM, HIP FRACTURE, SURGERY, DELAYED DISCHARGE Record review of facility medical records on 09/04/2014 revealed, Resident #3 had dementia, and was admitted to the facility in May 2014 for rehabilitation after a fall and left hip fracture, with a plan to return to previous living environment where he ambulated independently. Review of the facility Safety Device Data Collection form dated 05/16/14 revealed, the facility placed a mattress next to the bed for resident #3 for poor safety judgement, and the Safety Reduction Plan was to "Reduce while in therapy". An update to the Device Review dated 06/11/2014 noted, fall mattress was placed on left side of bed to prevent serious injury. Review of the facility Care Plan dated 06/11/14 revealed, a Safety Device Plan for a fall mattress to left side of bed for poor safety judgement. The Care Plan dated 06/18/2014 also noted an intervention for fall risk: mattress to floor, and low bed. In an interview on 09/04/2014 at 11:35 a.m., Staff G, a nursing supervisor, stated the facility only placed fall mattresses (a twin size bed mattress) instead of flat fall mats, next to beds for residents who are non-ambulatory. In an interview on 09/04/2014 at 11:40 a.m., Staff D, an administrative employee, stated the facility had adequate supply of fall mats, and (bed mattresses) were only placed next to beds of residents who were non-ambulatory. Further review of the facility Nursing-Therapy Communication revealed Resident #3 was cleared of all restrictions by orthopedics on 06/20/2014. Review of the facility Progress Notes dated 06/20/2014 revealed, the Orthopedic surgeon informed the facility the left hip was completely healed, and there were no further activity restrictions or needed appointments. Review of a facility Progress Note dated 07/02/2014 revealed, Resident #3 was observed to ambulate out of the patio door to the patio on his own when a wander alert system sounded. Review of the facility Physical Therapy Notes dated 07/03/2014 revealed, Resident #3 ambulated with stand-by assist along hallways for 38 minutes with intermittent rest breaks. Review of the Care Plan and Device Plan noted above revealed, no update to the intervention of the fall bed mattress, and no "reduce while in therapy", since the improvement in Resident #3's ambulation ability, including the unplanned ambulation outside to the patio in July 2014. Further review on 09/08/2014 of the facility Physical Therapy notes dated 07/01/2014 and 07/02/2014, one and two days before the fall on 07/03/2014, revealed Resident #3 ambulated 800 and 1000 feet with standby assist only. Although the Device Plan had noted a plan for the mattress to "reduce while in therapy", the facility did not ensure the update to the safety device plan was done to prevent falls after Resident #3 was ambulatory in late June when activity restrictions were lifted (as above), nor in early July when Resident #3 ambulated out the facility door on his own (as above). A bed mattress remained in place on the floor by the bed for Resident #3. Additional record review of the facility Progress Notes dated 07/03/2014 revealed, at 8:00 p.m., Resident #3 was found on the floor in his room by the bed mattress after the staff heard a loud noise. Review of a facility Progress Note dated the next day 07/04/2014 after the fall revealed, the facility replaced the mattress next to the bed with a mat for safety due to the unsteady surface of the mattress. Review of the Facility Investigation dated 07/04/2014 revealed, Resident #3 fell due to an uneven surface of the fall mattress, and the right hip was fractured, Resident #3 was sent to the hospital for surgery. The facility failure to ensure adequate safety plan update for the bed mattress intervention for Resident #3, and failure to ensure his environment remained free of accident hazards, contributed to the fall and fracture, which occurred after Resident #2 progressed in therapy.

Based on interview and record review, the facility failed to prevent use of phsycial restaint on Resident 1. Facility staff physically restrained and harmed Resident 1 when a staff person held her shoulder and arm for a blood draw without permission from and understanding by the resident. Findings include: Resident 1 was admitted in 2006 after a stroke. Her right arm was paralyzed. Her left side was weak. Her most recent minimum Data Set assessment, dated 12/15/11, identified she required one person to assist her with dressing, repositioning and transferring. She used a wheelchair for mobility. Her short-term and long-term memory and recall ability were intact. Her native language was Korean. She understood and spoke some English and some Japanese. Resident 1 usually understood, but missed some part/intent of messages. On 12/28/11 at 12:30 p.m., Resident 1 was interviewed with a Korean interpreter. She reported on 12/07/11 at about 5 a.m., an "outside person" (someone she did not know) entered her room and woke her up. The person wanted to draw blood from her. At first, Resident 1 was upset about someone she did not know entering her room and waking her up. She said "no". As she woke up and understood what the person wanted - to draw blood from her - she repeated "no" as she did not want her blood drawn. The "outside person" left her room. A few minutes later, the "outside person" returned to her room with licensed Nurse (LN) 1 . LN 1 spoke to her in English. The only thing she understood of what LN 1 said was "doctor order". She did not understand anything else he said to her. No one told her why the blood was needed. She had already said no, but LN 1 held her shoulder and arm while the "outside person" drew her blood. She could not resist when he held her arm and shoulder because her left side is weak and the right side is paralyzed. "They drew the blood anyway." She stated, "It was a mistake to draw the blood." Resident 1 explained if she were in the hospital, sick, they could draw blood. She was well, not in the hospital, and they did not need to draw blood. Review of the facility investigation revealed Resident was identified as having "limited English". On 12/07/11 Resident 1 told S2 she was "afraid of LN 1 because she said "no" to the blood draw but he didn't listen to her." On 12/09/11, using LN 2 as interpreter, Resident 1 told the facility staff she was "upset because he held her arm down to draw blood." Resident 1 thought LN1 did not understand her wishes. The facility documented Resident 1 did not resist or pull away from the staff. There was no evidence they asked Resident 1 why she did not attempt to pull away from the staff or how she felt about the blood draw being done after she told both the phlebotomist and LN 1 no. Review of the care plan for Resident 1 revealed no interventions for enhanced communication and understanding of how Resident 1 felt about blood draws outside the hospital setting.

Based on interview and record review, the facility failed to provide food items preferred by Resident 1. This failure to consistently implement their policy for delivery of preferred foods resulted in psychological harm for Resident 1 when staff delivered a sandwich containing foods to which he was known to have allergic reaction anaphylactic shock. Findings include: Resident 1 was admitted in September 2011 with recently diagnosed spinal disease that resulted in an inability to walk. His Minimum Data Set (MDS) assessment, dated 09/14/11, identified his cognitive ability score as 15/15. On 11/15/11 at 9:15 a.m., Resident 1 reported the facility was not careful about his diet and food allergies [REDACTED]. NA 1 went to the kitchen and asked for a sandwich for the resident. She returned and handed a sandwich to him. He unwrapped the sandwich. When he put it near his mouth, he could smell it contained tuna salad. Resident 1 was allergic to all forms of fish. He did not eat the sandwich. He stated if he ate fish his throat tightened, his eyes watered and his tongue became swollen. Resident 1 stated the facility staff knew he was allergic to fish because he had told them when they served fish at lunch a couple of days before. Resident 1 stated, "They put my life at risk that day." When the incident occurred, he "cried" and felt "stressed". Resident 1 was so "upset", he refused to eat anything prepared in the kitchen for several days. He wanted to purchase his own food from outside the facility. He questioned the care in the facility and was afraid it could happen again. He considered leaving the facility. Resident 1 felt the staff were "uncaring" and showed a "lack of respect" by bringing him such a sandwich. At 10:10 a.m., the Director of Nursing Services (DNS) reported the facility learned of Resident 1's fish allergy on 11/07/11 when crab cakes were served at lunch time. Resident 1 told the kitchen staff then he was allergic to fish. The DNS stated they followed their process and notified all departments in the facility as well as pharmacy services. His clinical record was updated with the allergy information. On 11/09/11, about 4 p.m., she was notified by staff that Resident 1 wanted to speak with her. She entered his room and observed he was "really upset". Resident 1 told her of the tuna salad sandwich and he would not eat anything from the kitchen. He wanted to buy his own food and cook it himself. He "cried tears". He did not want to stay and was considering leaving the facility. The DNS questioned both NA 1 and Kitchen Staff (KS) 1. NA 1 stated she did not tell KS 1 who the sandwich was for. KS1 stated he did not follow procedure and ask NA 1 who the sandwich was for as he should have. The DNS concluded Resident 1 had psychological harm from the incident and placed Resident 1 on alert charting. Review of the facility investigation revealed the sandwich was unmarked. It lacked a label to identify its contents. The facility confirmed Resident 1 did not eat any of the sandwich. The facility concluded neglect occurred and Resident 1 suffered psychological harm.

Based on observation, interview and record review, the facility failed to administer services effectively and efficiently in order to attain, and/or maintain, each resident's optimal physical, mental and psychosocial well-being. This failure resulted in harm for 3 residents and placed the other residents at risk for abuse, neglect and a decreased quality of care. Findings include: 1. Administration failed to ensure a resident was free from neglect. Facility staff neglected to provide care and services in accordance with a resident's plan of care, neglected to investigate a fall directly related to this failure and failed to notify the residents family and physician. These failures resulted in harm for a resident. Refer to F224 - Prohibit mistreatment/Neglect 2. Administration failed to ensure the facility abuse and neglect policies and procedures were operationalized when multiple staff had knowledge of neglect of a resident. Refer to F226 - Develop/ implement abuse/neglect policies 3. Administration failed to ensure a resident was free of any sufficient medication errors, that staff provided care and services in line with the standards of care, and to ensure staff followed pharmaccutical policies and procedures to administer medications safely. The failures represented an immediate jeopardy potentially placing all residents at risk for significant medication errors. Refer to F281- Standards of care, F333 -Significant medication errors, and F425 Pharmacy Services 4. Administration failed to notify the registered dietitian and accurately monitor the nutritional needs for a residents identified at risk for nutritional needs due to skin breakdown and disease process. This resulted in harm as evidenced by significant weight loss of 8.6 % in one month for a resident who required nutritional intake/supplements for wound healing and fluid loss due to episodes of diarrhea. Refer to F325- maintain nutritional status unless unavoidable

Based on interview and record review the facility failed to ensure an effective pharmaceutical system was in place to ensure safe medication administrator for residents with known drug allergies [REDACTED]. This failure resulted in Resident 9 to receive a medication they were known to be allergic to causing the resident to experience an adverse medication reaction with dizziness and low blood pressure. This failure was identified as immediate jeopardy placing all residents in the facility at risk for receiving medications with a known allergy. Findings include Resident 9 was admitted [DATE] with [DIAGNOSES REDACTED]. According to the residents clinical medical record she had multiple allergies [REDACTED]. (a class of medication to lower the blood pressure). The exact date of the onset of the ACE inhibitor allergy was unclear, however, the allergy was clearly noted in many areas in the residents clinical record including a Nursing Comprehensive Admission Data Collection and Assessment form showed the allergy record as early as 10/28/09. On 8/11/11 the consulting pharmacist recommended to the resident's physician that he should consider starting Resident 9 on an ACE inhibitor, Lisinopril, to reduce the risk of cardiovascular and renal adverse effects. On 9/14/11 the resident's physician approved the recommendation as was recommended by the pharmacist. According to the consulting pharmacist he had not been listing allergies [REDACTED]. Review of the resident's September 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s September MAR's. All of a months MAR pages for a resident are kept together to be used by the Licensed nurse (LN) administering the daily medications. Resident 9's allergies [REDACTED]. According to the resident's September 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/19/11 at 11:00 a.m., LN 4 described the procedure the staff followed when new orders were received for a resident. She stated the LN receiving the order would send the pharmacy the new order to have it filled. If the medication ordered was a time critical medication such as an antibiotic or stat (immediately) order they would take the first dose out of the emergency kit. When asked about checking allergies [REDACTED]. If an allergy was found than the physician would be notified. There was no documentation available to show if staff had followed the above procedure. On 10/19/11 at 11:15 a.m., LN 3 stated he usually looked at a resident's MAR indicated [REDACTED]. On 10/19/11 at 3:15 p.m. when the DNS was asked about the medication error she could not provide details saying she was not with the facility at the time of the error. She continued that since being made aware of the error she would be providing education to the nurses. The training would include not accepting a class of medication, such as ACE inhibitors as an allergy but for the LN to get the name of the medication and the reaction the resident had to the medication. When asked why she would be making the change, she stated the nurses may not of recognized the medication as being an ACE inhibitor. A review of the facility procedure/policy for "physician's orders [REDACTED]. The policy did not address checking for an allergy upon receipt of a new medication order. The facility procedure/policy for "Medication Error(s)" directed staff in step 11 to "Complete the Medication Error Report on all residents who are involved in a medication error. 11 a. "The nurse who discovers the error will initiate and complete the form. Step 13 "Develop and maintain processes for defining, identifying, and reviewing these significant medication errors collaboratively with Nursing, Pharmacy, and other appropriate staff through the PI Committee. The facility could not provide any documentation to show the steps in the above policy was followed or that they had made any changes after the error to prevent the error from reoccurring. See F42CFR 483.25(m)(2) F333 for the facilities failure to ensure Resident 9 was free of significant medication errors. See F42CFR 483.20(k)(3)(i) F281 for the facilities failure to ensure Resident 9 recieved services that met professional standards of qulaity care.

Based on interview and record review, the facility failed to failed to ensure 1 of 11 sampled residents (9) was free of significant medication errors. This failure of the multiple facility licensed nurses, the resident's physician, and the pharmacist to recognize the resident had an known allergy to the medication ordered and administered contributed to the residents complaints of dizziness, her development of low blood pressure and placed the resident at risk of developing more serious life threatening complications. The facility also failed to investigate how the incident occurred and to develop a plan to prevent similar medication errors from occurring. This failure was identified as immediate jeopardy and placed all residents in the facility at risk of being administered a medication with known allergic reactions. Findings Include Resident 9 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. According to the resident's annual Minimum Data Set assessment, dated 7/17/2011, the resident was cognitively intact including her short and long term memory. A review of the resident's clinical record revealed the resident had many allergies including an allergy to ACE inhibitors. ACE inhibitors are a class of medications used to lower blood pressure. Side effects of [MEDICATION NAME], an ACE inhibitor, include dizziness, stroke, chest pain, low blood pressure, [MEDICAL CONDITION] (rapid swelling under the skin which can lead to airway obstruction and suffocation) and increased potassium levels. The residents clinical record had been clearly marked with the resident's medication allergies including her allergy to ACE inhibitors prior to her being administered 2 doses of [MEDICATION NAME]. Resident 9's allergies were listed on the following places in the residents clinical record and readily accessible to the licensed nurses (LN), physicians and consulting pharmacist. - The allergy label on the front cover of the residents clinical record read " ALLERGIES Multi- see face sheet"." - Resident 9's face sheet, dated July 27,2011, located at the front of the residents clinical record listed the residents allergies, including her allergy to ACE INHIBITOR's. - The resident's printed physician's orders [REDACTED]. found to be clearly labeled with the residents allergies including her allergy to ACE inhibitors. - The resident's medication administration records (MAR) were reviewed back through July 2011 and were found to have the allergy to ACE inhibitors clearly noted at the bottom of the forms. - The " Report of Consultation" form, dated 7/14/11, given to the facility after the resident's cardiology appointment listed under Allergies "ACE- angio [MEDICAL CONDITION]". - The residents "Nursing Comprehensive Admission Data Collection and Assessment form", dated 10/28/09 listed the resident's allergies including the allergy to ACE inhibitors. In the pharmacist Consultation Report, dated 8/11/2011, the pharmacist recommended the physician should consider starting the resident on [MEDICATION NAME] 2.5 mg (milligram) daily based on the 2011 American Diabetes Association Clinical Practice Recommendations which suggest that antihypertensive therapy start with the addition of an ACE-Inhibitor (or angiotensin receptor blocker (ARB)) to reduce the risk of cardiovascular and renal adverse events. The Consultation Report form also recommended that the residents blood pressure should be checked 2-3 hours after the first dose, then every shift for three days, then weekly. The 8/11/2011 pharmacy Consultation Report recommendation for [MEDICATION NAME] was a resultant of a required monthly medication regime review by the pharmacist, which included reviewing the resident's clinical records. Allergies are not usually listed on the Consultation Report form or on the pharmacy monthly monitoring form, however Resident 9's allergy to ACE inhibitors was clearly identified in the residents clinical record and should have been caught by the pharmacist prior to them making the recommendation to the physician. On 9/14/11 the physician agreed to the [MEDICATION NAME] recommendation "I accept the recommendation(s) above, please implement as written." On 9/14/11 a facility LN transferred the approved recommendation which had been signed by the physician,to a telephone order (T.O.) form to have the resident's physician resign the order. The T.O. did not contain any allergy information. The LN then noted in a progress note (PN) in the resident's clinical record, dated 9/14/11, that "Pharmacy recommendations received, approved by MD and order noted." The front of the resident's chart was clearly marked with a bright colorful sticker indicating the resident had "multi-allergies - see face sheet". There was no indication the LN checked the face sheet for allergies prior to sending the telephone order to the physician, when writing the PN or prior to writing the order on Resident 9's MAR. According to the facility's "physician's orders [REDACTED]." There was no indication in the resident's clinical record that the order for [MEDICATION NAME] was faxed to the pharmacy. The Facility "Medication Administration" policy instructed LN to do the following prior to administering a medicaion: - Step # eight (8) LN's to "Read the MAR for the ordered medication dose, dosage form, route and time. - Step # nine(9) LN's to "Review resident allergies". Had the LN administering the medication checked the resident allergies which were listed on the resident's MAR's, she would have seen the resident was allergic to ACE inhibitors. According to Resident 9's September 2011 MAR indicated [REDACTED]. Neither LN administering the medicaiton recognized that the resident had an allergy to the medication. As ordered a LN recorded the resident's blood pressure taken 2- 3 hours after the first dose and recorded it on the MAR indicated [REDACTED]. No blood pressure was obtained prior to the administration of the first dose of the medication to use as a baseline. The blood pressure one week later was 136/72. In a day shift PN, dated 9/17/11, the nurse noted that the resident complained of pain, received her pain medication (which she had taken before). The LN then wrote they had retrieved [MEDICATION NAME] 5 mg from the facilities emergency kit, cut the tablet in half to get the correct dose and gave it to the resident. The LN documented the resident's blood pressure was 130/80, and that at 11:30 a.m. the resident complained of dizziness and her blood pressure was 114/60. LN noted she would continue to monitor. The PN from the evening LN, on 9/17/11 said "Noticed new order for [MEDICATION NAME] to this class of medications, ACE inhibitors...Faxed MD." The LN also noted the physician discontinued the medication and that the resident was without signs or symptoms of allergic reaction, even though Resident 9 complained of dizziness after recieving the 2nd dose. Resident was placed on alert to monitor the resident due to the medication error. On a Physician Fax Form, dated 9/17/11, the LN wrote that the resident was started on [MEDICATION NAME] 2.5 mg daily on 9/15/11. The licensed nurse (LN) wrote "However resident is allergic to this class of medication, ACE inhibitors, 2 doses of drug have already been given in the am of 9/16/11 and 9/17/11. Resident complained of dizziness in a.m., layed in bed for a couple hours with good effect." On 9/17/22 the order for the [MEDICATION NAME] was discontinued by the physician and staff was instructed to "advise the pharmacist". On 9/18/11 a PN in the residents clinical record, the day LN noted that the resident had no complaints of dizziness and recorded her blood pressure as 106/48. On 10/19/11 at 3:15 p.m. the Director of Nursing Services (DNS) stated she was not aware of this medication error since it had occurred prior to her coming to the facility in August 2011. She continued to state she could not locate a medication error incident investigation and did not know what measures the facility had taken to prevent reoccurrence of similar incidents. The DNS stated, "The nurse is ultimately responsible for ensuring residents received the proper medication. She stated nurses are to follow the 5 rights of medication pass and to check for allergies. In an interview on 10/19/11 at 4:35 p.m., the consulting pharmacist he stated he "Generally" checks allergies prior to making recommendations but that his main focus was on renal function and dosage. In an interview with Resident 9 on 10/20/11 at 9:50 a.m., she stated she had "many" allergies and could not recall what all they were. She stated she did not remember starting a medication for her blood pressure in September except for a "water pill" and one for her "involuntary movements" (The resident pointed to her mouth) that started with a "Z", she thought. On 10/20/11 at 4:00 p.m., the DNS stated the pharmacy had never filled the new order and then after reviewing the resident's clinical record the DNS stated it appeared the LN had taken the medication out of the E-kit to administer. A review of the E-kit list provided by the facility confirmed that a 5 mg [MEDICATION NAME] was available from the E-kit. 10/26/11 at 11:00 a.m., the pharmacy was contacted to clarify the delay in the resident recieving her first dose of the [MEDICATION NAME] which had been ordered on [DATE] and was not started until 9/16/11 and to inquire why staff had to remove the medication from the E-kit. The Executive Manager for the pharmacy stated the pharmacy had been faxed the new order to fill, However the resident's profile had been flagged with the allergy in their pharmacy system so the pharmacy had notified the facility "Twice in fact, the 14 th and 15 th I believe it was" informing them of the need to clarify the order due to the resident's allergy to ACE inhibitors. The Executive Manager stated the [MEDICATION NAME] order was never filled by the pharmacy.

Based on interview and record review the facility failed to follow their policy and ensure professional standards of care were followed for 2 of 11 sampled residents (9,148) for medication administration and emergency services. This failure resulted in Resident 9 receiving a medication they were allergic to, even though the order was reviewed and handled by multiple professional staff, causing Resident 9 to experience dizziness and low blood pressure, constituting an Immediate Jeopardy for Resident 9 and placed all residents in the facility at risk for being administered a medication in which they have a known allergy to. Staff failed to follow their policy regarding the need for specialized services for Resident 148's intravenous maintenance which placed the resident at risk for possible complications. Findings include: Resident 9: Definitions: -Individual medications belong to a "class" which meaning they are classified by the chemical type of the active ingredient or by the way it is used to treat a particular condition. -The medication [MEDICATION NAME] belongs to the "class" called ACE inhibitors. ACE inhibitors are medications used to lower the blood pressure and provides renal protection for residents that have diabetes. - A federal regulation requires a nursing facility to employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provisions of pharmacy services in the facility, which include monthly pharmacist reviews of each resident's medication regime. The overall goal of the pharmaceutical service system within a facility is to ensure the safe and effective use of medications. Resident 9 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's 7/10/11 annual Minimum Data Set Assessment (MDS), the resident was cognitively intact. Upon review of the Resident 9's clinical record revealed that Resident 9's allergies, including her allergy to ACE inhibitors, were clearly documented in several areas of the resident's record. The front of the resident's clinical record had a brightly colored allergy sticker on the front of the record that read, " multi- allergies, see face sheet " . The resident's face sheet, printed physician orders [REDACTED]. Documents in the resident's record showed the resident's allergy was identified many years ago. Her clinical record review also revealed that monthly medication reviews had been completed by the facility's consulting pharmacist and was documented on the monthly medication review form in the resident's record. On 8/11/11 the facility's consulting pharmacist recommended to Resident 9's physician that since the resident was a diabetic with high blood pressure , he should consider starting the resident on [MEDICATION NAME] for renal protection. The recommendation form did not list the resident's allergies and there was no other documentation in the resident's record that the pharmacist had discussed the resident's allergy to ACE inhibitors ( [MEDICATION NAME] belonged to the ACE inhibitor class)with the physician prior to recommending the [MEDICATION NAME]. In an interview with the consulting pharmacist on 10/19/11 at 4:35 p.m. he stated he " generally " checks for allergies prior to making recommendations. Failing to alert the physician to the known allergy of the resident placed the resident at risk for being administered a drug she was allergic to. Resident 9 was administered the medication and experienced dizziness and low blood pressure, which can be an adverse effect of this medication. A review of the resident's physician progress notes [REDACTED]. The last last on-site visit of the physician was recorded in the resident's record on 8/19/11. On 9/14/11 Resident 9's physician signed the [MEDICATION NAME] order twice. Once on the pharmacy Consultation Report and then again on telephone order where staff had transcribed the order from the consultation form. Neither of these forms showed the resident's allergies. There was no documentation found that showed the physician had communicated with the pharmacist or the resident about the resident's allergy. In reviewing Resident 9's September 2011 Medication Administration Records (MAR) revealed the LN that transcribed the [MEDICATION NAME] order from the signed physician order [REDACTED]. The LN did not transcribe the resident allergies to the new MAR page added to the rest of the September MAR's. The resident allergies were listed on the preprinted September MAR pages for the resident. According to the resident's September MAR indicated [REDACTED]. There was no documentation in the resident's clinical record indicating why there was a delay in starting the [MEDICATION NAME] ordered on [DATE]. When staff was asked about the delay they could provide no information regarding the reason for the delay. On 10/21/11 at 11:55 a.m. LN 7 stated that the pharmacy usually delivered in the early a.m. and that they make a " mid-day run somewhere around 4 p.m. " . She reported that if a medication was ordered in the evening it was usually delivered the next morning " But not always " . She continued that they sometimes had to take the first dose out of the facility medication emergency kit (E-kit) so they can get the medication started. In an interview with the DNS on 10/20/11 she stated she did not know why the LN had to take the doses of the [MEDICATION NAME] out of the E-kit or why the medication was delayed in getting started. She confirmed that it was the facility policy to get the first dose out of the E-kit if the medication ordered was a time critical order such as an antibiotic or a medication ordered to be given " Now " . Review of Resident 9's clinical record progress notes (PN) showed a LN had documented that the order for the [MEDICATION NAME] had been received. There was no further documentation in the clinical record regarding the medication until 9/17/11. On 9/17/11 the day LN documented she had retrieved a 5 mg dose of [MEDICATION NAME] from the E-kit, cut it in half to get the correct dose and administered it to the resident. (This was resident's second dose). The next PN was written by the evening LN on 9/17/11 documented the resident had experienced dizziness, that the LN noticed the resident's history of the allergy to ACE inhibitors, that she had notified the physician and that the medication had been discontinued. There was no documentation in the clinical record to show if and when the [MEDICATION NAME] order was faxed to the pharmacy, why the medication was not filled by the pharmacy, why the first dose was no administered until 9/16/11 or that the resident's history of an allergy to ACE inhibitors had been discussed with the pharmacy. The facility policy and procedure titled " Physician order [REDACTED]. " Staff present during the survey period was unable to say if the new order for the [MEDICATION NAME] had been sent to the pharmacy upon receipt of the order. During a telephone interview on 10/26/11 the pharmacy Executive Director stated that the facility staff had faxed the new order for the [MEDICATION NAME] to the pharmacy on 9/14/11. He added that when the pharmacy received the [MEDICATION NAME] order the pharmacy system had alerted them to the resident's allergy to the ACE inhibitors. The pharmacist then notified the facility staff " twice " of the resident's allergy and that [MEDICATION NAME] belonged to the ACE inhibitor class of medication. The pharmacy requested that facility staff contact the physician and clarify the order before the pharmacy could fill it. The pharmacy caught the allergy to the medication, notified the facility staff of the allergy concern and did not fill the medication as ordered. There was no evidence that the facility staff clarified the [MEDICATION NAME] order with the resident's physician which led to the resident receiving the medication even though she was allergic to it. During an interview with the Director of Nursing Services (DNS) on 10/18/11 at 2:55 p.m. she stated that LNs were expected to hold a medication until it was clarified. The LNs then communicated this information by passing the concern down to the other LNs shift by shift verbally and by noting it in the 24 hour report book and that each LN was responsible for reading the 24 hour report at the beginning of their shifts. There was no evidence that the nurses attempted to clarify the order or that there was any concern with the resident's medication passed on in the 24 hour report book. According to the facility policy and procedure " Medication Administration " step 23 directed staff to " Document in the 24 hour status report to identify resident/clinical issues that need review and/or action for follow-up at daily clinical review meetings. The staff's failure to follow the facility policy for clarifying medication, no holding the medication until clarified, and not alerting other staff of potential medication concerns for Resident 9 lead to the resident receiving a medication she was allergic to. On 10/19/11 at 3:15 p.m. the DNS stated she had not been made aware of the medication error at the time of the error so no investigation had been completed to determine the cause of the error and that a plan had not been put into place to prevent reoccurrence's. The DNS said she planned to start an investigation " Today " . She continued saying, it was ultimately the responsibility of the LN administering the medication to ensure the resident had no allergies to a medication prior to giving it to a resident. She continued " They are the last check. " The facility policy " Medication Administration " read that the licensed staff and/or medication assistant will check the following to administer medications. Step # 9 read: Review resident allergies. There was no indication that the two LNs that had administered the [MEDICATION NAME] had checked resident allergies prior to administering the medication. The facility policy " Medication Errors " instructed staff to: Complete the Medication Error Report form, to develop and maintain process for defining, identifying and reviewing these significant medication errors collaboratively with Nursing, Pharmacy, and other appropriate staff through the performance improvement committee. Staff failed to follow the facility policy which placed all resident's at risk for similar medication errors. On 10/20/11 Resident 9 stated she was not informed of a new medication for her blood pressure being ordered or discontinued in September. The resident stated she had " many " allergies to medications but could not list which ones. The facility policy " Medication Administration " step 5 read: Explain the procedure to the resident, include the type of medication ordered, the reason, the frequency and route. " There was no evidence the staff had informed the resident per policy. INTRAVENOUS (IV) MONITORING AND MAINTENANCE CARE: The facility's policies for peripherally inserted central catheter (PICC) and catheter flushing indicated that a physician's orders [REDACTED]. The order must include: flushing agent, strength/concentration, volume and frequency. The policies directed staff regarding dressing changes and assessment of the access site. The assessment was to include, but is not limited to, the absence or presence of [DIAGNOSES REDACTED], drainage, swelling, tenderness. Another facility form titled "Infusion Maintenance Table" located with the MAR indicated [REDACTED]. Resident 148 physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/11 at 9:12 a.m., LN 3 was observed to take 4 prepacked syringes to Resident 148's room. Three of the syringes contained NS 5cc and one syringe contained 5 cc of [MEDICATION NAME] (10u/cc). LN 3 stated that Resident 148 had a triple lumen catheter. The IV dressing was dated 9/9/11. LN 3 wiped each lumen with a alcohol wipe prior to administrating/pushing 5cc of NS into each lumen. After pushing 5cc of NS into each lumen, the LN pushed approximately 1cc of [MEDICATION NAME] from the pre filled [MEDICATION NAME] syringe into the brown colored line. The LN then removed the [MEDICATION NAME] syringe from the brown line and inserted the same syringe into the blue line.The LN then administered approximately 1.5 cc of [MEDICATION NAME] into the blue line, removed the syringe from the blue port. He then inserted the same syringe into the white port and pushed approximately 2cc [MEDICATION NAME]. When the LN completed the [MEDICATION NAME] pushes, he stated 0.5 cc remained in the prefilled syringe of [MEDICATION NAME]. Interview with two LN (LN8 & LN 7) stated when a resident has a PICC or central line, LNs are to complete the "omnicare treatment forms". These forms were specific to the types of catheters used and outlined what flushes were to be used, monitoring parameters and dressing changes. LN 8 reviewed the TAR and verified that there was no documentation regarding the monitoring of the IV site, or when the dressing had been or was to been changed for Resident 148. The Director of Nursing (DNS) provided a copy of the facility's "Clinical Competency Validation" forms for professional clinical skills for the evaluation and validation for safe clinical practice for IV management. The DNS was unable to provide documentation regarding competency validation for the facility licensed nurses (LNs). Not validating competency skills placed placed Resident 148 and the 4 other residents who had IV medications or maintainence at risk for complications.

Based on interview and record review, the facility failed to operationalize its written abuse/neglect/mistreatment policies and procedures. The facility failed to identify, protect, investigate, prevent and/or report an allegation of neglect. Failures by multiple facility staff to operationalize facility policies and procedures relating to recognize, protect, investigate and report potential neglect as required resulted in harm for Resident 31. Findings Include: Facility Policy: The facility followed their policy for abuse and neglect "Prevention, reporting, investigation, follow-up and final disposition" for incidents, dated 7/2010, and also followed the State "Nursing Home Guidelines for Incident Identification, Investigation and Reporting" book, dated 03/2006. "Prevention, reporting, investigation, follow-up and final disposition" policy included: - Report the incident to the immediate supervisor, physician and family. - Protect resident from further immediate harm or potential harm - Notify the Administrator and Director of Nursing Services immediately if alleged abuse, neglect, mistreatment, injuries of unknown source, and/or misappropriation of property. - Complete and Incident/Accident report, document the occurrence on the Accident/Incident report - Place page one of the Accident/Incident Report in the resident medical record for a resident occurrence. - Document for a minimum of 72 hours in the resident medical record. Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident required extensive to total assistance with all activities of daily living to include 2 person plus physical assist with a mechanical lift. The resident was alert and oriented. During an interview with Resident 31 on 10/14/11 at 8:30 a.m. he stated that over the weekend of October 8th and 9th, he requested assistance to go to the restroom, the Nursing Assistant (NA 1) wheeled him to the bathroom, she attempted to transfer him by herself by picking him up with her arms, she did not use the mechanical lift and she "dropped him." Resident 31 stated he feel on his knees, NA 1 then picked him up and sat him on his chair. On 10/10/11, the facility received a call from the [MEDICAL TREATMENT] Center, informing them Resident 31 was complaining of left knee pain and that the resident stated he had fallen in the facility. The day LN who received this information failed to: Initiate an incident report Protect resident from further immediate harm or potential harm Notify the Administrator and Director of Nursing Services immediately Notify the MD or family of report from [MEDICAL TREATMENT] and Failed to put Resident 31 on alert charting. According to the day LN, she verbally passed the information she received from the [MEDICAL TREATMENT] Center to the evening LN. The LN assigned to the resident on 10/10/11, evening shift also failed to Initiate an incident report Protect resident from further immediate harm or potential harm Notify the Administrator and Director of Nursing Services immediately Notify the MD or family of report from [MEDICAL TREATMENT] Failed to put Resident 31 on alert charting. Failed to assess the resident for pain/injury upon return to the facility from [MEDICAL TREATMENT]. On 10/11/11, (2 days after the fall), At around 5:30 a.m., the resident complained of pain, the night LN assessed the resident and noted swelling to the left knee. an order for [REDACTED]. Not until the resident was transferred to the hospital was an investigation initiated for significant injury of unknown source. The facility incident report indicated the suspected date of the incident was 10/09/11 (two days prior). That day according to NA 1, she was transferring the resident to the toilet without the use of the mechanical lift. When the resident was sitting on the elevated toilet seat, the resident started to slide off. The NA caught him and lowered him to the floor. The NA failed to report the incident to her immediate supervisor. During an interview with the DNS on 10/14/11 at 12:00 p.m., she stated that her expectation was for the LN who had received the fall allegation over the phone should have initiated the investigation and the evening LN should have started the investigation since it had not been started by the day LN. Her expectation was also for the resident's family and physician to have been notified. Multiple staff members with knowledge of an incident of possible neglect failed to immediately report and investigate this knowledge which demonstrated that the facility failed to have an effective abuse/neglect prevention program.

Based on observation, interview and record review the facility failed to ensure 1 of 4 sampled residents,( Resident 31) was free from neglect. Facility staff neglected to provide care and services in accordance with Resident's 31 plan of care, neglected to investigate a fall directly related to this failure and failed to notify the resident ' s family and physician. These failures resulted in harm for Resident 31. 483.12(c) defines Neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident required extensive to total assistance with all activities of daily living to include 2 person plus physical assist with a mechanical lift. The resident was alert and oriented. During an interview with Resident 31 on 10/14/11 at 8:30 a.m. he stated that over the weekend of October 8th and 9th, he requested assistance to go to the restroom, the Nursing Assistant (NA 1) wheeled him to the bathroom, she attempted to transfer him by herself by picking him up with her arms, she did not use the mechanical lift and she "dropped him." Resident 31 stated he feel on his knees, NA 1 then picked him up and sat him on his chair. During an interview with the resident's brother at 9:00 a.m, he stated he was very upset because an NA dropped his brother, the NA didn't tell anyone about the fall and he heard the NA had not used the Hoyer (mechanical lift). He further stated, his brother had a broken leg for days before anyone knew about it and sent him out to the hospital. On 10/10/11, the facility received a call from the [MEDICAL TREATMENT] Center, informing them Resident 31 was complaining of left knee pain and that the resident stated he had fallen in the facility. The day LN who received this information failed to initiate an incident report, failed to notify the MD or family of report from [MEDICAL TREATMENT] and failed to put Resident 31 on alert charting. According to the day LN, she verbally passed the information she received from the [MEDICAL TREATMENT] Center to the evening LN. The LN assigned to the resident on 10/10/11, evening shift failed to assess resident for pain/injury upon return to the facility from [MEDICAL TREATMENT] and since the day LN did not inititate the incident report, the evening LN failed to also initiate it. On 10/11/11, (2 days after the fall), At around 5:30 a.m., the resident complained of pain, the night LN assessed the resident and noted swelling to the left knee. At 7:00 a.m., an order for [REDACTED]. At 4:30 p.m., (8 and a half hours after assessment revealed swollen and painful knee and allegation of a fall had been communicated to the facility by the [MEDICAL TREATMENT] Center ) results revealed a [MEDICAL CONDITION] femoral condyle. Resident 31's MD was faxed the results. At 5:40 p.m., After not hearing from the MD, the facility called him to inform him of the x-ray results. The MD ordered Resident 31 to be sent to the hospital. At 7:30 p.m., the resident was sent to the emergency room for evaluation Not until the resident was transferred to the hospital was an investigation initiated for significant injury of unknown source. On the pain data collection and assessment dated [DATE], (a few days after the fall). The resident's pain was documented as 10/10, the resident's pain when moving around was also rated at a 10/10. (with 0 being no pain and 10 being most intense pain imaginable.) In an interview with LN on 10/12/11 at 9:20 a.m., LN stated that the resident complained of pain every day but not as frequent and as intense as he does now, since the fall. Quarterly pain data collection and assessment dated [DATE], (a few weeks before the fall) The residen 's pain was documented as 2-4, the residents pain when moving around was also rated at a 2-4. During multiple observations of Resident 31 throughout the survey, the resident was observed sitting in his wheelchair or lying in bed. When asked how he was doing he replied, "My leg is broken, they dropped me." The facility incident report indicated the suspected date of the incident was 10/09/11 (two days prior). That day according to NA 1, she was transferring the resident to the toilet without the use of the mechanical lift. When the resident was sitting on the elevated toilet seat, the resident started to slide off. The NA caught him and lowered him to the floor. The NA did not inform anyone about the fall at the time of incident. The facility investigation included an interview by the Director of Nursing Services (DNS), in which NA1 was asked why she did not follow the care plan and care delivery guide in regards to the resident transfer status (why she did not use the mechanical lift). The NA stated she didn't know why she didn't. During an interview with the DNS on 10/14/11 at 12:00 p.m., she stated that her expectation was for the LN who had received the fall allegation over the phone should have initiated the investigation and the evening LN should have assessed the resident upon return from the [MEDICAL TREATMENT] Center and started the investigation since it had not been started by the day LN. Her expectation was also for the resident's family and physician to have been notified. The DNS acknowledged that neglect was substantiated due to the following: NA 1 did not follow Resident 31 plan of care, NA 1 did not report the residents fall, the LN's assigned to the resident did not assess the resident in a timely manner, an investigation report was not initiated in a timely manner, the resident was not placed on alert charting and the physician and family were not notified of the allegation. She further acknowledged that these factors contributed to the resident not receiving medical treatment until days after the injury.

Based on observation, interview and record review the facility failed to notify the registered dietitian and accurately monitor the nutritional needs for 1 of 7 residents (29) identified at risk for nutritional needs due to skin breakdown and disease process. This resulted in harm as evidenced by significant weight loss of 8.6 % in one month for a resident who required nutritional intake/supplements for wound healing and fluid loss due to episodes of diarrhea. Findings include: The facility policy for " Weight Monitoring " , dated 4/10, instructed staff to monitor weight for stability. The LNs ' responsibility was to verify accuracy of the weight by comparing the weight with the most recently recorded weight, supervise the NAC while re-weighting the resident to assure that correct process is followed if the weight has changed with a gain or loss of 3% or greater. The policy indicated the LNs were to monitor weight reports for significant changes and for gradual insidious changes that may indicate a risk factor for nutrition or hydration status and or clinical condition. The policy indicated staff would notify the RD using the referral Log. The policy for "Nutritional Status", dated 4/10, indicated when weight changes, the resident ' s condition will be evaluated and staff would monitor intervention(s) and also reevaluate the effectiveness. The policy indicated interventions would be communicated to the "care giving" team. Both policies revealed that if weight was identified as a concern the facility ' s interdisciplinary team would review significant changes in their daily meetings in addition to informing other staff per 24 hour report. Resident 29 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. was 139 pounds and the resident required supervision with meals. Review of the clinical record indicated that the resident had numerous health issues. From June to October, the resident had urinary tract infections, episodes of [MEDICAL CONDITION] ([MEDICAL CONDITION]: a bacterial infection commonly leading to diarrhea and was treated with multiple antibiotics. In addition the resident had multiple pressure sores which required antibiotic therapy for wound healing. The resident's Nutritional Risk Data Collection and Assessment, dated 4/18/11, documented the resident had pressure sores, diabetes, dementia and [MEDICAL CONDITION]. The assessment documented the resident was 61 inches in height and weighed 150 pounds and was received a caloric count carbohydrate diet with a snack at bedtime (HS snack). On 10/18/11 at 8:07a.m., the resident was observed eating her meal in the dining room. The resident was observed to eat independently and consumed 50% of her meals in addition to her yogurt. She stated that the food was good. Review of the facility's weight flow sheet recorded Resident 29's weights are followed: 04/29/11: 150.6 pounds (#), 06/13/11: 151# 07/06/11 138.5# 07/26/11: 137 08/10/11: 138 09/13/11: 135 09/23/11: 134 10/05/11: 131 10/18/11: 129 The facility's meal tray monitor was used to monitor the resident's food intake at each meal.The documented data was used to enable an accurate and comprehensive assessment of intake in order to evaluate the interventions put in place, and to revise the interventions as needed, to prevent further weight loss. The form indicated that refusal of all or most of meal was 0-25% and less than half was 26-49% of the meal. The documentation of Resident 29 meal intake and HS snack indicated: The resident's intake of the breakfast meals recorded for June 2011-Resident 29 refused 9 times and ate less that 50% 12 meals. Her lunch was refused 9 times and ate less than 50% 12 times. The dinner meal was refused 6 times and ate less than 50% 7 times. The snacks were refused 23 times out of 30 offered snacks. The resident's intake of the breakfast meals for July 2011-Resident 29 refused 7 times and ate less than 50% 10 times. She refused lunch once and dinner 3 times and ate less than 50% of the meal 13 times and refused her HS snack 20 times out of 31 days. The Registered Dietitian (RD) reviewed the resident's nutritional status and recommendations and interventions put in place by the facility to address the significant weight loss and aid in wound healing and included: Increase protein with meals, and a supplement daily- one can " glucerna " . (5/30/11) HS snack plus increased the supplement to twice a day. (6/29/11) Supplement (glucerna) increased to three times a day. (7/23/11) Added protein powder and 30cc of Prostat once a day. (7/23/11) Monitor weights weekly. (9/6/11) Increase Prostat 30cc to twice a day, continue HS snack. 9/19/11. Review of the resident's laboratory studies revealed that the resident's protein level of [MEDICATION NAME] was low. The lab report, dated 9/16/11, revealed the level was still abnormal at 2.6 (normal range 3.0-4.7). In addition the pre-[MEDICATION NAME] on 6/10/11 was down to 20, then 34 on 7/21/11 and then dropped to 14 on 9/16/11. Additional lab values that were abnormal was the hemoglobin and hematocrit from 6/11 to present labs dated 10/20/11. Review of the resident's lab results revealed that in June 2010 her protein (pre-[MEDICATION NAME]) was 20, in July2011 increased to 34 and by September 2011 had decreased significantly to 14. Pre-[MEDICATION NAME] range is 18-45 mg/dL. On 10/18/11 at 8:33 a.m., during an interview with a Nursing Assistant (NA 2) stated that Resident 29 was on tray monitoring which documented the amount of food she consumed. The NA stated that if a resident consumed less than 50% of a meal, a supplement would be given. The NA also stated that she would inform the Licensed Nurse (LN) if the resident refused the meal and or supplement. On 10/18/11 at 8:38 a.m., during an interview with LN 1 stated if a resident refused a meal, the resident would be given a " med pass " supplement. She stated that if a resident also refused the supplement, the staff would reaproach the resident and attempt to offer the supplement later on during the shift. The LN stated if a resident is observed to refuse their meal or supplement for three or more days, she would notify the Resident Care Manager (RCM 9), the RD and the physician. She stated the resident would be placed on alert, weighed weekly, and the resident ' s vital signs, intake and output would be assessed and documented in nursing progress notes. The LN 9 also stated that is a weight is up or down 3 pounds, the resident is reweighed, assessed and then their weight is monitored for 1-2 weeks and the physician is notified. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR for July 2011 indicated that the LN was to provide the resident with a supplement (glucerna) twice a day, a protein drink (prostat) daily in addition to powder protein on scoop twice a day. There was no documented evidence regarding how much of the 3 nutritional supplements that the resident consumed. The LN documented that the HS snack had been provided even though the Meal Intake Detail Report for July 2011 revealed the resident refused her HS snack 20 out of 30 opportunities. The MAR for August and September also provided no documentation regarding the amount of supplement the resident consumed. Resident 20 ' s Plan of Care for Nutritional Risk, dated 4/22/11 and updated on 9/19/11 directed staff to monitor the resident ' s weight, monitor intake of meals and offer alternates as needed and provide supplements per physician's order [REDACTED]. On 10/18/11 at 10:30 a.m., the Resident Care Manager (RCM) LN 9, stated that if a resident has weight loss of 3 pounds or if a resident refuses their supplements the RD is notified. On 10/20/11 at 10:00 a.m., Resident 29 was asked about her appetite and supplements and HS snack. She stated "I kind of lost my appetite, I don't eat often, and I usually don't get my HS snack. On 10/20/11 at 2:46 p.m., the RD stated the supplements she had ordered for Resident 29 would provide the protein stores and would encompass resident ' s nutritional needs. On 10/21/11 at 2:45 p.m., the facility provided a copy of the dietitian referral log. The log documented that Resident 29 was referred on 7/22/11. Nursing administration and the RD stated that the resident's recorded re-weight on 7/4/11weight of 136.5 pounds was due to the resident's specialty boots not on the resident while she was being weighed. Record review revealed that the facility had not notified the RD until 7/22/11 for a weight loss of 8/6%. Resident 29's weight was 152 pounds on 6/13/11 and on 7/6/11 was recorded as 139#s, a 13 pound weight loss. There was no documented evidence that the LNs had assessed the reason for the weight loss. In addition, the RD continued to evaluate the resident's dietary interventions based on the weight loss and disease process. Even though the RD had placed dietary interventions for Resident 29, licensed nurses did not document the amount of supplements the resident consumed and the resident's protein laboratory values remained low and the pre-[MEDICATION NAME] protein level decreased from 34 to 14 (range 18-45) on 9/16/11. There was no documented evidence regarding how the resident should be weighed, with or without her specialty boots, and whether the LNs had observed the resident being weighed to verify accurracy of the weight. Review of Resident 29 clinical record revealed that the facility failed to consistently document the amount of nutritional supplements, delayed the notification of the RD, did not evaluate meal or snack monitoring or follow the RD ' s recommendations for increasing the supplement or reweighing the resident.

Based on observation, interview and record review the facility failed to develop a comprehensive plan of care with measurable goals and interventions for 2 of 24 sampled residents (32,29). Failure to develop a comprehensive plan of care for Resident 32 resulted in harm regarding the development of a pressure sore and placed Resident 29 at risk for further weight loss. Findings include: 1. The facility's policy on wound prevention and treatment for [REDACTED]. Resident 32 was admitted to facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital's transfer form, dated 6/4/11, under skin condition documented that Resident 32 had no skin breakdown and had a urinary catheter in place. The Minimum Data Set (MDS) assessment, dated 6/15/11, revealed that the resident required 2 person assistance with bed mobility, transfers and tolieting. The facility's Nursing Assessment form, dated 6/4/11,documented the resident had no pressure sores on admit to the facility. The initial pain assessment documented that the resident exhibited pain when he was moved. The Plan of Care (POC) for skin integrity assessment, revealed that Resident 32 was at risk of skin breakdown due to his need for frequent turning. The Care Delivery Guide used by nursing assistants indicated the resident used a sliding board to get from his wheelchair to bed and bed to wheelchair. Review of Treatment Administration Record (TAR) for June 2011, documented the resident had no pressure sores according to the documented skin assessment performed on 6/12/11 and 6/19/11. Staff documented the resident required additional pain medications due to his pain "upon moving and rolling" in bed and was unable to turn himself without help of staff due to weakness and his unrelieved pain. Other nursing notes documented the resident was more comfortable in chair than his bed. Skilled therapy notes were reviewed with the therapy supervisor on 10/20/11 at 12:48 p.m. The notes stated that the resident's wheelchair system was devised to assist him with mobility and the cushion in his wheelchair was for comfort and not pressure relief. When reviewing the skilled therapy notes the therapy supervisor stated with all his pain "he probably wasn't moving much". A physical therapy note, dated 6/20/11, documented that Resident 29 had two open areas on the buttocks. The note indicated that nursing staff would be educated on the need for a turning schedule and to use two staff members when transferring the resident, in order to avoid shearing of the buttocks. On 6/20/11, an incident report was completed and read: "staff noted redness on coccyx buttock on 6/19/11 and started cream and no back turning schedule". The form indicated the resident would be evaluated for an air mattress for his bed. A progress note provided to the physician read: "Resident has a stage 2 to 3 open areas on coccyx and left buttock due to his decreased mobility." The facility's pressure ulcer documentation, dated 6/19/11, documented the resident had two Stage II pressure sores. One location on his left ischial region and the other located on his coccyx region. (Stage 2 pressure sore- a partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). On 6/20/11, the resident was transferred to the hospital. The hospital's physician's admit note documented that Resident 32 had two pressure sores. A Stage 3 decubitus ulcer (pressure sore) on his coccyx with areas of surrounding ischemic tissue (Stage 3- full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). Resident 32 also had a stage 2 pressure sore on his buttock. Interview with the Director of Nursing Service (DNS) on 10/20/11, verified Resident 32's POC was not developed to include pressure relief interventions until after he developed the two pressure sores even though the staff had acknowledged his limited mobility and his inability to reposition himself independently in bed. Not until 6/20/11 was the resident's POC revised to inform staff to reposition and turn the resident while in bed every 2 hours and on 6/19/11 the TAR was revised, directing Licensed Nurses (LNs) to monitor the resident's redness on his buttocks and to apply a barrier cream every shift. Even when the interdisciplinary team reviewed the resident condition on 6/8/11, there was no interventions added to the POC to prevent skin breakdown even though the staff had recognized limited mobility due to pain. 2. The facility's policy on nutritional status, dated 4/09, directed staff to develop individualized interventions based on interdisciplinary assessments which may include, but not limited to: monitoring and recording intake, and to reevaluate interventions to determine effectiveness. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], revealed the resident's weight was 139 pounds and she required supervision during meals. The resident's last recorded weight was 129.5 pounds on 10/18/11. The resident's Nutritional Risk Data Collection and Assessment, dated 4/18/11, documented the resident had pressure sores, diabetes, dementia and [MEDICAL CONDITION]. The assessment documented the resident was 61 inches in height and weighed 150 pounds and was to receive a caloric count carbohydrate diet with a snack at bedtime (HS snack). Due to the resident's weight loss, the Registered Dietitian (RD) had recommended various supplements, a HS snack and a fortified diet to prevent further weight loss which was the RD identified as a significant loss of 8.6% in 30 days. The RD documented the resident's meal intake was decreased to 67% on 7/23/11. Some of the interventions the RD had recommended was a supplement three times a day, a HS snack and a powder protein drink. Another intervention for the POC was to weigh the resident weekly per RD's note dated 9/6/11. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documented evidence regarding how much of the 3 nutritional supplements that the resident consumed. The LN documented that the HS snack had been provided even though the Meal Intake Detail Report for July 2011 revealed the resident refused her HS snack 20 out of 30 opportunities. In addition, the RD had recommended the supplement of glucerna to be increased to three times a day however there was no documented evidence the POC had been updated to reflect this change. Resident 29 ' s Plan of Care for Nutritional Risk dated 4/22/11, and updated on 9/19/11, directed staff to monitor the resident's weight, monitor intake of meals and offer alternates as needed and provide supplements per physician's orders [REDACTED]. Even though the the comprehensive care plan review, dated 7/23/11, indicated a change in the resident's nutrition status there was no documented evidence the facility had addressed alternative interventions due to Resident 29's consistent refusal of HS snacks or updated the POC/MAR regarding the frequency and amount of supplements. Lack of a individualized interventions placed her at risk for additional weight loss.

Based on interview and record review, the facility failed to provide sufficient qualified staff for assessment of skin integrity and management of avoidable skin breakdown issues for two of two sampled residents with skin breakdown (Residents 1 and 2). Failure to hire and/or train staff for skin assessment and care resulted in harm for Residents 1 and 2 when they developed skin breakdown and placed other residents at risk of inadequate skin integrity monitoring and skin breakdown management. Findings include: 1. Resident 1 was admitted in April 2011 with multiple [DIAGNOSES REDACTED]. Her admission skin integrity assessment, dated 04/18/11, identified " wound" for the left ischium and coccyx. The right ischium, which had a history of [REDACTED]. There was no further evidence of written assessments describing each circled area. In May 2011, the right ischium redeveloped an open area 1.5 centimeters (cm) x 1.5 cm with a depth of 0.1 cm. On 09/15/11, Resident 1's physician documented the right ischium was a Stage IV pressure ulcer with odor. The most recent measurements of the area, dated 09/23/11, were 8 cm x 5.5 cm. The depth was 4.5 cm. Between June 2011 and August 2011 much of the documentation identified the ulcer as "infection associated [MEDICAL CONDITION]" (IAD). On 09/26/11 at 10:30 a.m., the Director of Nursing Services (DNS) reported she had not heard of IAD. She did not know where the term came from. Only Licensed Nurse (LN) 2, who performed the skin treatments for residents in the facility, had documented the term in Resident 1's clinical record. Since learning of this in late August 2011, the DNS had taken over the role for weekly skin assessments and supervised skin treatment of [REDACTED]. All skin treatments were now performed during the week when she was present. The facility policy for weekly skin assessments by the staff nurses was replaced temporarily. The DNS had staff nurses perform weekly skin checks rather than assessments. If they found anything, such as a bruise, laceration, [DIAGNOSES REDACTED] (redness), they had been instructed to notify the DNS. When she had interviewed several staff nurses, she identified inconsistencies in staff knowledge regarding assessment of skin issues. At 12:30 p.m., the DNS reported the facility LNs needed more training to assess and manage serious skin infections. At 1:10 p.m., LN 2 reported until she was hired for the facility she had no previous experience in wound management. She spent time observing at the wound clinic to learn staging of wounds and proper cleansing. She recalled an area on the right ischium of Resident 1 was open on 05/11/11 and the wound clinic debrided it every visit after that date. She documented the right ischial ulcer initially as a pressure ulcer. Later she changed to IAD because the former DNS told her that was what the ulcer was. LN 2 could not define or describe what IAD skin looked like. She did not know what nursing goals and interventions were appropriate for IAD. On 05/18/11, LN 2 documented the presence of a Stage 1 pressure ulcer (an observable, pressure related alteration of intact skin presenting as a defined area of persistant reddness) on Resident 1's left ischium. She reported she did not recall if she assessed whether it blanched to touch (associated with a Stage 1 pressure ulcer). She stated she should have done that and documented the results of that assessment. She could not recall the condition of the skin at various points in time as she did not consistently document skin ulcer assessments. 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment, dated 08/05/11, indicated the resident was severely impaired in her cognitive status. In an interview and chart review on 09/29/11 at 1:00 p.m., LN 8 stated there was no order for the allevyn heel dressing, but that the allevyn dressing was part of the skin protocol. The physician's orders [REDACTED]. In interviews on 09/29/11 at 2:43 p.m., Nursing Assistant (NA) 1, LN 2 and LN 7 stated they did not know what or where the podus boot was (a hard plastic boot made to protect the heel tissue from further damage). LN 2 stated the green boot (foam boot that was to be used for the unaffected heel) was the podus boot. LN 7 stated that the boot was discontinued. The chart was reviewed and showed the leg immobilizer was discontinued, not the podus boot. On 09/29/11 at 2:45 p.m., the DNS looked in the room and was unable to find the Podus boot. She stated the green boot was for protection of the right foot. The investigator informed her that the staff did not know what a podus boot was and they were signing daily that the boot was on including the day that staff were unable to find the boot. In an interview on 09/30/11 at 3:55 p.m., LN 3 stated the resident was on the "Yellow dot program". LN 3, LN 7, and LN 2 were unable to explain or provide a copy of the yellow dot program. LN 9, who was the facility education director provided a laminated copy of a turning schedule, but nothing else. NA 1 was unable to verbalize what the yellow dot program was. Refer to CFR 483.25(c), F 314 Treatment/Services to prevent/heal pressure sores.

Based on observation, interview and record review, the facility failed to prevent development and deterioration of avoidable pressure ulcers for two of two sampled residents (Resident 1 and 2) who were reviewed for skin integrity and management. Failure to adequately assess and evaluate for the presence and level of risk factors and individually address them when care planning resulted in reoccurence of a Stage 3 pressure ulcer that deteriorated to Stage 4 pressure ulcer for Resident 1 and development of an unstageable pressure ulcer for Resident 2. Findings include: The stages of pressures ulcers as defined by the National Pressure Ulcer Advisory Panel (NPUAP) include: A Stage III pressure ulcer is full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. A Stage IV pressure ulcer is full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supportins structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers. The presence of eschar can preclude accurate staging of an ulcer, resulting in it being referred to as unstageable. 1. Resident 1 admitted in April 2011, with multiple [DIAGNOSES REDACTED]. She had dementia, diabetes and gastro-[MEDICAL CONDITION] reflux disease. She had not walked in several years. On admission, Resident 1 was receiving a course of antibiotics for an infection of [MEDICAL CONDITION] (C diff), a [MEDICAL CONDITION] bacteria that can cause infectious diarrhea and can lead to life-threatening conditions. The antibiotic treatment was scheduled to end on 05/11/11. Licensed Nurse (LN) 1 documented Resident 1 had "wounds" on her left ischium and coccyx. There were no descriptions or measurements documented for either "wound." The right ischium had a recent history of a Stage 3 pressure ulcer. On 04/20/11, LN 2 documented she applied extra protective cream to the right ischium. There was no evidence of documentation for any monitoring of the right ischial area until 05/11/11 when the wound clinic, which was providing care for the left ischial pressure ulcer, measured an open area 1.5 centimeter (cm) x 1.5 cm on the right ischium. The depth was 0.1 cm. The wound clinic commented Resident 1 had "profuse, foul smelling diarrhea." They recommended a laboratory analysis of a stool specimen. A stool specimen test, dated 05/13/11, identified[DIAGNOSES REDACTED] infection. On 05/13/11, the physician ordered antibiotic treatment. When Resident 1 returned to the wound clinic on 05/26/11, the right ischial ulcer measured 3.5 cm x 3.5 cm with a depth of 0.4 cm. The clinic documented the presence of red and yellow drainage in similar amounts to 05/11/11 visit, and again the clinic asked about infection in her stool. The clinic instructed facility staff to "keep peri area clean and dry." On 06/09/11, LN 2 documented the right ischial ulcer measured 2.4 cm x 2.5 cm with a depth of 1.8 cm. She identified the wound as a pressure ulcer with[DIAGNOSES REDACTED]. On 07/07/11 LN 2 documented the right ischium was 2 cm x 2 cm with a depth of 1.5 cm. She noted the ulcer might have "tunneling", a condition in which the wound is larger under the surface of the skin. On 09/26/11 at 1:15 p.m., LN 2 reported she documented the right ischial ulcer as "infection associated [MEDICAL CONDITION]" (IAD). She stated the then Director of Nursing Services (DNS) told her that was what the wound seemed to be. LN 2 did not know what IAD was. No one in the wound clinic used that term to describe the wound. She did not know what risk factors or interventions were appropriate for IAD. She did not assess the wound; she did not participate in the care plan for Resident 1. Her sole focus was to do the treatments as ordered by the wound clinic. She stated sometimes the treatment dressings were off when she went to change them. LN 2 had no additional information. On 09/26/11 at 10:20 a.m., the current Director of Nursing Services (DNS), who started working in the facility in August 2011, reported she was not familiar with the term IAD that LN 2 primarily used to identify the right ischial ulcer between May and August 2011. She did not know why, if "tunneling" was present, it was not addressed in Resident 1's care plan. She was unable to find any documentation of assessment of the right ischial ulcer for May through July 2011. She did not know why the care plan did not address [DIAGNOSES REDACTED] as a risk factor for skin breakdown when the infection was first identified in May 2011. The DNS could not "figure out the chart, there are big gaps." She had no information of the training for LN 2 who performed the skin treatments from May through most of August 2011. The DNS reported there were several health care providers involved at different points in time without adequate indication of who was the primary provider for Resident 1. These providers differed in their approaches to treating Resident 1's issues. Nursing failed to clarify who was in charge and advocate for Resident 1. Currently Resident 1 had a known primary provider and received three antibiotics for infection. On 09/29/11 at 3:32 p.m., LN 9, the infection control nurse, reported he monitored Resident 1. The diarrhea was "almost constant" since she arrived. In late August 2011, an infection control physician coordinated specialty tests and placed Resident 1 on an antibiotic used to treat certain bacterial infections. LN 9 was not involved in care planning for Resident 1. No staff had requested he participate in Resident 1's care plan. He had no additional information. At 4:01 p.m., LN 3 reported Resident 1 moved to her unit in July 2011. The right ischial ulcer was a Stage 3 pressure ulcer at that time. She could not identify a goal for the right ischial pressure ulcer on the care plan. Resident 1 attended the wound clinic and LN 3 thought "they would take care of it." LN 3 knew the [DIAGNOSES REDACTED] was "a chronic problem." She added it to the care plan in late August 2011. She reported it should have been included in the care plan when Resident 1 was admitted in April 2011. LN 3 was not familiar with the term "IAD". No staff had ever mentioned it to her during Resident 1's stay in the facility. LN 3 knew of the inconsistency of two urinary care plans for Resident 1 with opposite interventions - one directing staff to give extra fluids and one directing staff to not give extra fluids. She reported she "should have updated it." On 09/30/11 at 7:45 a.m., LN 5 reported Resident 1 was turned to her left side and back in July and August 2011. Resident 1 had "bad diarrhea" in July 2011 and "really bad" diarrhea in August 2011. LN 5 reported she sometimes did dressing changes on the right ischial ulcer because it was soiled. She dated and initialed the dressing. Sometimes when she returned to work, her initials were still there, so the dressing had not been changed as scheduled. Review of Resident 1's clinical record revealed no evidence of documentation of assessment of the right ischial ulcer by staff between June and August 2011. The Treatment Administration Record (TAR) for July 2011 had "measure wounds each week" documented as done for 2 of 4 weeks. Although the resident was identified as part of the facility's "Yellow dot program", direct care staff could not explain to the investigator what this program actually was. There was no mention of "IAD" in the care plan. The skin integrity care plan goals were not updated to include risk factors for skin breakdown in a timely manner. The bowel elimination care plan contained no mention of diarrhea as a risk factor. Control or management of diarrhea was not identified as a goal with appropriate interventions. Even though Resident 1 had [DIAGNOSES REDACTED] in May 2011, the presence of a [DIAGNOSES REDACTED] infection was not added to the care plan until late August 2011. Identification of the primary provider at different times from June to September 2011 was challenging and unclear in the record. 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) assessment indicated the resident was severely impaired in her cognitive status. The resident's initial assessment indicated the resident did not have any skin issues. The facility identified the resident had multiple risk factors for development of a pressure ulcer. The risk factors included her dementia, English as a second language, diabetes, nutritional status, and her mobility in bed and in her wheel chair due to the leg immobilizer. Documentation on 08/23/11, in the interdisciplinary team notes indicated the resident had a significant weight loss of 7 lbs in two weeks along with nutritional compromise due to gastrointestinal problems. By 09/01/11, the resident lost 16 lbs per the Registered Dietician's documentation. Resident 2 was at increased risk for skin breakdown as evidenced by compromised nutrition. Documentation on 09/06/11 in the progress notes showed that LN 6 indicated the resident reported there was something wrong with her lower left leg. The LN assessed the lower leg and documented there was deep tissue damage measuring 3 cm by 3 cm on her left heel. The LN determined it was a blister that was dark brown to black in color. On 09/20/11 the heel ulcer was slightly larger and measured 3 cm by 3.2 cm. By 09/29/11 the area became larger again and measured 3.1 cm by 3.4 cm. The resident was observed on 09/29/11 at 12:20 p.m. to be lying on her back in bed, her heels were not being floated and she did not have protective boots on. Her foam boot was lying at the foot of the bed. There was a dressing (Allevyn) on her left heel. LN 2 stated the resident was non compliant with wearing the boot. The wound was observed on 09/29/11 at 2:00 p.m. with LN 2. LN 2 stated the wound was dark purple to black in color and it measured 3.1 cm x 3.4 cm. In an interview on 09/29/11, LN 3 stated the resident was able to self propel her wheel chair through the facility by using her left heel to "dig in" to the floor. The LN 3 did not provide any information on why the care plan had not been revised or interventions put into place to protect the resident's heel. LN 3 stated they took her shoes away from her after the blister was discovered. In an interview on 09/30/11, LN 6 stated the resident was independent with her wheel chair mobility and would use her one foot to self propel her wheel chair. Refer to CFR 483.10 (k)(2), 483.20 (d)(3), F 280, The right to pariticipate in planning care -revise CP.

Based on interview and record review, the facility failed to review or revise resident care plans as the residents' status changed for two of two sampled residents reviewed for skin integrity (Residents 1 and 2). Failure to update and address acute changes in skin integrity and include identified risk factors resulted in harm from skin breakdown for both residents and placed them at risk for additional unaddressed skin deterioration. Findings include: 1. Resident 1 was admitted to the facility in April 2011 for rehabilitation after surgical intervention for pressure ulcers in both of her feet. She had a history of [REDACTED]. Her hospital history identified she was a poor historian related to a [DIAGNOSES REDACTED]. She suffered from [MEDICAL CONDITION] and depression. Resident 1's admission skin assessment diagram, completed by the nursing home and dated 04/18/11, identified three circled areas - one over each buttock and one over the coccyx. The left buttock and coccyx circles were labeled "wound". The right one was unlabeled. On 04/18/11, Licensed Nurse (LN) 1 wrote Resident 1 was incontinent of bladder and bowel. There was a pressure ulcer on the left buttock and coccyx. The right buttock had a healed pressure ulcer. No additional details or description of the pressure ulcers were documented. On 09/26/11 at 1:10 p.m., LN 2 reported she recalled the left ischial ulcer was the primary wound on Resident 1's buttock. The right ischial area appeared intact in April 2011. From admission, Resident 1 was incontinent of bowel one to six times amost daily. A reopening of the right ischial ulcer occurred in early May 2011. The wound clinic debrided (removed dead tissue) every week from both ischial ulcers. LN 2 sometimes changed the dressings covering both the right and left ischium two or three times each day because they had stool on them. She did not know whether the dressings were changed during the night or who did them. She wrote instructions for the dressing changes and left them in the treatment record for weekend nurses to use. She did not know whether they implemented the instructions. LN 2 reported she did not participate in the care plan review nor did she contribute any updates for the changes in skin breakdown. She was not involved with Resident 1's care plan. On 05/11/11, the wound clinic documented an open wound on the right ischium with measurements of 1.5 centimeter (cm) x 1.5 cm. Review of Resident 1's care plan revealed a concern regarding skin integrity, dated 04/18/11. The goal for the Stage 2 right ischial ulcer, dated 05/18/11, was to maintain its size or get smaller in the next 30 days. On 06/15/11, LN 2 documented the right ischial ulcer was related to pressure and "C. diff diarrhea." ([MEDICAL CONDITION]-C. diff is a [MEDICAL CONDITION] bacteria that causes infection with diarrhea and can be life threatening.) On 6/19/11, the right ischial ulcer measured 2.3 cm x 2.4 cm with a depth of 1.5 cm. On 9/26/11 at 3:40 p.m., observation of Resident 1's right buttock found a Stage 4 pressure ulcer (full thickness skin loss with extensive destruction or damage to muscle, bone or supporting structures such as tendons) over the right ischial area. The most recent measurements, dated 09/23/11, were 8 cm x 5.5 cm. The depth was 4.5 cm. Approximately half of the tissue was pink (toward the lateral aspect of her body). The other half of the tissue, the part toward the center of her body, was necrotic (dead). The Director of Nursing Services (DNS) reported the color and tissue condition were much improved since the treatment changes of the past week. On 09/29/11 at 4:01 p.m., LN 3 reported she cared for Resident 1 beginning in July 2011. LN 3 stated the right ischial ulcer was a Stage 3 in July 2011. She could not identify where in the skin integrity care plan, the goal for the current right ischial ulcer was. LN 3 also knew of Resident 1's chronic bowel incontinence. She stated Resident 1 was unable to participate in a bowel program and was on a scheduled toileting program since admission. LN 3 could not identify how much or how often Resident 1 had bowel incontinence and did not know whether the scheduled toileting program was meeting the resident's needs. She was unaware of the frequency of bowel incontinence (295 times in 281 shifts) and diarrhea (58 times in 56 shifts). Additionally, although the [DIAGNOSES REDACTED] was a chronic problem for Resident 1, LN 3 could not find any inclusion of infection as a risk factor for care planning for skin integrity until 08/23/11, when a return of the [DIAGNOSES REDACTED] infection was found in a stool specimen. She stated it should have been included in the care plan from admission. Review of the care plan revealed there was no mention of diarrhea until 08/23/11, when the[DIAGNOSES REDACTED] infection found in Resident 1's stool was added. Additional review of the clinical record revealed Resident 1 had a history of [REDACTED]. The urinary care plan identified Resident 1 had functional, overflow, and mixed (urge and stress) types of incontinence. Staff were directed to provide different amounts of fluid at different times of day for the different types of identified incontinece. The selected interventions on the care plan for transient incontinence included to provide 8 ounces of water with meals. For overflow incontinence, interventions included to provide the 8 ounces of water with meals, 6 ounces of water with medication pass and six 8 ounce glasses of fluid each day. LN 3 had no information for the discrepancy and did not know which was the appropriate approach for Resident 1's individual care plan. Neither the bowel incontinence nor the urinary incontinence care plans discussed the impact of extensive bowel and bladder incontinence on skin integrity. Additionally, Resident 1 was diagnosed with [REDACTED]. There was no update to the urinary care plan for that change in condition. 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely impaired in her cognitive status. The assessment did not indicate the resident had any behaviors of non-compliance or rejection of care. On 07/29/11, documentation on the facility's initial skin assessment indicated the resident was at moderate risk for the development of pressure ulcers. On 08/05, 12 & 19/11 the facility reassessed the resident and determined the resident was at minimal risk to develop a pressure ulcer. The assessment indicated, however, that the resident was chair fast, her nutrition was probably inadequate and there was a potential problem that during movement the resident probably slid against the sheets, chair or other devices. She maintained good posture in bed but occasionally slid down in bed. These were all risk factors for pressure ulcer development. On 8/9/11, the facility documented on the Care Area Assessment (CAA) analysis tool for pressure ulcers that the resident had a right knee immobilizer in place for the fracture. The resident also had a recent decline in activities of daily living and was taking a narcotic for pain relief. Documentation indicated the narcotic could decrease the sensation of pain from prolonged pressure and could increase the risk for pressure ulcer development. Documentation also indicated there would be a care plan developed with interventions. On 09/29/11, review of the care plan revealed the plan did not include interventions for the potential problems noted above. The care plan had not been updated after the 8/9/11 MDS and had not been completed to reflect the risk factors that were identified during the assessment. In an interview on 09/29/11 at 12:20 p.m., LN 2 stated the resident was independent with bed mobility and non compliant with wearing the podus boot (a hard plastic boot made to protect the heel from further damage). In contrast, her MDS assessment indicated the resident was a two person extensive assist for bed mobility, and there was no documentation of non compliance with wearing the boot. The LNs were documenting on the treatment records the resident was wearing the boot at all times. In an interview on 09/29/11 at 4:37 p.m., the Director of Nursing stated that the facility had not been using the "Push" tool (an assessment and tracking tool) even though it had been checked on the care plan. The DNS stated the LNs must have checked the box out of habit. The facility did not use that tool. In an interview on 09/30/11 at 8:31 a.m., LN 6 stated she was the one that put the Allevyn dressing on the wound, because the resident would not keep her boot on. LN 6 stated there was no medicine on the foam dressing; it was just there to protect the heel. There was no physician's order for the Allevyn dressing and the treatment was not on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] There was no indication the resident and/or the resident's representative had any input into the development of the care plan. Refer to CFR 483.25(c), F 314 Treatment/Services to prevent/heal pressure sores.

Based on interview and record review, the facility failed to provide adequate supervision for 1 of 9 residents (3) reviewed for accident/incident investigations. Failure to ensure staff provided the supervision indicated in the care plan resulted in harm for Resident 3 as evidenced by her suffering a broken upper jaw. Findings include: Resident 3 was admitted in October 2009 with [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment, dated 05/08/11, identified she understood what was said to her only some of the time. She made herself understood only some of the time. She was not steady for transfer between the bed and wheelchair. Her care plan identified she was at risk for falling and directed the staff Nursing Assistants (NA) to lay her down in bed after all meals. On 05/03/11 at 11:25 a.m., Resident 3 stood up and fell from her wheelchair. She struck her head, resulting in a laceration to her left forehead. She was sent to the hospital for evaluation. The hospital discovered Resident 3's upper jaw was also broken. On 06/03/11 at 11:55 a.m., licensed Nurse (LN) 1 reported Resident 3 had been a known fall risk for a "very long time". Resident 3 fell in the facility in 2010 and fractured her hip. LN 1 stated Resident 3 was at risk of skin issues also and she was to lie down after meals to protect her skin as well. At 12:52 p.m., the Director of Nursing Services (DNS) reported the NA did not provide the supervision required and did not follow the resident's care plan and place her down in bed after breakfast. Required supervision and interventions for fall prevention were identified in the resident care plan and care guide (a document used by the NAs when caring for a resident). Review of the care plan revealed the resident was to be placed in bed after each meal. Review of the facility investigation revealed the NA failed to place the resident in bed after breakfast. She did not follow the care plan intervention to place the resident in bed after all meals.

Based on record review and interview, the facility failed to provide care and services in a manner that promoted residents dignity and self-worth. Affected was 1 of 3 sampled residents (3). The facilities failure to respond to two different physician's recommendations for an electric wheelchair resulted in the resident feeling mad, hopeless and unimportant as a person. Findings include: Resident 3 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 3's Minimum Data Set (MDS) assessment, dated 01/9/11, revealed resident had intact orientation, recall and was independent in his decision making ability. He used a manual wheelchair for mobility and needed oversight, encouragement and verbal cueing for wheelchair use. Chart review revealed on 01/29/11, that Resident 3 was seen in the emergency room (ER) for an injury he sustained to his right elbow a few days earlier. The hospital discharge documentation ,dated 01/29/11, noted it was ok for resident to use an electric wheelchair for a week to rest the right elbow. No electric wheelchair was provided resident. The facility stated it could meet his needs without it. On 02/22/11, the resident was seen by an orthopedic specialist for the increased swelling and redness to his right elbow and was diagnosed with [REDACTED]. The physician's recommended use of an electric wheelchair and for resident not to use his right arm to propel his wheelchair. During multiple observations of the Resident 3 on 02/16/11 & 02/28/11, he self propelled his manual wheelchair using his left arm and left leg. The resident was visibility short of breath. In an interview, on 02/16/11 at 10:05 a.m., Resident 3 stated he was "frustrated " and "mad" the facility had not gotten him an electric wheelchair. He stated not having the electric wheelchair meant he spent more time in his bed and he liked to go out more. He expressed frustration because the facility had not really told him much about why he wasn' t getting the wheelchair just that he didn' t need it. In a second interview on 02/28/11 at 12:45 p.m., Resident 3 stated the facility's failure to obtain an electric wheelchair "after two physicians" had recommended it made him feel "unimportant as a person" and "hopeless" in his recovery.

Based observation, interview, and record review, the facility failed to accommodate Resident 3's need for mobility assistance. Failure to assess and provide mobility assistance after he injured his right elbow resulted in harm as evidenced by weakness, physical fatigue, pain, and diminished quality of life. Findings include: Resident 3 was admitted in October 2010 for rehabilitation after back surgery. He had long-term weakness in his right leg. His most recent minimum Data Set (MDS) assessment, dated 01/09/11, identified his memory and recall ability were intact. He used a manual wheelchair for mobility and needed staff oversight, encouragement and verbal cueing for wheelchair use. On 01/25/11 an over-bed table struck his right elbow and injured it. On 01/26/11 nursing requested therapy services to evaluate the right elbow. On 01/27/11, Occupational Therapist (OT) 1 performed the evaluation and recommended scheduled ice treatment for [REDACTED]. On 01/27/11 Resident 3 complained of increased pain and requested pain relief medication for the right elbow. Nursing documented his elbow had "redness and increased swelling." On 01/29/11 Resident 3 requested to go to the hospital related to pain in his right elbow. He returned with his right arm in a sling. The hospital diagnosed his right elbow had a contusion, an injury below the surface of the skin, a bruise. He had hospital recommendations for pain relief medication and use of an electric wheelchair for a week. The facility healthcare provider concurred. Therapy services was notified on 01/29/11 of the need for an evaluation for use of an electric wheelchair. In an interview on 02/28/11, Physical Therapist (PT) 1 reported she spoke with the facility Administrator regarding a temporary electric wheelchair for Resident 3. The Administrator informed PT 1 facility staff would assist Resident 3 with his transportation needs rather than attempt to obtain an electric wheelchair for such a short time. Review of the screening evaluation, dated 02/04/11, revealed Physical Therapist (PT) 1 documented the facility planned to provide staff wheelchair mobility assistance to Resident 3 rather than seek an electric wheelchair. On 02/28/11 at 1:30 p.m., the Administrator reported she recalled speaking with PT 1 regarding Resident 3's mobility need. She told PT 1 facility staff would assist Resident 3 with his mobility needs rather than seek an electric wheelchair. The Administrator did not speak with RCM 1 or other staff regarding this intervention for Resident 3's mobility issues. On 02/28/11 at 11:23 a.m., Resident Care manager (RCM) 1 reported she had not received a copy of the "Nursing -Therapy Communication" form completed by OT on 01/26/11 nor was it discussed at the daily clinical meeting. RCM 1 stated the ice treatment should have been scheduled, offered, monitored and assessed for benefit. She did not know what happened to the sling placed by the hospital on [DATE]. She reported the right elbow injury should have been added to the care plan with interventions and goals, including mobility. She had no knowledge Resident 3 had issues with his manual wheelchair - either for staff assistance or self-propulsion. Rerview of Resident 3's clinical record revealed on 02/01/11 nursing performed a pain assessment on Resident 3 and documented he complained of continuing pain in his right elbow. The resident stated he was using his "right arm too much." No evidence of documentation of additional pain assessment or care planning for Resident 3's mobility problem was found in the clinical record. On 02/16/11 at 12 45 p.m., Resident 3 reported he thought he should have an electric wheelchair because he had problems using only his left side to self-propel the manual wheelchair. He had increased pain and "charlie horses" from overuse of the left side of his body. He spent more time in bed because using the manual wheelchair caused him more discomfort. At 2:50 p.m. that day, observation found Resident 3 self-propelling his wheelchair, using only the left arm and left foot down the hallway. He pulled himself along via the handrail when possible. He positioned his wheelchair at a table with a cup of coffee in the dining room. He returned to the service area for sugar for the coffee. He was short of breath on return to the table. Resident 3 reported he needed time to "catch his breath." He complained of feeling tired. He had told staff of this issue. On 02/22/11 Resident 3 was seen by an orthopedic specialist who diagnosed Resident 3 with bursitis, inflammation of the sac that facilitates movement between the bone and the tendon, of the right elbow. She initiated antibiotics for Resident 3 and noted he should not use his right arm to propel the wheelchair. She recommended an electric wheelchair to prevent Resident 3 from over usage of the right arm. Therapy documented they received a "Nursing-Therapy Communication" form on 02/25/11 requesting an evaluation for an electric wheelchair for Resident 3 and performed the evaluation on 02/28/11. Review of Resident 3's clinical record revealed no evidence of right elbow injury, right elbow infection, or mobility issues on his care plan. The "Resident Lifting, Transferring and Repositioning Data Collection" form instructed staff to complete a new data collection form whenever a resident had a change in mobility status. The most recent form was dated 01/24/11 prior to Resident 3's mobility issue.

Based on observation, interview and record review, the facility failed to provide a safe environment and prevent accidents for residents in the building. Affected were all residents assigned a bed that utilized a toggle switch control to lock the bed wheels. Failure to protect residents from accident hazards of unlocked bed wheels resulted in harm for Resident 7 who fell and suffered injury when the unlocked wheels of his bed moved and placed all other residents using this bed style at risk of fall and/or injury. Findings include: The facility had several styles of beds for resident use. One style was a bed with wheels. It had an electric control to adjust the height of the bed. When the bed height was up, the wheels at the foot of the bed, were lifted off the ground. The bed then rested on stationery posts preventing the bed from moving. When the bed height was in the lowest position, the wheels contacted the floor and rolled freely across the floor. A toggle switch, located on the foot of the bed, could be positioned "on" to lock the bed height adjustment control. This toggle switch served as the safety feature to lock the wheels off the floor and prevent the bed from moving. Resident 7 was admitted in May 2010 with [DIAGNOSES REDACTED]. His most recent Minimum Data Set (MDS) assessment, dated 08/30/10, identified his short-term and long-term memory and recall ability as intact. On 10/17/10 at 2 a.m., Resident 7 was found lying on the floor next to his bed. He suffered injuries of two abrasions on the right elbow and bruises to both elbows. Nursing provided assessment and placed dressing on the abrasions. Review of the facility investigation revealed the wheels on his bed were not locked when he fell . On 12/03/10 at 9:20 a.m., Resident 7 reported he was trying to fix the bed and the linens on the bed. He stated the bed was moving and pointed to the foot board. He lost his balance and fell . Observation of his bed found it was in a low position with the wheels just slightly off the floor. The safety toggle switch was in the "off" position. A fall mat was on the floor next to the right side of the bed. At 12:02 p.m., the Administrator reported the wheels on all beds should be locked. She did not know of any written policy for monitoring for locked wheels. Review of Resident 7's care plan revealed "fall/injury assessment", dated 08/03/10. Interventions included "bed safety checks each shift (locked bed wheels, height at low position)." Review of Resident 7's Medication Administration Treatment record for December 2010 revealed a "check bed for safety each shift (locked wheels/lowest position)", initiated 10/21/10. Nursing documented this was done, each shift on each day. At 2 p.m., the Assistant Environment Supervisor (AES) reported for the style of bed with the electric bed height control, the toggle switch on the foot of the bed must be in the "on" position to prevent a person from adjusting the bed height to the lowest position and engaging the wheels on the floor for free movement. He stated he reminded the housekeeping staff of this feature. No one had asked him to train staff of any other department. At 2:10 p.m., the AES examined the toggle switch on Resident 7's bed. The toggle switch was in the "off" position. He did not know whether nursing wanted it in the "on" position. At 2:13 p.m., Nursing Assistant (NA) 1 and NA 2 were asked to demonstrate how to adjust the bed height for a bed with the electric height control. They were not informed the toggle switch was in the "on" position. Neither NA knew why the electric control for bed height did not function. Neither NA knew the toggle switch existed or what its purpose was. Both NAs reported sometimes in-services were communicated as an electronic message via the facility informatics application. At 2:30 p.m., the Director of Nursing Services (DNS) reported she send an electronic message to all staff on 10/22/10 reminding them if they moved a bed, they should put it "back into the correct position and the brakes locked." The DNS reported she did not know of the toggle switch and did not include education of its function and operation in the message. Review of the electronic "message compliance report", dated 12/06/10, revealed 37 of 107 nursing staff had not yet acknowledged opening the message for review. At 3:15 p.m., observation of all assigned resident beds in the facility found 51 of 53 beds with a toggle switch safety for locked wheels were in the "off" position. Resident 8 reported her bed moved freely every time she changed it to the lowest position. Observation of her bed found it was a style without any locking mechanism for any of the wheels. See F225 for additional details.