Every finding on record at Everett Center

Based on interview and record review the facility failed to ensure resolution of grievances for 2 of 3 residents (Residents 87 and 46) and 1 of 1 resident group reviewed for grievances. Failure to thoroughly investigate, log and provide resolution related to individual and resident group grievances placed residents at risk for recurrent unresolved concerns and decreased quality of life. Findings included . According to the policy titled Grievance/Concern with a revised date of 10/15/2024, documented: Upon receipt of the Grievance/Concern Form, the Administrator or designee will document the grievance/concern on the Grievance Concern Log An appropriate department manager will investigate the grievance and notify the person filing the grievance of a resolution in a timely manner. A written resolution for grievances will be offered and will include a summary statement of the grievance, steps taken to investigate the grievance, summary of the pertinent findings or conclusions regarding the grievance and any corrective action(s) taken or not taken by the Center as a result of the grievance/concern. Review of the resident council minutes for the prior six months showed no documentation for September 2025. Review of the October 2025 minutes, dated 10/28/2025, documented three resident council members in attendance whose names were not included. The minutes documented resident concerns of nursing assistants taking breaks at the same time during important times such as lunch, showers, and recreation. A resident council concern response form dated 10/28/2025, did not include investigation of the stated concerns, only stated educated and trained staff to better ensure residents are not late. The form was not signed by any member of the management team and was not provided to any resident council members. The following month (November 2025) there was a meeting form stating no meeting was conducted. Review of the December 2025 minutes, dated 12/23/2025, stated there were nine residents in attendance. No resident names were listed. The form documented discussion of old business was N/A. The December minutes included numerous group concerns: - Communication failures, lack of care and leadership (unclarified)- Inconsistencies with meal tickets and food - Clothes coming back with a lot of lint - Some issues arising when staff change rotation (unclarified)A resident council response form was included, dated 12/23/2025, which only referenced dietary quality concerns. There was no further clarification of the other concerns listed in the meeting minutes, the form only stated dietary has handled the issue with no signature and no resolutions provided to the council. Review of the January 2026 resident council minutes, dated 01/15/2026, documented five unnamed residents in attendance. Discussion of old business was N/A and there were documented concerns with missing laundry, and some staff need education and customer service assistance, (unclarified). No resolution was provided. Review of the facility log of grievances from October 2025- February 2026 revealed none of the resident council grievances were on the log. In a group interview with eight members of the facility resident group on 02/18/2026 at 11:00 AM, residents were asked questions related to the facility response to the group grievances.- Resident 53 stated there was a problem with getting follow up on things, waits a long time, stated they just forget about it. - Resident 88 stated they had brought up some issues about the food but did not know how they would hear back about the outcome.- Resident 18 stated it was an ongoing issue that they bring up problems with call lights and concerns with staff and were told they want to know about our concerns, but in reality, nothing happens and we are never told anything, and the same problems keep happening. Resident 18 stated they think the staff were writing the minutes and then Staff A, Administrator, takes the binder so they never see it. Resident 18 stated there should be plenty of mention about the call lights. Resident 44 was observed nodding yes to agree with Resident 18. - The group stated the primary issue that keeps coming up was the response to call lights and responsiveness of staff, with no follow-up and that should be in the minutes. In an interview on 02/20/2026 at 1:43 PM, Staff A, stated they went to the resident council meetings and followed up with what the residents said. Staff A stated there had been grievances done for call lights and was aware call lights were a recurrent grievance issue but had no further information why the resident council minutes did not capture that from the meetings. Staff A stated they had not been doing individual grievances from the resident council and were doing them as one group grievance on the resident concern form. Staff A stated they believed that was how the residents had wanted it. Staff A was not able to state how they follow up with individual residents from the resident council meetings when the minutes did not include which residents were in attendance and which residents had which specific concerns. In a follow-up interview on 02/23/2026 12:28 PM, Staff A acknowledged that vague concerns noted in the resident council minutes had not been clarified. Staff A stated they had not been providing written follow-up to resident grievances only stated that someone followed up with them. Staff A acknowledged the grievances did not show documentation each specific concern was identified, investigated, that resolution occurred and was provided to the appropriate residents involved. Staff A acknowledged resident council grievances were not being logged and stated they had provided education. <RESIDENT 87>Resident 87 was admitted to the facility on [DATE]. In an interview on 02/18/2026 at 10:02 AM, Resident 87 stated that last Monday (02/16/2026) they waited two hours for assistance with toileting. Resident 87 stated a staff member answered their call light at noon and was told to wait for the next shift to arrive at 2:00 PM. Resident 87 stated she knew she had waited two hours as she remembered looking at the clock when the staff answered the call light. The resident stated they informed a manager on 02/17/2026. Review of Resident 87's Care Team meeting note, dated 02/17/2026 at 1:04 PM, documented resident verbalized waiting for care and that a grievance will be filed. Review of the updated Grievance Log, received on 02/20/2026 at 1:30 PM, did not show a grievance for Resident 87. In an interview at 02/23/2026 at 11:09 AM, Staff C, Registered Nurse /Unit Manager, provided Resident 87's grievance and reported it had been resolved. Review of Resident 87's grievance showed the grievance was filed on 02/18/2026 (one day after resident reported). The grievance did not contain specific details of the resident's concern, it only documented complained of wait time for call light to be answered. There were no details regarding time of day or the length of time the resident waited. The grievance showed the Administrator, Director of Nursing and Nurse Manager will address the grievance, however there was no follow up from the administrator or the Director of Nursing. The form did not rule out abuse or neglect, it did not identify staff involved and the plan showed the facility would educate evening shift NAC's (Nursing Assistants) on call light response time despite the concern occurring on day shift and was related to staff informing Resident 87 to wait two hours for care. In an interview on 02/23/2026 at 12:28 PM, Staff A stated the facility practice was to resolve grievances within three days. Staff A stated if it could not be resolved within three days they would follow up with the resident. Reviewed the grievance with Staff A. Staff A agreed that the grievance was not complete, was lacking details and resolution was not discussed with the resident until 02/23/2026, which was six days after the resident reported it. <RESIDENT 46>Resident 46 was admitted to the facility on [DATE]. According to the annual Minimum Data Set (MDS-an assessment tool) assessment, dated 01/29/2026, the resident was cognitive intact. In an interview on 02/18/2026 at 10:09 AM, Resident 46 stated yesterday (02/17/2026) evening, they waited one hour for the nursing assistant to answer their call light. The resident stated they were waiting for staff to change their brief. The resident stated they had talked with the administrator about the care concern. On 02/19/2026 at 1:00 PM, review of the grievance report, documented the concern as customer services and call light wait time. There was no documentation about the resident's statement of the details of their call light concern nor whether abuse or neglect was ruled out. There was no documentation that staff involved had provided information. In a record review and interview on 02/23/2026 at 12:28 PM, Staff A reviewed the grievance and stated the information on the grievance report lacked information. Staff A stated they expected staff to investigate the call light concerns with more specific details including specific time, duration, timeline, and staff that were talked with. Reference WAC 388-97-0460 (1)(2)

Based on observation, interview and record review, the facility failed to ensure residents' care plans were revised and accurately reflected the resident's care needs for 3 out of 18 sampled residents (Residents 8, 9 and 38) when reviewed for care planning and revision of care plans. This failure placed the residents at risk for unmet care needs, medical complications, inaccurate care plan documentation, and a diminished quality of life. Findings included .Review of the facility policy titled, Person-Centered Care Plan, reviewed 09/15/2025 stated the facility must develop and implement a person-centered plan of care for each resident consistent with measurable objectives and timeframes to meet their needs.the care plan will be reviewed and revised by the interdisciplinary team after each assessment. <RESDIENT 38>Resident 38 admitted to the facility on [DATE] with diagnosis of end stage renal disease with dependence on renal dialysis (life-sustaining treatment that filters toxins, waste, and excess fluid from the blood when kidneys fail). Review of Resident 38's admission Minimum Data Set (MDS – an assessment tool) dated 10/15/2025 showed the resident did not require the use of supplemental oxygen. Review of Resident 38's quarterly MDS assessment dated [DATE], showed the resident now required the use of supplemental oxygen. Review of Resident 38's care plan, print date 02/18/2026 showed no documentation the resident had respiratory deficit, or required the use of oxygen supplementation for breathing. In an interview on 02/18/2026 at 9:33 AM, Staff I, Director of Respiratory Therapy (RT) stated they were not familiar with Resident 38 as they did not have an advanced airway system (referring to all other residents on that unit had a tracheostomy – advanced airway system). In observations of Resident 38 on 02/18/2026 at 9:48, 10:24 AM, 10:40 AM, and 11:02 AM, they were observed to have an oxygen tube to the nares (nasal area), and an oxygen concentrator at bedside running with the settings at 2 liters per minute (Lpm). In an observation of Resident 38 on 02/18/2026 at 11:50 AM, the resident was observed in their wheelchair. They had oxygen tubing to the nares, which was attached to an oxygen tank set at 2Lpm. In an observation on 02/19/2026 at 8:45 AM, 11:02 AM and 1:32 PM, and on 02/20/2026 at 8:53 AM, they were observed to have oxygen tube to the nares, and an oxygen concentrator at bedside running with the settings at 2 liters per minute (Lpm). In an interview on 02/20/2026 at 10:28 AM, Staff J, Registered Nurse (RN) stated they when a resident was on oxygen supplementation, that it would be addressed on the care plan. Staff J stated Resident 38 received oxygen supplementation, as they needed it when they slept and they tended to sleep a lot. In an interview on 02/20/2026 at 12:09 PM, Staff K, Licensed Practical Nurse (LPN)/Nurse Unit Manager stated that any resident that required oxygen supplementation should have physician orders and their care plan should reflect that. Staff K stated they were aware that Resident 38 was on oxygen supplementation, as the extra fluid from their kidney disease made it difficult to breathe. Staff K was not aware that Resident 38's care plan had not been updated to reflect they required oxygen supplementation and stated the care plan should have been updated. In an interview on 02/20/2026 at 1:30 PM, Staff B, Director of Nursing Services (DNS) stated when a resident required the use of oxygen supplementation regardless of how it was delivered, it should be reflected in the physician orders and care plan. Staff B stated they had been made aware, Resident 38 did not have their care plan updated to reflect oxygen use and stated it should have been updated. <RESIDENT 8>Resident 8 was admitted to the facility on [DATE] with diagnoses to include panic disorder, generalized anxiety disorder, and major depression disorder. Review of Resident 8's physician orders dated 08/07/2025 – 02/18/2025 documented the resident was prescribed clonazepam (anti-anxiety medication) for anxiety, with several dose changes over the dates reviewed. Review of Resident 8's care plan, print date 02/19/2026, showed no care plan area to address how the facility would monitor for adverse side effects of the anti-anxiety medication. In an interview on 02/20/2026 at 12:09 PM, Staff K, LPN/Unit Nurse Manager stated all residents care plans should document the facility would monitor for any adverse side effects from all medications they are prescribed. Staff K reviewed Resident 8's care plan and agreed the monitoring for adverse side effects for Resident 8's anti-anxiety medication was not included in the care plan. In an interview on 02/20/2026 at 1:30 PM, Staff B, DNS stated any resident that could experience an adverse side effect from a medication they are prescribed should be included in the care plan. Staff B stated Resident 8's adverse side effects for anti-anxiety medication should have been included in their care plan. <RESIDENT 9> Resident 9 admitted [DATE] with diagnoses which included osteoarthritis and impaired gait. Review of the most recent physical therapy discharge summary documentation dated 07/23/2025 showed the resident received physical therapy from 05/19/2025 through 07/23/2025. The discharge summary stated Resident 9 had met their skilled goal of walking 100 feet using a walker and supervision/stand by staff assistance. The discharge recommendations included an ambulation HEP (home exercise program) with nursing staff using a walker, independent strength exercises, and stated 24/7 assistance available as needed. The summary stated the resident's prognosis to maintain current level of function was excellent with consistent staff support. In an interview on 02/18/2026 at 3:18 PM, Resident 9 stated they used to walk around the unit with therapy, but it was stopped. Resident 9 stated they also were not allowed to walk without someone with them and said the nursing staff tell them they do not have time, so they are only walking once in a while and feel they have lost strength. Resident 9 stated they felt frustrated because they were motivated to do more, but nobody was available to help. Record review of the Quarterly Minimum Data Set assessment dated [DATE] documented use of walker was no, and walking 10 ft was documented as not attempted. Record review of Resident 9's Care Plan and Task records on 02/20/2026 did not show any documentation of a program or task which included assistance with ambulation or exercises. In an interview on 02/23/2026 at 10:56 AM, Staff C, Registered Nurse, Unit Manager, was asked how recommendations for a home exercise program requiring the supervision or assistance of the nursing staff was implemented and Staff C stated they were not sure. In an interview on 02/23/2026 at 11:21 AM, Staff B, Director of Nursing Services, stated Resident 9 did require staff supervision to ambulate and stated they had seen Resident 9 walk with staff a couple times. Staff B did not have further information related to Resident 9's therapy and provider recommendations or resident goals. Staff B acknowledged there were no care planned interventions or tasks addressing the exercise recommendations, preferences or resident goals. Reference WAC 388-97-1020(5)(b)

Based on interview and record review, the facility failed to ensure residents received assistance for activities of daily living for 1 of 3 residents (Resident 9) reviewed for activities of daily living. Failure to provide Resident 9 assistance with ambulation per the resident's preferences and therapy recommendations, placed them and other residents at risk for decline in function and decreased quality of life. Findings included .Review of the facility policy titled Activities of Daily Living with a revision date of 05/01/2023, stated that based on the comprehensive assessment and consistent with the resident's needs and choices, the facility must provide the necessary services to improve or maintain the resident's ability and prevent avoidable decline in function. Resident 9 admitted [DATE] with diagnoses which included osteoarthritis and impaired gait. Review of the most recent physical therapy discharge summary documentation dated 07/23/2025 showed the resident received physical therapy from 05/19/2025 through 07/23/2025. The discharge summary stated the resident had met their skilled goal of walking 100 feet using a walker and supervision/stand by staff assistance. The discharge recommendations included an ambulation HEP (Home exercise program) with nursing staff using walker, independent strength exercises, and stated 24/7 assistance available as needed. The summary stated the resident's prognosis to maintain current level of function was excellent with consistent staff support. In an interview on 02/18/2026 at 3:18 PM, Resident 9 stated they used to walk around the unit with therapy but it was stopped after they were doing good. Resident 9 stated they wanted to be able to go to the therapy gym and use the bike, as well as walk around, because they would like to lose weight. Resident 9 stated they were told they could not use the bike in the gym because they weren't on therapy anymore and there was nobody to watch them. Resident 9 stated they also were not allowed to walk without someone with them and said the nursing staff tell them they do not have time, so they are only walking once in a while and feel they have lost strength. Resident 9 stated they felt frustrated because they were motivated to do more but nobody was available to help. Record review of a provider note dated 02/09/2026 included recommendation to encourage restorative exercises as tolerated. Review of a provider note dated 12/18/2025 documented the resident's frustration and negative mood with a desire for more exercise and weight loss, with recommendations which (non-specifically) included exercises. Record review of the Quarterly Minimum Data Set assessment dated [DATE] documented use of walker was no, and walking 10 ft was documented as not attempted. Record review of Resident 9's Care Plan and Task records on 02/20/2026 did not show any documentation of a program or task which included assistance with ambulation or exercises. In an interview on 02/20/2026 at 10:04 AM, Staff E, Occupational Therapist/ Rehab Unit Manager, stated Resident 9 was currently being seen by occupational therapy related to issues with their hand, but had not received physical therapy for a while. Staff E stated Resident 9 had asked about using the bike because they wanted to lose weight and Staff E stated they told them that would not help. Staff E stated Resident 9 was able to do some exercises independently or with the nurses and did not believe the resident was on a restorative program. In an interview on 02/23/2026 at 9:12 AM, Staff D, Certified Nurse Aide/ Restorative Aide, confirmed that Resident 9 was not receiving any restorative nursing services and stated if Resident 9 was doing any walking or exercises, it was with the nursing staff on the floor. In an interview on 02/23/2026 at 10:15 AM, Staff N, Certified Nurse Aide, stated Resident 9 usually got up in their wheelchair, needed someone to be there for them to transfer and was able to tell them what they needed. Staff N stated they were not sure if Resident 9 was set up on any kind of exercises and thinks they did them on their own. When asked how much assistance Resident 9 required for ambulation, Staff N stated they were not sure, because they have never seen Resident 9 walk. In an interview on 02/23/2026 at 10:56 AM, Staff C, Registered Nurse, Unit Manager, was asked how recommendations for a home exercise program requiring the supervision or assistance of the nursing staff was implemented and Staff C stated they were not sure. In an interview on 02/23/2026 at 11:21 AM, Staff B, Director of Nursing Services, stated Resident 9 was independent at wheelchair level and did their own exercises. Staff B stated Resident 9 did require staff supervision to ambulate and stated they had seen Resident 9 walk with staff a couple times. Staff B stated Resident 9 had not had a decline in function. Staff B did not have further information related to Resident 9's stated preference for increased ambulation and exercise related to their weight loss goals or how nursing staff would be aware of the therapy and provider recommendations or resident goals. Staff B acknowledged there were no care planned interventions or tasks addressing the exercise recommendations, preferences or resident goals. Reference WAC 388-97-1060 (2)(a)(ii),(b)

Based on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 16) reviewed for activities had an accurate assessment of recreational care needs and received an ongoing program of activities to meet the individual resident's physical and mental needs. Based on the reasonable person concept, not having adequate recreation and/or sensory stimulation placed the resident at risk for social isolation, lack of stimulation and diminished quality of life.Findings included.Review of a facility policy, titled, Recreation Services Policy and Procedures, dated 08/07/2023, documented all patients who have limited tolerance in group or independent programs will have consistent and individualized recreation opportunities.Resident 16 was admitted to the facility on [DATE]. According to the Minimum Data Set (an assessment tool), dated 02/02/2026, the resident was in a persistent vegetative state (a condition where person cannot speak, interact or show awareness of their surroundings due to a severe brain injury).During observations on 02/18/2026 at 10:27 AM and 2:00 PM, Resident 16 was lying in bed in their room. There was no TV on or music playing.During observations on 02/19/2026 at 8:46 AM, 9:49 AM, 1:09 PM and 4:50 PM, Resident 16 was lying in bed. There was no TV on or music playing. During all observations on this date except at 1:09 PM, no lights were on and the room was dark.During observations on 02/20/2026 at 7:38 AM, 10:21 AM, 12:20 PM and 3:01 PM, Resident 16 was lying in bed. There was no TV on or music playing. During all observations on this date, no lights were on and the room was dark except at 12:20 PM. At 12:20 PM a staff member was checking the equipment in the room and had the light on.Review of Resident 16's recreation assessment, dated 02/03/2026, documented they were usually understood, and it was somewhat important to listen to music and watch TV/movies.Review of Resident 16's care plan focus area documented, it is important that resident has the opportunity to engage in daily routines that are meaningful, relative to their preferences, dated 02/03/2026. There was no goal listed for the focus area. Interventions for Resident 16 included I enjoy watching/listening to TV and I enjoy listening to music and prefer_______. The space was left blank despite a note indicating to specify type of music.Review of Resident 16's recreation participation record, from 01/27/2026 through 02/20/2026 showed activities occurred on 01/29/2026, 02/03/2026, 02/09/2026 and 02/17/2026.During an interview on 02/20/2026 at 12:29 PM, Staff M, Nursing Assistant Certified, reported they worked with Resident 16 two-three times a week. Staff G reported that they had not seen the TV on in the room or heard any music playing in Resident 16's room. Staff G reported they had not seen any family or friends visit since Resident 16 admitted .During an interview on 02/20/2026 at 10:08 AM, Staff H, Recreation Assistant, reported that they were provided with a list of residents that required 1:1 visits that day. Staff H reported residents requiring 1:1 visits were placed on a rotation and would be scheduled once every two weeks. Staff H reported that when they completed a 1:1 visit with a resident in a vegetative state, the visit lasted 10 minutes.On 02/23/2026 at 1:07 PM, a joint interview was held with Staff F, Recreation Director and Staff G, recreation assistant. Staff F reported that a resident's activity participation was the responsibility of all facility staff. Staff F reported that any staff could offer in-room activities (word games, music, movies or art supplies) and open blinds for residents in their rooms. Staff F stated care giving staff was responsible for getting residents up for group activities. Staff F and Staff G both stated they had not been in contact with Resident 16's family since they admitted . Reviewed the recreation activity record and observations of the room being quiet and dark with staff F and Staff G. Staff K stated they did not feel there had been adequate sensory stimulation for Resident 16. Staff B stated care giving staff should have turned on the TV and opened the blinds in the room for Resident 16. Reference WAC 388-97-0940-(1)(2)

Based on interview and record review, the facility failed to provide written bed hold notice to residents at the time of transfer to the hospital for 3 of 4 sampled residents (Residents 2, 11, 45) reviewed for hospitalization. This failure placed residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.Findings included .<RESIDENT 2> Resident 2 was admitted to the facility on [DATE]. Review of a progress note dated 07/31/2025 at 11:40 PM, documented that the dialysis center called the facility and reported that Resident 2 had been sent to the emergency room. A subsequent progress note showed Resident 2 returned to the facility on [DATE] at 3:24 AM. Review of the bed hold notice showed it was signed by a staff member on 07/31/2025, but no time was documented. The space for the resident or representative section documented refused and was dated 07/31/2025. There was no documentation as to who had refused or the date and time the contact was made. Review of Resident 2’s progress note documented that they were transferred to the hospital on [DATE] at 8:45 PM and was readmitted on [DATE]. Review of the bed hold notice showed it was signed by a staff member on 08/05/2025, but no time was documented. The space for the resident or representative section documented refused and was dated 08/05/2025. There was no documentation as to who had refused or the date and time the contact was made. <RESIDENT 45> Resident 45 was admitted to the facility on [DATE]. According to the 5-day Minimum Data Set (MDS- an assessment tool), dated 08/20/2025, the resident was cognitively intact. Review of a progress note dated 08/02/2025 at 8:18 PM documented Resident 45 was transferred to the hospital. Review of the bed hold notice showed it was signed by a staff member on 08/02/2025 but no time was documented. The space for the resident or representative section documented refused and was dated 08/02/2025. There was no documentation as to who had refused or the date and time the contact was made. In an interview on 08/27/2025 at 2:00 PM, Resident 45 denied being offered a bed hold when they were being transferred to the hospital on [DATE]. In an interview on 08/28/2025 at 9:19 AM, Staff G, Registered Nurse, stated that they did not know what a bed hold was, and they had not offered that to residents when they transferred them to the hospital. In an interview on 08/28/2025 at 9:25 AM, Staff D, Director of Social Services, stated that they did not do bed holds and the business office staff were responsible. In an interview on 08/28/2025 at 9:30 AM, Staff E, Business Office Manager, stated that they offered the bed hold notice to the resident if they were being transferred to the hospital. Staff E stated the majority of their residents were not alert and oriented. Staff E stated when they called resident representatives, they frequently were unable to be reached so they would just write “refused” on the notice. Staff E stated that they did not document the time and date or the person they tried to reach on the notice or in the clinical record. In an email interview on 08/29/2025, Collateral Contact 1, Resident 45's family member, documented they had not received a call about a bed hold when the resident was sent to the hospital on [DATE]. <RESIDENT 11> Resident 11 readmitted to the facility on [DATE]. According to the quarterly MDS, dated [DATE], Resident 11 was cognitively impaired. Review of Resident 11’s progress notes from 05/01/2025 to 08/28/2025, documented Resident 11 was transferred to the hospital on [DATE], 06/01/2025, 06/06/2025, 06/08/2025 and 06/17/2025. There was no documentation whether Resident 11’s representative was provided with written information about a bed hold policy or what their decisions were. Review of Resident 11’s bed hold notices, dated 05/05/2025, 06/01/2025, 06/06/2025, 06/08/2025 and 06/17/2025, showed a bed hold was offered and the notice was signed by a staff member. On the portion where the resident or the representative should sign, was documented “Refused”. There was no documentation as to who had Refused or the date and time the contact was made. In an interview on 08/29/2025 at 9:45 AM, Staff E, stated they called and offered the bed hold notices to residents or representatives after residents were transferred to the hospital. Staff E stated they documented “Refused” because they could not reach Resident 11’s representative. Staff E stated they did not document when and who they attempted to contact. Staff E stated they should have documented they could not contact the representative instead of documenting “Refused”. Refer to WAC 388-97-0120 (4)

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of insulin (injectable medication that regulates blood sugar) in 3 of 5 medication carts (Carts 3, 5, and 4) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and a diminished quality of life. Findings included.Review of the facility's policy titled, Insulin Pens, revised on 05/01/2025, showed once insulin pens were opened, they should be clearly labeled and may be stored at room temperature. The License Nurse (LN) was to follow the manufacturer's recommendations for product expiration. Review of Humulin N (an intermediate-actin human insulin) multidose insulin vials and KwikPen (a prefilled insulin pen) manufactures package insert, showed the insulin was good for 31 days once opened and stored at room temperature. Review of NovoLog insulin FlexPen (a prefilled insulin pen) and Novolog multidose insulin vials (a man-made rapid acting insulin) manufactures instructions (www.novolog.com), showed the insulin was good for 28 days once opened and stored at room temperature. Review of Lantus insulin (a long-acting insulin) pens and vials manufacture instructions (www.lantus.com), showed the insulin was good for 28 days once opened and stored at room temperature. Review of Lispro multidose insulin (rapid acting human insulin) vial and KwikPen manufactures package insert, showed the insulin was good for 28 days once opened and stored at room temperature. <MEDICATION CART 3>On 08/24/2025 at 10:23 AM, Medication Cart 3 was observed with Staff L, Licensed Practical Nuse (LPN). The following insulins were observed stored in the medication cart at room temperature:- Resident 38 had an undated Lispro insulin vial and a Humulin N insulin pen dated 06/13/2025.-Resident 63 had an undated NovoLog FlexPen and vial. - Resident 16 had an undated NovoLog FlexPen.- Resident 95 had an undated Lantus SoloSTAR pen (a prefilled insulin pen). In an interview on 08/24/2025 at 10:33 AM, Staff L stated insulin was dated once pulled out of the refrigerator and placed in the medication cart. Staff L stated depending on the type of insulin it was good for 28 or 30 days once removed from the refrigerator. Staff L verified no dates were found on Resident 38, 63, 16, and 95's insulin and Resident 38's insulin was expired. In an interview on 08/24/2025 at 10:45 AM, Staff K, Registered Nurse (RN), stated insulin was dated and good for 28 days when removed from the refrigerator and placed in the medication cart. <MEDICATION CART 5>In an observation on 08/24/2025 at 10:51 AM, Cart 5 was observed with Staff J, LPN. The following insulins were observed stored in the medication cart at room temperature:-Resident 2 had a Lispro insulin pen dated 07/14/2025.- Resident 78 NovoLin N FlexPen dated 07/16/2025. In an interview on 08/24/2025 at 10:58 AM, Staff J stated insulin was good for 28 days once pulled from the refrigerator. Staff J was aware of Resident 2 and 78's expired insulin. <MEDICATION CART 4>In an interview and observation on 08/24/2025 at 11:00 AM, Cart 4 was observed with Staff I, LPN. Resident 74 had a Humalog KwikPen, dated 07/22/2025. When asked Staff I how long insulin was good for when opened and removed from the refrigerator, Staff I stated 28 days. Staff I was aware Resident 74's insulin was expired. On 08/24/2025 at 1:37 PM, Staff B, RN/Director of Nursing Services, was interviewed. Staff B stated the LN was to date any type of insulin when opened, removed from the refrigerator, placed in individual bags, and stored in the medication cart. Their expectation was the LN would check the date of the open insulin prior to administration. Staff B stated depending on the type of insulin, the LN should discard the insulin per the manufacturer's instructions. Refer to WAC 388-97-1300(2)

Based on interviews, record reviews, and observations the facility failed to maintain accurate and complete medical records and ensure the medical record contained the required information for 1 of 4 residents (Resident 1) reviewed for restorative services, and 1 of 3 residents (Resident 45) reviewed for change of conditions. These failures placed residents at risk for delay in care, unmet care needs, and a diminished quality of life. Findings included .In a review of the facility policy, Health Information: Electronic Medical Records, Forms and Information-Electronic Signatures revised 05/01/2022, documented staff would document resident information electronically and any documentation not converted electronically would be completed manually.Review of the facility policy titled, Restorative Nursing, revised date 08/07/2023, documented restorative nursing program needed to be documented by a licensed nurse in the Care Plan Evaluation progress note. <RESTORATIVE EVALUATION> <Resident 1>Resident 1 readmitted to the facility on [DATE]. According to the comprehensive MDS assessment dated [DATE], the resident received restorative programs. Review of Resident 1's care plan, print date 08/25/2025, documented Resident 1 had restorative programs for passive range of motion. Review of Resident 1's EHR from 01/01/2025 to 08/25/2025, showed there was no documentation of restorative programs evaluations. In an interview on 08/27/2025 at 1:44PM, Staff P, Nursing Assistant Certified/Restorative Aide, stated Resident 1 had a passive range of motion restorative program three times a week.In a joint interview on 08/27/2025 at 2:13 PM with Staff Q, Clinical reimbursement coordinator, and Staff B, Director of Nursing, Staff Q stated they had a restorative review meeting every week with the therapy manager and the restorative aid. Staff Q stated they discussed restorative program plans, goals, progression, and if they needed to modify the restorative programs during the meeting. Staff Q stated they documented the meeting minutes in the binder but there was no documentation of restorative programs evaluations. Staff B stated they would find the binder that contained meeting minutes and restorative programs evaluations. No further information provided. <CHANGE OF CONDITION> <Resident 45>In an email interview with Resident 45's family member, Collateral Contact 1, they reported that there was a delay in carrying out provider orders in the facility. Review of Resident 45's physician order, dated 08/02/2025 at 8:19 AM, documented an order for laboratory tests. This order was confirmed by Staff H, LPN, on 08/02/2025 at 2:35 PM. In a telephone interview on 08/27/2025 at 9:35 AM, Staff H stated that Resident 45 was not feeling well and had some nausea during their shift on 08/02/2025. Staff H reported the provider saw the resident and had put in lab orders and left the facility without talking to them. Staff H stated they tried to call the provider to clarify and confirm the order because the resident was already on antibiotics. Staff H stated they called the provider twice to obtain clarification and that they still wanted the labs drawn. Staff H stated there was an additional delay as they did not have access to order labs electronically. Review of the progress notes dated 08/02/2025 showed no documentation of the series of events as described by Staff H. Reference WAC 388-97-1720 (1)(a)(i)(ii)(iii)(2)(a)(d)(e)(f)

Based on observation, interview and record review, the facility failed to ensure call lights (an alerting device for staff to assist residents in need) were within reach for 1 of 1 resident (Resident 4), reviewed for accommodation of needs. This failure placed residents at risk for delayed care, potential avoidable accidents, and diminished quality of life.Findings included .Review of the facility policy titled, Call Lights, revise date 07/15/2025, documented each patient would be evaluated for any special accommodations to use the call system and staff would ensure the call light was within reach of the patient. Resident 4 readmitted to the facility on [DATE]. According to the Annual MDS (Minimum Data Set-an assessment tool), dated 06/12/2025, the resident was cognitively intact. In a phone interview on 08/24/2025 at 1:53 PM, Collateral Contact 2 (CC2), a family member of Resident 4, stated Resident 4 could not always reach the call light. CC2 stated Resident 4 could only use their head to activate the call light. CC2 stated the call light frequently was not in place during their visits. Review of Resident 4's Activity of Daily Living care plan, documented interventions for Resident 4 included a soft touch call light, staff to clip the call light to the pillow next to the resident's head, initiated on 08/11/2021. In an observation and interview on 08/25/2025 at 10:49 AM, observed Resident 4's call light lying on top of their abdomen. The call light was a soft touch call light (flat and round call light). When asked how they used the call light, Resident 4 demonstrated by turning their head to the right side. Resident 4 indicated by nodding their head that staff often left their call light on their abdomen. In an interview and observation on 08/25/2025 at 2:00 PM, CC2 stated they visited Resident 4 at 11:30 AM and found the soft touch call light on top of their abdomen. Observed the soft touch call light was changed into a head activated call light system (a triangle shaped call light). CC2 stated Resident 4 used a head activated call light during hospitalization and it was much easier for them to use. In an observation and interview on 08/26/2025 at 8:30 AM, Resident 4's call light was two inches away from their head and face. Resident 4 attempted to turn their head to the right side but could not reach the call light. Resident 4 attempted twice. Resident 4 indicated by shaking their head that they could not reach the call light. In an observation on 08/26/2025 at 9:38 AM and 12:02 PM, observed the call light was too far away from Resident 4's head. In an observation on 08/27/2025 at 9:12 AM, observed the call light was too far from Resident 4's head. Resident 4 turned their head to the right side, but could not reach the call light. In an interview on 08/27/2025 at 9:35 AM, Staff R, Nursing Assistant Certified (NAC), stated Resident 4 was alert, non-verbal, and could not move their limbs. Staff R stated they needed to place the call light close to the resident's head so the resident could activate the call light. In an interview and observation on 08/28/2025 at 10:03 AM, Staff S, NAC, observed Resident 4's call light a few inches away from their head. Resident 4 turned their head but could not reach the call light. Staff S stated the call light was too far from the resident's head and placed the call light closer. Resident 4 demonstrated they were able to reach the call light. Refer to WAC 388-97-0860 (2)

Based on observation, interview and record review, the facility failed to ensure that care planned interventions for fall management were in place for 1 of 2 residents (Resident 5) reviewed for falls. This failure placed resident at an increased risk of injury if a fall occurred. Findings included .Resident 5 admitted to the facility on [DATE].Review of a facility report for Resident 5's fall on 06/10/2025, showed that there had been a fall mat on the left side of the bed. The report showed the new intervention was to place a fall mat on the right side of the bed in addition to the other fall mat.Review of Resident 5's Kardex (lists care needs of the resident), dated 08/27/2025, showed Fall mat on the right side of the bed and Fall Matts to floor.During an observation on 08/25/2025 at 10:12 AM, no fall mat was noted on the floor on either side of Resident 5's bed.During observations on 08/26/2025 at 9:35 AM and 08/27/2025 at 10:33 AM, Resident 5 was in bed with no fall mat observed on the floor on either side of the bed.During an interview and observation on 08/27/2025 at 11:09 AM, Staff N, Registered Nurse and Staff O, Nursing Assistant Certified, were in the room providing care to Resident 5. When asked about fall mats at the bedside, both Staff N and Staff O stated they had not seen fall mats in Resident 5's room. Staff O checked the closet and there were no fall mats.During an interview and record review on 08/27/2025 at 11:14 AM, Staff M, Licensed Practical Nurse/interim Resident Care Manager, reviewed the Kardex for Resident 5. Staff M reported Resident 5 was to have fall mats in place at the bedside.During an interview and observation on 08/27/2025 at 11:18 AM, Staff M confirmed the fall mats were not at bedside. Staff M checked the closet and the bathroom and could not locate the fall mats. Refer to WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to conduct thorough investigations for 4 of 8 residents (Residents 58, 71, 73 and 78) whose investigations were reviewed for thorough investigations. The failure to conduct thorough investigations placed residents at risk for repeat incidents, injury, and for unmet care needs due to a lack of thorough investigations after incident occurred, and there was a failure to preserve evidence necessary for thorough investigations. These failures placed residents at risk for repeat incidents and injury. Findings included . Review of the facility policy Abuse Prohibition dated 10/24/2022 showed actions to prevent abuse, neglect, exploitation, or mistreatment , including injuries of unknown source will include providing patients, families, and staff with information on how and to whom they may report concerns, incidents, grievances , without fear of retribution and provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect, and or misappropriation of property is more likely to occur. The facility will initiate an investigation within 24 hours of an allegation of abuse that focuses on: - Whether abuse or neglect occurred and to what extent - Clinical examination for sings of injuries, if indicated. - Causative factors; and - Interventions to prevent further injury The investigation will be thoroughly documented within the risk management Portal. Ensure that documentation of witnessed interviews is included. The facility is to take steps to revise the care plan, take steps to resolve patient and family concerns and allegations, and clearly recording the same. <RESIDENT 71> The resident admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following a stroke, epilepsy, depression, anxiety, Post Traumatic Stress Disorder and muscle weakness. According to their admission Minimum Data Set (MDS) assessment, dated 02/03/2025, they had moderate cognitive impairment, and no fall history. The MDS indicated they needed extensive assistance of 2-persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. 1ST FALL Review of an incident investigation, dated 02/18/2025 at 6:40 AM, showed a nurse found the resident on the floor a little bit away from their bed. The nurse noted the resident had a minor bump on their head which the report showed the resident said it had been there a while. The report showed the resident denied hitting their head. The Provider was notified, and orders were received for continuous monitoring and cold compression to the bump on the head. A scoop mattress was added as an intervention although the fall was reported to be from trying to go out of the room. The investigation was not thorough, it did not include on what side of the bed or if the resident was at the foot of the bed. There was no documentation as to where the bump was located or the size of the injury or why ice was necessary for an old injury. The investigation did not include a witness statement from the Nurse's Aide Certified (NAC) who had cared for the resident that night. 2ND FALL Review of an incident investigation, dated 02/25/2025, showed at 4:15 AM, a NAC notified the Registered Nurse (RN) that the resident was on the floor lying on his left side facing the bed with their back facing the door, legs straight facing the sink. The resident's head was at the head of the bed, and they were supporting their head with a pillow. The intervention added was close observation in the nurse's station while the patient is awake and becoming agitated. The incident investigation did not note the resident had been agitated. The investigation showed the resident could not remember why they fell . The facility conclusion was that the resident got out of bed without assistance, due to lack of awareness of their physical limitation. The investigation included a change in condition evaluation for 02/27/2025, 2 days after the fall (there was a fall on 02/27/2025 as well). The investigation was not thorough, it didn't include: - medication information, though the resident was on medications from several of the classes of medications listed on the investigation form, -predisposing situational factors included, though there was a section Predisposing Situational Factors on the investigation form, -statement section showed there were no statements, although a statement was attached. 3rd FALL Review of an incident investigation, dated 02/27/2024, showed at 7:00 AM, a NAC found the resident on the floor sitting in front of the roommate's bed. The residents tube feeding pump and pole was on their bed and the tubing was stretched but still connected. The roommate stated the resident crawled to their side of the bed and tried to take their wheelchair. The intervention added as one on one observation to prevent further falls and injury. The care plan showed a fall matt was added to the care plan on 03/04/2025, 8 days after the fall. The investigation was not thorough, it didn't include: - medication information, though the resident was on medications from several of the classes of medications listed on the investigation form, -predisposing situational factors included, though there was a section Predisposing Situational Factors on the investigation form, -statement section showed there were no statements, a statement was attached and noted the fall to occur at 5:30 AM rather than 7:00 AM on incident report. The NAC documented the resident said they slid when trying to pull their wheelchair. The NAC who provided care to the resident and completed the statement did not include when the resident was last toileted or checked on. -neuro checks started at 7:15 AM although NAC stated they found the resident on the floor at 5:30, a conflicting time. Did not address conflicting times. -no information documented about when the resident had last been toileted or checked on. -The investigation showed staff assisted the resident back to bed using a gait belt. The resident's plan of care is for mechanical lift with two staff for transfers. There was no mention this was addressed with the involved staff. <ABUSE/NEGLECT ALLEGATIONS> In an interview on 03/11/2025, Collateral Contact (CC) 3 reported their loved one had to wait an hour to get changed. CC 3 stated most of the aides were good but there were a few aides that stand in the hall visiting and ignoring call lights. CC 3 stated this was frustrating while waiting an hour to get the soiled brief changed while staff is laughing and visiting with each other. CC 3 stated their loved one had falls and the staff try to make them feel bad by saying they are heavy care. CC 3 stated they knew that there are standards of care, and this facility was not meeting them. They said there were two grievances filed for them. The first one was a few weeks after they admitted , and they never received follow up. CC 3 said a male night aide hurt (Resident 71's) wrist and another time a male aide made their right upper arm hurt and it popped. CC 3 said they were both male aides who worked at night. The resident and CC 3 did not know their names but could point them out if they saw them. CC 3 stated they told the doctor about both incidences. CC 3 stated the staff used to lock the wheelchair brake on their bad side, and they would go in circles, unable to move their wheelchair forward. CC 3 stated their loved one would become frustrated and, staff observed the locked wheelchair and (Resident 71's) frustration and did not help them. Resident 71 stated a male nurse, Staff U, RN told them they would not take their vital signs unless they took pain medications. The resident stated they refused the medications and felt harassed. CC 3 stated they had talked with Staff D, RN/Resident Care Manager and the other nurse manager and they tried to spin the issues on (Resident 71). They said staff respond to their concerns with Well if (Resident 71) didn't do that, then we wouldn't do this. CC 3 said the facility had called them about all the falls but one. Resident 71 stated they hit their head a couple of times during the fall, and they were scared to go to sleep after because the nurse did not take their vital signs. CC 3 asked if staff should be taking vital sings every 15 minutes after a fall, then every 30 minutes, then hourly. CC 3 stated another concern is the staff purposely move the residents call light out of their reach. Resident 71 and CC 3 both stated they were concerned about retribution from administration. In an interview on 03/11/2025 at 1:56 PM, the delay in incontinent care, two separate incidences of rough handling with pain by 2 male NAC's, locked wheelchair brakes, call light out of reach on multiple occasions were discussed with Staff A, Administrator and Staff B, Director of Nursing. Staff A stated Resident 71 had behaviors and used to push his call light all the time. Staff A said they had not heard any of this and did not believe there were any grievances for Resident 71. Staff B stated Resident 71 was receiving one on two supervision because of his falls. In an interview on 03/12/2025 at 9:12 AM, Resident 71 was alert and oriented and said the staff took their call light away from them again last night. The call light was observed to be clipped at the bottom left corner of their bed, out of reach. CC 3 stated the call light is either there when they come in or wrapped over the outlet on the wall. CC 3 stated Staff A came into the room last night and asked them why they did not fill out a grievance form. CC 3 stated they told Staff A that they should not have to fill out a form, they reported concerns to the nurse which they thought was the chain of command. CC 3 stated that Staff A told them that they were bending over backwards for them. CC 3 stated Staff A was dismissive to their concerns. At 2:20 PM, CC 3 stated they showed Staff A the finger shaped bruise on (Resident 71's) right bicep and Staff A responded, That is not much of a bruise. CC 3 stated the nurse on last night came in and confronted them and asked if I had reported a bruise had occurred on their shift to Staff A. CC 3 said the nurse seemed scared and afraid they were going to get reprimanded. In an interview and observation on 03/13/2025 at 1:31 PM, Resident 71 was in bed with CC 3 at bedside. Resident 71's was observed to have a left inner calf fingerprint shaped 1 cm by 1 cm brown bruise. CC 3 stated they did not know where the bruise came from. CC 3 said the resident had 4 falls at the facility, twice they hit their head and one they purposely crawled out of bed to get help as their call light was not in reach. Resident 71 stated they had a concern last night with Staff U, RN who did not wake them up and gave them medications in their tube. The resident stated he woke up when Staff U was plunging something into his tube, and they did not like that. The resident said they asked Staff U what medications they were given at that time, and the nurse would not tell them what the medications were. CC 3 said they did not like when staff do anything with their tube when they were not awake. In an interview on 03/13/2025 at 3:42 PM, Staff B, DNS was asked about the left leg and arm bruising as they were not on the incident report log. Staff B informed CC 3 is reporting bruises of unknown origin. Staff B stated, But the skin check And did not finish their statement. In an interview and observation on 03/14/2025 at 8:32 AM, Resident 71 motioned to me to come in from the hall. Resident 71 stated that the nurse on right now tried to give them medications and they wanted to wait until their wife arrived first and the nurse said no. This surveyor went to interview Staff E, RN. Staff E stated they administered Resident 71's medications, and the resident kept saying they were waiting for their wife. Staff E said they were not aware of the residents' concerns with medication administration and they assumed the resident was just saying they were waiting for their wife. Staff B, DNS walked up and stated they had updated the care plan for nurses to make sure the resident is awake, tell them what medications you are giving, seek permission first. Staff B said Staff U had been in serviced and they were going to in-service the other nurses today. Review of the care plan on 03/14/2025 at 8:40 AM up until 03/17/2025 at 11:00 AM, showed no revision to the care plan on the resident's preference for medication administration. Review of the change in condition evaluation dated 03/11/2025 at 1:57 PM, showed Staff D, RN noted an abuse allegation was reported by the resident's wife. In an interview on 03/17/2025 at 9:20 AM, Staff D, RN stated they had not heard any concerns about rough handling from Resident 71. Staff D stated the resident did complain about staff but could not say if the staff was male or female. Staff D did not probe into further details when the resident complained about staff. In an interview on 03/17/2025 at 10:47 AM, Staff B was asked about the allegation involving Staff U. Staff B stated they completed a grievance on this matter, and they revised the care plan. Staff B was informed this surveyor could not see any care plan revisions about this. Staff B stated the leg bruise was probably from a fall and showed up days later. In an interview on 03/17/2025 at 11:47 AM, Staff E, RN stated if a resident had concerns with the way they were treated, they would notify the RCM, DNS and then an investigation had to be done to make sure or see if it really happened. In an interview on 03/17/2025 at 12:30 PM, Collateral Contact 4, Resident 71's sister asked to talk to me outside and stated the nurses were still not waiting for (Resident 71) to wake up before attempting to give medications. CC 4 said the past weekend staffing was terrible and there was not enough staff. CC 4 said one aide got in trouble and was crying for reporting something to management. CC 4 stated staff are scared to get in trouble with management. During our interview, staff in the Administrator office kept looking out the window. Staff A, Administrator came outside at one point. CC 4 said when they report something, administration avoids eye contact with them. They said it was not worth reporting anything because nothing changes. CC 4 said the resident is very guarded with their tube after it had been placed inappropriately at the hospital, and it was very upsetting to them, and they try to protect that area of their stomach. CC 4 stated the resident was developing a pressure sore and they had been asking for an air mattress for weeks. CC 4 stated the resident sat in their BM for 3 hours Saturday morning. CC 4 stated the day shift aide was upset and told them the bed was messy and wet. CC 4 said the resident reported their call light was taken away from them at 1:30 PM. They said almost every single time they arrive, the call light was out of the residents reach. In a joint interview on 03/17/2025 at 1:38 PM, Staff A and B stated they were unaware investigations were not thorough and did not include indicated statements from assigned caregivers, review of conflicting times, or circumstances and what the root cause was. Staff A and B were informed of the allegation that Resident 71 had been in their soiled brief for 3 hours on Saturday. Staff A and B did not ask for further details. At 3:48 PM, this surveyor met with Staff A and B to ensure they were going to investigate the prolonged exposure to the soiled brief. At that time, Staff B wrote down the details. Staff A stated they had offered placement at another facility as the resident as family did not seem happy there. Review of the neglect allegation investigation for Resident 71 dated 03/11/2025 at 1:45 PM, showed patient and spouse complained to the surveyor they were waiting one hour to get help to change the (incontinent brief), and they had some problems with NAC's but did not remember who they were. CC 3 stated they filed two grievances and never heard back from the staff about them. One was the night a NAC hurt Resident 71's right wrist and right arm and it popped. Another concern was staff locked the resident's wheelchair breaks which made the resident upset. The resident felt harassed because the staff blame them. Also, staff hide the call light from them. The investigation showed the DNS completed a new Brief Interview for Mental Status (BIMS, an assessment to determine cognitive status) during the investigation and documented the resident was an unreliable historian and was consistently confused. The report showed Resident 71 was placed on one-on-one supervision rather than the two on one for 12 hours reported. The investigation showed the residents consistent state of confusion and cognitive impairment, it is reasonable to conclude the resident was confused about the source of their wrist pain. The investigation was not thorough, it didn't include: - An investigation of resident reporting being harassed - An investigation of withholding the call light - An investigation of locked wheelchair brakes, impairing the resident's ability to self-propel - An investigation of lying in feces for an extended period of time. - Review of staffing for the Resident - Did not include statements from each assigned nurse and NACs for Resident 71 or in immediate area who had cared for Resident 71 - Interviews from each interviewable resident on this resident's unit <RESIDENT 78> Resident 78 admitted on [DATE] with diagnoses to include traumatic brain injury, muscle weakness and multiple fractures as a result of a motor vehicle accident. Review of the 01/21/2025 MDS showed the resident was cognitively intact and had no falls. Review of the physician orders beginning 01/15/20205 showed activity restrictions as helmet to be worn when out of bed. Hard cervical collar on neck at all times. Non weight bearing to right leg and boot to be worn when out of bed. Review of the fall incident report investigation dated 03/07/2025 at 12:00 AM, showed resident 78 was found on the floor by Physical Treatment (PT) after the resident had a shower. The report showed the resident stated they got up to reach out for their hairbrush when their leg gave up and they fell to the floor. There was no mention of their right leg brace being on or off at the time of the fall. Review of the attached statement showed the Physical Treatment Assessment (PTA) walked into the Resident 78's room and found the resident on the floor by their bed next to their wheelchair. The resident stated they were walking taking a few steps to get a brush on the counter and lost their balance and fell to the floor. The statement showed the residents helmet was on the floor and the neck brace was on the bed and wheelchair was not locked. There was no mention of the time they were found or if their right leg brace was on at the time of the fall. Review of a progress note dated 03/07/2025 at 11:21 AM showed Resident 78 was found on the floor by PT. The resident had just had shower and was dressed up by the NAC 5 minutes before the incident. PT who was passing by found resident on the floor by the bedside. Call light was within reach prior to the fall, bed in the lowest position, floor clean dry with no clutter and adequate lighting within the room. The investigation was not thorough, it didn't include: - Statement from assigned nurse's aide and shower aide who provided care minutes before the fall - Mental status - Predisposing Situation factors - Or address the helmet being removed on the floor, neck brace off on the bed or if the left leg brace was on at time of fall. - Clarification as to what time the fall occurred. The intervention was education to the resident on calling for help before attempting to transfer and did not include ensuring personal items were within reach. 44110 <RESIDENT 58> Resident 58 admitted to the facility on [DATE], with diagnoses that included history of stroke, post-polio syndrome (causes paralysis), and diabetes. The admission MDS assessment dated [DATE] showed the resident was in a vegetative state, with impairments to one side of their body, and was dependent for all cares. The assessment stated the resident currently had an unhealed pressure ulcer. Review of Resident 58's initial wound assessment dated [DATE], by a contracted wound provider, showed the resident had a stage 3 pressure ulcer to their left lateral calf. The wounds to right leg and sacrum were noted to have been resolved. Review of Resident 58's weekly wound assessment dated [DATE], by a contracted wound provider showed the resident continued to have one Stage 3 pressure ulcer to their left lateral calf. Review of Resident 58's progress notes showed on 02/21/2025 at 4:39 PM, the nurse documented left lateral leg had two separate areas. The note only reflected measurements for one area, and did not specify if it was the old pressure ulcer or new wound. Review of Resident 58's weekly wound assessment dated [DATE], by a contracted wound provider showed the resident had two new wounds. The first wound was located on the right heel and was classified as a Stage 3 full thickness wound. The second wound was located on the residents left heel and was classified as a deep tissue pressure injury. Review of the facility state reporting log for February 2025 showed an entry for a other skin on 02/26/2025. The log showed there was no injury. The log showed the findings where the origin had been established, and the action taken was a care plan revision and medical treatment. Review of the facility investigation dated 02/26/2025 showed during wound rounds the contracted wound provider found a new pressure injury to the right heel, and a new deep tissue pressure injury (DTPI) to the left heel. The immediate action taken was to update the care plan and update the treatment orders, provider and family notified. The section of the investigation that showed predisposing environmental factors listed none. The section of the investigation that showed predisposing situation factors listed other (describe in note below) which showed the resident was bed bound, limited activities, diabetic and malnourished. The summary stated the root cause of the skin issue was due to the resident's diagnosis, and medical history, and that after gathered information from staff the facility was able to rule out abuse and neglect. The investigation included a note from a nursing aide that stated the resident had a new skin area, and from the nurse that had rounded with the contracted wound provider that stated there was a new wound. The investigation did not reflect a thorough investigation, there was no collection of evidence or information related to the resident's care that would of show that the residents' new wounds were unavoidable. The investigation did not show the facility had ruled out neglect. In an interview on 03/17/2025 at 1:12 PM, Staff B, stated that they ruled out neglect for Resident 58 through review of the medical records, and staff. Staff B was asked why that was not included in the investigation and stated they probably should have done more to show the staff had been compliant with the care plan interventions in place to prevent or worsening of the ongoing pressure ulcers. 42927 <RESIDENT 73> Review of a facility investigation showed Resident 73 obtained a skin tear to their right calf on 02/26/2025. The nurse that found the skin tear documented that the skin tear happened because of poor positioning of Resident 73's Lower extremities (legs). The nurse's statement did not state if the skin tear had just occurred or why the positioning caused the skin tear. The investigation summary did not show evidence that the cause of the skin tear was identified. The summary did not include any environmental factors, any assessment if the staff had positioned Resident 73's legs appropriately or if staff had caused the skin tear during care. During a joint interview and record review on 3/17/2025 at 7:50 AM, Staff A reviewed the investigation summary for the skin tear incident. Staff A stated the summary did not show how the skin tear occurred. Staff B stated they did not determine the cause of the skin tear. Staff B stated the investigation was not thorough. Staff B stated they did not identify the cause of the skin tear and put no interventions in place to prevent any further skin tears from occurring. This is a repeat deficiency from 10/01/2024. Reference: (WAC) 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, were completed within the required timeframes and/or included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for nine of sixteen residents (Residents 13, 58, 66, 67, 71, 73, 78, 80, and 334) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, dated October 2024, showed: A comprehensive admission minimum data set (MDS- assessment tool) assessment was required to be completed by 14th calendar day of the resident's admission day. A comprehensive annual MDS assessment was required to be completed by 14th calendar day of the assessment reference date (ARD). The RAI consisted of three basic components: the MDS assessment, the CAA process, and the RAI Utilization Guidelines (instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information). The CAAs reflect conditions, symptoms, and other areas of concern that are common in nursing home residents and are commonly identified or suggested by MDS findings. Interpreting and addressing the care areas identified is the basis of the CAA process and can help provide additional information for the development of an individualized care plan. Review of the facility's policy titled, MDS Clinical System Process Part 4 - CAA and Care Planning Process, dated 11/01/2024, showed the CAA process provides clarification of a patient's functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. The assessment of the causes and contributing factors gives the interdisciplinary team (lDT) additional information to help them develop a comprehensive plan of care. <RESIDENT 71> Resident 71 admitted on [DATE] with diagnoses to include with diagnoses that included hemiplegia (unable to move one side of the body) affecting their left side, depression, anxiety and Post Traumatic Stress Disorder. Review of the admission MDS dated [DATE] included the following triggered CAA's: functional abilities, falls, psychotropic drug use, psychosocial well-being, and pressure ulcers. Review of the MDS assessment, dated 02/02/2025 showed the CAAs did not contain comprehensive summaries or analysis that included the current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's CP was needed. The CAAs were blank except for the auto populated information from the MDS assessment. <RESIDENT 78> Resident 78 admitted on [DATE] with diagnoses to include traumatic brain injury and multiple fractures after a motor vehicle accident. Review of the admission MDS assessment, dated 01/21/2025, included the following triggered CAA's: psychotropic drug use, falls and functional abilities. Review of the MDS assessment, dated 01/21/2025, showed the CAAs did not contain comprehensive summaries or analysis that included the current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's CP was needed. The CAAs were blank except for the auto populated information from the MDS assessment. 44110 <RESIDENT 58> Resident 58 admitted to the facility on [DATE], with diagnoses that included history of stroke, post-polio syndrome (causes paralysis), and diabetes. In a review of Resident 58's admission MDS dated [DATE] showed the resident had unhealed pressure ulcers, and was not able to take anything by mouth and received all of their nutrition and hydration from a enteral feeding (providing nutrition directly into the gastrointestinal (GI) tract through a tube). The CAA was triggered for pressure ulcers, feeding tube, and nutrition. Review of each CAA showed all areas were blank and incomplete. 42927 <RESIDENT 66> Resident 66 admitted to the facility on [DATE] with diagnosis of intracerebral hemorrhage (bleeding in the brain which causes abnormal function of thought, movement and function), dysphagia (affects ability to swallow). Review of Resident 66's physician orders, showed the diet order, dated 02/05/2025, was nothing by mouth. Resident 66 had orders to have nutrition via enteral tube/feeding tube. Review of a Braden assessment (assessment for risk of developing bed sores), dated 02/05/2025, showed Resident 66 was at high risk of developing a pressure ulcer (bed sores). Review of the Care Area Assessments for Activities, feeding tube, and pressure ulcer, dated 02/18/2025, showed that the sections for resident and/or family representative input and the section to describe impact of this problem/need on the resident and your rationale for care plan decision were blank. There was no documentation or assessment if these areas were a concern for Resident 66. There was no documentation of complications or risk factors or how to mitigate the risk with specific interventions which should be carried onto the care plan or the need for any referrals to other health professionals. <RESIDENT 73> Resident 73 admitted to the facility on [DATE] with diagnosis of a pressure ulcer. Review of Resident 73's Pressure ulcer CAA, dated 10/25/2024, showed that the sections for resident and/or family representative input and the section to describe impact of this problem/need on the resident and your rationale for care plan decision were blank. There was no documentation or assessment if these areas were a concern for Resident 73. There was no documentation of complications or risk factors or how to mitigate the risk with specific interventions which should be carried onto the care plan or the need for any referrals to other health professionals. 51551 <RESIDENT 67> Resident 67 admitted to the facility on [DATE]. Review of Resident 67's comprehensive admission MDS assessment dated [DATE], showed the assessment completion date was 10/25/2024, 22 days after admission. <RESIDENT 80> Resident 80 admitted to the facility on [DATE]. Review of Resident 80's comprehensive admission MDS assessment dated [DATE], showed the assessment completion date was 02/18/2025, 19 days after admission. <RESIDENT 334> Resident 334 admitted to the facility on [DATE]. Review of Resident 334's comprehensive admission MDS assessment dated [DATE], showed the assessment completion date was 03/14/2025, 16 days after admission. <RESIDENT 13> Resident 13 admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (mental health condition that disrupts thought process, and perception mixed with depression), major depression and panic disorder. Review of Resident 13's MDS information on 03/13/2025, an annual comprehensive assessment was scheduled to be started on 02/20/2025, with an expected completion date of 03/06/2025. Review showed that out of the 18 areas to assess only six had been completed. The MDS was incomplete and past due. In an interview on 03/14/2025 at 9:44 AM, Staff X, Registered Nurse/MDS Coordinator, stated they were aware of the late completion of MDS assessments. In the follow up interview on 03/14/2025 at 12:10 PM, Staff X stated they did not know the deadline for comprehensive admission MDS assessment was 14 calendar days of the resident's admission day, not the ARD. During an interview on 03/14/2025 at 2:26 PM, Staff X, Registered Nurse (RN)/MDS Coordinator, stated that when they complete a CAA worksheet, they review the area to make sure the issue is still appropriate for the resident. If the issue was still pertinent, they click on the square to show that the issue will be care planned. Staff X stated they did not document risk factors or complete an analysis of the issue, nor did they include resident/family input if they were going to include the issue on the care plan. Staff X stated if the care area was no longer an issue for the resident, they would document a short summary as to why it was no longer an issue for the resident. During a phone interview on 03/14/2025 at 2:28 PM, Staff Z, RN/MDS Coordinator stated they reviewed the clinical record when completing the CAA's but did not document any assessment or analysis of the issue on the CAA worksheet or in the clinical record. In an interview on 03/14/2025 at 03:25 PM, Staff B, Director of Nursing, stated they expected all MDS assessments be completed timely. Reference: (WAC) 388-97-1000 (b)(c)(ii)(2)(f)(g)(p)(3)(a)

Based on interview and record review, the facility failed to act on the consultant pharmacist's monthly medication regimen review (MRR) recommendations in a timely manner for 1of 5 residents (Resident 13) reviewed for unnecessary medications and 1 of 6 months (November) reviewed for timely completion. Failure to act timely on the pharmacist's recommendations placed all residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Review of the facility policy titled, Medication Monitoring, Medication Regimen Review and Reporting, revised 01/2024 stated the MRR was a thorough evaluation of the medication regimen of the residents with a goal to promote positive outcomes and minimize adverse consequences and potential risks .the consultant pharmacist will conduct the MRR at least monthly to monitor the medication regimen and that the resident receives medications that are clinically indicated .a report would be available to the facility within 48 hours of completion of the MRR .recommendations are acted upon within 30 calendar days. <RESIDENT 13> Resident 13 admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (mental health condition that disrupts thought process, and perception mixed with depression), major depression and panic disorder. Review of Resident 13's physician orders showed an order for ziprasidone (antipsychotic medication) 40 milligrams (mg) one capsule a day to treat schizoaffective disorder. Review of MRR recommendation dated 01/29/2025 state the resident was on an antipsychotic medication and there was no Abnormal Involuntary Movement Scale (AIMS) assessment completed great than six months and based on monitoring guidelines recommendation were to complete. The provided had checked the box that they agree with the recommendation to complete an AIMS assessment and signed and dated by the provider on 02/24/2025. At the bottom of the recommendation there was a note that was written Done and was initialed (not legible) dated 02/25/2025. Review of Resident 13's medical record showed the last AIMS assessment completed was dated 05/09/2024. In an interview on 03/17/2024 at 9:17 AM, Staff T, Licensed Practical Nurse (LPN) stated the AIMS assessment is usually completed by the Resident Care Manager (RCM), however if they are triggered to complete on their shift, they will complete the assessment. In an interview on 03/17/2025 11:54 AM, Staff D, Registered Nurse (RN)/RCM they are usually responsible for completing the assessments that are triggered. Staff D was not sure why Resident 13's AIMS assessment was not triggered to be completed every six months. Staff D stated they assist with the pharmacy recommendations, usually the nursing ones, and will also follow up with the provider ones if they are not completed timely. Staff D was not aware that the pharmacy recommendation for Resident 13 was not completed timely. <NOVEMEBER MRR> Review of the November MRR executive summary from the consultation pharmacist report dated 11/20/2024 showed there was 104 recommendations forwarded to the facility: 93 recommendations to the medical provider, and 11 for nursing recommendations. In a review of the November MRR on 03/14/2025 of the 93 physician/provider recommendations the following was documented: - 60 were addressed on 01/06/2025 (47 days after the initial report), - 19 were addressed on 01/17/2025 (58 days after the initial report), - 6 were addressed on 01/19/2025 (60 days after the initial report). - 3 were addressed on 01/23/2025 (64 days after initial report). RESIDENT 70 Review of MRR dated 11/18/2024 for Resident 70, showed a recommendation to clarify an order for injectable (inserted into the body via a syringe) heparin (blood thinning medication) for duration of use, and if long term use was needed to switch to an oral agent. The order had been agreed to by the provider on 01/19/2025, and initialed (not legible) and dated 01/24/25. The recommendation stated the medication had already been discontinued. Review of Resident 70's medical record showed the medication was discontinued on 01/17/2025, 58 days after the report was made. RESIDENT 34 Review of MRR dated 11/20/2024 for Resident 34, showed a recommendation to clarify an order for injectable (inserted into the body via a syringe) heparin (blood thinning medication) for duration of use, and if long term use was needed to switch to an oral agent. The order had been noted by the provider on 01/19/2025, it stated to discontinue the heparin and to start the resident on aspirin 81 mg every day, it was initialed (not legible) and dated 01/20/25. Review of Resident 34's medical record showed the medication was discontinued on 01/19/2025, 60 days after the report was made. <RESIDENT 19> Review of MRR dated 11/19/2024 for Resident 19, showed a recommendation to clarify an order for injectable (inserted into the body via a syringe) heparin (blood thinning medication) for duration of use, and if long term use was needed to switch to an oral agent. The order had been agreed to by the provider on 01/19/2025, and initialed (not legible) and dated 01/20/25. Review of Resident 19's medical record showed the medication was discontinued on 01/19/2025, 60 days after the report was made. <RESIDENT 72> Review of MRR dated 11/19/2024 for Resident 72, showed a recommendation to clarify an order for injectable (inserted into the body via a syringe) enoxaparin (blood thinning medication) and oral aspirin 81 mg both for deep vein thrombosis (DVT) prevention as the resident should only be on one or the other. The order had been agreed to by the provider on 01/07/2025 and requested to discontinue the enoxaparin. Review of Resident 72's medical record showed the medication was discontinued on 01/10/2025, 51 days after the report was made. <RESIDENT 69> Review of MRR dated 11/19/2024 for Resident 69, showed a recommendation to clarify an order for injectable (inserted into the body via a syringe) enoxaparin (blood thinning medication) for duration of use, and if long term use was needed to switch to an oral agent for deep vein thrombosis (DVT) prevention. The order had been agreed to by the provider on 01/19/2025 and requested to discontinue the enoxaparin and to start the resident on aspirin 81 mg every day, it was initialed (not legible) and dated 01/20/25. Review of Resident 69's medical record showed the medication was discontinued on 01/19/2025, 60 days after the report was made. In an interview on 03/14/2025 at 11:14 AM, Staff B, Director of Nursing Services (DNS) stated that they receive the MRR report from the pharmacist usually within 48 hours of the completion of the review. They have the expectation that all the MRR's will be completed with in 30 days. In an electronic interview on 03/14/2025 at 2:39 PM, Collateral Contact 5 stated that their expectation was that the facility would implement the recommendations into the medical record in a timely manner. In a combined interview on 03/17/2025 at 1:12 PM, Staff A, Administrator and Staff B, DNS were unaware that the MRR for the month of November were completed and implemented late. No further information was provided. Refer to WAC 388-97-1300(4)(c) 51312

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were removed when expired in 3 of 5 medication carts. The facility failed to monitor daily temperatures for 2 of 3 refrigerators that stored medications. The facility failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe physical or psychological dependence) controlled medications were in a separate locked permanently affixed compartment not accessible to others. The facility failed to ensure 1 of 1 resident (Resident 78) was assessed for self-medication program. These failures placed residents at risk for receiving expired medications and vaccines, and potential for drug diversion from not securely locking controlled medications. Findings included . According to facility policy titled Medication Storage dated 01/2025 showed: - . Controlled substances stored in a refrigerator should be secured such as separately locked, permanently affixed compartment. - . The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily .if no vaccines are stored in the refrigerator, document temperature checks at least once daily. - Outdated, . discontinued . are immediately removed from stock, disposed of according to procedures for medication disposal. <MEDICATION CARTS> In an observation and interview on 03/12/2025 at 1:20 PM, the Medication Cart 4 in Station 2 had 1 expired medication bottle of Iron (Ferrous Sulfate) 27 milligram (mg). According to Staff E, Registered Nurse (RN), the nurses were supposed to check the medication cart for any expired medications. Staff E took the expired medication out of the cart and stated they would dispose of it. In an observation and interview on 03/12/2025 at 2:20 PM, Medication Cart 3 in Station 1 had 2 expired medications found. They were a bottle of Omeprazole (Delayed Release) 20 mg with expiration date of 12/2024 and a bottle of Saline Nasal Spray 1.5 fluid ounce, with expiration date of 01/2025. Staff S, Licensed Practical Nurse (LPN) stated that the pharmacist was the one that inspects their medication cart for expired medications and that they were just at the facility inspecting the medication carts 2 days ago. Staff S stated they will dispose the expired medications. In an observation and interview on 03/12/2025 at 2:30 PM, Medication Cart 2 in Station 1 had 1 expired medication bottle of Naloxone HCl 4 mg. nasal spray with expiration date of 10/2024. Staff L, LPN stated they would dispose of the expired medication. <REFRIGERATORS WITH MEDICATIONS> In an observation and interview on 03/11/2025 at 2:30 PM, refrigerator inside the medication room in Station 1 contained medications such as insulin pens, a box of Mounjaro medication(a glucagon-like peptide 1 medication injected weekly to treat type 2 diabetes [too much sugar in the blood] to be stored at 36-46 degrees Fahrenheit), emergency kit (E kit) that contains insulin vials, Gabapentin liquid medications with sticker that showed refrigerate. Review of daily temperature log which was placed on the door of the refrigerator showed missing temperature logs for March 1,2,5 and 7, 2025. Staff H, LPN/Infection Preventionist Nurse (IP Nurse) stated they were responsible for checking the vaccine refrigerator to ensure they were checked twice a day. In an observation and interview on 03/11/2025 at 2:50 PM, refrigerator inside the medication room in Station 2 contained some insulin pens, a box of Mounjaro medication, a locked metal container and a Prevnar (a vaccine to protect against pneumococcal pneumonia) 20 milliliter (ml) single dose syringe. Review of the temperature log showed missing temperature logs for 03/082025 and 03/10/2025 and temperature logs were only done once a day. Staff D, Resident Care Manager (RCM) stated that the Prevnar medication should not have been stored at that refrigerator instead they would bring it to the refrigerator in Station 1 that stored just vaccines. <CONTROLLED MEDICATION STORAGE> In an observation and interview on 03/11/2025 at 2:30 PM, the refrigerator in the medication room in Station 1 did not have a lock and inside was a plastic container that was not affixed inside the refrigerator. The plastic container had a red zip tie with numbers. Inside plastic container were multiple things, some were not visible to see but there was a box of Lorazepam 2 mg/ml (a controlled substance, to treat anxiety and seizures). Staff H, Iinfection Preventionist (IP) Nurse stated they think it was an E kit but was not able to find the list of medications that was inside the plastic container. Staff H stated they would ask and find out. In an interview on 03/11/2025 at 3:20 PM, Staff H, IP Nurse stated that the container was not an E kit and provided a copy of what was in the container. The paper given showed it was for a specific resident, and it listed Lorazepam 2 mg/ml with 5 vials. There were more things inside the container, but Staff H did not provide me any more list. In an observation and interview on 03/11/2025 at 2:50 PM, the refrigerator inside the medication room in Station 2 showed a locked metal box that was not affixed inside the refrigerator. Staff D, RCM used a key to open the box and inside showed a box of Lorazepam liquid for a specific resident. Staff D stated the resident no longer was at the facility. In an interview on 03/13/2025 at 1:05 PM, Staff C, Registered Nurse/Resident Care Manager (RCM), stated that the red zip tie used for the plastic container that stored controlled medication in Station 1 was considered as being locked. They stated that when a staff breaks the zip tie, the staff would write down the number in the narcotic book. In an interview on 03/14/2025 at 3:25 PM, Staff B, Director for Nursing Services stated that Medication Cart nurses were supposed to check expired medications in their carts, the RCM does weekly checks for expired medications and their pharmacy consultant comes in once a month to check on expired medications in the medication carts. Staff B stated the temperature checks for the refrigerator with vaccines inside should be done twice a day and the temperature checks for refrigerators with medications should be checked daily. Staff B stated night shift nurse were responsible for checking and documenting the temperatures for the refrigerators and the IP Nurse audits the temperature logs daily. When asked about the storage of controlled medications inside the refrigerators, Staff B stated they should be double locked and considered the zip tie as a lock for the plastic container that was inside the refrigerator in Station 1. They stated that when the nurse breaks the zip tie, they write down the number that was on the zip tie in their narcotic book and replace it with a new one and write down the number of the new zip tie in the narcotic book. Staff B stated they planned to change that plastic container. Staff B stated they were not aware that containers that stored controlled medications should be permanently affixed inside the refrigerator. 36787 Review of the facilty policy titled, Medications self-administration, revised 10/15/2024 showed patients who request to self'-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer: o A physician/advanced practice provider (APP) order is required. o Self-administration and medication self-storage must be care planned. o When applicable, patient must be provided with a secure, locked area to maintain medications, o Patient must be instructed in self-administration. o Evaluation of capability must be performed initially, quarterly, and with any significant changes <MEDICATIONS AT BEDSIDE> <RESIDENT 78> Resident 78 admitted on [DATE] with diagnoses to include traumatic brain injury. The resident had no cognitive impairment. In an observation on 03/12/2025 at 11:04 AM, Resident 78 was sitting up on the side of the bed. There was a bottle of Blue [NAME] pain ointment with an expiration date of 6/2019 and a bottle of Papaya Enzyme Plus pills with an expiration date of 6/2027 on the nightstand to the right of their bed. Both bottles were labeled Keep Out of Reach of Children. There was no nurse present in the room or in the hall. In an observation on 03/13/2025 at 8:24 AM, Resident 78 was in their wheelchair eating breakfast, the Blue [NAME] pain ointment and bottle of Papaya Enzyme Plus remained on the nightstand. There was no nurse present in the room or in the hall. At 3:20 PM, similar observations of the bottles were present. Resident 78 stated she used the Blue [NAME] for pain relief and the Papaya pills for digestion. There were observations of the medications at bedside on 03/14/2025 at 8:31 AM, 10:28 AM, and 12:45 PM. There was no nurse present in the room or in the hall. The medications remained in the same location on the nightstand on 03/17/2025 at 8:53 AM. Review of Resident 78's physician orders showed they were not on a self-medication program. Review of Resident 78's care plan showed they were not on a self-medication program. Review of Resident 78's clinical record showed there was no assessment completed to assess if the resident was safe to self-administer their medications independently. In an interview on 03/17/2025 at 9:20 AM, Staff D, RN stated they had one resident on a self-medication program which was not Resident 78. In an interview on 03/17/2025 at 11:47 AM, Staff E, RN the assigned nurse for Resident 78, stated they had no residents on a self-medication program. Staff E stated if they found resident medications at bedside, they would explain to them they would need to have a self medication program or they would take the medications after explaining that to them. In an interview on 03/17/2025 at 1:38 PM, Staff B, Director of Nursing Services stated they were unaware Resident 78 had unsecured medications at bedside and lack of assessment and care plan for a self-medication program. No additional information was provided. This is a repeat deficiency from SOD dated 10/01/2024. Refer to WAC 388-97-1300(2)

Based on interview and record review the facility failed to ensure a system in which residents' records were complete, accurate, accessible, and systematically organized for 4 of 5 residents (Residents 40, 52, 71 and 78) reviewed for unnecessary medication. This failure included incomplete assessments, restorative care and incomplete documentation involving resident incidents. This placed residents at risk for unmet needs, condition deterioration, unrecognized changes in condition and adverse outcomes. Findings included . Review of a facility policy titled, Charting and Documentation, revised 02/24/2025, showed the purpose to provide a complete account of the patient's total stay from admission through discharge, provide information about the patient that will be used in developing a plan of care, and as a tool for measuring the quality of care provided to the patient. -Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the patient's medical records in accordance with state law. -Document pertinent changes in the patient's condition, reaction to treatment, medication. etc. as well as routine observations. -Documentation shall be completed during the shift in which the assessment, observation, or care service occurred -Documentation shall be accurate, relevant, and complete, containing sufficient details about the patient's care and/or responses to care. <RESIDENT 71> Resident 71 admitted to the facility on [DATE]. Review of the January Medication Administration Record (MAR) documented Resident 71 received Clopidogrel (blood thinner) daily and included an Anticoagulant Medication Monitoring: Monitor for discolored urine, black tarry stools, sudden severe headache, N&V, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and or V/S, SOB, nose bleeds- Nurses were directed to document -Y if monitored and none of the above observed. -N if monitored and any of the above was observed, select chart code other/see nurses notes and progress note findings. every shift beginning 01/28/2025. Review of Resident 71's January 2025 anti-coagulant monitor: N documented on 01/29/2025 day shift and evening shift, and 01/31/2025 day shift. Review of Resident 71's February 2025 MAR documented nursing staff did not obtain and or document blood pressures and heart rates before administration of Metoprolol (blood pressure medication) 02/19/2025 through 02/28/2025. Review of Resident 71's February anti-coagulant monitor documented N on the following: 02/01/2025 evening and night shift. 02/02/2025 evening and night shift 02/04/2025 evening and night shift 02/05/2025 all shifts (day, evening and night shifts) 02/06/2025 evening and night shift 02/07/2025 evening and night shift 02/08/2025 day shift 02/10/2025 evening and night shift 02/11/2025 all shifts 02/12/2025 all shifts 02/14/2025 evening shift 02/15/2025 all shifts 02/16/2025 all shifts 02/17/2025 evening and night shift 02/19/2025 evening and night shift 02/20/2025 all shifts 02/21/2025 evening and night shift 02/22/2025 all shifts 02/24/2025 evening and night shift 02/25/2025 evening and night shift 02/26/2025 all shifts 02/27/2025 day shift 02/28/2025 evening and night shift Review of the progress notes for Resident 71 showed the resident had a fall on 02/18/2025 at 6:40 AM. There was not assessments and documentation every shift for 72 hours after the fall. There was fall documentation on 02/19/2025 at 11:35 AM, 3:30 PM and 10:13 PM, 02/20/2025 at 8:20 PM and 02/21/2025 at 8:20 PM. Review of the progress notes for Resident 71 showed the resident had a fall on 02/25/2025 at 4:15 AM and another fall on 02/27/2025 at 7:00 AM. There was not assessments and documentation every shift for 72 hours after the fall. There was fall documentation on 02/26/2025 at 6:40 PM, 02/27/2025 at 7:00 AM, 1:47 PM ad 11:18 PM then on 02/28/2025 at 9:36 AM and 3:57 PM. There was no alert documentation on 03/01/2025. Review of Resident 71's March anti coagulation monitors documented N on: 03/01/2025 day, evening and night shifts Review of Resident 71's progress notes for the January, February and March 2025 showed there were no progress notes in relation to the anti-coagulation monitors marked N see progress notes for any of the dates. Review of Resident 71's March 2025 MAR showed nursing staff did not obtain and or document blood pressures and heart rates before administration of Metoprolol (blood pressure medication) 03/01/2025 through 03/16/2025. <RESIDENT 78> Resident 78 admitted on [DATE]. Review of the January MAR showed the resident received Enoxaparin (blood thinner) injections twice a day from 01/15/2025 to 01/29/2025 and included an Anticoagulant Medication Monitoring: Monitor for discolored urine, black tarry stools, sudden severe headache, N&V, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and or V/S, SOB, nose bleeds- Nurses were directed to document -Y if monitored and none of the above observed. -N if monitored and any of the above was observed, select chart code other/see nurses notes and progress note findings. every shift beginning 01/23/2025. Review of Resident 78's January anti-coagulant monitor: N documented 01/24/2025 day shift 01/26/2025 day shift 01/27/2025 day and evening 01/28/2025 day shift 01/29/2025 day shift 01/30/2025 X documented instead of Y or N Review of Resident 78's February anti-coagulant monitor N documented on: 02/01/2025 day shift 02/02/2025 day shift 02/04/2025 day shift 02/07/2025 day shift 02/10/2025 day shift Review of the progress notes for the January and February 2025 showed there were no progress notes in relation to the anti-coagulation monitors marked N see progress notes for any of the dates. Review of fall incident investigation on 03/07/2025 showed the time of the fall was midnight. Review of the progress note dated 03/07/2025 at 11:21 AM, showed the resident was found on the floor by Physical Therapy (PT) after the resident had reached for a brush and their leg gave up. The note did not say when the fall occurred. The note lacked information on which leg indicated and if the resident had been wearing their right leg brace. There was not assessments and documentation every shift for 72 hours after the fall. There was fall documentation on 03/07/2025 at 11:22 AM, then 03/10/2025 at 6:05 PM and 6:18 PM. There was no alert documentation on 03/08/2025 or 03/09/2025. In an interview on 03/17/2025 at 9:20 AM, Staff D, Registered Nurse (RN) stated the expectation was nurses document any change of condition, skin issues, any new medications or changes. Staff D said medical records runs the report every day for missing documentation. Then gives them a report for us to follow up on. Staff D reviewed Resident 71 and 78s' anticoagulation monitors and stated the documentation was correct and if a side effect was observed the nurses would document that. In an interview on 03/17/2025 at 11:47 AM, Staff E, RN stated the review the MARS to ensure everything is documented. Staff E said that nurses are to document every shift for 72 hours for alert charting and include a head-to-toe assessment to make sure there are no injuries. Staff E stated if there were no adverse effects for the anti-coagulation monitor, they would document a Y and they would document a N if there were side effects and then we would follow up, call the provider and document that. 50725 <RESIDENT 40> Resident 40 admitted on [DATE] with admitting diagnosis to include Stroke. According to the quarterly Minimum Date Set (MDS - an assessment tool) assessment, dated 02/19/2025 resident had mild cognitive impairment. In a record review on 03/13/2025 at 1:30 PM, Resident 40's electronic chart did not show any notes regarding the allegation the resident made from a staff member who laughed at them when they requested to be turned, that was reported to Staff B, Director for Nursing Services (DNS) on 03/11/2025. In an interview on 03/14/2025 at 3:10 PM, Staff D, RN/Resident Care Manager stated that the facility does alert charting (refers to a system where a patient's chart is tagged or flagged to indicate special charting procedures or precautions that need to be followed for a specific time). Staff D stated they initiate alert charting for residents who had change in condition such as abnormal vital signs, skin issues, falls, behaviors. They document every shift for 72 hours. In an interview on 03/13/2025 at 3:25 PM, Staff B, DNS stated that the facility initiates alert charting when there's a change in condition for the resident such as, skin issues. Staff B stated that resident reporting an allegation will be put on alert charting. Staff B explained that they had a new system in their electronic chart that when a nurse starts a change in condition tab it will automatically initiate alert charting. With this new system, the nurses were not documenting alert charting in the progress note rather it will be in the Assessment tab under Skilled nursing assessment. In an interview on 03/17/2025 at 8:30 AM, Staff D stated the electronic chart is where you can find Resident 40's alert charting documentation. It showed some chronological charting dated from 03/11/2025 to 03/14/2025. In an interview on 03/17/2025 at 10:05 AM, Staff V, RN, stated that there will be one change of condition entry and then after that it would show skilled notes which is for the alert charting. Record review on 03/17/2025 at 10:33 AM, Resident 40's electronic chart under assessment tab showed Change of Condition assessment where it talked about resident's allegation of a staff laughing at them when resident requested to be turned. Effective date showed 03/11/2025 but created date was 03/14/2025 which was 3 days after allegation was reported. In the body of the note, it also showed Late Entry. Further review on the skilled notes, there was an effective date of 03/11/2025 then Late Entry on top of the note but did not show for what day the late entry was and the vital signs that were in the note was dated 03/14/2025. There was no mention about the allegation in the body of the note. Another skilled note showed an effective date of 03/12/2025, then Late Entry on top of the note but did not show for what day the late entry was, vital signs were dated 03/12/2025. There was no mention about the allegation in the body of the note. Another skilled note seen with an effective date of 03/13/2025 then Late Entry was on top of the note, but it did not show for what day the late entry was. The vital signs were dated 03/14/2025 and there was no mention about the allegation in the body of the note. The notes were not done every shift but rather daily. 51551 <RESIDENT 52> Resident 52 admitted to the facility on [DATE]. Review of Resident 52's Quarterly MDS assessment dated [DATE], showed the resident was dependent for bed mobility and transfers. The resident had impaired range-of-motion to both sides of their upper and lower extremities. Review of Resident 52's current care plan showed Resident 52 had restorative programs for passive range of motion and splint three to five days a week. Review of the electronic health record (EHR) showed there was no documentation of restorative programs evaluation or restorative progress notes. In an interview on 03/14/2025 at 9:44 AM, Staff X, Registered Nurse/Resident Care Manager, stated they had a restorative review meeting every week with the rehab manager and the restorative aide. Staff K stated they discussed if residents' s restorative programs needed to be adjusted. Staff X stated they only wrote the meeting minutes on paper, but they did not document evaluation or notes in EHR. In an interview on 03/14/2025 at 3:25 PM, Staff B, Director of Nursing (DNS), stated they expected restorative programs to be evaluated and should be documented in the EHR. In an interview on 03/17/2025 at 1:38 PM, Staff A, Administrator and Staff B, DNS stated they were unaware of incomplete documentation. Reference WAC 388-97-1720 (1)(a)(i)(ii)(iii)

Based on observation, interview, and record review, the facility failed to accurately assess and ensure 1 of 1 resident (Resident 28) received the necessary care and services in accordance with professional standards of practice and maintained the highest practicable level of well-being. Failure to ensure that Resident 28 received services related to a midline IV (an 8-12 cm catheter inserted in the upper arm with the tip located just below the armpit) was adequately managed potentially placed Resident 28 at risk for infection and unmet care needs. Findings include . <Resident 28> Resident 28 was a long-term care resident, with a diagnosis to include persistent vegetative state (lack of awareness of themselves or the surroundings), and was dependent on a ventilator (a machine to assist with breathing). Review of facilities policy titled, Dresing Change for Vascular Access Devices on 03/14/2025 showed, Sterile dressings are to be maintained on all peripheral and central vascular access devices to protect site, provide microbial barrier, and provide device securement. To prevent local and systemic infection related to the IV catheter. Review of facility policy titled Maintaining Patency of Peripheral and Central Vascular Access Devices, on 03/14/2025, stated that vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen. l. A prescriber's order is needed for all IV flushes. 2. All vascular access devices should be flushed routinely when not in use to maintain patency. Review of document titled PICC/Midline Insertion Sheet dated 02/12/2025 at 6:30 PM showed Midline IV was placed by contract staff in Resident 28s' right arm on 02/12/2025. During an observation on 03/11/2025, at 1:35 PM, Resident 28 was found with a midline IV in the right arm. The IV dressing appeared discolored, with its edges curled up, exposing the IV catheter insertion site. The area around the catheter insertion site was purple directly around the catheter and red surrounding the purple area. The needless connector contained a brown substance, and the catheter tubing that was connected to the insertion site was unclamped and had a brown substance in it. The IV dressing was dated 2/12 and bore initials. During a record review of doctor orders with a print date of 03/11/2025, directed the nurses to DC (discontinue) midline IV on 02/25/2025. In an interview at Resident 28's bedside on 03/11/2025 at 1:42 PM, Staff C Registered Nurse (RN)/Resident Care Manager (RCM) stated that they did not know when the dressing had been changed. Staff C stated that dressing changes should be on Tuesdays and as needed, and Staff C agreed that Resident 28's IV dressing was not intact and should have been changed. Staff C stated the date on the dressing was 02/12. In an interview at Resident 28's bedside on 03/11/2025 at 1:56 PM, Staff E, RN, stated they had been Resident 28's nurse that day and they had not flushed the IV because there were no orders to flush the IV and that the IV dressing was not intact and was dated 2/12. During an interview on 03/14/2025, at 11:39 AM, Staff H, Licensed Practical Nurse/Infection Preventionist nurse, stated that IV dressings should be changed weekly and as needed and that IV lines should be flushed after the administration of medication. While reviewing Resident 28's record, Staff H noted that Resident 28 did not have orders for IV flushes or dressing changes. Staff H was unsure if the resident had any IV flushes or dressing changes and stateded that the doctor's orders showed the IV should have been removed and taken out on 02/25/2025. This is a repeat deficiency from SOD dated 10/01/2024. Reference WAC 388-97-1060(4)

Based on observation, interview, and record review, the facility failed to ensure that the resident was assisted by staff with activities as outlined in the care plan for 1 of 4 residents (Resident 43) reviewed for activities. This failed practice placed the resident at risk for isolation and decreased opportunities for a meaningful life in their areas of wellness. <Resident 43> Resident 43 was a long-term resident of the facility. According to the Minimum Data Set assessment dated [DATE], showed the resident was severely cognitively impaired and requires extensive assistance with daily activities. Record review of policy titled Recreation Services Policies and Procedures dated 08/07/2023 stated the purpose of the policy was 'to provide individuals with a wide variety of experiences that are available on a regularly scheduled basis consistent with their assessed life routines, preferences, interests, and personal engagement styles'. Review of a document titled, PASARR level II dated 2/24/2022, showed Resident 43 like to be around people, is young and curious and would like to explore their environment and could manipulate objects. Review of a document titled Care Plan with a print date of 03/11/2025, showed Resident 43 should be assisted to activities, assisted to sit at the nurse station, and be provided with sensory items. Resident 43 also enjoys watching TV and listening to music. During an observation on 03/12/2025 at 11:07 AM, Resident 43 was sitting on their bed with the TV turned off, holding a stuffed animal with one of their legs on the mattress on the floor. During an observation on 03/12/2025 at 1:29 PM, Resident 43 was sitting on their bed with the TV turned off. Resident 43 was hitting their leg and moaning while looking around the room. During an observation on 03/12/2025 at 2:00 PM, Resident 43 was sitting on their bed with the TV turned off. Resident 43 was hitting their leg and moaning. At the same time, BINGO was being played in the dining room. During an observation on 03/12/2025 at 3:25 PM, Resident 43 was sitting on their bed with the TV turned off. During an observation on 03/13/2025 at 1:00 PM Resident 43 was sitting in their wheelchair in their room, the TV is on. During an observation on 03/13/2025 at 1:59 PM, Resident 43 was sitting on their bed, making noises and fidgeting. The TV was on, and cartoons were playing. During an observation on 03/13/2025 at 2:44 PM, Resident 43 was sitting on their bed grinding their teeth. During an observation on 03/13/2025 at 2:53 PM Resident 43 was in their room and there was a painting activity occurring in the dining room. During an observation on 03/14/2025 at 12:06 PM, Resident 43 was in their room sitting in their wheelchair. The wheelchair was facing the wall, and the TV was behind them. Resident 43 was trying to position themselves so they could watch TV. During an observation on 03/14/2025 at 2:16 PM, Resident 43 was in their room sitting in their wheelchair. The wheelchair was facing the wall, and the TV was behind them. Resident 43 was trying to position themself so they could watch TV. At the same time, an activity called 'BINGO' was being held in the dining room. During an interview on 03/14/2025, at 2:16 PM, Staff AA, Activities Director, stated that Resident 43 was one of the residents who received person-centered rounding, and they attempted to take them to parties or movies. Staff AA stated that Resident 43 had not been taken to any activities this week, and there had been no room visits due to being too busy and their brain getting scattered, so (Resident 43) had fallen through the cracks. Reference WAC 388-97-0940 (2)

Based on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 3 nurses (Staff G) observed for medication administration and 1 of 5 residents (Resident 334) reviewed for blood pressure parameters prior to medication administration. This failure place residents at risk for adverse effects, complications and potential for drug diversion. Findings included . According to the facility policy titled: Medication Administration, dated 01/2025, showed: - Medications are to be given at the time they are prepared. - The person who prepares the dose for administration is the person who administers the dose. - If a dose of regularly scheduled medication is refused the nurse shall document in the Electronic Medication Administration Record that the dose with refused and enter and explanatory note. <RESIDENT 38> Resident 38 admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus (a long term condition which body has trouble controlling blood sugar and using it for energy), osteoarthritis ((type of arthritis that occurs when flexible tissues at the ends of the bones wears down) and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). According to the quarterly Minimum Date Set (MDS- and assessment tool) assessment dated [DATE], showed Resident 38 had moderate cognitive impairment. In an observation and interview on 03/13/2025 at 8:05 AM, Staff G, Registered Nurse (RN) was preparing Resident 38's morning medications. The medications that Staff G placed in the medicine cup were, Oxycodone 5 milligram (mg) - 1 tablet (tab), Tylenol 325 mg - 2-tab, Gabapentin 300 mg - 2 capsules (cap), Duloxetine 60 mg- 1 cap, Amlodipine 10 mg - 1 tab, Lisinopril 20 mg - 1 tab and Januvia 100 mg - 1 tab. Staff G went to resident's room. As soon as staff was inside the room and informed resident that they have their medications, resident stated, they did not want the medicine and told staff to get out of their room. Staff tried to inform the resident again that they have their medication, resident's voice got louder, and they again informed staff they don't want to take the medicine and told Staff G to get out of their room. Staff G went outside the room to their medication cart. Staff G stated that they would re-approach the resident later and stated that resident has a history of refusing medications and sometimes would take the medication later. Staff G was observed to place the medicine cup containing the medications on top of their medication cart. There was no resident name labeled on the medicine cup and it was not covered. In an observation and interview on 03/13/2025 at 8:35 AM, Staff G stated that another staff member would approach Resident 38 and attempt to give the medication to Resident 38. Staff H, Infection Preventionist Nurse/Licensed Practical Nurse (LPN) went to Resident 38's room then Staff G took the medicine cup with medications and handed it to Staff H. Staff G informed Staff H what medications they were then left the room and went to their medication cart. Staff G did not wait to see if resident accepted and swallowed the medications. Staff H was in the room with the resident, the door to the resident's room was partially closed and you could not see inside the room. In an interview on 03/13/2025 at 12:55 PM, Staff I, LPN, stated that if a resident refuse to take their medication, they would first ask the resident why they were refusing to take their medication and would try to explain what the medications were and what they were for and if the resident continued to refuse the medications, then they would try to re-approach at a later time. Staff I stated that they would write down the name of the resident on the medicine cup and lock it in their medication cart. If a resident refused twice, they would dispose the medication in the drug buster and notify the provider and family, then they would document in resident's chart of the refusal and inform the oncoming nurse. In an interview on 03/13/2025 at 1:46 PM, Staff D, RN/Resident Care Manager (RCM) stated that if a resident refused to take their medication, they would find out why resident refused to take their medications and if resident continued to refuse then they would ask another nurse to take over the resident's care and notify their RCM. They added that if a resident that was refusing to take their medication was confused, they would attempt to build a rapport with the resident and re-approach. When asked what they would do with the medication that they had prepared and the resident refused to take them, Staff D stated that they were not sure of the facility policy. They said they would put the medications in their medication cart or if they would have to dispose it. When asked what was their process on having another nurse give the medication that another nurse has prepared, Staff D stated that if there's narcotic in the medication cup then they would watch the other nurse give the medication to the resident to confirm that the resident actually took their medication and both the nurses would sign in the Medication Administration Record (MAR). In an interview on 03/14/2025 at 3:25 PM, Staff B, Director of Nursing Services (DNS) stated that if a resident refused to take their medication, the staff would attempt to give it two more times and if the resident still refused them then they would dispose of the medication and notify the provider, family and update the care plan. When asked what the expectation was on what the nurse should do to the prepared medication that resident refused to take, Staff B stated that per policy the nurse must dispose of the medication. They added that some staff know which residents change their minds when re-approached so they would hold on to the medication and place it in their medication cart. However, per their facility policy, the medication must be disposed if resident refuses to take them. When asked what's the process when one nurse prepares the medication and another nurse will give it to the resident, they stated that the nurse that prepared the medication should explain what medications were in the cup by listing the medications and keeping an eye on the nurse while they were giving the medicine to the resident to prevent any drug diversion. 51551 <RESIDENT 334> Resident 334 admitted on [DATE] with diagnoses to include hypertension (high blood pressure). Review of Resident 334's March 2025 MAR, showed Resident 334 had three different types of antihypertensive medications to be given at 9:00 AM and 5:00 PM. The MAR showed all the three medication orders directed nurses to hold the medications for systolic blood pressure (top number of blood pressure reading) less than 100. There was no blood pressure recorded on the MAR. Review of Resident 334's March 2025 vital signs record, showed no blood pressure were recorded at 9:00 AM on 03/02/2025, 03/03/2025, 03/04/2025, 03/06/2025, 03/08/2025, 03/11/2025 and 03/12/2025. There was no blood pressure recorded at 5:00 PM on 03/01/2025, 03/02/2025 and 03/07/2025. Review of Resident 334's electronic health record showed no blood pressure record on the above dates and times. In an interview on 03/13/2025 at 1:20 PM, Staff Y, LPN, stated blood pressures should be checked prior to giving antihypertensive medications and documented under vital signs. Staff Y stated they could not locate the blood pressure record on the above dates and times, and they were not sure why the blood pressures were not documented. In an interview on 03/13/2025 at 3:02 PM, Staff L, LPN, stated they were to check blood pressures prior to giving antihypertensive medications. Staff L stated the blood pressures should be documented under vital signs or progress notes. Staff L stated they could not locate the record either under vital signs or in the progress notes. In an interview on 03/14/2025 at 8:39 AM, Staff C, RN/RCM, stated all nurses were to check blood pressures before administering antihypertensive medications and blood pressures should be recorded under vital signs. Staff C stated they could not find blood pressures record on the above dates and times and would look for them and get back to the surveyor. No further information was provided. In an interview on 03/14/2025 at 3:25 PM, Staff B, Director of Nursing, stated nurses had to follow the order and take blood pressures prior to administering antihypertensive medications. Staff B stated the blood pressures were to be documented in the MAR, or under vital signs, or in the progress notes. Staff B stated if no documentation could be found, the nurses missed taking blood pressure. Reference WAC 388-97-1620 (2)(b)(ii)

Based on interview and record review, the facility failed to ensure that 2 of 5 residents (Residents 71 and 74) reviewed for Pre-Admission Screening and Resident Review (PASRR) assessments, were accurately completed prior to or upon admission to facility, or updated if resident's conditions change. This failure placed residents at risk for not receiving timely and necessary mental health services, and decreased quality of life. Findings included . Review of the facility policy titled, Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients dated 02/16/2024 showed the Social Worker or designated staff will assure that all patients with Mental Disorders (MD) and/or Intellectual Disability (ID) receive appropriate pre-admission screenings according to federal and/or state regulations. The purpose is to ensure that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. Social Services will be responsible for coordinating updates as needed and per state requirements and notifying the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a patient who has a MD or ID for patient review. <RESIDENT 71> Resident 71 admitted to the facility on [DATE] with diagnoses to include major depressive disorder, anxiety disorder and Post Traumatic Stress Disorder (a mental condition caused by an extremely stressful or terrifying event). Review of the Admission Minimum Data Set (MDS - an assessment tool) assessment, dated 02/04/2024, showed the resident was being treated with antipsychotic, antianxiety and antidepressant medications and there were indications for the use. Review of Resident 71's Level 1 Pre-Admission Screening and Resident Review (PASRR), dated 01/28/2025, showed the resident had a mood disorder and no psychotic disorder, or anxiety disorder. The PASRR was marked exempted hospital discharge with the attending physician certifying that the resident would require fewer than 30 days of nursing facility services. The PASRR was marked No Level II evaluation indicated at this time due to exempted hospital discharge. A Level II must be completed if scheduled discharge does not occur within 30 days. Review of a social service progress note on 01/30/2025 at 5:00 PM, showed Resident 71 admitted on [DATE] from the hospital and a PASRR Level 1 was received, noting the resident was positive for SMI (significant mental illness) with diagnosis of Mood Disorder, negative for intellectual disability with no level II evaluation indicated due to exempted hospital discharge. The note showed a Level II would need to be completed if scheduled discharge did not occur within 30 days and social services would follow up as needed. Review of Resident 71's psychotropic drug use care plan dated 02/01/2025 directed staff to arrange for PASRR re-evaluation if there was a significant change in status that results in new evidence of possible mental disorder, intellectual disability and/or related condition. Review of Resident 71's January Medication Administration Records (MARs), showed they were receiving the following medications: -Aripiprazole (antipsychotic, a drug that changes the activity of natural substances in the brain) daily for moderate episode of major depressive disorder. -Lorazepam (antianxiety medication) as needed every 8 hours for anxiety and depression. -Sertraline (antidepressant medication) daily for depression Review of Resident 71's February MAR, showed they were receiving Aripiprazole, Lorazepam and Sertraline and the following psychotropic medications were added: -Quetiapine (antipsychotic medication) twice daily for agitation was ordered on 02/27/2025 -Remeron (antidepressant) at bedtime for major depressive disorder was added 02/27/2025 and Sertraline was discontinued. Review of Resident 71's March MAR, showed they were receiving Lorazepam, Remeron, and the following psychotropic medications were added: -Clonazepam (antianxiety medication) twice daily as needed for confusion and agitation was added on 03/05/2025. Lorazepam was discontinued. -Benadryl (medication to relieve allergy symptoms with known side effect of drowsiness) as needed nightly at bedtime for insomnia was added 03/14/2025. Benadryl is no longer recommended for older adults related to the high risk of side effects and safer alternatives available. Review of Resident 71's clinical record on 03/17/2025 at 11:00 AM, showed there was no referral for a Level II PASRR, and the resident had admitted on [DATE], 48 days prior. In an interview on 03/17/2025 at 1:38 PM, Staff A, Administrator stated they were unaware of any PASRR issues in the facility including for Resident 71 and 74. Staff A stated they were cited for PASRR last survey, and they had audited PASRR's and had not missed any until these ones. 51312 <Resident 74> Resident 74 admitted to the facility on [DATE] with diagnoses to include mild cognitive impairment and bipolar disorder (a mental health condition that causes extreme mood swings). Review of Resident 74's Level 1 PASRR, dated 1/15/2025, showed the resident had a diagnosis of bipolar disorder (a mood disorder). Sections IIA, IIB, and III were blank, and the PASRR was not signed by a physician as required for hospital exemption. Section IV was marked; No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur. A review of Resident 74's records on 3/12/2025 at 1:02 PM showed there was no referral for Level II PASRR, and the resident had admitted on [DATE], 38 days prior. In an interview on 03/13/2025 at 11:28 AM, Staff F, Social Services, stated that they were responsible for PASRR's and worked with admissions to ensure accuracy. While reviewing resident records, Staff F stated that they had not yet contacted the PASRR coordinator regarding Resident 74 and that the resident should have had their PASRR completed on 02/24/2025. Reference WAC 388-97-1915(1)(2)(a)(c)

Based on observation, interview, and record review, the facility failed to ensure call lights (an alerting device for staff to assist residents in need) were within reach for 3 of 4 residents (Residents 47, 71 and 78), reviewed for accommodation of needs. This failure placed the residents at risk for delayed care, accidents/falls, anxiety and a diminished quality of life. Findings included . Review of the facility's policy titled, Call Light Policy, dated 02/01/2023 showed that patients will always have a call light or alternative communication device within their reach, when unattended. Staff will respond to call lights and communication devices promptly to ensure safety and communication between staff and patients. <RESIDENT 71> Resident 71 admitted to the facility on [DATE] with diagnoses that included hemiplegia (unable to move one side of the body) affecting their left side, depression, anxiety and Post Traumatic Stress Disorder. In a joint interview on 03/11/2025 at 1:26 PM, Resident 71 and their spouse, Collateral Contact (CC3) 3 stated staff purposefully move their call light out of their reach. Both stated they were worried about retribution for reporting their concern. In an interview on 03/11/2025 at 1:56 PM, Staff A, Administrator was informed about Resident 71 and CC3s concerns about the call light purposefully being moved out of the residents reach. Staff A stated Resident 71 had behaviors and used to push their call light on all the time. In an interview on 03/12/2025 at 9:12 AM, Resident 71 stated the staff took their call light away from them again last night. CC1 stated they or Resident 71's sister (CC 4) came to visit at 9:00 AM and the resident's call light was hanging up on the wall, out of their reach. In an interview on 03/12/2025 at 2:20 PM, Resident 71 was in bed with CC 3 at the bedside. The call light was found clipped at the bottom of the left corner of the mattress, out of their reach. CC 3 said the call light was either there or wrapped over the outlet on the wall when they arrive. At 3:28 PM, the call light remained out of the residents reach. In an observation on 03/13/2025 at 9:00 AM, the privacy curtain was pulled mostly around Resident 71. The call light was observed pinned to the lower portion of the left upper mattress corner and out of the residents reach. In an interview and observation on 03/13/2025 at 1:31 PM, CC3 stated that Resident 71 had four falls since admission, one of which was when they purposely crawled out of bed to look for help when the staff had left their call light out of reach, and they needed help. In observations on 03/14/2025 at 10:30 AM, Resident 71 was in bed and their call light was observed clipped to the bottom upper left corner of their mattress, out of their reach. At 1:30 PM and 2:26 PM, the call light remained in the same location out of the residents reach. In an interview on 03/17/2025 at 11:43 AM, Resident 71 was in bed with the curtain mostly closed and their call light was out of reach. In an interview on 03/17/2025 at 12:30 PM, CC4 stated Resident 71 reported to them this morning that their call light was taken away from them at 1:30 AM and left on the counter. CC4 stated they are at the facility several days a week and almost every single time they arrive to visit the residents call light is out of their reach. <RESIDENT 78> Resident 78 admitted to the facility on [DATE] with diagnoses to include a traumatic brain injury and multiple fractures after a motor vehicle accident. In an observation on 03/14/2025 at 10:28 AM, Resident 78 was up in their wheelchair in their room playing cards. Their call light was out of reach on the other side of their bed. In an interview on 03/17/2025 at 9:20 AM, Staff D, Registered Nurse (RN)/ Resident Care Manager (RCM) stated call lights should be in reach of the resident and answered in 15 to 20 minutes. In an interview on 03/17/2025 at 11:47 AM, Staff E, RN stated the expectation is that call lights be within reach of the resident. 44110 <RESIDENT 47> Resident 47 admitted to the facility on [DATE] with diagnoses that included glaucoma (eye disease that leads to vision loss), Dementia, and anxiety. The resident's native tongue was Mandarin (a Chinese dialect) and understands little English. In a continuous observation and interview on 03/12/2025 starting at 1:11 PM, Resident 47's call light was observed to be wrapped in a circular motion under the bed, and not within reach of the resident. At 1:49 PM, activity staff were observed to enter room to speak with Resident 47's roommate, then leave. The call light was observed to continue to lay on the ground. At 2:04 PM, an unknown Nursing Assistant Certified (NAC) was observed to investigate the room and leave, the call light remained on the ground. At 2:11 PM another unknown staff member went into the room, then exited, no change to the position of the call light. At 2:19 PM, Staff O, Licensed Practical Nurse (LPN) was observed to enter the room, look at the resident and then exit the room. Staff O was asked why they had entered the room, and responded they thought they heard the resident yelling for help. Staff O was asked if the resident was able to use their call light, and Staff O stated yes, they have a soft to touch light they use frequently. Staff O was asked if the call light should be within reach for the resident and they responded that the call light should always be within reach. Staff O then walked back into the room and observed the call light wrapped in a circular ball under the bed and retrieved the call light and placed it within reach of the resident. In an interview on 03/14/2025 at 12:50 PM, Staff P, NAC, stated that they round frequently on all their residents and will always ensure they have their call light within reach. Staff P stated Resident 47 will always use their call light and calls often. In observations on 03/17/2025 at 8:51 AM, 9:16 AM, and 10:02 AM, Resident 47's call light was observed to be lying on the floor under bed out of reach of the resident. In an interview on 03/17/2025 at 8:56 AM, Staff Q, NAC stated that they round frequently on all their residents and will always ensure they have their call lights are within reach. Staff Q stated Resident 47 will always use their call light and calls often. In an interview on 03/17/2025 at 11:54 AM, Staff D stated it was their expectation that staff are ensuring that residents always have their call lights within reach. Staff D was advised of observations of Resident 47's call light on the floor, and stated staff should be checking every time they are in the room. In a joint interview on 03/17/2025 at 1:38 PM, Staff A, Administrator and Staff B, Director of Nursing Services stated they were not aware call lights were out of reach of residents. Reference: (WAC) 388-97-0860 (2)

Based on observation, interview, and record review, the facility failed to ensure a dignified existence was maintained for 1 of 1 sampled resident (Resident 58) reviewed for resident rights. The facility failed to ensure Resident 58's dignity, based on reasonable person as their roommate (Resident 29) watched and listened to pornography video (sexually explicit) on their laptop that could be overheard in the hallway. This failure placed all residents at risk for a diminished self-worth and a diminished quality of life. Findings included . According to Center for Medicare and Medicaid (CMS), document titled, Psychosocial Outcome Severity Guide, revised October 2022, states reasonable person concept was used to determine whether an individual's actions or responses align with what a hypothetical reasonable person would do under similar circumstances. It defines the behavior expected of an ordinary, prudent, and rational individual. Review of the facility policy titled, Resident Rights, revised on 02/01/2023 stated the purpose was to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth. Resident 58 admitted to the facility on [DATE], with diagnoses that included history of stroke, post-polio syndrome (causes paralysis), and diabetes. The Admission Minimum Data Set (MDS- an assessment tool) assessment dated [DATE] showed the resident was in a vegetative state (a disorder of consciousness or an altered consciousness) and was dependent on staff for all cares. In a continuous observation on 03/12/2025 1:35 PM, outside Resident 58's room, moaning and sexual conversation was heard from the doorway into the hallway. Resident 58's roommate (Resident 29), who has lying in their bed (closest to the doorway) was watching pornography, loudly on their laptop that sat across the front of their bed, while Resident 58 lay in their bed in the same room approximately four feet away. At 1:40 PM, several staff members were observed to walk past the doorway to the room where the audio/video could be heard, no staff reacted or responded to this. At 1:48 PM, another staff member walked up to the doorway, paused and stuck their head into to the room (made a listening motion with the head) then walked away. At 2:02 PM, an unnamed nurse assistant certified (NAC) stopped at the door, again stuck their head in to listen, then walked away. At 2:12 PM another staff member was observed to respond to the noise and stopped in front of the door then quickly walked away. In an observation and interview on 03/12/2025 at 2:20 PM, Staff O, Licensed Practical Nurse (LPN) walked up to the doorway of room [ROOM NUMBER] (Resident 58's) to listen to where the moaning was coming from. Staff O stated that the resident (Resident 29) watches pornography all the time, and since they are hard of hearing they tend to turn the volume up very loud. Staff O stated they try to remind them to turn it down. Review of Resident 58's care plan on 03/12/2025, showed no documentation that the resident was content to listen to pornography all the time from the resident's roommates (Resident 29's) laptop. Review of Resident 29's care plan on 03/12/2025 showed there was no documentation the resident chose to watch pornography loudly on their laptop. In an interview on 03/17/2025 at 8:56 AM, Staff Q, NAC stated they have worked at the facility for over [AGE] years. Staff Q stated they used the care plan and Kardex to drive their care for each resident. Staff Q stated Resident 58 requires full dependent care from the staff, they are not able to advocate for themselves and they anticipate all their care. Staff Q stated that they know Resident 58's roommate (Resident 29) watches pornography loudly and will get aggressive if you attempt to disturb them, so they will get the nurse when it happens. In an interview on 03/17/2024 at 9:17 AM, Staff T, LPN stated they have worked at the facility for about five years. Staff T stated the care plan and Kardex are the driver to what level of care each resident requires. Staff T stated Resident 58's roommate (Resident 29) watches pornography on their laptop and will curse at you if you attempt to interfere with them. Staff T stated they (Resident 29) used to not have a roommate so they would just close the door so others could not hear or see from the hallway. Staff T stated they know that Resident 29's son will try and block the websites on the laptop, but they always find a way. Staff T stated they remember in the past they offered headphones, but Resident 29 refused. Staff T stated the facility would need to do something since Resident 58 was living in that room now. In an interview on 03/17/2025 11:54 AM, Staff D, Registered Nurse (RN)/Resident Care Manager (RCM) stated they have been the RCM for about 4 months, and they had worked at the facility a year ago previously. Staff D stated they are usually the primary responsible party to update the care plan for their unit of residents. Staff D stated they were aware of Resident 58's roommates (Resident 29's) behavior to watch pornography on their laptop. Staff D stated the roommate was hard of hearing, so they tended to play the volume loudly. Staff D stated they will get really upset if you approach them so they would usually just close the door. Staff D stated they were aware of the situation, however since Resident 58 was in a vegetative state they had not initiated any interventions. Staff D stated they had not reapproached Resident 29 to try and get them to wear headphones. In an interview on 03/17/2025 at 12:06 PM, Staff B, Director of Nursing Services (DNS) stated this was the first time they had heard about Resident 58's roommate (Resident 29) watching pornography loudly on their laptop. In a joint interview on 03/17/2025 at 1:12 PM, Staff A, Administrator and Staff B stated they were not aware that Resident 58's roommate (Resident 29) had been watching pornography loudly. Staff A and Staff B stated that Resident 58 was in a vegetative state. Staff A and Staff B were asked if a reasonable person would want to lie in bed and listen or even see graphic pornography played over and over in their room, both agreed they would not. Reference WAC 388-97-0180(1)(2)(3)

Based on interview and record review, the facility failed to ensure 3 of 4 residents (Residents 1, 2, and 3) reviewed for admission/readmission process remained free of significant medication errors. Failure to accurately review and transcribe admission orders for 2 of 4 residents (Residents 1 and 2) and failure to provide medications within physician prescribed medication parameters for 2 of 4 residents (Residents 2 and, 3). Resident 1's admission medication orders were not reconciled with the hospital discharge documents which resulted in the resident receiving two medications erroneously, including a blood thinner that had been listed as an allergy (with a note in the transfer order to NEVER go on a blood thinner again), which caused gastro-intestinal (GI) bleeding twice before; and resulted in the resident not receiving two medications should have been initiated upon admission to the facility. Resident 1 experienced harm when they urinated blood and had abdominal pain. These failures placed all residents at risk for serious medication errors, complications, and adverse health outcomes. On 01/30/2024 at 3:51 PM, the facility was notified of an Immediate Jeopardy (IJ) situation related to CFR 483.45 (f)(2)- F760 -Residents are Free of Significant Med (medication) Errors. The IJ was determined to have begun on 01/09/2024 when Resident 1 was readmitted to the facility. The IJ was removed on 01/31/2024 when the facility had assessed the admission order process and educated the licensed nurses and providers on the new admission order process. After removal of the IJ, the remaining noncompliance at F760 remained at an E scope and severity, a pattern with no actual harm, with potential for more than minimal harm. Findings included . Review of a facility policy, titled, Reconciliation of Medications on Admission, revised July 2017, showed: -Information used to reconcile the medication list was the admission order sheet and the discharge summary from the referring facility. - Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications for the purpose of preventing unintended changes or omissions at transition points in care. - Review the list carefully to determine if there were discrepancies/conflicts. - Document the medication discrepancy and what actions were taken to resolve the discrepancy. <RESIDENT 1> Resident 1 had been a resident of the facility since 10/27/2022. Their most recent admission was from the hospital on 01/09/2024. Resident 1's re-admitting diagnoses included upper gastrointestinal (GI) bleeding from stomach ulcers, acute blood loss anemia, Klebsiella bacteremia, sepsis (body attacks organs/tissues due to bacteremia), Pulmonary emboli (blood clots in lungs), deep vein thrombosis (blood clots in arms or legs), and ventilator dependent (use of machine to assist resident to breathe). Review of the facility risk management system report titled, medication, dated 01/24/2024, showed Collateral Contact 1 (CC1), Nurse Practitioner, notified the facility Resident 1 had received apixaban (blood thinner that decreases the risk of blood clotting) in error. The investigation showed Resident 1 had two documents on discharge, the Skilled Nursing Facility (SNF) hospital transfer orders and the critical care discharge (d/c) summary, which had conflicting information regarding what medications to order on admission to the facility. Review of the SNF hospital transfers orders, dated 01/09/2024, showed a medication allergy of apixaban. The medication list showed Resident 1 was to be on meropenem (antibiotic) thru intravenous (IV) every six hours for two days, and sucralfate (provides coating to stomach ulcer to protect it from stomach acid) four times a day. There was no documentation on the SNF transfer orders for Resident 1 to have apixaban or oxycodone (opioid medication) ordered when readmitted to the facility on [DATE]. Review of the hospital critical care d/c summary, dated 01/09/2024, showed Resident 1 had apixaban given in the hospital but it caused GI bleeding and had to be discontinued. The note showed Resident 1 should NEVER go on an anticoagulant (medication to thin blood) again. The critical care d/c summary had a section labeled expected medication list at discharge which showed apixaban and oxycodone as an order. The critical care d/c summary showed Resident 1 was to have meropenem IV every six hours for two days and sucralfate four times a day. Review of Resident 1's facility admission orders dated 01/09/2024, showed an order for apixaban twice a day with an order date of 12/15/2023. There was an order for oxycodone as needed with an order date of 12/16/2023. The facility admission orders did not have sucralfate or meropenem on admission to the facility. Review of CC1's progress note, dated 01/18/2024, showed facility staff had notified them that Resident 1 had gross hematuria (blood in urine) this morning. Review of a progress note, dated 01/20/2024 at 8:57 AM, showed Resident 1 had complained of abdominal pain at 1:26 AM. The progress noted showed Resident 1 had been found to have a stomach ulcer and was provided pain medication. At 1:45 AM, Resident 1 was found unresponsive and emergency services were summoned. Emergency services performed resuscitation without success and reported Resident 1's death at 2:45 AM. Review of the facility discharge summary, completed on 01/29/2024 by CC1, showed Resident 1's diagnosis as pneumonia with pulmonary emboli. During an interview on 01/30/2024 at 10:47 AM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the process for admissions/readmissions was admission orders were inputted from the SNF hospital transfer orders and the d/c summary from the hospital. Staff D stated if the SNF hospital transfer orders and the d/c summary had conflicting information, the provider would need to be contacted and determine which medications to give. Staff D stated facility practice was to confirm admission orders with two nurses to verify accuracy, but there have been times when there haven't been two nurses available, so they had confirmed orders by themselves. During an interview on 01/30/2024 at 11:59 AM, Staff B, interim Director of Nursing Services, stated the SNF hospital transfer orders should be what the staff use to determine the medication orders for admission. Staff B stated two nurses should review admission orders. Staff B stated they expected the nurse to contact the provider if there was a discrepancy and document in the clinical record what the resolution was. Staff B stated there had been a medication error and Resident 1 should not have been given apixaban upon readmission to the facility. During an interview on 01/30/2024 at 12:43 PM, Staff C, RCM/LPN, stated they had done the readmission for Resident 1. Staff C stated the admission orders were compiled from the SNF hospital transfer orders. Staff C stated they had been the only nurse manager working on the day of readmission and did not have time to review the hospital documents. Staff C stated they looked at the SNF hospital transfer orders and noted there was no notation of having new or changed medications, so they just reactivated Resident 1's previous orders. Staff C stated they did not see apixaban had been added as an allergy on the SNF hospital transfer orders. Staff C stated they did not review the orders with the nurse practitioner, they had just left a note on their desk of Resident 1 being readmitted . During an interview on 02/02/2024 at 8:23 AM, Staff B stated they had reviewed hospital records and confirmed Resident 1 also had medication errors for sucralfate, meropenem and oxycodone. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] and was most recently readmitted to the facility on [DATE], after a hospital stay from 01/05/2024 to 01/11/2024. Resident 2's diagnoses included pneumonia, chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood), and atrial fibrillation (a fast irregular heart rate). Resident 2 was significantly cognitively impaired. Review of Resident 2's SNF hospital transfer orders and the hospital d/c summary, dated 01/11/2024, included the following medications: -Vancomycin (an antibiotic) IV for three doses and to administer the first dose on 01/11/2024 at 9:00 PM. - Midodrine (medication to raise blood pressure) three times a day. The order had parameters to hold the medication if the systolic blood pressure (SBP - top number of blood pressure) was greater than 130. Review of Resident 2's facility January 2024 Order Summary Report, showed the following medications without clarification from the physician upon readmission to the facility on [DATE]: - Tylenol as needed (prn) every four hours for temp or mild pain, order date 08/26/2022. - Calcium-Vitamin D daily, order date 10/20/2023. - Fleet enema prn for constipation if no results from Dulcolax within two hours, order date 08/26/2022. - Ipratropium-albuterol inhalation 3 ml twice daily, order date 01/11/2024. - Milk of Magnesium as needed for constipation, order date 08/26/2022. - Senna oral syrup every 24 hours prn for constipation, order date 08/26/2022. Review of Resident 2's January 2024 Medication Administration Record (MAR), showed the following: -Vancomycin IV was started on 01/12/2024 at 9:00 AM (hospital orders stated to start on 01/11/2024 at 9:00 PM). - Amoxicillin (an antibiotic), ordered 01/04/2024, was administered on 01/11/2024 at 9:00 PM, without a current physician order. - Calcium-Vitamin D was administered daily from 01/12/2024 to 01/31/2024. - Ipratropium-albuterol which was ordered to be administered and was not on the January 2024 MAR, which was on the SNF hospital discharge orders and was ordered to be administered starting 01/11/2024. - Midodrine was administered three times daily at 9:00 AM, 1:00 PM, 9:00 PM, and was to be held if the SBP was greater than 130. The resident received midodrine as ordered, while in the facility, without documentation the SBP was being monitored. Review of Resident 2's nursing progress notes from 01/11/2024 through 01/29/2024, showed no documentation the facility had clarified the above medication discrepancies or notified the physician of the medication errors. Review of the EMR from 01/11/2024 through 01/29/2024, showed no documented SBP correlating with the time the medications were administered. During an interview on 02/02/2024 at 8:27 AM, Staff B stated if a medication had parameters for a blood pressure (BP), they would expect the nurse to check the BP before giving the medication and hold the dose if it was outside of the ordered parameters. Staff B reviewed the midodrine order on the January 2024 MAR for Resident 2. Staff B reported there were no BP's, but the nurses have other places to document BP readings and would follow up. During an interview on 02/02/2024 at 11:01 AM, Staff B reviewed the amoxicillin order on the January 2024 MAR and stated the amoxicillin had been documented as administered on 01/11/2024. Staff B reviewed the SNF transfer orders from the hospital and stated that it appeared the amoxicillin should not have been administered but they would have to check. During an interview on 02/07/2024 at 4:12P M, Staff B stated they had no further information for the amoxicillin given in error. Staff B deferred the BP readings for midodrine to Staff C. During an interview on 02/07/2024 at 4:57 PM, Staff C stated the midodrine order had not been entered correctly so there was no documentation the nurses were completing the BP's before administering the medication. <RESIDENT 3> Resident 3 admitted to the facility on [DATE] and was most recently readmitted to the facility on [DATE], after being hospitalized from 12/17/2023 to 12/28/2023. Review of the resident's diagnoses included and infected wound on their coccyx (bottom), stroke, high blood pressure, tachycardia (a heart rhythm that beats faster than usual), and a persistent vegetative state. Review of Resident 3's SNF hospital transfer orders, dated 12/28/2023, included the following medications: -Albuterol nebulizer (a machine that turns liquid medications into a fine mist for easier absorption into the lungs) solution every six hours prn. - Bisacodyl suppository every day. Review of Resident 3's facility's Order Summary Report, date 12/28/2023, showed the following medications were not reconciled or clarified on readmission to the facility 12/28/2023 with the physician: -Albuterol prn every two hours (was ordered every six hours SNF hospital transfer orders), order date 12/08/2023. -Ascorbic Acid (vitamin C) every morning, order date 12/08/2023. -Bisacodyl suppository one as needed prn for constipation, order date 12/08/2023 (SNF hospital transfer orders directed the suppository to be daily). Additional review of the facility's 12/28/2023 Order Summary Report, showed the following medications with specific parameters of when to hold the mediation: -Lasix (a diuretic) every day and to hold the medication if the resident's SBP was below 110 or heart rate (HR) below 60 beat per minute (BPM), order date 12/08/2023. - Lisinopril (medication to treat high blood pressure) every day, and to hold the medication if the resident's SBP is below 110, order date 12/08/2023. -Propranolol (medication to treat an irregular heartbeat) 10 mg two tablets every eight hours, order date 01/04/2024. Licensed staff was directed to hold the medication if the resident's SBP was below 110 or their HR was below 60 BPM. Review of Resident 3's December 2023 and January 2024 MAR, showed: -Vitamin C was given 12/29/2023 to 01/30/2024, without an updated order from their readmit of 12/28/2023. - Lasix was administered five times in January when their SBP was below 110 (on 01/05/2024, 01/13/2024, 01/15/2024, 01/19/2024, and 1/24/2024). - Lisinopril was given five times when their SBP was below 110 (on 01/05/2024, 01/11/2024, 01/13/2024, 01/15/2024, and 01/24/2024). - Propranolol was to be administered at midnight, 8:00 AM and 4:00 PM. The medication was given six times when the resident's SBP was below 110 (01/04/2024, 01/05/2024, 01/13/2024, 01/15/2024, 01/17/2024 and 01/24/2024). The medication was not given five times (on 01/10/2024, 01/11/2024, 01/15/2024, 01/23/2024, and 01/26/02024) with a code documented on the MAR as an X (no correlating chart code on MAR and no recorded BP). Additionally, the medication was held four times (on 01/13/2024, 01/19/2024, 01/21/2024, and 01/26/2024) with a code documented on the MAR as HD=Hold/See Nurse Note, and held once on 01/08/2024 with a cod of NN-No / See Nurse Notes. Review of Resident 3's nursing progress notes, dated 01/01/2024 through 01/29/2024, showed no correlating documentation why the medication was held when per the directions on the January 2024 MAR, when the nurse coded a NN or a HD which directed the nurse to document in the progress notes. The progress notes did not reveal why the medication was not administered or their SBP or HR was not documented when the nurse documented an X on the January 2024 MAR. The nursing progress notes showed no documentation the facility had clarified the above medication discrepancies or notified the physician of the medication errors. During an interview on 02/02/2024 at 8:27 AM, Staff B stated if a medication had parameters for a BP, they would expect the nurse to check the blood pressure before giving the medication and hold the dose if it was outside of parameters. During an interview on 02/07/2024 at 4:57 PM, Staff C stated they had reviewed the BP's for Resident 3 on 01/04/2024, 01/05/2024, 01/13/2024, 01/15/2024, 01/16/2024, 01/17/2024, 01/19/2024 and 01/24/2024 and that the SBP was below 110. Staff C stated the nurses had given the medications outside of the ordered parameters and they would need education. WAC Reference 388-97-1060 (3)(k)(iii) This is a repeat citation from annual survey with exit date of 9/20/2023.

Based on observations, interview and record review, the facility failed to provide sufficient qualified staff to provide care and services for 46 of 46 residents (Residents 2, 4, 5, 7, 10, 12, 13, 14, 15, 16, 20, 21, 23, 24, 27, 28, 30, 31, 33, 35, 36, 39, 40,43, 45, 47, 51, 52, 54, 55,56, 57, 58, 64,65, 66, 68, 124, 275, 276, 278, 374, 375, 376 , and 1 anonymous resident and 6 of 6 family members (for Resident 10, 53, 55, 73, and 276, and 1 anonymous) that had concerns related to staffing on 2 of 2 units (Unit 1 and 2) reviewed for sufficient staffing. Failure to timely respond to resident call lights, administer medications timely or as ordered, to provide adequate nursing supervision and oversight to the Nursing Assistant Certified (NAC's), resulted in delay of toileting needs, delay of repositioning for comfort and pressure ulcer prevention, missed bathing, missed restorative nursing, delay in meeting residents health and safety, and a delay of meeting other needs which placed residents at risk for diminished quality of life, and a decrease in resident safety and health needs. Additionally, on 09/07/2023, 29 residents (Resident 5, 7, 10, 12, 13, 14, 15, 20, 27, 28, 30, 31, 36, 43, 44, 45, 47, 51, 52, 54, 57, 64, 66, 68, 124, 275, 276, 278, and 376) received their scheduled 8:00 AM medications late which was over one-hour outside of the prescribed scheduled time to include drugs from various drug classes causing an unknown number of medication errors. The facility's staffing practices and their non-compliance with federal and state regulations placed their residents' health and safety in jeopardy. On 09/07/2023 at 5:12 PM, the facility was notified of an Immediate jeopardy (IJ) situation related to CFR 483.35(a)(1)-(2) F725, Sufficient Nursing Staff, related to the facility's failure to provide sufficient staffing to meet the residents acuity needs which could lead to serious harm and serious medical complications due to the facility's inability to ensure resident safety, and to ensure residents received care and services that included: timely administration of medications, turning and repositioning for pressure redistribution and comfort, incontinent care, and staff following and identifying infection control practices. These failures have been occurring since 09/07/2023 at 5:12 PM when the facility was notified of an Immediate Jeopardy situation by the survey team. The immediacy was removed on 09/19/2023 at 11:47 AM, after onsite validation by the surveyors when the resident's call lights were observed to be responded to timely and residents had no concerns with staff response. Further the facility assessment was updated to ensure adequate daily staffing based on the acuity of the resident population, by obtaining a staffing agency to supplement open shifts. Staff A, Administrator, and Saff B, Director of Nursing Services, reviewed the daily staff schedules to ensure adequate daily staffing to meet residents needs which was verified by resident and staff interviews. After removal of the IJ, the deficient practice at F725 remained at an F scope and severity, widespread with no actual harm, with potential of minimal harm, following the removal of the IJ. Findings included . <FACILITY ASSESSMENT> Review of the facility's assessment, dated 01/01/2023, showed 10-15 nurses and 15-30 NAC's were to work at any given time and the facility's budget projected 23 NAC's were needed daily. The assessment showed the facility averaged 36 residents with tracheostomies (a surgical procedure to create an opening in the neck into the windpipe), and 22 residents with ventilators (a medical device that provided a resident with oxygen when they were unable to breathe on their own). The facility assessment showed 30 residents were dependent for all care needs including repositioning and 44 residents required one to two staff to complete their (ADL's) to include: dressing, transferring, grooming, bed mobility, walking toileting and bathing. The facility assessment stated the facility needed ten to 15 nurses and 15 to 30 nurse aides at any given time. <ADMISSION CENSUS> Review of the facility's last 30 days of admission data on 09/07/2023, showed the facility admitted 17 (9 new admissions and 8 re-admissions) residents. <PAYROLL STAFFING DATA REPORT> Review of the facility past four quarter reports, dated 07/01/2022 through 06/30/2023, showed the facility had excessively low weekend staffing; there had been no change over the past year. <STAFFING PATTERN> Review of the staffing from 07/28/2023 to 08/28/2023, showed the facility had wide variances of staffing from day to day. The AM (6:00 AM to 2:30 PM) shift staffing showed they had four to five nurses and five to ten NAC's. The PM (2:00 PM to 10:30 PM) shift, had four to six nurses and six to ten NAC's, and the night (10:00 PM to 6:00 AM shift had two to three nurses and three to nine NAC's. Review of the facility schedules compared to the staffing pattern compared to time clock (punch detail) information for 07/28/2023 to 08/28/2023 revealed conflicting information every day. <RESIDENT INTERVIEWS> Residents were asked: Do you feel there was enough staff available to make sure you get the care and assistance you need without having to wait a long time? RESIDENT 12 Review of Resident 12's current care plan in the electronic medical record, print date 09/18/2023, showed they required moderate assist for transfers and toileting, initiated 11/07/2017, and to offer resident toileting before and after meals to help reduce the risks of self-transfers, initiated 11/07/2022. Review of an incident investigation, dated 09/03/2023, showed the Resident 12 had an unwitnessed fall in their bathroom at 9:00 AM. The resident sustained a right-hand acute fracture of their 4th and 5th metacarpal bones (bones in the hand) and right radius (arm bone). There was no documentation the facility had determined if the resident's care plan had been followed by staff before this fall. Review of the incident investigation dated 09/03/2023, and review of the clinical record showed there was no documentation staff had offered the resident help with toileting before or after breakfast on 09/03/2023. In an interview on 09/04/2023 at 10:24 AM, Staff NN, LPN, stated Resident 12 fell yesterday and fractured their hand, and the resident had not used their call light. Staff NN stated they had been short of nurses yesterday. In an interview on 09/04/2023 at 10:52 AM, Resident 12 (was interviewed using an interpreter on the phone in the resident native language) did not provide any information except to state some staff are nice, and some staff are not so nice. RESIDENT 13 In an interview on 08/28/2023 at 9:13 AM, Resident 13 stated there was not enough staff. The resident stated they sometimes sit in their bowel movement for up to two hours as there was only one staff doing it all. RESIDENT 33 In an interview on 08/28/2023 at 10:32 AM, Resident 33 said they did not have enough staff and they have waited two hours to get their call light answered. Resident 33 said the nursing care was trash. The resident said if they had the authority, they would shut this place down. The resident said they gave them their morning medication they needed by 8:00 AM not until after 1:00 PM. The resident stated, Don't believe what the nurses say, they lie. Believe what you see. RESIDENT 24 In an interview on 08/28/2023 at 10:36 AM, Resident 24 stated the call lights take way too long to be answered. The resident stated staffing was bad all days and all shifts, and weekends were worse. Resident 24 stated they needed help to get out of bed to go to the bathroom, but they ended up going by themselves. They said they could not wait, they could get in the bathroom, but then could not get out because they needed help with wiping. Resident 24 said call lights were a chronic problem here and said, it just takes them too long. RESIDENT 20 In an interview on 08/28/2023 at 11:47 AM, Resident 20 said their biggest complaint was response time to their call button. The resident stated the facility was understaffed with the NAC CNA staff. They had a concern with their wait time in general. Resident 20 said there would be times they would be having trouble breathing, they would need suctioning and it was frightening to wait when they needed their tracheostomy needed to be suctioned. They said if they were in an uncomfortable position, it would take a while to get repositioned. RESIDENT 23 In an interview on 08/28/2023 at 2:01 PM, Resident 23 stated there were not enough female NAC's. Resident 23 wished to have female staff care for them. They said a couple weeks ago there were no female aides, so they had to call one in. The resident said typical call wait time was 45 minutes in the morning and 30 minutes at night. In a follow up interview on 09/18/2023 at 1:21 PM, Resident 23 stated they received care from Staff DD, Licensed Practical Nurse on Saturday night shift (09/16/2023) whom they were not to receive care from. Resident 23 said staff told them that there was only one female to help, and Staff DD came in. Resident 23 said Staff DD was aware they were not to care for them, but they did. RESIDENT 4 In an interview on 08/29/2023 at 8:50 AM, Resident 4 said they don't have enough staff here. The resident said the staff tell them they could only bathe once a week because they don't have enough staff. Resident 4 stated staff don't come for a long time when they use their call light, and weekends are worse. They said staff take a long time on weekends, but they didn't know how long, commenting it's just too long. The resident stated when staff answered their call light, they would ask them why it took them so long to come, and staff tell them they don't have enough staff. RESIDENT 40 In an interview on 08/28/2023 at 2:27 PM, Resident 40 said they do not have enough staff from their point of view. They said the staff have a lot of people to care for. RESIDENT 14 In an interview on 08/28/2023 at 2:47 PM, Resident 14 stated there was not enough staff and staff told them the facility was understaffed. RESIDENT 39 In an interview on 08/28/2023 at 3:14 PM, Resident 39 stated they did not get the help that they needed without waiting a long period of time. RESIDENT 66 In an interview on 08/28/2023 at 3:43 PM, Resident 66 stated they did not think the facility had enough staff especially in the evenings. Resident 66 stated, I just want help. RESIDENT 58 In an interview on 08/29/2023 at 9:16 AM, Resident 58 stated the facility needed more nursing staff. They said the new management did not come into check on them. RESIDENT 35 In an interview on 08/29/2023 at 9:36 AM, Resident 35 stated the facility did not have sufficient staffing. Resident 35 said they sometimes had to wait a whole shift to be changed, especially in the evenings. They said, I just want help. In an interview on 09/15/2023 at 11:10 AM, Resident 35 stated call lights were responded to a little slow last evening. They stated they had their call light on at 3:00 PM and fell asleep while waiting. RESIDENT 16 In an interview on 08/30/2023 at 9:15 AM, Resident 16 stated the facility did not have enough staff. Ther resident said they did not always get their shower and they wanted to get up in their wheelchair daily, but staff just did not do it. The resident said they would ask staff to get them up and staff would say ok, they say ok, but they don't. The resident stated they really wanted to get out of their bed every day. RESIDENT 276 In an interview on 09/06/2023 at 10:30 AM, Resident 276 stated the call lights were not better. They said they waited at least a half an hour until staff responded to their call light, and they worry that if they had a heart attack, staff would not respond in time. The resident stated staff told tell them they do not want to clean up messes, so the resident needed to use the urinal, but staff left the urinal across the room, and they could not get to it. The resident stated staff do not think of those things. Resident 276 said they had to train them (staff) I have had to train them all to slow down when they moved my legs. The resident stated that is why I am in here and if they could just take 30 more seconds it is easier on me. I really have to advocate for myself. In a follow up interview and observation on 09/12/2023 at 12:11 PM, Resident 276 was observed in bed leaning over to the right with a pained expression. Their untouched lunch tray was present. They said they were having a rough day and had waited for their call light to be answered for two 2 hours today so they could have their toileting needs met. The resident said someone finally came in before noon. The resident said the wait made them feel angry, made my blood boil which then increased their pain. The resident said staffing had not improved in the past week or so. Staff B, Director of Nursing Services, was notified of the resident's concern at 12:14 PM. RESIDENT 30 In an interview on 09/06/2023 at 10:31 AM, Resident 30 said it takes forever for their call light to be answered. They said they think staff ignore them because staff tell them they use their call light too much. Resident 30 stated day shift had worse staffing than other shifts. RESIDENT 375 In an interview on 09/13/2023 at 8:30 AM, Resident 375 stated they were able to use their call light, that wasn't the problem, the main problem with the call light was when they used it to call for help, staff did not come, they said it was a long wait. They stated they didn't monitor the time it took for them to come, but it was too long. RESIDENT 15 In an interview on 09/15/2023 at 9:25 AM, Resident 15 stated they like to go to bingo but sometimes they couldn't go because staff they had problems getting two people to help them out of bed in the afternoon. RESIDENT 51 In an interview on 09/15/2023 at 1:15 PM, Resident 51 communicated, using their Tobi communication device, that it was very hard to get assistance from 1:00 AM to 5:00 AM and in the evenings. They stated that staff told them they were short staffed. Collateral Contact 17 (CC 17), Resident 51's family member, was present and stated that there were new staff people here a few weeks ago and they wondered where the staff were. CC17 stated the resident was told by the staff that there was only one that there was only one female NAC and that they had to find another female NAC, and that it could take up to hours before they came back. CC 17 stated they had reported this to the facility staff also. RESIDENT 56 The resident admitted to the facility on [DATE] with diagnoses to include brain damage, cognitive communication deficit (difficulty with thinking and how someone used language) and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/02/2023, showed they had moderate cognitive impairment and were totally dependent on staff for their care needs. In an interview on 09/19/2023 at 3:07 PM, Staff FFF, Recreation Assistant, stated Resident 56 liked going to church service and sometimes they were up, and they could bring them to the activity. Staff FFF stated most of the time Resident 56 was not up for the activity, as staff did not have time to get them up. Staff FFF stated they would remind the staff to get the resident up, and still at times the nursing assistant were not able to get the resident up (out of bed). ANONYMOUS RESIDENT In an interview, Anonymous Resident 1 (AR-1) stated they had to wait an hour for respiratory care. They stated they needed suctioning badly and were struggling for air. AR-1 said they had to clap their hands to get someone's attention. AR-1 stated it was a long time until staff responded, and they were pissed, heated in the moment. AR-1 stated they would continue to be mad until they received the care that the respiratory therapists were hired to provide and were paid for. Date and time not included to protect anonymity. <FAMILY INTERVIEWS> Family members were asked: Do you feel there was enough staff available to make sure the family member (the resident) received their care and assistance needed without having to wait a long time? RESIDENT 55 In a family interview on 08/28/2023 at 1:08 PM, CC8, Resident 55's family member, stated the facility did not have enough staff and Resident 55 was not taken care of right away. CC8 stated the resident had not had a shower in the last three months. CC8 stated that during a care conference in August 2023, they requested the facility provide a weekly shower and for the resident to be clean shaven twice a month. CC8 stated the nurse had told them that they were the only nurse on the floor. CC8 stated last weekend they had visited for 90 minutes, and staff did not reposition Resident 55. Review of the Review of the July 2023 V2 report (staff documentation of care report), showed that Resident 55 received a shower on 07/10/2023. There was no other documentation of showers or bathing during the month. Review of the August 2023 V2 report showed that Resident 55 received a shower on 08/03/2023, and that they received a bed bath on 08/17/2023 and 08/27/2023. Review of the [DATE] V2 report for dates 09/01/2023-09/07/2023 showed that Resident 55 received a bed bath on 09/07/2023. RESIDENT 10 In family interview on 08/28/2023 at 2:18 PM, CC4, Resident 10's family member, stated weekend staffing is terrible, and so bad that you can't call on the weekend and get someone to answer the phone. RESIDENT 53 In a family interview on 08/30/2023 at 8:47 AM, CC9, Resident 53's family member, said there was not enough staff at the facility, the resident had been left in the same position in bed, and staff did not shave the resident. RESIDENT 276 In a family interview on 08/31/2023 at 12:10 PM, CC12, Resident 276's family member, stated last week the resident had sat in their waste for an hour and a half, and no one came to help them until the next shift came on. RESIDENT 73 Resident 73 admitted to the facility on [DATE] and discharged Against Medical Advice on 08/12/2023, The resident had history of falls, was blind in one eye, had chronic spine problems and chronic pain. Review of resident's care plan that was in effect when they discharged on [DATE], showed they required one-person extensive assist with transfers and toileting. In a phone interview on 09/04/2023 at 12:59 PM, CC14, Resident 73's family member, stated while the resident was in the facility they would have to go to the bathroom (BR), there was no one to help get them to the BR, and it took hours to get them help. CC14 stated Resident 73 was a fall risk so staff didn't want them to even get out of bed on their own, so they would have to sit in wet depends (briefs), but they were able to go to the BR, they just wore the Depends (incontinent briefs) because they leaked urine. CC14 stated the resident could have gotten up to the BR by themselves, but staff didn't want them to, staff said to call for help, but they wouldn't come for hours, then when the staff did finally come, they would wag their finger at them for getting up without help. CC14 stated there just was not enough staff to get them up, so they would have to just lay there. CC14 stated the staff kept telling them they didn't have enough staff. CC14 stated the resident was there to get therapy and to get better mobility, but staff kept telling the resident to stay in bed, which was the opposite of what they were there for. CC14 said the resident told them that staff wanted them to stay in bed all weekend until their therapy on Monday. CC14 stated they had picked up a plastic bag with clothing that had been put in the closet at the facility, when they opened it, there were sweatpants inside it that were soaked in urine. CC14 stated Resident 73 wanted to go home and had called to be picked up, and they weren't getting help anyway, so they took them home. CC14 stated when you have to go to the bathroom, and no one comes and helps you, that was a problem. In an interview on 09/05/2023 at 3:48 PM, Staff B was asked about CC14's allegations their family member did not receive help with their toileting and transferring, Staff B was unable to provide any information. ANONYMOUS FAMILY MEMBER In an interview with an Anonymous family (AF-1) member, stated staffing is bad here. The facility brings new staff in, but they do not want to stay. I have met with administration about staffing issues. The staff said they were not getting paid on their paychecks. The facility has lost one NAC after another. We have lost amazing nurses. I tell them get the staffing, get the staffing. AF-1 had asked to meet with Staff B, but Staff B did not meet with them. Date, time, and name were not included to maintain anonymity. <ANONYMOUS CONCERNS> Review of a written anonymous concern (AC-1) received on 08/29/2023, showed a resident had pressed their call button and was left soiled for an hour and a half. AC-1 showed the night nurses were withholding the resident's pain medications; the resident was not getting their pain medications on time. The resident could receive pain medication every four hours, the resident would call for the medication, and the nurses were flippant and said, Oh, it is four hours already. Ok. Then they go away and don't return for another thirty to forty-five minutes. To wait thirty or forty minutes is retaliation. Names and time were not included to protect anonymity. Review of an AC-2 received on 09/03/2023 at 4:11 PM, showed the staffing and care issues at the facility had for quite some time and the building was in big serious trouble because of staffing. AC-2 described that the facility had a tracheostomy/ventilator unit with at least 30-40 residents who were completely dependent on staff for all their needs. There were days when staff were forced to work with only three to four nurses instead of six on day and evening shifts and only two nurses at night instead of four. The concern indicated there were four NAC's instead of ten at times. The concern showed weekends and Mondays had skeleton staffing, which affected the delivery of resident care. Showers were not being provided, call lights were not being answered for a long period of time, at times it could take two to eight hours, the residents on the ventilator unit were not being turned as often as they needed to be, were not being cleaned or washed appropriately related to staff not having enough time to do their work. AC2 had reported their concerns to the facility's administration and corporation. They stated the facility had half of the staff they needed to safely care for the residents. Names were not included to protect anonymity. <OBSERVATIONS> In an observation of Unit 1 on 09/05/2023 at 3:18 PM, the call light for room [ROOM NUMBER]-B went off for 45 minutes. Staff were observed to walk past the room but did not respond to the call light. In an observation on Unit 2 on 09/06/2023 at 10:16 AM, the call light for room [ROOM NUMBER]-A was on for 34 minutes and room [ROOM NUMBER]-A was on for 29 minutes. At 10:41 AM, Staff P (the nurse assigned to Unit 2) left the unit and stated they were going on break. Staff were observed to walk past the room but did not respond to the call light. In an observation on Unit 1 at 09/06/2023 at 11:09 AM, the call light for room [ROOM NUMBER]-B was on for 54 minutes. Staff were observed to walk past the room but did not respond to the call light. In an observation of Unit 2 at on 09/06/2023 at 1:56 PM, the call light for room [ROOM NUMBER]-A was on for 44 minutes. At 2:08 PM, the call light for room [ROOM NUMBER]-A was on for 54 minutes, Staff P was observed sitting at the nurse's station throughout this time. At 2:54 PM, Staff C, LPN/RCM, stopped at the nurse's station then went into their office, closed the door, and the call light was observed to be unanswered. Staff were observed to walk past the room but did not respond to the call light. In an observation on 09/08/2023 at 11:15 AM, CC16, Resident 11's family member, was upset at the nurse's station. CC16 was irritated and stated to Staff DD can anyone tell me if [Resident 11] has been out of bed all week, I know (the resident) cannot tolerate too much but still . Staff DD said they didn't know, and they would talk to them in a few minutes in Resident 11's room. <INSUFFICIENT NURSING STAFF TO ADMINISTER MEDICATIONS ON-TIME> RESIDENT 2 In an observation on 08/31/2023 at 10:50 AM, Staff P, LPN, left Resident 2's room and stated they had administered the resident's medications late because they were very busy and didn't have enough time to get medications administered in time. Review of Resident 2's Medication Administration Records (MARs), for 08/31/2023 showed the following morning medications to be administered at 8:00 AM and 9:00 AM, to include three high blood pressure medications, pain medications, a bowel medication, vitamins, and an aspirin. The medications were all given late, at 10:50 AM. RESIDENT 56 In an interview and observation on 08/30/2023 at 2:49 PM, Staff P stated they were going to be administering Resident 56 Gabapentin (medication for seizures), starting their tube-feeding (liquid nutrition that is delivered directly into the stomach through a tube that is surgically placed) and their water flush (practice of using water to clear the feeding tube before and after feedings or medications). Staff P stated the resident should have received their Gabapentin by 1:00 PM. Staff P stated they were late with the Gabapentin because a resident had a fall. Staff P stated they had not notified their nurse manager they were late with medication administration, because they had not seen the nurse manger. Review of Resident 56's August 2023 MAR, showed on 08/30/2023 Gabapentin was scheduled to be administered at 12:00 PM, (almost three hours late), Jevity (tube-feeding solution for nutrition) and the water flush to being at 55 milliliters and hour was scheduled to have started at 1:00 PM, (almost two hours late). RESIDENT 7 Review of Resident 7's September 2023 MAR, showed on 09/07/2023 the resident was scheduled to receive medications to treat their diabetes, high blood pressure, help decrease their secretions, a probiotic medication, and bowel medications at 8:00 AM. All were administered late. RESIDENT 12 The resident admitted to the facility 12/07/2020 with diagnoses to include Parkinson's disease, diabetic neuropathy (nerve pain), chronic pain, high blood pressure, Parkinson's disease (a disorder of the central nervous system that affects movement), generalized muscle weakness, abnormalities of gait and mobility, unsteadiness on their feet and a history of falling. Review of the resident's September 2023 MARs, showed on 09/07/2023 Resident 12 was scheduled to receive medications to treat their Parkinson's, pain, high blood pressure, clot prevention, vitamins, and constipation at 8:00 AM. All medications were administered late. RESIDENT 20 Review of Resident 20's September 2023 MAR, showed on 09/07/2023 the resident was scheduled to receive medications to treat their Myasthenia Gravis (a neuromuscular disorder that leads to weakness of skeletal muscles), depression, and a probiotic at 8:00 AM. All medications were administered late. In an interview on 09/07/2023 at 9:01 AM, Staff Z, Registered Nurse (RN), stated they had not yet administered all their residents' 8:00 AM medications. Staff Z stated it was impossible to administer all their medications on time because there were too many. Staff Z stated the insulin and blood glucoses on her medication pass alone take 40 minutes to one hour, and then they still had to administer all of their other medications and that was impossible to do in the 1-hour before and after timeframe. Staff Z stated each of their residents had extensive medications and they could not realistically administer them all in the allotted 2-hour timeframe. Staff Z stated it was an unrealistic expectation that they should have to administer all their residents' medications on-time. Staff Z stated they had not administered 8:00 AM medications to 12, 7, 20, 28, 124, 57, 376, and 47. Similar findings were found through record review of the September 2023 MAR, showed 21 additional residents were impacted regarding late medication administration on 09/07/2023 for their scheduled 8:00 AM (on both units) that included Resident 5, 10, 13, 14, 15, 27, 28, 30, 31, 36, 43, 44, 45, 47, 51, 52, 54, 57, 64, 66, 68, 124, 275, 276, 278, and 376 (a total of 29 residents receive their 8:00 AM medication late on 09/07/2023). Review of the 09/07/2023 AM staffing sheets, showed there were three nurses worked on Unit 1, and two nurses worked on Unit 2. In an interview on 09/07/2023 at 12:20 PM, Staff B stated they knew they had a staffing problem. The staff did not even want to pick up another shift. They were working 16-hour shifts and were burned out. <RESIDENT COUNCIL MEETING> During a resident council meeting with the surveyor on 08/31/2023 at 4:04 PM, residents were asked about staffing in the facility: -At 4:04 PM, Resident 65 stated they waited a long time to get their medications. - At 4:05 PM, Resident 24 stated call lights took a long time to be answered and sometimes they waited hours. The resident said they missed showers and there were not enough staff to shower them after missing their scheduled day. - At 4:08 PM, Resident 21 stated they had to wait a long time to use the bathroom and had waited over an hour to use the bathroom. Resident 21 said staffing on weekends was the worst. They said they were to receive two showers a week but only got a shower once a week, and no showers were given on weekends. - At 4:30 PM, Resident 7 stated there was not enough staff on the weekends. <GRIEVANCE CONCERN LOG> Review of the grievance concerned log showed the following staffing concerns: -On 06/23/2023, Resident 24 reported a concern regarding their call light response time. - On 06/30/2023, Resident 13 reported a concern regarding their call light response time. - On 09/01/2023, Resident 376 reported a call light response grievance. <GRIEVANCE REPORTS> Review of a handwritten grievance form from Resident 374's family member, dated 07/15/2023, showed the resident had been dealing with recent health issues so therefore, they wanted to ensure the facility had adequate staffing. The family member waited to make sure NAC's were there before they would leave the resident, and almost every weekend there were staffing issues. At 10:15 PM, a NAC stated to them they were working the hallway where Resident 374 resided. The family member wrote they had waited and waited, asked the nurse to call someone, and see if they could get someone in here (staff to help the facility) That had been the normal for (name of facility) and they were deeply concerned for the residents. Since (resident 374) started having seizures the resident was the family members main concern. The grievance form showed to please ensure to have enough staff so they could go home by the latest [at] 10 PM. On 07/17/2023 (no time was indicated), Staff EEE, former Administrator, wrote the facility's action plan was to continue to monitor staffing needs. Review of a handwritten grievance form from Resident 276, dated 08/24/2023, showed on the night of 08/23/2023 to 08/24/2023 the resident pushed their call button and noted the time was 6:15 AM. Resident 276 pushed the call button several times after this, and luckily, they only needed to be cleaned up of piss and feces. At 7:36 AM, a staff member on the next shift changed them. Resident 276's concern was that the night shift nurse or attendant showed no concern for my having possible blood clotting or other life-threatening event by choosing to ignore my call light! Requests were made for the 06/23/2023, 06/30/2023 and 09/01/2023 call light grievances. No grievances fo [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines (IPC) and standards of practice for 2 of 2 units (Station 1 and 2) reviewed for IPC procedures. The facility failed to ensure that residents had transmission-based precautions (TBP) in place for 9 of 9 residents (Residents 14, 9, 61, 20, 15, 35, 278, 56 and 8), staff completed hand hygiene consistently, Personal Protective Equipment (PPE) was used appropriately, and that cross contamination did not occur during a CRAB (Carbapenem-resistant Acinetobacter baumannii) OXA (oxacillinase) (CRAB OXA - Acinetobacter bacteria that affects residents within health care settings that is difficult to treat and is identified as a multi-drug resistant organism MDRO) outbreak. These failures led to three residents (Residents 26, 25, and 42) to experience a facility acquired infection with CRAB OXA and placed all residents and staff at risk for potential exposure to CRAB OXA or other infections and a decreased quality of life. On 08/30/2023 at 5:48 PM the facility was notified of an Immediate Jeopardy (IJ) situation related to CFR 483.80 (a)(1),(2)(i)(iii)(iv)(A)-(vi) F880, Infection Prevention & Control, related to the facility's failure to prevent the spread of CRAB OXA to three residents during a facility outbreak on Station 1 which could lead to serious harm or potential death as the bacteria is resistant to many antibiotics and difficult to treat. Station 1 is a specialized unit of residents who have respiratory conditions and require breathing assistance through tracheostomies (artificial opening on the neck used for an airway) and/or the use of ventilators (machine that helps resident breathe by pumping air into the lungs). The facility failed to implement the proper use of PPE, monitor staff's adherence to ICP practices, failed to ensure adequate hand hygiene practices were followed, and failed to ensure cross contamination did not occur. These failures have been occurring since 04/20/2023 when the Local Health Jurisdiction (LHJ) requested a meeting with facility management due to their observations of continued breaks in infection control practices. The IJ was removed on 09/05/2023 after onsite validated by surveyor when all staff education was completed for TBP, hand washing, standards of IPC, identification, and placement of residents in correct TBP, and providing education related to IPC practices to vendors and visitors who entered the facility. After removal of the IJ, the deficient practice at F760 remained at a E scope and severity, a pattern with no actual harm, with potential for more than minimal harm, following the removal of the IJ. Findings included . Review of the Centers for Disease Control (CDC) article titled, Acinetobacter in Healthcare settings, dated 11/13/2019, showed persons most at risk to obtain an infection are residents on breathing machines (ventilators) and/or have a catheter (tube inserted into bladder), or open wounds. The bacteria may spread by contact with contaminated surfaces or equipment that was not adequately disinfected or through person to person spread via contaminated hands. Review of a facility policy titled, Enhanced Barrier Precautions, dated 08/01/2023, showed that residents with an indwelling medical device (enteral feeding tube, urinary catheter, tracheostomy, or ventilator) who reside on a unit where residents are known to be infected or colonized with targeted MDRO should be placed on Enhanced Barrier Precautions (EBP): - An appropriate EBP or Contact Precaution (CP) sign will be posted on the resident room door. - Gown and gloves are required prior to a high contact care activity with residents such as dressing, bathing, transferring, providing hygiene, assisting with toileting, or changing linens. - Perform hand hygiene when exiting room. Review of a facility policy titled, Wound Dressing: Aseptic (clean not sterile technique), revised on 12/01/2021, showed staff should apply clean gloves, remove the resident's soiled dressing, perform hand hygiene, apply new gloves, then cleanse the wound and apply the wound dressing. <CRAB OXA> In a virtual meeting between surveyors, the LHJ and [NAME] State Department of Health (DOH) staff on 08/29/2023 at 9:00 AM, Collateral Contact 7 (CC7), epidemiologist at the Snohomish Health Department (SHD), reported they observed breaks in infection control practices during visits to the facility, dating back to April 2023, when they had a meeting with facility management. CC7 stated the facility had not contained the CRAB OXA outbreak, and the facility had developed another case in July 2023. Review of facility line listing for CRAB OXA outbreak, provided by facility on 08/29/2023, showed five residents listed as diagnosed with CRAB OXA. On 08/29/2023 at 2:41 PM, Staff T, [NAME] President of Clinical Operations, provided a document that they stated was minutes from a meeting between the LHJ, DOH, and facility staff, dated 04/20/2023. Staff T stated this was the first time they were aware the LHJ had concerns with the facilities infection control practices. RESIDENT 25 Resident 25 admitted to the facility on [DATE] with diagnoses of chronic respiratory failure and ventilator dependent. Review of the census data in the medical record showed the resident resided in rooms on the specialized respiratory unit (Station 1). Review of Resident 25's clinical record showed that they were tested for CRAB OXA on 07/19/2023 and the results were positive. RESIDENT 26 Resident 26 admitted to facility on 09/14/2021 with diagnoses of chronic respiratory failure, lung disease and ventilator dependent. Review of the census data in the medical record showed that resident resided in rooms on the specialized respiratory unit (Station 1). Review of Resident 26's clinical record showed they had been tested for CRAB OXA on 03/08/2023 and 03/29/2023 and both tests were negative for the organism. On 05/09/2023, Resident 26 was tested for CRAB OXA, and the results were positive. RESIDENT 42 Resident 42 admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, lung disease and ventilator dependent. Review of census data in the medical record showed that resident resided in rooms on the specialized respiratory unit (Station 1). Review of Resident 42's clinical record showed that they had been tested for CRAB OXA on 02/17/2023 and the results were positive. During an interview on 08/29/2023 at 10:21 AM, Staff E, Infection Preventionist (IP)/Licensed Practical Nurse (LPN), stated the CRAB organism liked warm moist environments, which was why the residents on the respiratory unit were at highest risk, and CRAB had a high mortality rate. Staff E stated good hand hygiene was the most important thing to prevent the spread of the CRAB organism to others. During a phone interview on 09/06/2023 at 12:26 PM, CC7 stated the LHJ listed residents that tested positive for CRAB OXA at the facility were facility acquired infections (an infection acquired while residing in the facility). CC7 stated obviously the resident that tested negative twice and then tested positive at the facility would be considered a facility acquired infection, but the prevalence of CRAB OXA within [NAME] state was low, so unless there had been another known exposure, the LHJ linked all the facility positive tests to the current facility outbreak. During an interview on 09/11/2023 at 11:06 AM, Staff E stated if a resident tested positive for CRAB OXA at the facility, it would be considered a facility acquired infection. <CROSS CONTAMINATION> During an observation on 08/29/2023 at 1:18 PM, Staff UU, housekeeper, was cleaning room [ROOM NUMBER]. There was a sign for contact precautions posted on the wall outside of the room and a PPE supply bin outside of the door. Staff UU was observed coming out of the room after cleaning the bathroom, placed a garbage bag into the garbage bin on the housekeeping cart while wearing gloves, then with the contaminated gloves obtained a new garbage bag off the roll of bags on the cart. Staff UU, with the same contaminated gloves, went back into the bathroom, returned to the housekeeping cart, placed the used cleaning cloth over the handle of the cart, obtained a clean mop head from the container, and attached it to the mophandle without changing their contaminated gloves. As Staff UU was mopping, part of the mop handle touched the resident in bed A's (bed closest to door) catheter bag. Staff UU was observed to remove the soiled mop head and placed it over the handle of housekeeping cart and put the mop handle onto the cart without disinfecting it. Staff UU then removed their gloves and completed hand hygiene. Staff UU, with bare hands, removed the used mop head and the used cleaning cloth from the handle of the housekeeping cart, and placed them into plastic bags, then was observed to perform hand hygiene. Staff UU, pushed the housekeeping cart by the contaminated handle to the shower room, obtained a clean mop head, opened the door, and entered the shower room. Staff UU was not observed to disinfect the housekeeping cart handles or the shower room doorknob, entered the shower room, then donned gloves without performing hand hygiene. On 08/30/2023 at 8:18 AM, the Station 1 shower room was observed to have a personal electric razor labeled with Resident 42's name (a resident known to be diagnosed with CRAB OXA) was sitting on top of folded towels, hospital gowns, and a bath blanket that were on top of the plastic and mesh barrel. On top of the folded linens were individual containers of barrier cream and body lotion that appeared to have been used as they were not full. There were also two white socks that were not folded laying with the linens but did not appear dirty. Next to the shower chair, that was in the stall area, was a bath bench with a square pink bin full of no rinse soap, conditioner, shaving cream, aftershave, a hair pick with strands of hair in it, and a disposable razor without the blade guard and had small hairs within the blades. The bottles within the bin appeared to have been used. The bin had partially dried white liquid pools that resembled liquid soap covering the bottom. On the wall in the shower room was a sign that stated, Not to leave personal items in shower room. During an observation and interview on 08/30/2023 at 8:23 AM, Staff E joined the surveyor in the shower room. Staff E stated all residents should have their own supply of grooming items and bottles should not be shared between residents. Staff E stated personal items were not to be left in the shower room and they should not be placed on top of clean linens. Staff E stated the disposable razor had been used and that it should have been disposed of in the sharp's container (medical waste container that is puncture- resistant). Staff E stated since Resident 42's razor had been in the shower room; it had contaminated the area and the linens needed to be removed and the area disinfected. During an observation on 08/30/2023 at 1:12 PM, Staff BB, NAC, and Staff CC, NAC, were observed to use the mechanical lift in room [ROOM NUMBER] and then push it into the hallway, along the wall. They were not observed to disinfect the lift machine after use. During an observation on 08/30/2023 at 2:34 PM, Staff EE, NAC, was observed coming out of the clean linen room with a large stack of bath blankets held against their clothing. During an observation on 09/07/2023 at 9:12AM, Staff O, LPN, returned to the medication cart from a resident's room, cleaned the stethoscope using a disinfectant wipe without wearing gloves and then resumed medication pass touching the computer screen without performing hand hygiene. <PPE> During an observation on 08/29/2023 at 10:30 AM, Staff Y, NAC, was observed with their procedure mask positioned with their nose exposed. Staff Y was then observed to reposition their mask by pulling on the top front of the mask, and no hand hygiene was completed. Staff Y stated they had a difficult time keeping the procedure mask properly placed over their nose. During an observation and interview on 08/30/2023 at 2:49 PM, Staff P entered room [ROOM NUMBER] B (bed next to the window) that had a sign posted showing the resident was on EBP. Staff P did not don PPE prior to entering room and was observed to assess the resident's abdomen and administer water and medications thru an enteral tube (tube inserted through abdomen into stomach to deliver nutrition and medications). Staff P stated that they should have worn a gown, but stated they did not fully understand what EBP was for. <Hand Hygiene> During an observation on 08/29/2023 at 12:54 PM, Staff P was observed connecting the intravenous (IV) medication (medication given in liquid form through a tubing that is inserted into the vein) to Resident 278's IV line. After applying gloves and cleaning the hub (the access point) of the resident's IV line, Staff P, with gloved hands grabbed the garbage can and pulled it closer to them. Staff P then primed (filled the tubing with fluid, removing the air so that it can be safely connected to the resident) the IV tubing for the medication and connected the tubing to the resident's IV line. Staff P did not change gloves or complete hand hygiene after touching the garbage can before they connected the resident's IV. Staff P stated they had moved the garbage can and had not changed their gloves prior to connecting the IV line. On 08/29/2023 at 1:03 PM, Staff N, LPN, was observed doing a bandage change on Resident 16's head wound. After Staff N removed the used bandage and discarded it, Staff N did not remove their gloves or perform hand hygiene. Staff N stated that he double gloved so that they did not have to do hand hygiene during the bandage change. During an observation on 08/30/2023 at 2:13 PM, Staff Z was observed at the bedside of a resident that had a sign posted showing that resident had EBP. Staff Z was observed leaving the room and did not perform hand hygiene. During an observation on 09/01/2023 at 12:15 PM, Staff P was observed to remove a gown from the storage bin outside room [ROOM NUMBER], donn the gown, and then completed hand hygiene using hand gel. <TBP> In a virtual meeting on 08/29/2023 at 9:00 AM, CC7 stated facility was notified by the LHJ and the DOH on 08/22/2023, that all residents on the specialized respiratory unit (Station 1) and any residents with an indwelling medical device on Station 2 needed to be placed in EBP. RESIDENT 14 Resident 14 resided on the same unit as residents with CRAB OXA infections. During an observation on 08/29/2023 at 1:27 PM, a storage bin with PPE supplies was noted outside of Resident 14's doorway. There was no sign present to alert staff of what type of TBP was required to enter the room. During an interview on 08/29/2023 at 1:28 PM, Staff O, LPN, stated Resident 14 was on contact precautions related to an infection with a MDRO and the resident had an intravenous access. RESIDENT 9 Resident 9 resided on the specialized respiratory unit and the same unit as the residents with the CRAB OXA cases. Review of Resident 9's medical record showed that they had an enteral feeding tube and a tracheostomy. During an observation on 08/29/2023 at 1:27 PM, no TBP sign was posted outside of Resident 9's room, nor was there a supply of PPE outside of the room to use before you entered. On 08/29/2023 at 12:47 PM, Staff S, Respiratory Therapy Manager, stated residents that have a portal of entry such as catheter, tracheostomies or use of a ventilator should be on EBP. Staff S stated they did not know why Resident 9 did not have a EBP sign or bin of PPE supplies outside of their door. RESIDENT 61 Resident 61 resided on the specialized respiratory unit and the same unit as the residents with the CRAB OXA cases. Resident 61 was noted to have a tracheostomy. During an observation on 08/29/2023 at 2:00 PM, no TBP sign was posted outside of Resident 61's room, nor was there a supply of PPE outside of the room to use before you entered. During an interview on 08/29/2023 at 10:21 AM, Staff E stated they were not familiar with the facility policy for EBP, and their understanding was residents were on EBP on Station 1 if they had a respiratory condition. Staff E could not elaborate why not all residents on Station 1 with a respiratory condition were on EBP. RESIDENT 56 Resident 56's clinical record showed they had an enteral tube in place. During an observation on 08/29/2023 at 2:10 PM, no TBP sign was posted outside of Resident 56's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 15 Resident 15's clinical record showed they had a urinary catheter in place. During an observation on 08/29/2023 at 3:32 PM, no TBP sign was posted outside of Resident 15's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 35 Resident 35's clinical record showed they had an enteral tube in place. During an observation on 08/29/2023 at 3:32 PM, no TBP sign was posted outside of Resident 35's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 278 Resident 278's clinical record showed they had an IV line in place. During an observation on 08/29/2023 at 3:32 PM, no TBP sign was posted outside of Resident 278's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 20 During an interview on 08/28/2023, Resident 20 stated they had pressure ulcers (bed sores) on their buttocks. During observations on 08/28/2023 at 11:49 AM and 08/29/2023 at 10:25 AM, no TBP sign was posted outside of Resident 20's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 8 Resident 8's clinical record showed they had an enteral tube in place. During an observation on 08/29/2023 at 2:10 PM, no TBP sign was posted outside of Resident 8's room, nor was there a supply of PPE outside of the room to use before you entered. <OTHER> During an observation on 08/30/2023 at 2:49 PM, Staff P was observed to fill an enteral administration bag, dated 08/29/2023 at 1:00 PM, with formula. Staff P stated enteral bags were to be changed every 24 hours. Staff P discarded the outdated enteral administration bag after prompted by surveyor. During a meeting on 09/07/2023 at 12:17 PM, with Staff A, Administrator, Staff B, Director of Nursing Services, Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, and the surveyors, Staff B stated nurses were working short staffed and were burned out. CC2 stated because nurses were burned out and working short staffed, they were going to make mistakes, which included not following standards of IPC practices. WAC Reference 388-97-1320 (1)(a) 33954 43411

Based on interview and record review, the facility failed to ensure 18 of 18 diabetic residents (Residents 18, 57, 22, 12, 24, 376, 47, 46, 41, 28, 17, 29, 7, 4, 21, 375, 20, 124) that resided on 2 of 2 units (Station 1 and 2) remained free of significant medications errors related to administration of insulin (high-risk medication) and to monitor blood sugars (level of blood sugar) as ordered. Failure to administer insulin within the required time frame of one hour before/after the scheduled time parameter resulted in residents receiving insulin injections significantly late (up to seven and one-half hours late), insulin administered simultaneously with the next scheduled dose (risk for hypoglycemic episode), and to follow the scheduled orders for monitoring blood glucose which resulted in residents receiving doses of insulin that were ordered to be held, not administered, or administered insulin when there were no hold parameters ordered, and did not notify the physician or document in progress notes when indicated based on residents' blood glucose levels, which placed residents at serious risk for harm and adverse consequences when insulin is not administered as ordered and placed resident's at an increased risk for diabetic complications due to inadequate medication management. In addition, the facility failed to administer medications within scheduled parameters for a variety of high risk drug classes for 29 of 63 residents (Residents 4, 5, 7, 12, 13, 14, 15, 20, 27, 28, 30, 31, 36, 43, 44, 45, 47, 52, 54, 57, 64, 66, 68, 124, 275, 276, 278, 375 and 376) which resulted in medication errors on 09/07/2023. On 09/09/2023, 18 of 18 residents on 1 of 2 units (Station 2) of 1 of 3 medication carts (Residents 18, 57, 22, 12, 24, 376, 47, 46, 41, 28, 17, 29, 7, 4, 21, 375, 20, 124) did not receive their scheduled morning medications as the scheduled nurse had called out for their shift. The facility's failed medication management practices and non-compliance with acceptable standards of medication administration practiced placed residents' health and safety in jeopardy. On 08/31/2023 at 7:44 PM the facility was notified of an Immediate Jeopardy (IJ) situation related to CFR 483.45 (f)(2) Free from Significant Med (medication) Errors, when a review of the August 2023 Medication Administration Records (MR's), showed 18 of 18 diabetic residents had numerous episodes/doses when they received their insulin injections greater than one-hour after the scheduled time and up to seven and one-half hours late and when nurses failed to follow physician orders for insulin/blood glucose medication management. These failures have been occurring since 08/31/2023 at 7:44 PM. The IJ was removed on 09/14/2023 when the medication administration records showed medications were administered timely and nurses confirmed medications were administered per physician orders. After removal of the IJ, the deficient practice at F760 remained at a E scope and severity, a pattern with no actual harm, with potential for more than minimal harm, following the removal of the IJ. Review of the State Operations Manual showed an adverse consequence was defined as a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. Medication management as based in the care process and includes recognition or identification of the problem/need ,assessment, diagnosis/cause identification, management/treatment, monitoring, and revising interventions. Findings included . Review of the facility policy titled, Administering Medications, revised date April 2019, showed: -The Director of Nursing Services (DNS), supervises and directs all personnel who administer medications and/or have related functions, -Medications are administered in accordance with prescribed orders, including any required time frame, -Medication administration times are determined by resident need and benefit, not staff convenience, -Medication errors are documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training. -Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. -As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered. Review of the facility policy titled, The Seven Rights of Medication Administration, undated, showed the seven rights to be: 1) right person, 2) right medication, 3) right dose, 4) right time, 5) right route, 6) right reason, and 7) right documentation. Review of the facility policy titled, Diabetes - Clinical Protocol, undated, showed: the physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the MAR and care plan. An adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. Medication management is based in the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring, and revising interventions, as warranted as well as documenting medication management steps. <RESIDENT 57> Resident 57 admitted to the facility on [DATE] with diagnoses to include diabetes (a group of diseases that result in too much sugar in the blood). Review of Resident 57's August 2023 MAR, showed the resident received glargine insulin (a long-acting insulin) 27 units twice daily at 6:00 AM, and 20 units daily at 8:00 PM, and to hold if the blood glucose (BGs) was less than 150, BGs checked, and Humalog (intermediate-acting insulin) insulin was ordered per the resident's individualized sliding scale three times a day. In an interview on 08/31/2023 at 5:53 PM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), was interviewed about Resident 57's insulin medication management that included: - 20 doses of Humalog insulin administered more than one-hour after the scheduled time, to include the 08/01/2023 dose scheduled for 11:30 AM dose that was administered at 1:16 PM, the 08/09/2023 dose scheduled for 7:30 AM was administered at 1:48 PM, the 08/09/2023 dose scheduled for 4:30 PM that was administered at 10:56 PM, the 08/10/2023 dose scheduled for 4:30 PM that was administered at 9:41 PM, the 08/14/2023 dose scheduled for 4:30 PM was administered at 11:04 PM, the 08/17/2023 dose scheduled for 4:30 PM was administered at 9:59 PM, the 08/24/2023 dose scheduled for 4:30 PM that was administered the next day (08/25/2023) at 1:48 AM, the 08/25/2023 dose scheduled for 4:30 PM that was administered at 9:39 PM, and the 08/31/2023 dose scheduled for 7:30 AM was administered at 10:26 AM, - Eight doses of glargine insulin administered when there was an order to hold the insulin for a blood glucose (BG) less than 150, to include doses on 08/01/2023 at 6:00 AM when the BG was 114, 08/08/2023 at 6:00 AM when the BG was 141, 08/09/2023 at 6:00 AM when the BG was 137, 08/11/2023 at 6:00 AM when the BG was 112, 08/12/2023 at 6:00 AM when the BG was 122, 08/16/2023 at 6:00 AM when the BG was 149, 08/17/2023 at 6:00 AM when the BG was 142, and on 08/28/2023 at 6:00 AM when the BG was 144. - 12 doses of glargine insulin administered more than one-hour after the scheduled time, e.g. the 08/02/2023 dose scheduled for 6:00 AM was administered at 8:10 AM, the 08/04/2023 dose scheduled for 6:00 AM was administered at 8:10 AM, the 08/07/2023 dose scheduled for 8:00 PM was administered at 10:23 PM, the 08/09/2023 dose scheduled for 8:00 PM was administered at 10:57 PM, the 08/12/023 dose scheduled for 8:00 PM was administered at 10:03 PM, the 08/14/2023 dose scheduled for 8:00 PM was administered at 11:07 PM, the 08/21/2023 dose scheduled for 8:00 PM was administered at 10:18 PM. - Numerous nurses had documented the same BG each day for the ordered 6:00 AM, 7:00 AM and 7:30 AM BGs, that occurred on 25 days between 08/01/2023 - 08/30/2023, e.g. on 08/01/2023 at 6:00 AM, they documented BG of 114, they also documented BG of 114 at 7:00 AM and they also documented BG of 114 at 7:30 AM, and on 08/02/2023 they documented BGs of 182 at 6:00 AM, 7:00 AM, and 7:30 AM. Staff C provided no information regarding these specific medication errors, but stated in general that nurses should have done a progress note in the electronic medical record (EMR) each time the medication was given late, when insulin was administered outside of the physician orders, and if the nurse did not document in the resident's EMR, then they needed to be educated. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. Review of Resident 57's MAR, copied at 12:49 PM on 09/07/2023, showed their 8:00 AM medications still had not been administered to include: -Aspirin 81 mg (milligrams) scheduled to be administered at 8:00 AM, -Carbidopa-Levodopa (medication to treat the resident's Parkinson's disease) scheduled to be administered at 8:00 AM, -Tamsulosin (medication to treat resident's enlarged prostate) scheduled to be administered at 8:00 AM, <RESIDENT 5> Resident 5 admitted to the facility on [DATE] with diagnoses to include diabetes. In an interview and record review with Staff C on 08/31/2023 at 6:06 PM. The following was discussed: -A nurse administered Resident 5's Humalog insulin on 08/11/2023 at 5:00 PM when their BG was 61, Staff C was unable to state if the nurse should have administered that insulin. - Staff C was asked if it was acceptable practice for nurses to administer the 8:00 AM and 12:00 PM scheduled doses of insulin at the same time (simultaneously), Staff C was unable to provide any information. - Review of the August 2023 MARs, showed the same nurse administered Humalog insulin 6 units scheduled for 8:00 AM, at the same time they administered Humalog insulin 8 units scheduled for 12:00 PM, both doses were administered at 11:48 AM (double dosed medication), the nurse documented the BG of 173 for both the 8:00 AM dose and the 12:00 PM dose. The resident's glucose at 5:00 PM was 66 that required the 5:00 PM dose of Humalog insulin to be held. Staff C was unable to provide any information what the facility process was for nurses to document if the nurse did not follow the seven rights to medication administration and forgot to document a medication when administered. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. Review of Resident 5's MAR, dated 09/07/2023, showed they had medications scheduled to be administered daily at 8:00 AM to include: -Escitalopram (medication to treat the resident's depression), -Esomeprazole Magnesium (medication to treat the resident's acid reflux), -Fluticasone Propionate (medication to treat resident's allergies), -Folic acid (supplement), -Gabapentin (medication to treat resident's pain), -Guaifenesin (medication to treat resident's cough), And there was no documentation on the MARs to indicate what time these medications were actually administered. <RESIDENT 10> Resident 10 most recently admitted to the facility on [DATE] and had diagnoses to include diabetes. Review of Resident 10's June 2023 MARs, showed an order for Cozaar (medication being given to the resident to treat their high blood pressure), and to hold a dose if the heart rate was less than 60, on 06/16/2023 at 8:00 AM, the nurse administered the medication when the resident's heart rate was 51. Review of Resident 10's April 2023 MARs, showed: -an order for amiodarone, a medication being given to the resident to treat their irregular heart rhythm atrial fibrillation. The order showed the medication to be held if the heart rate was less than 60. The MAR showed amiodarone was given by a nurse on 04/01/2023 at 8:00 AM when the heart rate was 57, and on 04/01/2023 at 8:00 PM when the heart rate was 58. -an order for cozaar, a medication being given to the resident to treat their high blood pressure. The order showed the medication to be held if the heart rate was less than 60. The MAR showed Cozaar doses were given by a nurse on 04/01/2023 at 8:00 AM when the heart rate was 57, and at 8:00 PM when the heart rate was 58. -an order for glipizide, a medication being given to the resident to treat their diabetes. The order showed the medication to be held if if the blood sugar less than 125. The MAR showed Glipizide doses were given by a nurse on 04/16/2023 at 8:00 AM when the blood sugar was 96, and at 04/17/2023 at 8:00 AM when the blood sugar was 123. -an order for metformin, a medication being given to the resident to treat their diabetes. The order showed the medication to be held if if the blood sugar was less than 110. The MAR showed a metformin dose was given by a nurse on 04/16/2023 at 8:00 AM when the blood sugar was 96. Review of Resident 10's March 2023 MARs showed an order for metformin. The order showed the medication to be held if the blood sugar was less than 110. The MAR showed four doses were given when the blood sugar was less than 110 to include on 03/02/2023 at 8:00 AM when the BG was 104, on 03/05/2023 at 8:00 AM when the BG was 106, on 03/06/2023 at 8:00 AM when the BG was 98, and on 03/17/2023 at 8:00 AM when the BG was 102. Review of Resident 10's August 2023 MARs showed an order for glargine insulin every morning at 7:00 AM. From 08/01/2023 - 08/31/2023, they received 20 doses that were more than one-hour after the scheduled time, to include doses at 11:26 AM (four hours 26 minutes late) on 08/13/2023, 10:12 AM (three hours 12 minutes late) on 08/17/2023, 10:36 AM on 08/18/2023, 10:26 AM on 08/22/2023, 11:38 AM on 08/23/2023, 10:08 AM on 08/25/2023, 10:42 AM on 08/26/2023, 11:07 AM on 08/29/2023, 10:14 AM on 08/30/2023, and 10:57 AM on 08/31/2023. Review of Resident 10's August 2023 MAR, showed an order, dated 07/19/2023, to administer metformin (oral medication used to treat diabetes) twice daily, but to hold it if their BG was less than 110. Review of the resident's clinical record showed there was no documentation that nurses had checked the resident's BG at all prior to administering the Metformin. The resident received 61 doses of Metformin without their BG being checked prior to administration. In an interview on 08/31/2023 at 5:31 PM, Staff C stated they could not find any documentation the nurses were checking the resident's BGs. Staff C checked the EMR and stated the nurse practitioner failed to enter the order properly, so the nurses were not prompted to check the resident's BGs prior to administering the medication. Staff C stated no nurses had told them they didn't have time to administer all their medications within the required time frame. Review of Resident 10's August 2023 MARs, showed an order for metoprolol (medication being given to the resident to treat their irregular heart rhythm atrial fibrillation), to be given at 8:00 PM, and to hold it if the heart rate was less than 60, on 08/18/2023 a nurse administered the medication when the resident's heart rate was 52. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. Review of Resident 10's MARs for 09/07/2023, showed they had medications scheduled to be given at 8:00 AM to include: -aspirin 81 mg, -cozaar (medication to treat their high blood pressure), -duloxetine (medication to treat their depression), -empagliflozin (medication to treat their heart failure and diabetes), -fish oil (supplement), -furosemide (diuretic/water pill to treat their heart failure), -gabapentin (medication to treat their diabetic nerve pain), -metformin (medication to treat their diabetes), -methocarbamol (medication to treat their muscle spasms and pain), -spironolactone (medication to treat their heart failure and high blood pressure), 42927 <RESIDENT 34> Review of Resident 34's August 2023 MARs, showed a physician order for Novolog (rapid acting) insulin four times a day, scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. 45 of the 124 doses administered were documented as given outside of the one-hour window. Two of the doses were administered over four hours late. On 08/08/2023 the 6:00 AM dose was documented as given at 10:41 AM, and on 08/15/2023 the 12 AM dose was documented as given at 4:41 AM. Three times the insulin dose was not held and administered when the resident's BG was < (less than) 140, on 08/01/2023 at 12:00 PM when the BG was 119, on 8/02/2023 at 6:00 PM when the BG was 129, and on 08/27/2023 at 6:00 PM when the BG was 129. There was no documentation in the EMR indicating why the insulin was not held or if the physician had been notified. Review of Resident 34's physician orders included Levemir (extended release) insulin two times daily at 9:00 AM and 9:00 PM. There were 23 of the 62 doses were documented as given outside the one-hour window. There were 10 doses that were documented as given more than four hours late on 08/02/2023 at 9:00 AM dose was documented as given at 1:27 PM, 08/03/2023 at 9:00 AM dose was documented as given at 1:26 PM, 08/07/2023 at 9:00 AM dose was documented as given at 2:09 PM, 08/14/2023 at 9:00 AM dose was documented as given at 1:48 PM, 08/17/2023 at 9:00 AM dose was documented as given at 1:46 PM, 08/20/2023 at 9:00 AM dose was documented as given at 1:44 PM, 08/22/2023 at 9:00 AM dose was documented as given at 1:18 PM, 08/26/2023 at 9:00 AM dose was documented as given at 1:08 PM, 08/27/2023 at 9:00 PM dose was documented as given at 1:07 AM on 08/28/2023, and on 08/30/2023 at 9:00 AM dose was documented as given at 2:41 PM. In an interview on 08/31/2023 at 5:21 PM, Staff N, LPN, stated when they only had two nurses on the unit, they could not get their medications administered timely. <RESIDENT 20> Review of Resident 20's August 2023 MARs, showed a physician order for lispro (rapid acting) insulin every six hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Resident 20 was to have the insulin dose based on the BG results. Resident 20 had a physician order for insta-glucose (used to treat low BG levels) as needed for BG less than 70. The resident had scheduled mealtimes at 7:50 AM for breakfast, 11:50 AM for lunch, and 5:00 PM for dinner. Resident 20 had been administered lispro insulin on 12:42 AM on 08/02/2023 with subsequent BG on 08/02/2023 at 6:00 AM was 47. Resident 20 had been administered lispro insulin on 2:43 AM on 08/04/2023 (over nine hours after resident's last meal) with subsequent BG on 08/04/2023 at 6:00 AM was 47. On 08/08/2023 at 6:00 AM, resident 20's BG level was 60. Resident 20 had been administered lispro insulin on 1:47 AM on 08/25/2023 (over eight hours after last meal) with subsequent BG on 08/25/2023 at 6:00 AM was 58. Review of the progress notes and MAR showed no documentation that insta-glucose was given per orders, no nursing documentation regarding the resident's condition and the physician was not notified when they had a low BG. Resident 20 had a physician order for glargine (extended release) insulin 32 units one time a day scheduled at 6:00 AM and glargine insulin 26 units once a day scheduled at 9:00 PM. There were no parameters in the physician orders to hold the glargine insulin based on the BG results. The glargine insulin was not given at 6:00 AM on 08/08/2023, 08/09/2023, 08/10/2023, 08/17/2023, 08/23/2023, 08/24/2023, 08/25/2023, 08/29/2023, and 08/30/2023. The MAR showed a code of NG. According to the key on the MAR, NG meant the medication was not given as parameters were out of range. There were no progress notes to explain why the medication was not given as ordered or that the MD was notified. Resident had ten out of 52 doses of glargine insulin administered during the month outside of the one-hour window to provide medications. Review of Resident 20's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 21> Review of Resident 21's August 2023 MARs, showed an order for Humalog insulin before meals and to hold dose if BG <150. There was no documentation of the BG levels documented on the MAR. Seventeen of the 70 doses of Humalog administered were documented outside of the one-hour window, and three doses were documented as given more than four hours late: on 08/09/2023 the scheduled 4:30 PM dose was documented as given at 10:19 PM, on 08/18/2023 the 4:30 PM dose was documented as given at 11:32 PM (a BG was documented in the vital sign section with value of 179 done at 11:30 PM), and on 08/28/2023 the 4:30 PM dose was documented as given at 11:10 PM. Review of the August 2023 MAR, showed Resident 21 had a physician order for glargine insulin twice a day. Twelve of the 62 doses administered were documented outside of the one-hour window, and on 08/14/2023 at 8:00 AM the insulin was documented as given at 1:17 PM, more than four hours late. <RESIDENT 66> Review of Resident 66's August 2023 MARs, showed a physician order for lispro insulin twice a day at 4:30 PM and 9:00 PM. Staff were to hold the dose if the BG was <150. The lispro was administered four times during the month when the BG was <150: on 08/01/2023 the BG was 117, on 08/12/2023 the BG was 147, on 08/19/2023 the BG was 115 and on 08/20/2023 the BG was 139. Review of the August 2023 MARs, showed Resident 66 had 24 of the 62 doses of lispro insulin administered outside of the one-hour window. There were three incidents when the lispro insulin was given more than three and a half hours late: on 08/03/2023 the 9:00 PM dose of insulin was documented as administered at 1:23 AM (on 08/04/2023), on 08/14/2023 the 9:00 PM dose was documented as administered at 1:56 AM (on 08/15/2023), and on 08/25/2023 the 9:00 PM dose was documented as given at 12:28 AM (on 08/26/2023). Review of the August 2023 MARs, showed Resident 66 had an order for glargine insulin scheduled twice a day at 11:00 AM and 8:00 PM. The MAR showed 27 of the 62 doses of glargine insulin was administered outside of the one-hour window. There were two incidents when the glargine insulin was given more than five hours late: on 08/03/2023 the 8:00 PM dose was documented as administered at 1:22 AM (on 08/04/2023), and on 08/18/2023 the 8:00 PM dose was documented as administered at 2:15 AM (on 08/19/2023). Review of Resident 66's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 2> Resident 2 had scheduled mealtimes at 7:50 AM, 12:00 PM, and 5:00 PM. Review of the August 2023 MARs, showed Resident 2 had a physician order for Humalog insulin before meals scheduled at 6:30 AM (over an hour before breakfast), 11:30 AM and 4:30 PM. Resident 2 had a physician order for Humalog insulin coverage before meals, based on the results of the BG, scheduled at 8:00 AM, 12:00 PM and 5:00 PM. Documentation showed nurses often administered the resident two separate injections of Humalog rather than combining the dose, causing Resident 2 to have additional injections. On the following dates and times, Resident 2 received an additional injection: 08/02/2023 breakfast and lunch doses, 08/03/2023 breakfast dose, 08/04/2023 lunch dose, 08/05/2023 lunch dose, 08/06/2023 dinner dose, 08/08/2023 dinner dose, 08/09/2023 lunch dose, 08/10/2023 lunch dose, 08/11/2023 lunch dose, 08/12/2023 lunch dose, 08/13/2023 dinner dose, 08/16/2023 lunch dose, 08/17/2023 lunch dose, 08/19/2023 breakfast dose, 08/21/2023 breakfast dose, 08/22/2023 breakfast and lunch dose, 08/25/2023 lunch and dinner dose, and 08/26/2023 breakfast, lunch and dinner dose. Review of the August 2023 MARs, showed Resident 2's Humalog insulin was documented as administered outside of the one-hour window 23 out of 110 doses. There were five doses documented as administered more than four hours late: on 08/03/2023 4:30 PM the insulin was documented as given at 8:46 PM, on 08/13/2023 the 6:30 AM dose and 11:30 AM dose were documented as administered at the same time at 11:11 AM, on 08/13/2023 the 5:00 PM dose was documented as administered at 6:22 PM, on 08/24/2023 the 4:30 PM dose was documented as given at 10:36 PM, and 08/26/2023 the 5:00 PM dose was documented as given at 6:24 PM. Resident 2 had a physician order for glargine insulin twice a day. Review of the August 2023 MAR, showed 21 of the 58 doses of glargine insulin was documented as administered outside of the one-hour window. Two doses were documented as administered more than four hours late: on 08/14/2023 the 8 PM dose was documented as given at 11:46 PM, and on 08/15/2023 the 8:00 AM dose was documented as given at 11:16 AM. On 08/31/2023 at 10:50 AM, Staff P, LPN, was observed to leave Resident 2's room and stated they had administered the resident's morning medications late because they were very busy and didn't have enough time to get medications administered in time. Review of the 08/31/2023 MAR, showed Resident 2 received three high blood pressure medications, pain medications, a bowel medication, vitamins, and an aspirin at 10:50 AM. The medications were all given late, as they were scheduled at 08:00 AM. In an interview on 08/31/2023 at 11:15 AM, Staff C stated they had talked to Staff P and they had not told them they were late with Resident 2's medications that morning, but that they had forgot to save them in the EMR when they had administered the medications. Staff P stated they were medication errors, and they would investigate them. <RESIDENT 13> Resident 13 had scheduled mealtimes at 7:50 AM, 12:00 PM, and 5:00 PM. Review of the August 2023 MARs showed Resident 13 had a physician order for lispro (rapid acting) insulin before meals. The order showed staff were to hold dose per hypoglycemia protocol, but Resident 13 did not have orders for hypoglycemia protocol on their MAR. Lispro insulin administration was documented outside of the one-hour window 13 out of 71 times. Three doses were documented as administered more than four hours late: on 08/24/2023 the 7:30 AM dose was documented as administered at 2:00 PM, and the 11:30 AM dose was documented at 2:03 PM. On 08/30/2023 the 4:30 PM lispro insulin was documented as given at 12:04 AM (on 08/31/2023). Review of the August 2023 MARs, showed Resident 13 had a physician order for glargine insulin twice a day. The staff were to hold the dose of insulin when the BG was <100. On 08/04/2023, the dose was not administered and showed a BG of 113 with a code of NG was documented on the MAR. There were no progress notes to explain why the medication was not given as ordered. Glargine insulin was documented as administered outside of the one-hour timeframe 17 out of 55 doses. Four doses were documented as given more than four hours late: on 08/07/2023 the 8:00 PM dose was documented as given at 12:31 AM (on 08/08/2023), on 08/11/2023 the 8:00 PM dose was documented as given at 12:53 AM (on 08/12/2023), on 08/15/2023 the 8:00 PM dose was documented as given at 12:46 AM (on 08/16/2023), and on 08/30/2023 the 8:00 PM dose was documented as given at 12:08 AM (on 08/31/2023). Review of Resident 13's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 22> Resident 22 had scheduled mealtimes at 7:50 AM, 12:00 PM and 5:00 PM. Review of the August 2023 MARs, showed Resident 22 had a physician order for Humalog insulin with meals. Staff were to hold the insulin dose when the BG was <150. Ten of the 91 doses administered were documented outside of the one-hour window. Three doses were documented as being given more than four hours late: on 08/14/2023 the 5:00 PM dose was documented as given at 9:04 PM, on 08/18/2023 the 5:00 PM dose was documented as given at 10:14 PM, and on 08/30/2023 the 5:00 PM dose was documented as given at 8:56 PM. Three times the Humalog insulin was given when the BG was <150: on 08/07/2023 at 8:00 AM the BG was 130, on 08/21/2023 at 8:00 AM the BG was 144, and on 08/27/2023 at 8:00 AM the BG was 118. Review of the August 2023 MARs, showed Resident 22 had a physician order for glargine insulin twice a day. There were 16 out of 61 administered doses of glargine insulin documented as given one-hour outside of window. Five doses were documented as being given more than four hours late: on 08/14/2023 the 5:00 PM dose was documented as given at 9:04 PM, on 08/15/2023 the 7:00 AM dose was documented as given at 2:29 PM, on 08/18/2023 the 5:00 PM dose was documented as given at 11:15 PM, on 08/25/2023 the 5:00 PM dose was documented as given at 9:17 PM, and on 08/29/2023 the 5:00 PM dose was documented as given at 10:07 PM. <RESIDENT 40> Review of the August 2023 MARs showed Resident 40 had a physician order for Humalog insulin with meals and bedtime. Ten of the 49 doses administered were documented outside of the one-hour window. One dose was documented as being given more than four hours late: on 08/03/2023 the 9:00 PM dose was documented as given at 1:56 AM (on 08/04/2023). Resident 40 had a physician order for glargine insulin once daily scheduled at 8:00 PM. There were no parameters in the physician orders to hold the insulin based on the BG reading. The glargine insulin was not given on 08/02/2023, 08/04/2023, 08/05/2023, 08/08/2023, 08/10/2023, 08/12/2023, 08/14/2023, 08/16/2023, 08/18/2023, 08/20/2023, 08/22/2023, 08/23/2023, 08/24/2023, 08/25/2023, 08/28/2023, and 08/30/2023 with a code of NG shown on the MAR. There were no progress notes to explain why the medication was not given as ordered. Six of the 14 doses of glargine insulin administered were documented outside of the one-hour window. Two doses were documented as given more than four hours late: on 08/03/2023 the 8:00 PM dose was documented as given at 1:55 AM (on 08/04/2023) and on 08/07/2023 the 8:00 PM dose was documented as given at 12:09 AM (on 08/08/2023). <RESIDENT 33> Review of Resident 33's August 2023 MARs showed an order for Novolog (rapid acting) insulin before meals. Out of the 91 doses of Novolog administered, 32 were documented outside of the one-hour window. Five doses were documented as given more than four hours late: on 08/05/2023 the 7:00 AM dose was documented as given at 1:19 PM, on 08/07/2023 the 7:00 AM dose was documented as given at 12:54 PM, on 08/08/2023 the 7:00 AM dose was documented as given at 2:29 PM, on 08/30/2023 the 11:00 AM dose was documented as given at 3:31 PM and on 08/31/2023 the 7:00 AM dose was documented as given at 12:26 PM. Resident 33 had a physician order for glargine insulin twice a day. Review of the August 2023 MAR showed on 08/13/2023 the 8:00 PM dose was not signed as given and the MAR was blank. Out of the 59 doses administered, 38 were documented outside of the one-hour window. Five doses were documented as given more than four hours late: on 08/05/2023 the 8:00 AM dose was documented as given at 1:20 PM, on 08/07/2023 the 8:00 AM dose was documented as given at 12:54 PM, on 08/08/2023 the 8:00 AM dose was documented as given at 2:29 PM, on 08 [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for 4 of 5 residents (Residents 10, 14, 16, and 66) reviewed for unnecessary psychotropic medications. The facility did not have a system that consistently monitored target behaviors, ensured there were valid indications for use of antipsychotic medications, involved the interdisciplinary team (IDT) in medication management process, considered gradual dose reeducations (GDR), and consistently attempted behavioral interventions prior to medications use. Resident 10 experienced harm when they developed significant adverse side effects that were sleepiness and lethargy (fatigue, tiredness, and exhaustion both physically and mentally) which were side effects of antipsychotic medications after being administered unnecessary psychotropic medication without recognition or treatment by the facility. The lack of addressing the serious s/e and medication use without established need represented an Immediate Jeopardy (IJ) situation. On 09/15/2023 at 5:12 PM, the facility was notified of an Immediate Jeopardy (IJ) situations related to CFR 483.45(c)(3)(e)(1)(2)(d), F758, Unnecessary Psychotropic Medications, when the facility was found to be treating Resident 10 with the antipsychotic medication Seroquel for dementia with psychosis. Target behaviors were not consistently identified or consistently documented in 12 months, no GDR was documented, the facility failed to recognize and take action when staff identified in the progress notes the resident experienced adverse s/e's to include sleepiness and lethargy. Additionally, Resident 10 was treated with the psychotropic drugs duloxetine (an antidepressant medication) for depression, and trazodone (an antidepressant medication) for sleep. The facility was aware of the deficient practice on 09/15/2023 when they were notified of an Immediate Jeopardy situation by the survey team. The IJ was removed on 09/19/2023 after onsite validation by surveyor when review of Resident 10 and other residents that received psychotropic medications, verified the facility IDT collaborated with the residents provider and the pharmacist to ensure resident/s were reviewed for documentation to support appropriate diagnoses, indications, target behaviors, s/e's, gradual dose reductions, were addressed and documented. The facility provided education to licensed nurses, nursing assistants, the facility's Medical Director/Resident 10's physician and the nurse practitioner on the facility's policy and procedures related to the use of psychotropic medications. After removal of the IJ, the deficient practice at F758 remained at a G scope and severity, isolated, actual harm that is not immediate jeopardy, following the removal of the IJ. Findings included . Review of the facility policy titled, Psychoactive Drug Management, dated 09/20/2022, showed the purpose was to provide a therapeutic environment that supported residents to obtain or maintain the highest physical, mental, and psychosocial well-being. The policy identified antipsychotic medications, also called major tranquilizers, as the most powerful and dangerous of the psychotropic medications. The policy indicated: -Following admission, quarterly, annually and upon significant change of condition, the interdisciplinary team (IDT) will review and make recommendations based on resident needs to include: The effectiveness of non-drug interventions, the need for psychotropic medications, possible alternatives to use of psychotropic medications and possibility of dose reduction program. -If an antipsychotic medication was initiated within the last year, the facility has attempted a gradual dose reduction (GDR - a stepwise tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) between two separate quarters with at least one month in between attempts. If no antipsychotic GDR has been attempted, the prescriber has documented a tapering was clinically contraindicated (a symptom or medical condition that makes a particular treatment or procedure inadvisable because the resident is likely to have a bad reaction). -The pharmacy consultant and the IDT will reassess the resident at least quarterly to determine the effectiveness of psychoactive drug use. Any resident with a new antipsychotic medication order will be referred to the psychiatrist for review and will be reevaluated as needed. Any order for psychoactive medications must include the diagnosis for use, and specific behavior manifested. Non-drug (non-pharmacological - approaches to care that are provided as part of a supportive and psychosocial environment) interventions are documented and on the care plan. Review of the facility policy titled, Behavior Management, dated 02/01/2023, showed that residents exhibiting behavioral symptoms will be individually evaluated to determine the behavior. The IDT identifies the underlying concerns that contribute to changes in the resident's behavior. Staff will implement non-pharmacological interventions as the first line of approach to managing challenging behaviors. Behaviors and interventions will be addressed in the care plan. The facility will monitor identified residents who exhibit behavioral symptoms and refer the resident to mental health services if necessary. Review of the Food and Drug Administration (FDA) black box warning is the most serious type of warning issued by the FDA for certain medications that carry serious safety risks. Review of a black box warning showed, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. SEROQUEL is not approved for elderly patients with dementia-related psychosis. <RESIDENT 10> Resident 10 admitted to the facility 08/18/2022 with diagnoses to include fracture of a thoracic vertebra (a fracture of their back) and a fracture of their left radius (arm bone) sustained in a fall. Review of the Admission Minimum Data Set (MDS - an assessment tool) assessment, dated 08/25/2022, showed Resident 10 had severe cognitive impairment, had no psychotic disorder, no depression diagnoses, no behavioral symptoms documented, and did have symptoms of delirium to include inattention (lack of attention) and disorganized thinking. Review of Resident 10's hospital discharge summary, dated 08/17/2022, showed an order for quetiapine (Seroquel) 25 milligram (mg) two tablets twice daily as needed. The summary did not show no diagnoses of dementia, no psychiatric diagnosis, and quetiapine was a new medication for the resident. The resident had unchanged medications to include duloxetine and trazodone. Review of a Resident 10's Level I Pre-Admission Screening and Resident Review (PASRR - a required screening form used to screen for a mental disorder or intellectual disability), dated 08/17/2022, showed the resident did not have dementia or a psychotic disorder, and they were not referred for a Level II evaluation (an evaluation for a mental disorder or intellectual disability). The PASRR identified the resident had a history of auditory hallucinations and required Haldol (antipsychotic medication) during their recent hospitalization , and was also started on Seroquel. The PASRR indicated the resident had no serious mental illness, intellectual disability, or related conditions. The PASRR identified it was negative PASRR. Review of the Admission Minimum Data Set (MDS - an assessment tool) assessment, dated 08/25/2022, showed Resident 10 had severe cognitive impairment, and did have symptoms of delirium to include inattention and disorganized thinking. The MDS did not show the resident had depression, behavioral symptoms, psychotic disorder or depression. Review of progress note, dated 08/24/2022, Staff G, Social Service Director, documented Resident 10's psychotropic medications initiation/increase due to dementia with associated behavioral symptoms as recorded on the behavior monitoring flow sheet. The reason for the increase was due the resident failed a GDR on admission and had an increase in behavioral symptoms. Review of Resident 10's medical records, showed no GDR's were attempted since the resident admitted to the facility on [DATE], there was no physician documentation that GDR's were contraindicated, and there were no corresponding behavior monitor flow sheets initiated on admission. Review of a Psychotropic/therapeutic Medication Use Evaluation, dated 08/24/2022, showed Resident 10's behavior symptoms have increased, in the past 30 days new medications (psychotherapeutic/antipsychotic) due to dementia with associated behavior symptoms as recorded on behavior monitoring flow record, and other dementia with psychosis. Staff were to monitor medication s/e's refer to Behavior Monitoring and Interventions flow record and MAR. Review of Resident 10's Psychotropic/therapeutic Medication Use Evaluation, dated 09/07/2022, showed: - Other concurrent clinical concerns, falls, insomnia, pain, - In the past 30 days new meds have been initiated (psychotherapeutic/antipsychotic), target behaviors hallucinations/delusional thoughts. - Reason for medication Initiation or Increase: Dementia with associated behavior symptoms as recorded on behavior Monitoring flow record. - Psychotherapeutic med: Seroquel 25mg twice daily, last dose change was on 09/01/2022. - Medication s/e monitoring: no s/e's noted. Review of Resident 10's focused care plan problem At risk for complications related to the use of psychotropic drugs, dated 08/30/2023, showed care plan interventions to include: Complete behavior monitor flow sheet, GDR's as ordered, monitor for changes in mental status and report to the physician if indicated, monitor for continued need for medication as related to behavior and mood, monitor for s/e's and consult with physician or pharmacists as needed, and obtain a psych evaluation as order. Review of Resident 10's Medication Administration Records/Treatment Administration Records (MARs/TARs) for 08/18/2022 through 09/14/2023, showed: -orders for Duloxetine twice daily for depression, started in August 2022 through September 2023, no target behavior monitoring was found in August 2022. This was not implemented until 09/01/2022. There was documentation they had a target behavior on 09/12/2022, but there was no explanation in the related nursing progress notes what it was. There were no documented target behaviors or adverse s/e's from October 2022 - 09/15/2023. -orders for trazodone for depression and insomnia, started in August 2022 through September 2023 (except for the time periods they were hospitalized ), no target behavior monitoring, or adverse s/e's monitoring were found in August 2022, and sleep monitoring was not implemented until 09/07/2022. There were no documented adverse s/e's from October 2022 - 09/15/2023. The facility failed to monitor the resident's treatment for insomnia/sleep from February 2023 - 09/14/2023 despite being administered trazodone for insomnia. -multiple orders for Seroquel: In August 18, 2022, the resident was admitted with as-needed Seroquel, then the order progressed to scheduled Seroquel once daily, on 08/24/2022. On 08/29/2022, the Seroquel was increased to twice daily. The order was decreased to once daily Seroquel on 09/01/2022 due to the resident was having symptoms that included drowsiness and not being as alert and conversant as they usually were. Except for their hospitalization in January 2023, the resident was continued on Seroquel once daily from 09/01/2022 through 09/15/2023. There was no documentation of target behavior monitoring or adverse s/e monitoring at all in August 2022. On 09/01/2022, staff implemented target behavior monitoring for hallucinations and delusional thoughts and started adverse s/e's monitoring. There was a documented target behavior documented on 09/12/2022, but no explanatory information was found in the nursing progress notes. There were no documented target behaviors from 09/13/2022 - 09/15/2023, except for on 03/18/2023, 03/19/2023, 03/25/2023 and 03/26/2023, when the nurse documented a 2 on the behavior monitor which indicated the resident had delusional thoughts. There was no corresponding progress note for those four days explaining how those target behaviors had manifested. There were no documented adverse s/e's documented on the Seroquel side effect monitor from September 2022 - 09/15/2023. Review of a provider notification note, dated 05/04/2023, showed Resident 10 was lethargic and confused. Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, CC2 reviewed the notification on 05/05/2023 and would evaluate the resident. Review of CC2's note, dated 05/05/2023 at 00:00 (timed stamped in the electronic medical record), showed Resident 10 appeared to be more lethargic and confused than previous visits. The note did not contain further documentation regarding contributing factors to their increase in lethargy and confusion). Review of a provider notification note, dated 05/11/2023, showed the resident was tired and sleepy. Their blood pressure was 210/96 (high). CC2 signed the notification on 05/12/2023 and ordered a high blood pressure medication to be given as needed. Review of CC2's notes, dated 05/24/2023, 05/26/2023, 05/30/2023, 05/31/2023, 06/02/2023, 06/06/2023 and 06/15/2023 at 00:00, showed Resident 10 was sitting up in wheelchair (w/c) asleep. Review of CC2's note, dated 06/19/2023, showed Resident 10 was seen for follow-up after the resident had a fall and was seen in the emergency department (ED) on 06/15/2023. The resident did not have any severe injuries. Review of CC2's note, dated 06/26/2023, showed Resident 10 was sitting up in their w/c sleeping. The resident was arousable but fell asleep right away and had been feeling very fatigued. The resident's general exam was . Sitting up in wheelchair asleep . Review of the Annual MDS assessment, dated 06/27/2023, showed Resident 10 had severe cognitive impairment, had no delusions, no hallucinations, no behavioral symptoms, no signs or symptoms of delirium, and no psychotic disorder. Review of a provider notification note, dated 06/29/2023, showed a Licensed Practical Nurse (LPN), notified provider Resident 10 was lethargic and sleepy on the day shift. CC2 reviewed the note on 07/03/2023 and would evaluate the resident. Review of CC2's note, dated 06/29/2023, showed Resident 10 was lying in bed, lethargic but arousable. The resident had recurrent major depression, had been calling family sobbing and expressed they wished to live with their family again. Family reported the resident has been very tearful the last few weeks and they were concerned about the resident's mental health. Currently there were no behavioral health specialists (BHS) providers in the facility. Will need to obtain a psychiatrist evaluation when available again. Review of CC2's note, dated 07/05/2023, showed Resident 10 was seen sitting up in their w/c with family at the bedside. The resident was alert but falls asleep quickly while sitting up. Resident 10's family was concerned regarding the resident's mental status because they were calling them more frequently at night and more agitated with confusion of where they were. CC2 documented to obtain a psychiatrist evaluation when available again. Review of CC3's, physician, progress note, dated 07/07/2023, showed Resident 10's physical exam was they were in their wheelchair (w/c) in no acute distress and fatigued. Their assessment included dementia with psychosis, frequently confused, and was unsure of where they were. Review of CC2's note, dated 07/10/2023 and 07/12/2023, showed Resident 10 was sitting in their w/c, drowsy but arousable, diagnosis of dementia with psychosis, frequently confused and was unsure of where they were. Review of CC2's note, dated 07/14/2023, 07/17/2023, 07/18/2023, and 07/19/2023, showed Resident 10 was sitting up in their w/c drowsy but arousable. Review of CC2's note, dated 07/20/2023, showed the resident had been more lethargic, more frequently, and the family noticed Resident 10 had a decrease in their mood. Despite resident's increased tearfulness . CC2 was hesitant to increase Resident 10's trazodone related to the resident started to have falls and confusion from low oxygen levels. The resident would need to have a psychiatrist evaluation when available again. Review of CC2's note, note dated 07/21/2023, 07/27/2023, 08/01/2023, 08/02/2023, and 08/08/2023, showed Resident 10 was sitting in their w/c, drowsy but arousable, diagnoses of dementia with psychosis, frequently confused and was unsure of where they were. Review of CC2's note, dated 08/09/2023, showed Resident 10 was sitting in their w/c drowsy, arousable, initially agitated, and confrontational. Oxygen was placed on the resident, became less agitated, and then was pleasantly confused. The general assessment indicated the resident had dementia with psychosis, was frequently confused, and they were unsure where they were. Review of CC2's note, dated 08/10/2023 and 08/14/2023, showed Resident 10 was sitting in their w/c, drowsy but arousable, diagnoses of dementia with psychosis, frequently confused and was unsure of where they were. Review of a nursing progress note, dated 08/17/2023 at 3:02 PM, showed Resident 10 had increased confusion, and was sent to hospital for jerky movements and a shaky body. Review of CC'2, dated 08/17/2023, showed Resident 10 with a new onset of myoclonus (involuntary muscle jerks that can be from chemical or drug intoxication which included anti-psychotics or antidepressants). The resident was sitting in their wheelchair (w/c) drowsy but arousable, having severe intermittent myoclonus which almost led the resident to near falls from their w/c. The resident was transferred to the ED for further evaluation. On 08/28/2023 at 11:26 AM, Resident 10 was observed asleep in their bed. On 09/01/2023 at 9:26 AM, Resident 10 was observed in their room asleep sitting in their w/c. On 09/04/2023 at 10:35 AM and 12:30 PM, Resident 10 was observed asleep in their w/c beside their bed. On 09/08/2023 at 7:59 AM, Resident 10 was observed asleep in their bed. At 9:15 AM, the resident was observed in their room asleep in their w/c. In an interview on 09/08/2023 at 10:08 AM, Staff G, Social Services Director, stated they could not find documentation Resident 10 had experienced any hallucinations or delusions since they admitted in August 2022. Staff G said the facility had not been having quarterly behavior or interdisciplinary team (IDT) meetings regarding the use of the resident's psychotropic medications, and stated, truthfully we need to get better at that. Staff G stated Resident 10 had not been evaluated by a psychiatrist, but they've wanted to do that. Staff G stated they were involved in the resident's psychotropic medication monitoring process and no GDRs had been attempted. Staff G stated they did not think Resident 10's PASRR (dated 08/17/2022) was correct and the resident needed a new PASRR. Staff G stated the resident's medical record was not accurate to support the use of their psychotropic medications. On 09/08/2023 at 11:35 AM, CC4 and CC5, two of Resident 10's family members, were interviewed. CC5 stated Resident 10 had been very sleepy, and last week they were unable to wake the resident when they visited. CC5 stated they did not know of any psychiatric diagnoses the resident may have had. CC4 stated Resident 10 did not have a diagnosis of dementia or psychosis. CC4 stated Resident 10 did have some hallucinations or delusions, but that was more related to when the resident was in the hospital, and the hospital staff asked them to stay to help calm Resident 10 down. When asked about the facility had documented the resident had been taking an antipsychotic medication for years, CC4 stated that had just been when the resident was in the hospital, and it was related to them receiving Percocet (a potent opioid used for pain management). CC4 stated the resident was very sleepy all the time, and they felt it was medication related. CC4 stated staff have told them the resident woke up early in the morning and stayed awake. CC4 stated they think the resident had some Sundowners syndrome (a state of confusion occurring in the late afternoon and lasting into the night) which caused them some confusion, and this had been present for a while. In an interview on 09/08/2023 at 12:04 PM, CC1, Consultant Pharmacist, stated they had missed that there was no sleep monitoring in place since February 2023 for Resident 10, they were not aware of the resident's three falls as they were not notified by the facility, they had not identified any irregularities in the Medication Regimen Review (MRR) since February 2023, they were not aware of any target behaviors or s/e's, and they had not recommended any gradual dose reductions (GDR). CC1 stated they were not aware of any target behaviors being identified, and they were unaware the resident had experienced any s/e's, and if they did, they would have used that information. CC1 did not read progress residents' progress notes unless they had been alerted by staff of a concern. CC1 was asked about Resident 10's clinical indications for use of the Seroquel, they stated the resident had a diagnosis of psychosis so that was good enough for them. CC1 was unable to state when they had last attended a GDR meeting, they stated they thought the meetings were monthly, but the facility moved the appointments. On 09/08/2023 at 1:57 PM, Resident 10 was observed asleep in bed. On 09/11/2023 at 8:25 AM, Resident 10 was observed asleep in bed with the room lights on and their breakfast tray sitting untouched on bedside table. An interview was done on 09/12/2023 at 11:00 AM, with CC2 and Staff II, physician/Medical Director, and Staff B, Director of Nursing Services. Staff II and CC2 were not able to provide any information what the clinical indications were for Resident 10's treatment with Seroquel. Staff B stated the Seroquel was used due to the resident was being treated for dementia with psychosis and they had increased behaviors. The staff were asked regarding psychiatrist evaluation per CC2's progress note, dated 07/05/2023, CC2 stated this I write referrals, they take months. Review of the EMR, showed as of 09/12/2023 Resident 10 had not yet been evaluated by a psychiatrist. On 09/13/2023 at 8:25 AM, Resident 10 was observed asleep in bed with their breakfast tray on over bed table in front of them untouched. At 10:39 AM, the resident was observed asleep in their w/c sitting in front of the sink with their mouth wide open. On 09/13/2023 at 1:11 PM, Resident 10 was observed asleep in their w/c. In an observation and interview on 09/13/2023 at 2:41 PM, Resident 10 was sitting in their w/c, and stated I'm just sitting here trying to keep my eyes open, I'm so sleepy all the time, I just don't know why. Resident 10 stated the whole day went by today and they did not remember a thing, On 09/14/2023 at 8:35 AM, Resident 10 was observed asleep sitting at the edge of the bed with their arm resting on the bedside table and their head was resting on their arm. At 9:45 AM and 1:40 PM, the resident was asleep in bed with their mouth wide open. In an interview on 09/14/2023 at 1:40 PM, Staff U, [NAME] President of Operations, stated the doctor was only able to give information back as well as the information staff give to them. On 09/15/2023 at 8:29 AM, Resident 10 was observed asleep in their w/c. 42927 <RESIDENT 16> Resident 16 first admitted to the facility on [DATE] with a diagnosis of depression. Review of Resident 16's September 2023 physician orders, showed an order for mirtazapine (antidepressant) 45 mg once daily with an order date of 02/06/2023. Review of the medical record showed the resident readmitted to the facility on [DATE] after a hospital stay. Review of Resident 16's physician orders for mirtazapine, since their initial admitted [DATE], showed the resident had been on 45 mg once daily for depression, except for an attempted dose reduction down to 30 mg on 12/30/2016 thru 01/09/2017, at which time the dose was increased back to 45 mg. During an interview on 09/11/2023 at 10:43 AM, Staff G stated if the facility staff had reviewed a psychotropic medication for a dose reduction, the documentation would be on the psychotropic/therapeutic medication use evaluation form in the record. Review of the clinical record showed the last psychotropic/therapeutic medication use evaluation was completed on 04/14/2021. During an interview on 09/11/2023 at 2:41 PM, Staff G stated that if there has not been a psychotropic/therapeutic medication use evaluation completed since 04/14/2021, then there was no documentation of why the facility had not attempted a dose reduction in the past year for Resident 16's mirtazapine. Staff G stated that they cannot state the last time resident's mirtazapine was reviewed. 43954 <RESIDENT 14> Resident 14 was admitted to the facility on [DATE] with diagnoses to include Bipolar II disorder (mental illness characterized by depressive episodes and hypomanic episodes), panic disorder and anxiety disorder. Review of Resident 14's August 2023 MAR, showed Resident 14 had orders for: - lorazepam (antianxiety medications) 0.25 mg scheduled two times daily for anxiety, was initiated on 09/08/2022. - valproic acid (medication to treat seizures and bipolar disorder) 250 mg three times daily for bipolar disorder management, initiated on 04/22/2023. - hydroxyzine (an antihistamine antianxiety medication) 25 mg every six hours as needed (PRN) for itching or anxiety, initiated 08/15/2023, there was no stop date. Resident 14 received hydroxyzine nine times. There was no corresponding documented rational why the resident received the PRN medication. - fluoxetine (antidepressant/antianxiety medication) 40 mg daily for panic disorder. - lorazepam 0.25mg every six hours PRN for anxiety, panic attacks, initiated 08/14/2023, and was increased on 08/15/2023 to 0.5 mg every six hours PRN for anxiety, panic attacks. The resident received lorazepam six times with no corresponding documented rationale why they received the medication, why the medication was increased, or an order to stop the PRN medication after 14 days. Review of Resident 14's September 2023 MAR, showed Resident 14 received hydroxyzine PRN two times and lorazepam PRN zero times. There was no corresponding documented rationale why the resident received the medications, or an order to stop the PRN medication after 14 days. In an interview on 09/13/2023 at 10:35 AM with Staff G, Social Services Director stated the GDR's were documented under assessments and if unable to find it there, then a GDR had not been attempted. No further information was provided. In a joint interview on 09/14/2023 at 3:10 PM, Staff D, LPN/Resident Care Manager (RCM), stated they were unsure if there was a difference in processing a PRN order from a routine medication order. In this same interview, Staff C, LPN/RCM, stated that PRN psychotropic medication orders need to have a 14 day stop date, and then the resident was evaluated at that 14 day stop date. Staff C stated GDRs were documented under the assessments. No further information was provided. In an interview on 09/19/2023 at 10:07 AM, Staff B stated GDR's were completed quarterly. Staff B was unable to locate a GDR attempted for Resident 14. Review of Resident 14's EMR showed no documentation to support PRN hydroxyzine and lorazepam medications longer than 14 days. There was no GDR documentation located in the medical record regarding any of Resident 14's psychotropic medications. 47047 <RESIDENT 66> Resident 66 admitted to the facility on [DATE] with diagnoses that included Diabetes Type 2, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and history of falling. In an interview and observation on 08/31/2023 at 10:34 AM, Resident 66 stated they have been taking medications to treat anxiety and depression for many decades. Resident 66 stated about once a year they see a provider that managed their psychotropic medications. Resident 66 stated they had been falling at home prior to hospitalization and while at the facility. Resident 66 stated they have been using hydroxyzine since early 2000. Resident 66 was observed lying in bed, stated they were tired, and wanted to sleep. Review of Resident 66's June 2023 MAR, showed an order for hydroxyzine every four hours PRN for anxiety for 14 days starting 06/15/2023. The resident received hydroxyzine one to three times a day during the 14 days period, the order ended on 06/30/2023. The nurses were directed to monitor for any antianxiety s/e's, specifically sedation, morning hangover, ataxia (a loss of coordination), and nausea every shift and were to document any s/e's in the progress notes. There were no documented side effects from 6/15/2023 through 06/29/2023. There were no behavioral monitors, documented signs, or symptoms of anxiety, or any non-pharmacological interventions used prior to the administration of the PRN antianxiety medication. Review of CC2's progress note, dated 07/05/2023, showed Resident 66's hydroxyzine had been discontinued a few days ago and the resident felt they were more anxious. The resident's use of the antidepressant alone was not enough for them as they had been taking hydroxyzine for years. CC2 ordered hydroxyzine 0.5 mg PRN every four hours for anxiety, with no indication regarding the duration of the PRN medication. Review of Resident 66's 07/01/2023 through 08/31/2023 MAR, showed on 07/05/2023 hydroxyzine 0.5 mg was started every four hours PRN for anxiety with no end date. The resident received hydroxyzine one to three times a day, except for two days in July and one to three time a day, except for three days in August. There were no behavioral monitors, documented signs or symptoms of anxiety, or any non-pharmacological interventions used prior to the administration of the PRN antianxiety medication. In an interview on 09/11/2023 at 12:01 PM, CC2 stated they did not know why Resident 66's hydroxyzine order was not changed from PRN to be administered daily. Reference: (WAC) 388-97-1060 (3)(k)(i)(4)

Based on interview and record review, the facility failed to monitor for change of condition related to hyperglycemia (high blood sugar level) and to notify the physician of an acute respiratory change in condition potentially delaying evaluation and treatment for 1 of 1 residents (Resident 71) reviewed for a change in condition. Resident 71 was harmed when they experience an acute change in respiratory status which was not communicated to the medical provider and placing them at risk for worsening of their medical condition hyperglycemia. Findings included . Resident 71's readmitted to the facility on [DATE] with diagnoses to include brain damage and chronic respiratory failure requiring a ventilator (a machine used to medically support or replace the breathing of a person who was ill or injured). The resident did not have a diagnosis of diabetes documented. Resident 71 expired in the facility on [DATE]. Review of a laboratory (lab) report, dated [DATE], showed Resident 71 had a blood glucose (BG level of sugar in the blood) of 411 (high, the normal reference range is 75 - 110). Review of Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, progress note, dated [DATE], showed Resident 71's labs were within normal limits except for a glucose of 411. Review of a lab report, dated [DATE], showed Resident 71 had a urine glucose of 500. Review of CC3's, Medical Doctor, progress note, dated [DATE], showed no documentation regarding Resident 71's abnormal blood or urine glucose. Review of CC20's, Dietitian, progress note, dated [DATE] and [DATE], showed no documentation regarding Resident 71's abnormal lab results. Review of a lab report, dated [DATE], showed Resident 71 had a BG of 704 (high critical value). In an interview on [DATE] at 9:35 AM, Staff B, Director of Nursing Services (DNS), stated they would investigate the [DATE] abnormal BG as they could not find documentation in Resident 71's clinical record that the facility had addressed the resident's abnormal BG. In an interview on [DATE] at 10:33 AM, CC2 stated they had consulted with Resident 71's cardiologist (a physician that specializes in treating diseases of the heart and blood vessels), and they were not concerned about the resident's glucose because the resident was not a diabetic and had a lot of health issues. In a phone interview on [DATE] at 2:44 PM, Staff II stated a lab A1C (the A1C is a lab test that reflected a person's average BG's levels over the past 3 months) should have been done after Resident 71's 411 BS was found. Staff II stated they did not see any reason to do an A1C before the 411 BG. Staff II stated the facility should have done another re-check of Resident 71's glucose with a glucometer (small portable machine that is used to measure how much glucose was in the blood), and they did not see that was done, and they should have been monitored. In an interview on [DATE] at 2:54 PM, Staff B stated they could not find any documentation a nurse had reviewed Resident 71's lab results. Staff B stated they had not known the resident had a urine test done with abnormal results. Staff B stated that is two labs we did not do the right thing by the resident. Staff B stated Resident 71 should have been placed on alert for a change in condition and monitored. Staff B stated staff should have obtained orders to monitor the resident's BG these we have to fix. Staff B stated the nurses should have reviewed both lab reports, our nurses are here all the time, so they should have been looking for the lab reports and the results, and they should have made progress notes who they contacted and what orders they received. In an interview on [DATE] at 11:49 AM, CC20, Dietitian, stated they did look at Resident 71's labs and results and if they found anything abnormal, they would consult with or notify the providers regarding them. In an interview on [DATE] at 2:02 PM, CC20 stated Resident 71's glucose of 411 was concerning, but the interdisciplinary team (IDT) had not said anything about it. CC20 stated the resident was not diabetic so they didn't know why their glucose was so high. CC20 stated the urine glucose of 500 was concerning. CC20 was asked why there was no mention of the abnormal glucose results (in their progress notes), they stated there needed to be more monitoring to see what was actually going on. In a phone interview on [DATE] at 9:43 AM, CC3 called to discuss Resident 71. CC3 stated if they entered that they reviewed labs in their notes, it would have been an error, that it was an error in documentation. They stated labs would have been given to CC2 or Staff II. CC3 stated I wouldn't say I reviewed the labs, the resident was probably dehydrated. They stated they were not aware of the glucose, or they would have acted on it. CC3 stated, Those notes get things inserted that don't belong there, I'm sure that's the only issue there, it's boilerplate terminology [standardized text] that gets inserted in my documentation, it's not accurate. CC3 stated their documentation that they were following up on hypernatremia (high concentration of sodium in the blood) was copied over from a prior note, that's just an error in my documentation, if I had those labs, I would have addressed it. CC3 stated this resident deserved better then [the resident] got. CC3 stated, had I known about those I would have done something about it. Review of CC1's, Consultant Pharmacist, progress note, dated [DATE], showed they documented a medication regimen review (MRR - a thorough evaluation of the medication regimen was performed, with no irregularities found. In an interview on [DATE] at 12:04 PM, CC1 stated they did review labs during the MMR's. CC1 stated they were concerned about Resident 71's high glucose, they stated a physician should have been called or faxed about the high glucose. CC1 stated they did not pick up on the abnormal glucose labs, which they stated were concerning. Review of a Respiratory Therapy (RT) assessment, dated [DATE] at 1:50 AM, showed Resident 71's breath sounds were clear. Review of a RT assessment, dated [DATE] at 8:53 AM, showed Resident 71 breath sounds had rhonchi (abnormal breath sounds that occur when there were secretions or obstruction in the larger airways) in both lungs and the breath sounds were diminished (decreased and harder to hear normal lung sounds) in the right lower lobe. The RT documented breath sounds were diminished, and the nurse was notified. Review of a progress note titled, eINTERACT SBAR (an acronym for Situation, Background, Assessment, Recommendation, a technique that can be used to facilitate prompt and appropriate communication) Summary for Providers, dated [DATE] at 10:12 AM, showed Staff O, Licensed Practical Nurse (LPN), documented Resident 71's change in condition was reported to be a fever 99.1 (no units of measure). There was no documentation regarding the resident's respiratory change in condition, and there was no documentation to support a medical provider was notified. Review of Staff O's progress note, dated [DATE] at 10:15 AM, showed Resident 71 has had a low grade temperature of 99.6 (no units of measure), skin was warm and dry to touch and red, right lower lobe breath sounds were diminished, the left lower lung breath sounds had course sounds, oxygen saturation was 100% via their ventilator, the resident was incontinent of bowel and bladder, will update the physician. Review of an IDT note, dated [DATE] at 12:56 PM, showed at 11:00 AM this morning Resident 71 was found blue with no pulse. RT and nursing staff immediately placed the resident on the floor and began CPR (cardiopulmonary resuscitation), the AED (Automated External Defibrillator) and crash cart were present, a CODE BLUE (a medical emergency) and 911 were called. The team provided 11 minutes of CPR with no shocks before emergency medical system (EMS) arrived and took over. In a joint interview on [DATE] at 11:00 AM, with CC2, Staff II, Staff B, and CC6, [NAME] President of Operations for the physicians group. CC2 stated they did not remember if they had been notified of Resident 71's acute respiratory change in condition. Staff II stated obviously they would have expected notification of the resident's respiratory condition. In an interview on [DATE] at 1:27 PM, Staff O stated Staff D, LPN/Resident Care Manager, talked with CC2. In an interview on [DATE] at 3:42 PM, Staff D, stated they did not talk to any providers regarding Resident 71 the day the resident coded. Staff D stated they would have made a progress note if they had talked to a provider on the phone. This is a repeat deficiency from [DATE]. Reference: (WAC) [DATE] (1) 47047

Based on observation, interview and record review, the facility failed to ensure necessary care and services were provided to treat and prevent Pressure Ulcer (PU)/Pressure Injury (PI) for 2 of 4 residents (Resident 53 and 39), residents reviewed for PUs. This caused harm to Resident 53 who was admitted without a PU and developed a right ankle Stage III (full thickness loss of skin) PU and a Deep Tissue Injury (DTI-Persistent non-blanchable deep red, maroon or purple discoloration) to their groin and was not provided the planned preventative measures. The facility did not consistently complete comprehensive and accurate assessments, develop/update and implement person centered care plans to address the residents' risk factors for developing and deteriorating PUs, or monitor to ensure the implementation of care plan interventions. This failure placed Resident 39 at risk for additional PUs and all residents at risk for developing PUs/PIs and a decreased quality of life. Findings included . Review of the Minimum Data Set (MDS, an assessment tool) 3.0 Resident Assessment Instrument manual, v1.19.1, dated October 2019, showed a PU/PI defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, because of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. PUs/PIs were defined as: - A stage III PU is defined as full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (non-viable [dead] tissue) may be present but does not obscure the depth of tissue loss. - An unstageable PU/PI was full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it was obscured by slough or eschar (dead tissue that falls off from healthy skin. -A stage IV is defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. - A Deep Tissue Injury (DTI) is purple or [NAME] area of discolored intact skin. The area may be preceded by tissue that is painful, firm, mushy, warmer, or cooler as compared to adjacent tissue. Review of the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facility's, revised 02/02/2023, showed an avoidable PU is defined as a PU that developed in the facility and the facility failed to do one or more of the following: Evaluate the resident's clinical condition risk factors: define and implement interventions that are consistent with resident's needs, goals, and recognized standards of practice; or failed to monitor and evaluate the impact of the interventions or revise the interventions as appropriate. <RESIDENT 53> Resident 53 admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood), anoxic brain damage (brain damage from a lack of oxygen to the brain), epilepsy (brain disorder that causes recurring, unprovoked seizures), abnormal posture (rigid body movements and chronic abnormal positions of the body), and persistent vegetative state (chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). The resident admitted with no PUs. Review of the Braden Scale for Prediction PU Risk (a tool used to assess the risk of developing PUs/PIs, and a score greater than 19 indicates the resident is not at risk for PU/PI development) tool, dated 05/26/2023, was coded a 9 indicating the resident was at severe risk for developing PUs/PIs. Review of Resident 53's Annual Minimum Data Set (MDS- an assessment tool) assessment, dated 08/20/2023, showed the resident was totally dependent on staff and required two-person assist for all Activities of Daily Living to include bed mobility, transfers, dressing, toileting, eating and bathing. Review of the Pressure ulcer/injury Care Area Assessment (CAA - a process designed to assist the assessor to systematically interpret the information recorded on the MDS and use a current, evidence-based clinical resources to help the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident and be care planned) showed the CAA was triggered due to incontinence and impaired mobility. Per the CAA staff was to monitor the resident's skin daily by the NAC during care and abnormalities or concerns reported promptly to Licensed Nurse (LN). The LN would assess their skin weekly and the resident to be referred to Registered Dietician, Medical Doctor and wound team as needed. The resident had a pressure redistributing mattress and cushion in their wheelchair. Review Resident 53's care plan, created on 05/10/2022 and updated on 09/11/2023, showed the resident required total assistance for all ADL's and was at risk for skin breakdown related to their impaired mobility, generalized weakness, bowel incontinence and use of a urinary catheter (a flexible tube which is inserted into the bladder through the urethra to drain urine into a collection bag). Interventions included were to always use soft boots on both feet, assist the resident in turning and repositioning every two to three hours and check the skin as determined by tissue tolerance (the ability of the skin to withstand the effects of unrelieved pressure), float heels (an intervention in which the heel are suspended in the air) while in bed, obtain physical and occupational therapy evaluations to improve functional mobility, a low air loss mattress (a mattress made of multiple air cells that alternately fill with air and deflate to change the pressure on the skin) to bed to promote wound healing, wound specialist visits and weekly skin checks by the nurse. An incident report, dated 06/07/2023, showed Resident 53 developed a unstageable PU to their right lateral ankle that measured 1.5 centimeters (cm) by 1.5 cm. Resident 53 was noted to have been positioned so that no pressure was applied to their ankle. The incident report showed the resident was in a persistent vegetative state, had contractures to both lower extremities and could not reposition themselves as the factor for the development of the PU. The resident was seen by the contracted wound care company that day and treatment orders were obtained and updated the resident's care plan. Review of Resident 53's skin breakdown care plan, dated 06/07/2023, showed the focus problem was updated to indicate the resident had an actual re-opening to the right lateral ankle and left groin Moisture Associated Skin Breakdown (MASD). The care plan goals and interventions were not updated to reflect ny new interventions regarding the right lateral ankle open area (unstageable) and the left groin MASD. Review of a Situation-Background-Assessment-Recommendation (SBAR - a communication form between members of a health care team about a resident's condition), dated 06/21/2023, showed Resident 53 developed a DTI to their left groin with the presence of blood due their legs being severely contracted which caused pressure and moisture associated skin damage to occur. Review of a progress noted, dated 06/22/2023, Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, showed the resident had a new wound in their groin that measured 3x1.5cm, most likely related to an increase in the resident's contractures. Review of a wound progress note, dated 06/28/2023, CC11, Physician Assistant-Certified from the facility contracted wound care company, showed Resident 53 had significant contractures to both their lower extremities and their left lower leg was internally rotated. The resident's Stage III right lateral ankle PU was documented as a 0.4 by 0.8 by 0.1 (no unit of measure identified) area. The resident's left groin MASD was documented as a 2 by 1 by 0.1 area no unit of measure identified). Recommendations included to reposition, and offload (minimize or remove weight placed on an area so it is completely free of pressure to help prevent and heal ulcers) per the facility protocol. Review of CC11's wound progress note, dated 07/26/2023, showed Resident 53's chronic groin full thickness ulcer measured 1x 0.5 x 0.1 (no unit of measure identified). The resident's right lateral ankle Stage III PU measured 0.8 x 1.6 x 0.1 (no unit of measure identified). Review of CC11's wound progress note, dated 8/30/2023, showed Resident 53 had a contracture to their right lower extremity which made offloading difficult. Resident 53's right ankle PU was a Stage III and had worsened over last week and measured 1.5x1.3x.07 (no unit of measure identified). Recommendations included to reposition and offload Resident 53's right ankle per facility protocol. There was no measurements of the left groin chronic ulcer. In an interview on 08/30/2023 at 2:24 PM, Staff W, Nursing Assistant Certified (NAC), stated they believed Resident 53 had started to become contracted a couple of months after they had admitted to the facility. Staff W stated realistically they were not able to reposition all the residents every two hours. On 08/30/2023 at 9:21 AM, 08/31/2023 at 10:18 AM, and 09/05/2023 at 8:25 AM, Resident 53 was observed in bed and not wearing any soft boots. On 8/31/2023 at 10:18 AM, 11:03 AM, and 12:58 PM, Resident 53 was observed in the same position. Resident 53 was lying in bed, the head of bed elevated, their upper body was straight, their legs positioned to the left with pillows placed around the resident and in between their legs. Resident 53 was covered with a sheet and wearing a hospital gown. No soft boots were observed on the resident's feet. In an interview on 09/05/2023 at 8:48 AM Staff I, Nursing Assistant Registered (NAR) pending, stated most of the time there were two staff to reposition Resident 53. The resident's legs were very stiff, and that staff used pillows to position the resident because they wanted their legs to face a certain position. Staff I stated the took their direction on how to care for the residents from the nurse, and the Kardex (a tool that directs aides on how to provide care to a specific resident) did not provide much information regarding how to care for residents. On 09/08/2023 at 10:01 AM, Staff N, LPN, stated staff tried to reposition Resident 53 and repositioning every two hours was ideal. Staff N stated repositioning the resident was to help Resident's skin heal, but they did not feel the resident was being repositioned every two hours. In an observation and interview on 09/13/2023 at 9:50 AM, Resident 53 observed resident lying in their bed, on their back, their legs bent with pillows between them. Resident 53's PU was observed with CC11. CC11 stated Resident 53 had a facility acquired Stage III right lateral ankle PU that measured 0.8 x 1.0 (no units of measure identified), and the wound would be hard to heal due to Resident 53's contractures. RESIDENT 39 Resident 39 was a long term care resident with diagnoses that included amyotrophic lateral sclerosis (ALS also known as [NAME] Gehrig's Disease- a rare neurological disease which affects voluntary muscle control), acute and chronic respiratory failure with hypoxia (impairment of gas exchange between the lungs and blood) and dependence on respirator [ventilator] (unable to wean off a ventilator and breathe independently). Review of the Significant Change MDS assessment, dated 06/07/2023, showed Resident 39 had a Stage I PU and a Stage II (Partial-thickness skin loss with exposed dermis) PU. The MDS assessment indicated the resident had one of these PUs presents upon admission, and was totally dependent on staff to meet all their ADLs. Review of the CAA, dated 06/19/2023, showed the resident was at risk for pressure related injuries. There was no description of where the PUs was located, or interventions implemented. Review of CC11's wound healing progress note, dated 06/07/2023, showed CC11 was asked to evaluate Resident 39 due to a new PI to their sacrum. The new sacrum PI measured 2.8 x 4.5 x 0 (no units of measure identified) described as a DTI related to pressure on their sacrum. Recommendations included wound care, lotion applied to all areas of dry skin, and offloading and repositioning per the facility policy. Review of the Braden Scale for Predicting PU Risk tool, dated 06/07/2023, Resident 39 score was a 13, which placed the resident at moderate risk for development of PUs. Review of CC11's wound healing progress note, dated 06/14/2023, showed Resident 39 had an 2.3 x 3 x 0 unstageable PU on their sacrum. Recommendations included wound care, lotion applied to all areas of dry skin, and offloading and repositioning per the facility policy. Resident 39 discharged to the hospital on 06/19/2023 and readmitted on [DATE] with a new diagnosis of sepsis (infection in the blood). Review of Resident 39 June 2023 Treatment Administration Record, dated 06/30/2023, showed to apply skin prep and leave open to air daily to the resident's right lateral foot and right medical foot DTI. Review of the Braden Scale for Predicting PU Risk tool, dated 07/05/2023, showed Resident 39's score was a 13, which placed the resident at moderate risk for development of PUs. Review of CC11's wound healing progress note, dated 07/05/2023, showed Resident 39 had an unstageable PU on their sacrum that measured 3.3 x 1.7 x 0 (no units of measure identified), and a right plantar (bottom) lateral foot DTI that measured 1.7x0.8x0 (no units of measure identified). Recommendations included wound care, lotion applied to all areas of dry skin, and offloading and repositioning per the facility policy. Review of Resident 39's Braden Scale for Predicating PU Risk tools, dated 07/23/2023, showed a score of an 11, and on 08/02/2023 showed a score of a 12. A score below 12 indicated the resident was at high risk for developing PUs. Review of CC 11's wound healing progress note, dated 08/02/2023, showed Resident 39 had a Stage III sacrum PU that measured 3.2 x 1.5 x 0.1 (no units of measure identified), and a DTI PU to the right plantar (bottom) lateral foot that measured 2 x 2 x 0 (no units of measure identified). Resident 39 continued to be non-participatory with offloading and preferred to lay on their back. Review of CC 11's wound healing progress note, dated 08/09/2023, showed Resident 39 had a Stage III sacrum PU that measured 5 x 2 x 0.2 (no units of measure identified), and a DTI PU to the right plantar (bottom) lateral foot that measured 2 x 2 x 0 (no units of measure identified). Resident 39 continued to be non-participatory with offloading and preferred to lay on their back. Review of CC 11's wound healing progress note, dated 08/23/2023, showed Resident 39 had a Stage III sacrum PU that measured 5 x 3 x 0 (no units of measure identified), and a DTI PU to the right plantar (bottom) lateral foot that measured 2 x 2 x 0 (no units of measure identified). Resident 39 continued to be non-participatory with offloading and preferred to lay on their back. Review of Resident 39's focused skin breakdown care plan, dated 11/17/2021 and updated 08/29/2023, showed the resident was at risk for skin breakdown related to their diagnoses, refusals to turn/reposition, used of multiple pillows under their body, had actual skin breakdown on their sacrum and a right foot DTI. The resident's goal was the wound/skin impairment would heal as evidence by a decrease in size. Interventions included education to Resident 39 regarding use of pillows and importance of repositioning, weekly skin checks, and use of barrier cream. In an interview on 08/28/2023 at 3:19 PM, Resident 39 stated (communicated by the use of an electronic device by Tobii) they were not being repositioned every two hours as they should be. Review of CC 11's wound healing progress note, dated 8/30/2023, showed Resident 39's sacrum Stage III PU that measured 5 x 3.5 x 0 (no units of measure identified), and a DTI PU to the right plantar (bottom) lateral foot that measured 0.5 x .05x 0 (no units of measure identified). Resident 39 continued to be non-participatory with offloading and preferred to lay on their back. Review of Resident 39's August 2023 Medication Administration Record (MAR), showed the licensed nurse was to document the resident's refusals to be repositioned starting 08/29/2023. There was no documentation on 08/29/2023, 08/30/2023, or 08/31/2023. Review of CC11's wound healing progress note, dated 09/06/2023, showed Resident 39's sacrum pressure ulcer had deteriorated to a Stage IV (full-thickness skin and tissue loss) PU that measured 4.5 x 3 x1.4 (no units of measure identified), and a DTI PU to the right plantar (bottom) lateral foot that measured 0.5 x .05 x 0 (no units of measure identified). Resident 39 was repositioned onto their left side by wound team and educated on allowing staff to turn them to their left and right side and not just trying to bridge with pillows. Review of the 09/01/2023 through 09/19/2023 MAR, showed no documentation that Resident 39 refused to be repositioned. In an interview on 09/12/2023 at 10:57 AM, Staff HH, NAC, stated they usually reposition Resident 39 every two hours. Staff HH stated Resident 39 would call staff to assist with repositioning and did not refuse. Staff HH stated the resident liked to be repositioned and would direct staff on what direction they wanted to face. In a joint interview on 09/12/2023 at 11:31 AM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manger (RCM), and Staff D LPN/RCM, stated Resident 39 does not like to turn onto their sides and used a special air mattress, but when the resident used pillows it would offset the function of the mattress. Staff D stated Resident 39 had been educated on allowing staff to reposition them, and multiple discussions with the resident's family member regarding repositing and refusals to be repositioned. There was no other information provided by Staff C and Staff D as to how address Resident 39's refusals and how to prevent additional deterioration of the pressure ulcer. In an interview and observation on 09/13/2023 at 10:38 AM, of Resident 39's wounds were observed with CC11, Staff D and Staff C. CC11 stated the sacrum wound was facility acquired and currently a Stage IV PU. CC11 stated that little purple area, and pointed to 10-12 o'clock (referencing the position of the hands on a clock) of the inside of the wound. CC11 stated that area was not there last week and that was how CC11 stated, that's how you can tell [the resident] is not offloading. CC11 then addressed Resident 36 and informed the resident they needed to offload and that the (sacrum) wound had worsened. CC11 stated the sacrum PU measured 4.8 x 3.2 x 1.6 (no units of measure identified). CC11 stated they documented in their weekly progress note their refusal to be repositioned. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to comprehensively assess and ensure timely and appropriate services/interventions were provided to maintain, increase and/or prevent decrease in range of motion (ROM - is the extent that a joint can move within the expected [normal] range of values) for 2 of 5 residents (Resident 53 and 9) reviewed for ROM and restorative nursing services. This failure caused harm to Resident 53 who developed significant, potentially avoidable, right and left leg and ankle contractures, decreased ROM of the right and left legs and right and ankles, and placed other residents at risk for developing new contractures and/or worsening of existing contractures. Findings Included . Review of the facility's Restorative Nursing Services Policy and Procedure, undated, showed that restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. physical, occupational or speech therapies.), restorative goals and objectives are individualized and resident-centered, and outlined in the residents plan of care, residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care, and restorative goals may include but are not limited to: Adjusting or adapting to changing abilities, developing, maintaining, or strengthening their physiological resources, maintaining their dignity, independence and self-esteem, and participating in the development and implementation of their plan of care. <RESIDENT 53> Resident 53 admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood), anoxic brain damage (brain damage from a lack of oxygen to the brain), epilepsy (brain disorder that causes recurring, unprovoked seizures), abnormal posture (rigid body movements and chronic abnormal positions of the body, persistent vegetative state (chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings.) Review of a physical therapy (PT) evaluation, dated 05/06/2022, showed Resident 53's ROM in their right and left hips, and right and left knees were within normal limits (WNL). Resident 53's right and left ankles had impaired ROM with respect to the downward movement, and the movement upwards was WNL. Review of the PT discharge summary, dated 05/26/2022, recommended Resident 53 begin a restorative nursing/maintenance program. The PT discharge summary did not direct staff what was to be done on the RNP/maintenance program. Review of Resident 53's care plan, dated 05/10/2022 and updated 11/16/2022, showed the resident required total assistance for Activities of Daily Living (ADL's) with the goal to anticipate their needs, provide oral hygiene, and rolling from side to side in bed. Interventions included to provide functional passive range of motion (PROM - movement of a join performed by someone without any active effort from the resident) to both upper and lower extremities during nursing routine care. Review of a PT evaluation, dated 05/17/2023, showed Resident 53's was referred for PT evaluation related to positioning and the development of a pressure ulcer (PU). The evaluation showed the resident's right and left hips, knees and ankles ROM was impaired with significant rigidity (inability to be to bend or be forced out of shape) and spasticity (a disruption in muscle movement patterns that causes certain muscles to contract all at once when trying to move or even at rest). Review of Resident 53's PT discharge summary, dated 06/15/2023, recommended nursing to continue propping, support, float heels, pillows between knees and under knees to prevent skin breakdown and contracture. The discharge summary did not recommend any other ROM to be performed. Review of Resident 53's care plan, dated 05/10/2022 and revised on 09/27/2022, showed the care plan had not been updated to reflect the PT discharge summary's recommendations. Review of Resident 53's Electronic Medical Record (EMR) from 06/05/2023 through 07/31/2023, showed no documentation to indicate the resident received PROM during routine nursing care. In a phone interview on 08/30/2023 at 9:04 AM, Collateral Contact 9 (CC9), Resident 53's family member, stated the resident was no longer receiving therapy and was not aware of any restorative programs. On 8/31/2023 at 9:15 AM, 10:18 AM, 11:03 AM, and 12:58 PM, Resident 53 was observed lying in bed in the same position with, their legs contracted up toward their abdomen. In an interview on 09/08/2023 at 12:45 PM, Staff OO, Physical Therapist Assistant/Director of Rehabilitation, stated the change in Resident 53's ROM was significant. Staff OO stated at the end of therapy, a restorative nursing (RNP) or a functional maintenance program (FMP) was developed for residents if needed. Staff OO stated a referral form was completed by the PT or Occupational Therapist (OT) and sent to nursing either in person or sometimes in an email. Staff OO stated the prior RNP coordinator was no longer working at the facility. Staff OO stated they would look for a referral for Resident 53, however, was not able to provide documentation to support a referral was made or completed. Staff OO stated there were things that could prevent contractures for instance when a change in a resident's ROM is identified, nursing to request an OT or PT referral, or to refer a resident to the contracted physiatrist (a medical doctor who specialized in medicine and rehabilitation). Staff OO stated that Resident 53 was to receive passive range of motion after reivew of the PT discharge summary. Staff OO stated the therapy staff work closely with the nursing staff, mainly the Resident Care Managers (RCM's), and they should be referring residents to therapy as needed. In an interview on 09/05/2023 at 8:48 AM, Staff I, Nursing Assistant Registered (NAR) pending, confirmed Resident 53 had contractures of both their legs. Staff I described Resident 53's legs as very stiff, the resident preferred to have their legs face a certain position, and their legs were crossed very tight. Staff I stated when Resident 53 was touched they clenched, and in their observations, it was not a comfortable experience for the resident. Staff I stated they did not know if the resident's reaction was due to pain or a sense of awareness. Staff I stated not every aide performed PROM to Resident 53, occasionally, but not every day. In an interview on 08/30/2023 at 2:24 PM, Staff W, Nurse Assistant Certified (NAC), stated they believed Resident 53 had started to become contracted a couple of months after they were admitted to the facility. In an interview on 09/05/2023 at 10:06 AM, CC2, Advanced Registered Nurse Practitioner, when asked about Resident 53's contractures, stated there was a physiatrist that was contracted by the facility, and they would refer the resident for an evaluation. In an interview on 09/12/2023 at 12:48 PM, Staff II, Medical Director/Medical Director, stated they usually relied on nursing assessments, nursing staff, and the Director of Nursing Services to address issues related to residents' contractures. Staff II stated part of contracture management was to notify the doctor and for the resident to be reassessed by the PT and/or OT. <RESIDENT 9> Resident 9 admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure, persistent vegetative state, and a tracheostomy (artificial opening on the neck used for an airway) and gastrostomy (opening in the stomach to allow for artificial nutrition or food) management. Review of Resident 9's Quarterly MDS assessment, dated 06/08/2023, showed the resident required total assistance of two staff for bed mobility, personal hygiene, bathing, and dressing with impairments of all extremities. Review of Resident 9's care plan, revised on 10/31/2018 and revised on 04/28/2023 showed the resident was to have a RNP related to a decrease in their ROM due to a functional deterioration. The care plan showed the family wanted the resident to continue to receive RNP and maintain range of motion as a goal. Interventions included active range of motion (AROM) to the left upper extremity, AROM to both lower extremities, and PROM to the right upper extremity five to seven times a week. The care plan showed Resident 9 was to have a right hand/wrist splint daily for four hours, initiated on 06/30/2016. Review of Resident 9's Quarterly Minimum Data Set (MDS), a resident assessment tool, dated 06/14/2023 showed that resident was dependent on the extensive assist of 2 staff for bed mobility, personal hygiene, bathing, and dressing with impairments of all extremities. Observations on 08/28/2023 at 8:38 AM, 9:18 AM, 10:40 AM, 10:58 AM, 11:48 AM, and 1:59 PM. Resident 9 was observed lying in bed without a right hand/wrist splint present. Observations on 08/29/2023 at 8:49 AM, 12:39 PM, 1:04 PM , Resident 9 was observed lying in bed without their right hand/wrist splint. Observations on 08/30/2023 at 9:06 AM, 9:44 AM, 2:04 PM and 2:54 PM, Resident 9 was observed without a right hand/wrist splint present. Observation on 08/31/2023 at 9:57 AM, 10:51 AM, 11:23 AM, 2:19 PM and 5:14 PM, Resident 9 was observed without their right hand/wrist splint. Observations on 09/05/2023 at 8:38 AM, 9:40 AM, 1:08 PM, and 3:05 PM, Resident 9 was observed with no right hand/wrist splint. In an interview on 09/11/2023 at 11:13 AM, Staff M, Nursing Aide Certified (NAC), stated that they had worked at the facility for three years. Staff M stated Resident 9 required two two-person assistance for all care needs. Staff M stated the resident had no splints, braces, or other devices for their upper extremities. Staff M stated Staff R was the restorative aide. In an interview on 09/13/2023 at 10:40 AM, Staff SS, NAC, stated Resident 9 was dependent on two staff for all care, stated they do not do restorative care for the resident, and Staff R was responsible. Staff SS stated there was no specific interventions in place for Resident 9's upper extremities. In a joint interview on 09/14/2023 at 3:10 PM, Staff C, Licensed Practical Nurse (LPN), Resident Care Manager (RCM), and Staff D, LPN/RCM, stated restorative was documented the tasks section of the EMR. Staff C stated the restorative nurse used to monitor the restorative programs to verify completion. They stated the restorative nurse left around July 2023. Staff C stated they were not aware who was currently provided oversight to the RNP's. Review of Resident 9's June 2023 Survey v2 Report NAC's EMR documentation, showed the resident received restorative ROM and splint/brace assistance 18 out of 30 days. Review of Resident 9's July 2023 Survey v2 Report, showed they received restorative ROM 15 days out of 31 days and splint assistance 17 out of 31 days. Review of Resident 9's August 2023 Survey v2 Report, showed they received restorative ROM and splint/brace assistance 10 out of 31 days. In an interview on 09/19/2023 at 10:07 AM, Staff B, Director of Nursing Services, currently stated Staff R was the only restorative aide currently, and the facility's plan was to get the programs caught up. Staff B stated there was missed restorative documentation, braces and splints had to be completed per the physician order, and the restorative aid documented the RNP resident's EMR. This is a repeat deficiency from 05/02/2023. WAC reference: 388-97-1060 (3)(d)(j)(ix) 47047

Based on observation, interview and record review, the facility failed to implement identified interventions to prevent pressure ulcers in one of two residents (16) reviewed for pressure ulcers. Failure to implement identified interventions including turning and repositioning caused harm to Resident 16 who developed pressure induced deep tissue injuries to both of their heels, and an unstageable pressure ulcer (PU) to the occiput (back of head). Findings included . Review of the facility skin policy titled, Skin Integrity Management, dated 05/26/2021, showed staff were expected to continually observed and monitored the resident for changes and to implement revisions to the care plan as needed to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The facility was expected to develope a comprehensive, interdisciplinary care plan including prevention and wound treatments, as indicated. The Resident Assessment Instrument (RAI) Manual defined the stage of a PU as followed: - A stage II PU was described a partial thickness loss of the skin. - A stage III PU was described a full thickness loss of the skin. - A stage IV PU was described as having full thickness tissue loss with exposed bone, tendon, or muscle. Slough (non-viable tissue) or eschar (dead or devitalized tissue), may be present on some parts of the wound bed. - An unstageable pressure injury (ulcer) was full thickness skin and tissue loss was obscured by slough or eschar, note: once slough and eschar were removed, a Stage III or Stage IV PU would be revealed; and - A Deep Tissue Injury (DTI) was described as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration. Resident 16 was a long-term resident who readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment, dated 08/31/2021, revealed the resident was comatose, required extensive assist of two staff for bed mobility, transfers, and personal hygiene. The MDS assessment indicated the resident had upper and lower extremity functional limitation of range of motion and three unstageable PU's, which two were present when the resident readmitted to the facility. The resident had no turning or repositioning program, nutrition, or hydration identified on the MDS to manage skin problems. Review of teh prior MDS assessments on 05/21/2021 and 07/25/2021, showed no PU's were present. Review of the resident's hospital discharge summary dated 07/30/2021 at 3:58 PM, showed a stage 3 pressure injury (PI) to the sacral region. The physician directed staff to reposition Resident 16 side to side; limit the back, limit linens, offload (remove weight or pressure) wounds with pillows above and below the wound. Review of a progress note on 07/31/2021 at 1:22 AM, showed a skin check was performed and the following new skin injury/wounds were identified. Both buttocks had 9 centimeters (cm) by 7 cm pressure areas and the left leg (knee area) had a 6 cm by 2 cm area. Review of the facility's contracted wound care company note dated 08/06/2021, showed the resident had an abdominal wound at the tube feeding insertion site. There was no documentation regarding the wounds to the resident's buttocks or left leg. Review of the progress note dated 08/09/2021 at 7:44 AM, showed a Nurse's Aide Certified (NAC) was changing the resident when they observed drainage on the resident's pillow. The NAC noticed an opening to the back of the resident's head. The Licensed Nurse (LN) came to assess and noticed a 1 cm by 1.8 cm open area. The LN also noted skin impairments to both of their heels. The left heel measured approximately 3 cm by 7 cm and the right heel measured 1.5 cm by 2 cm. The areas were dark purple/red in color. Review of the Braden assessment (a PU risk assessment score) dated 08/13/2021, revealed the resident was at severe risk for PU's as their skin was often moist, the resident was bedfast and completely immobile. Review of the facility's contracted wound care company note dated 08/13/2021, showed that facility staff reported to the provider, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On exam, deep tissue injuries (DTI) were present to both heels and occiput. The left ischium and sacrum had unstageable PI. The sacrum was likely a Kennedy ulcer (wound that develops in final weeks of life). The occiput PI had a 4 cm by 3 cm by 3 cm with 50% epithelization (process of covering) and 50% granulation (new tissue) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The sacral PU measured a 9.4 cm by 7 cm with 50% epithelization and 50% slough (dead skin cells) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The left ischial tuberosity (ischium) measured 3.5 cm by 2 cm with 50% epithelization and 50% slough with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The left heel measured 3 cm by 7 cm with 200% epithelization with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The right heel wound measured 2 cm by 3 cm with 100% epithelization. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment orders were provided for each wound as well as additional orders to provide pressure relief/offloading, reposition, and a low air loss mattress. Review of the facility's contracted wound care company note dated 08/20/2021, showed a slight increase of the sacral PI and the occiput wound was now classified as unstageable due to slough in the base of the wound. Review of the facility's contracted wound care company note dated 09/03/2021, showed the resident developed a new blister measuring 3.2 cm by 2.2 cm to the left medial (towards middle) foot. Review of Resident 16's medical record on 08/09/2021 at 7:44 AM, showed the bilateral heel DTI's and occiput pressure ulcers were developed in the facility. Review of the resident's care plan titled, actual risk skin breakdown care plan revised on 09/01/2021, showed the resident had actual skin breakdown. The interventions included to assist with turning and repositioning for comfort and pressure relief every two to three hours, offload/float heels while in bed as tolerated. The nutritional intervention showed to encourage the resident to consume all fluids of choice during meals (although the resident could not swallow and received artificial nutrition). The care plan did not location of the PU's, staging of the PU's or the dates they were acquired. Review of the Kardex (a guide to provide care) directed staff to assist with turning and repositioning for comfort and pressure relief every two-three hour as tolerated. Review of the July, August, and September 2021 Treatment Administration Record (TAR) did not include staff were to turn and reposition the resident every two hours. In an interview on 09/01/2021 at 2:59 PM, the resident was deemed not-interviewable. In observations on 09/01/2021 at 9:15 AM, 11:04 AM, 11:36 AM, 12:04 PM, and 1:42 PM the resident was in bed on their back and their heels were not floated but, on an overlay (pressure redistribution) mattress. In observations on 09/02/2021 at 9:09 AM, and 2:16 PM, the resident was in bed on their back and their heels were not floated but on an overlay mattress. In an observation on 09/03/2021 at 12:11 PM, 2:16 PM, and 3:04 PM the resident was in bed on their back and their heels were not floated but on an overlay mattress. Their head was resting on a plastic pillow. In an observation on 09/07/2021 at 2:16 PM, the resident was in bed with their head resting on a standard reusable vinyl-coated pillow. They were on their back with their heels on an overlay mattress. In an observation on 09/08/2021 at 3:04 PM, the resident was in bed with their head resting on the pillow. They were on their back with their heels on an overlay mattress. In an observation on 09/09/2021 at 12:03 PM, 2:08 PM, and 3:28 PM, the resident was in bed with their head resting on the pillow. They were on their back with heels planted firmly on a pillow rather than floating (suspended to relieve pressure). Dark red/maroon wounds were present on both heels. In an observation on 09/10/2021 at 9:16 AM, 10:28 AM, 11:45 AM, 12:40 PM, 1:38 PM, the resident was in bed with their head resting on the pillow. They were on their back with both heels not floating, the heels were planted firmly on the pillow. In an observation on 09/13/2021 at 9:26 AM, 10:30 AM, 11:55 AM, 2:03 PM, 2:46 PM, and 3:45 PM, the resident was in bed with their head resting on the pillow. They were on their back with both heels not floating, the heels were planted firmly on the pillow. In an observation on 09/14/2021 at 8:14 AM, 9:22 AM, 10:28 AM, 11:25 AM, 12:30 PM, 1:00 PM, 7:15 PM, 8:09 PM, and 8:45 PM the resident was in bed with their head resting on the pillow. They were on their back with both heels not floating, the heels were planted firmly on the pillow. In an observation and interview on 09/14/2021 at 10:07 PM, Staff B, Licensed Practical Nurse (LPN), performed wound care and Staff NN, NAC, assisted with positioning of the resident. The resident was in bed on a ventilator with their eyes closed. The left inner and outer heel had black wounds approximately 2.5 cm by 2 cm and 1.25 cm by 1.25 cm. Below the left great toe was a 2 cm by 2 cm purple area. The resident's right heel had three circular areas of purple/black areas approximately 2 cm by 2 cm. The sacrum open area measured approximately 9 cm by 6 cm and had 30% pink areas and slough areas. Staff B stated the resident should be repositioned every two hours. Staff NN stated the staff could position the resident on their side. Staff NN said they try to turn the resident every 15 minutes so there was not too much pressure on every spot too long. Staff B stated the left ischial area was a stage IV pressure wound but stated they were not supposed to stage wounds as an LPN. The left ischial wound was about 3.5 cm by 1.5 cm with slough in wound bed. Staff NN lifted the resident's head to reveal an occiput wound approximately 3.5 cm by 2.75 cm. The pillow in place was the standard reusable vinyl pillow. Staff B stated they (the facility) guessed the cause of the occiput wound was from lying in bed and hyperextending their neck. Staff B stated all the wounds showed up at about the same time but could not give an exact date. Staff NN repositioned the resident resting his feet directly on the pillows (and not floating their heels). In an observation on 09/15/2021 at 10:20 AM, 11:25 AM, 12:25 PM, and 2:09 PM, the resident was in bed with their legs positioned to the left and their head resting on the pillow. Their heels were resting directly on a pillow (and not floating their heels). In an interview on 09/15/2021 at 12:21 PM, Staff I, Registered Nurse/MDS nurse, stated the resident had multiple wounds. Staff I stated they used the contracted wound agency's measurements and staging documentation for their MDS coding then revised the care plan off of that assessment. Staff I stated the resident developed the occiput wound in the facility. Staff I did not code for a turning or repositioning program for the resident on the 07/30/2021 MDS assessment. In an interview on 09/15/2021 at 2:52 PM, Staff D, LPN, stated the resident had wound care to the left medial and distal (outer) foot, a left inner foot blister, the sacrum was open and unstageable, and their peg tube site was macerated (skin breakdown from excessive moisture). Staff D stated the resident was on an air mattress, had wound care daily, and the wound team saw the resident weekly. They stated the resident was in a vegetative state and was completely dependent on the facility staff for all care needs. Staff D stated the resident's knees were very contracted, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation on 09/16/2021 at 9:04 AM, 10:00 AM, 10:40 AM, 1:51 PM, 2:41 PM and 3:29 PM the resident was in bed with their head resting on the pillow. They were on their back with both heels not floating, the heels were planted firmly on the pillow In an interview on 09/20/2021 at 3:19 PM, Staff C, LPN, stated Resident 16 was on a LAL (low air loss) mattress with skin issues more indicative of skin failure. For interventions, we offloaded him with pillow placement and did wound care. When asked what interventions were in place to prevent additional PU's and prevent deterioration of current PU's, Staff C stated, Just repositioning, dietary usually followed and they were tube fed. We discussed goals of life with family. (Resident 16) was completely dependent on staff for all care and in a vegetative state. In an interview on 09/24/2021 at 12:58 PM, Staff PP, Physician's Assistant- Certified, with the facility's contracted wound care agency, stated facility staff reported to them the resident's left ischium and both heel ulcers developed while the resident was in the hospital. Staff PP stated they did not confirm this with the hospital or facility clinical record. Staff PP confirmed the occiput PU developed at the facility. They said the resident initially had multiple blood blisters on both heels. Staff PP said they did not measure or document each of them as the areas received the same treatment. Staff PP stated nursing staff had the resident on a specialty mattress and should have had the resident on a turning schedule with Podus boots (boots to alleviate pressure to heels) to both feet in place. Staff PP stated when they arrived for weekly rounds, the resident was positioned on their side with Podus boots on and there was no pressure to the occiput area. Staff PP was informed this surveyor had not observed Podus boots on this resident on any occasion over multiple observations during a three-week period. Additionally, the resident was often positioned on their back with their head and heels resting on pillows in the location of the PU's. Staff PP stated the facility was used to these very high-risk patients who were at high risk for developing pressure injuries. Staff PP stated the resident should have been turned, offloaded from the areas of pressure, and had Podus boots on. Reference: (WAC) 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure staff maintained respectful, dignified interactions with three of four residents (#6, #12 and Anonymous #4A) reviewed. Failure to ensure respectful staff-to-resident interactions caused harm to Resident #6 who felt demoralized by a staff member and placed other residents at risk for diminished quality of life and for potential verbal abuse. Findings included . Review of the facility policy titled, Treatment: Courteous and Respectful, revised 07/01/19 revealed: - the center would promote respectful and dignified care for residents in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life while recognizing each patient's individuality; - Dignity meant that in their interactions with residents, any staff, including temporary or volunteers, carried out activities that assisted the resident to maintain and enhance his/her self-esteem and self-worth and incorporate the residents needs, preferences, and choices; - The purpose was to provide residents with the right to a quality of life that supported independent expression, and respect; and - The process included staff would show respect when communicating with, caring for, or talking about residents. Resident #6 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Stools moving through the intestine drain through the stoma into a bag attached to the abdomen). Review of quarterly Minimum Data Set assessment dated [DATE], revealed Resident #6 was cognitively intact and had no behaviors, hallucinations, or delusions. She required extensive assist for bed mobility, transfers, toileting and dressing. Review of facility investigation dated 07/22/19, revealed a written statement that Resident #6 made about Staff A, Registered Nurse. The statement included Staff A was very rude, demoralizing, and that every time the resident would try to explain her [MEDICAL CONDITION] bag to Staff A, she (Staff A) would leave the room. Additionally, the statement included Staff A threatened to withhold medication if the resident questioned her. Resident #6 requested Staff A no longer worked with her because the resident felt anxious and threatened. On 08/01/19 at 3:10 PM, the resident stated Staff A was trying to change her [MEDICAL CONDITION] bag and because her [MEDICAL CONDITION] bags were so different, the resident tried to explain to Staff A how to change the bag. The resident stated Staff A became very rude when she was trying to explain to her how to do it and said, Do you want to get your medications? and Do you want me to just leave and not finish? Resident #6 stated Staff A would leave her room numerous times when the resident would try to explain how to deal with her [MEDICAL CONDITION] bag or anything else to Staff [NAME] On 08/07/19 at 2:05 PM, Resident #6 stated she felt dehumanized from the way Staff A had treated her. STAFF INTERVIEWS On 08/06/19 at 1:10 PM anonymous Staff AF, Licensed Practical Nurse (LPN), stated many residents did not like Staff A and had complained about her care. Anonymous Staff AF stated other residents complained about Staff A being rude and argumentative. Staff AF said most of those residents had already been discharged . On 08/06/19 at 1:20 PM, anonymous Staff AG, LPN, stated residents and much of the staff did not like Staff A because she was so rude. On 08/07/19 at 1:00 PM, anonymous Staff AA, Nursing Assistant (NA), stated Staff A verbally fought with other nurses in view of residents and families. Anonymous Staff AA stated rumor through the facility was that Staff A was moved from the other nurses station to the one she was working currently because she did not get along with residents and staff on the other station. In a telephone interview on 08/14/19 at 5:30 PM, anonymous Staff AE, NA, stated she has had issues with Staff A yelling and saying rude things in the past. Staff AD stated Staff A had issues with residents on the other nurse's station and was moved to another station. On 08/16/19 at approximately 5:00 PM, the Director of Nursing Services (DNS) provided names of four current residents who refused care from Staff [NAME] On 08/20/19 at 9:45 AM, Staff C, Registered Nurse/Resident Care Manager, stated there had been concerns with Staff A's conduct. Staff C stated Staff A had times of improvement and then went back to having problems. Staff C stated she stepped in on an interaction with Staff A and a resident on one occasion. Staff C stated management had been aware of the concerns with Staff [NAME] On 08/20/19 at 12:30 PM, anonymous Staff AC, Registered Nurse, stated there were problems with Staff A and administration was aware. On 08/20/19 at 12:45 PM, anonymous Staff AB, LPN, stated Staff A was too strict and harsh with residents and that her moods fluctuated widely. Staff AB stated there was something not right with Staff [NAME] RESIDENT INTERVIEWS On 08/06/19 at 1:20 PM, Resident #12 and her husband stated they had requested Staff A no longer care for Resident #12. They did not recall precise details, however recalled Staff A had left in the middle of a dressing change and was gone for four hours. They also stated Staff A was rude, snippy, unpleasant. Resident #12's husband stated he had observed Staff A in confrontation with another nurse and his perception was that she behaved threateningly. He stated he spoke with the former administrator and thought the facility was going to take some disciplinary action. On 08/13/19 at 5:00 PM, anonymous Resident #4A stated it was common knowledge in the facility there were problems with Staff A and that she had been moved to the other nurse's station because she did not get along with staff and residents on the station she worked with prior. Anonymous Resident #4A stated there were a number of residents who did not want Staff A providing their care. Anonymous Resident #4A was hesitant to provide names for fear of retaliation. Reference: (WAC) 388-97-0860 (1)(a)

Based on observation, interview, and record review, the facility failed to evaluate electrical equipment a resident brought from home for safety hazards and risks, and failed to ensure adequate supervision to prevent accidents for one of one residents (#3) reviewed [MEDICAL CONDITION] to use of electrical equipment not evaluated prior to use. This failure resulted in Resident #3 [MEDICAL CONDITION] his right forearm and placed him at risk for complications including, additional injury, and psycho-social harm. Findings included . Review of the facility policy titled: Electrical Safety and Work Related Practices, revised 07/15/15, revealed: The maintenance department will inspect all patient/resident's personal electrical equipment before use in the resident's room. Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE], showed he was cognitively intact. Resident #3 required extensive assistance with bed mobility, transfers, toileting, dressing, hygiene and locomotion. Review of a physician's order dated 05/05/18, showed the resident received [MEDICATION NAME] (medications to improve breathing) nebulizer treatments every 4 hours as needed for breathing problems. Review of progress note dated 04/02/19 at 6:02 AM, showed Resident #3 had [MEDICAL CONDITION] his right arm caused by his personal nebulizer machine. One of the [MEDICAL CONDITION] measured 4.0 centimeter (cm) by 1.0 cm, and the second burn measured 4.0 cm by 0.5 cm. There was no documentation found which revealed the degree (severity) of the burns. On 04/05/19 at 10:15 AM, two thinly scabbed red marks were observed on the resident's right posterior forearm. The first area measured approximately 3.0 cm by 1.0 cm and the second area measured approximately 3.0 cm by 0.5 cm with a red circular area measuring approximately 1.0 cm in diameter. The resident stated the wounds [MEDICAL CONDITION] his nebulizer machine. He stated [MEDICAL CONDITION] when he received a breathing treatment during the night about a week ago. He said he had pulled the nebulizer machine onto his bed and must have laid his arm on the machine, because he woke up with the burns. He stated the nurses usually did not return to his room when his breathing treatment was completed, so he kept the machine on his bed where it was easier to reach to turn off himself. He stated [MEDICAL CONDITION] painful the first days and were still sore. Resident #3 stated the nebulizer machine was his personal machine which he brought from home when he admitted to the facility. He denied knowledge of whether facility maintenance had evaluated the machine. On 04/08/19 at 11:55 AM, Staff A, Licensed Practical Nurse (LPN), stated he was Resident #3's nurse for the day shift. Staff A stated if a resident brought in his/her home nebulizer machine to the facility, he would not use it; he would get a facility nebulizer machine. On 04/08/19 at 1:50 PM, Staff C, LPN, stated when residents brought any electrical equipment to the facility, it had to be checked by the maintenance department for safety prior to use. On 04/08/19 at 2:35 PM, Staff D, LPN, stated when she did nebulizer treatments she parked her medication cart right outside the resident's room so she was close for monitoring, and put a note on the cart as a reminder to check the resident in about 5 minutes. Staff D stated there was a facility rule which required electrical equipment brought in by residents to be checked by maintenance prior to use. On 04/08/19 at 2:40 PM, Staff E, Maintenance Supervisor, stated all electrical equipment had to be checked by maintenance prior to use. Staff E stated he was unaware Resident #3 had been using his personal nebulizer machine at the facility. On 04/08/19 at 3:30 PM, Staff E stated he had no recollection or documentation of checking the nebulizer machine Resident #3 had brought to the facility from home. On 04/08/19 at 3:50 PM, the Director of Nursing Services (DNS) acknowledged Resident #3 had been using his own nebulizer machine. The DNS stated she was not aware if it had been assessed by maintenance prior to use. In a telephone interview on 04/09/19 at 3:15 PM, Staff B, Registered Nurse, stated she started a nebulizer treatment (breathing treatment) for Resident #3 sometime between 12:30 and 1:00 AM on 04/02/19. Staff B stated she used the nebulizer machine the resident had brought from home. Staff B stated at 1:00 AM the resident informed her his nebulizer machine had [MEDICAL CONDITION] his right forearm. Staff B stated she observed the nebulizer sitting on its side on the resident's bed. Staff B stated she observed [MEDICAL CONDITION] his right arm. Staff B stated the resident usually turned the machine off himself when the treatment was done. When asked if the facility had a policy for residents' electrical equipment to be assessed by maintenance, she stated I would assume so. Reference: (WAC) 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to implement identified interventions to prevent pressure ulcers in one of two residents (#42) reviewed for pressure ulcers. Failure to implement identified interventions including turning and repositioning caused harm to Resident #42 who developed a stage III right scapula (shoulder blade) pressure ulcer and a stage IV right ischium (buttock) pressure ulcer (PU). Findings included . Review of the facility skin policy titled, Skin Integrity Management, dated 11/28/16, showed staff continually observed and monitored the resident for changes and implemented revisions to the care plan as needed to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The facility developed a comprehensive, interdisciplinary care plan included prevention and wound treatments, as indicated. The Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed: -A stage II pressure injury (ulcer) was described a partial thickness loss of the skin; -A stage III pressure injury (ulcer) was described a full thickness loss of the skin; - An unstageable pressure injury (ulcer) was full thickness skin and tissue loss was obscured by slough (non-viable tissue) or eschar (dead or devitalized tissue); and -A Deep Tissue Injury (DTI) was described as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration. Resident #42 admitted to the facility 08/02/18 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 08/08/18, revealed he had severe cognitive impairment, required extensive assist of two staff for bed mobility, transfers, toilet use and personal hygiene. The MDS indicated the resident had upper and lower extremity functional limitation of range of motion and no PUs. Review of the admission Care Area Assessment (CAA) dated 08/08/18, showed Resident #42 was at risk for skin breakdown related to his diagnoses, being incontinent and need for physical assistance. The resident had an enteral tube (a tube used to receive nutrition) and [MEDICAL CONDITION] (a surgical procedure to create an opening in the neck into the windpipe) which placed him at risk for pressure related device injuries due to the equipment, ties and tubing. The CAA showed the development of PUs placed the resident at risk for life threatening infections. The plan was to proceed with care planning to avoid complications and minimize the risk of developing PUs. Pressure ulcer development placed him at risk for life threatening infections. Review of the Braden assessment (a PU risk assessment score) dated 08/08/18, revealed the resident was at high risk for PUs related to having limited sensory perception, skin that was often moist, there was a problem with friction and shearing and he was chair fast. Review of the admission at risk for skin breakdown care plan showed it was incomplete. The care plan did not include the resident's risk factors as stated in the CAA or provide an appropriate goal. The interventions were not resident centered and did not specify how often to turn and reposition the resident, how to offload/float his heels, types of pressure redistribution surfaces for his bed and chair nor nutritional interventions. Review of the actual skin breakdown care plan directed staff to encourage the resident to consume all fluids during meals, although the resident was unable to swallow. The care plan directed staff to float his heels while in bed and reposition him every hour. Review of the Kardex (guide to provide care) directed staff to ensure resident was out of bed three times a week for up to two hours as tolerated. There were two different turn and reposition directives; one for him to be turned every hour and another for every two hours. Review of the (MONTH) 2nd to (MONTH) 20th (YEAR) Treatment Administration Record (TAR) showed staff were to turn and reposition the resident every two hours. Review of the facility's contracted wound care company note dated 01/08/19, showed the resident developed a wound to his left ear. Review of the facility's contracted wound care company note dated 02/05/19, showed that the right buttock PU was deteriorating. The note stated the facility was planning to arrange a care conference with the resident's family to discuss options including palliative (end of life) care or an extensive medical work up. The resident's wound healing potential was guarded and the goals were to prevent new wounds from developing, reducing pain, and decreasing the risk for infection/sepsis. Review of the (MONTH) TAR, showed staff were to turn and reposition the resident every hour and as needed beginning 02/13/19. Review of a Skin Integrity Report dated 02/27/19, showed the left knee had an unidentified skin issue measuring 2.0 centimeter (cm) by 1.8 cm, right knee with an unidentified skin issue measuring 2.5 cm by 2.8 cm. The left outer elbow had an unidentified skin issue measuring 1.0 cm by 1.1 cm , the left inner arm had an unidentified skin issue measuring 0.4 cm by 0.1 cm, right elbow had an unidentified skin issue measuring 1.2 cm by 1.3 cm. There were no care plan revisions, or treatments to prevent skin deterioration. Review of a Skin Integrity Report dated 03/01/19, showed both of the resident's inner knees had red spots measuring 1.0 cm by 1.0 cm. There was no further mention of this in the medical record. Monitoring and interventions were not in place for these newly identified skin issues. Review of the (MONTH) 2019 TAR showed conflicting interventions: the staff were to float the resident's heels on pillows while in bed, and ensure Sage (a type of pressure reducing device) boots were were in place every shift. Review of a physician progress notes [REDACTED]. The physician ordered a MRI (test to visualize bone) to check for osteo[DIAGNOSES REDACTED] (an infection in the bone). Review of a wound consult report, dated 03/19/19, showed history: 11/13/18: We are asked to evaluate for wounds to his right buttock and right scapula (shoulder bone). Staff stated that the wound to his right scapula was found 10/28/18 and is unstageable (covered with dead or other tissue making staging impossible). Right buttock wound was found today .Right scapula wound measures 1.8 centimeters (cm) by 2.0 cm. unstageable eschar to the base (black dead tissue). Debridement (removal of dead tissue) was performed .reclassified as a stage 3 post debridement. Right buttock is a stage 2 pressure injury which measure 1.8 X 1.9 X 0.1 cm. The 03/19/19 assessment at the end of the report showed Patient completed MRI which confirmed osteo[DIAGNOSES REDACTED] (infection and inflammation of the bone). Physician is arranging surgical consult for bone biopsy (surgery to take a sample of bone to look for infection). In an interview on 03/18/19 at 10:09 AM, the resident was deemed not-interviewable. On 03/18/19 at 10:00 AM, the resident was observed to be lying on his back in bed with his heels resting directly on the mattress. On 03/19/19 at 8:36 AM, 10:09 AM, and 11:29 AM, the resident was observed to be lying on his back in bed with his heels resting directly on the mattress. On 03/19/19 at 1:28 PM, 2:54 PM and 3:07 PM, the resident was observed to be lying on his back in bed with his heels resting directly on the mattress. On 03/20/19 at 9:07 AM and 9:39 AM and 11:23 AM, Resident #42 was observed in the same partially side lying position in bed facing the door with heel protectors on. On 03/21/19 at 8:41 AM, 11:00 AM, 1:21 PM, and 3:13 PM, Resident # 42 was observed in bed in the same supine position with his heels resting on the mattress. On 03/22/19 at 4:54 AM, the resident was observed to be lying on his back with his heels resting directly on the mattress. During an interview on 03/22/19 at 5:11 AM, Staff V, Nursing Assistant (NA), stated he was responsible to care for 23 or 24 residents. Staff V stated normally there were three NAs on the night shift, but not always. Staff V stated two staff members were needed to turn the residents and it was easier with three NAs on duty. Staff V stated staff made rounds twice a shift at 10:00 PM and 3:00 PM to provide care to residents. Staff V stated he only gets to turning residents twice a shift. On 03/22/19 at 6:44 AM, the resident was lying on his back with his heels resting directly on the mattress. On 3/22/19 at 10:39 AM and 12:14 PM, the resident was observed in the same above position. On 03/25/19 at 9:14 AM, Resident # 42 was observed lying on his back with his heels on the mattress. On 03/25/19 at 11:14 AM, the resident was observed facing the window with his heels resting on the mattress. On 03/25/19 at 1:13 PM, the right ischium PU was observed with Staff J, RN. The wound was approximately 2.5 cm by 3.0 cm, deep inside, extending through the muscle and bone was exposed. The wound was consistent with a stage IV pressure ulcer. The wound bed was observed to be 90% granulating tissue with 10% slough and no eschar. During an interview on 03/25/19 at 2:16 PM, the Director of Nursing Services (DNS) was informed review of the TAR showed conflicting turn and repositioning directives and per documentation repositioning did not consistently occur. In an interview on 03/25/19 at 3:37 PM, Staff H, Regional Clinical Quality Specialist, was asked about the process for preventing pressure ulcers. Staff H stated in December, Resident #42's chart was randomly audited. This was when he identified the resident's facility acquired pressure wounds. Staff H was alerted to the concerns of the wound developing with the care plan not being followed and staffing concerns identified with this resident. During an interview on 03/26/19 at 9:14 AM, with the facility's contracted wound care company Advanced Registered Nurse Practitioner (ARNP) stated, We picked (Resident #42) up in (MONTH) for his right buttock and right scapula wound. The right scapula (wound) was unstageable and was found on 10/28/18. His red buttock was initially observed on 11/13/18, and it was a stage II .Then a stage III. The ARNP was asked what equipment and interventions were in place at that time. The ARNP stated she thought the resident was on an air mattress. The ARNP stated the resident could not reposition himself and today his right scapula had reopened. The ARNP stated the resident's buttock wound last week was necrotic (black dead tissue) with slough. There was osteo (osteo[DIAGNOSES REDACTED]) to the bone. He is going to see a surgeon (MONTH) 12th for possible further debridement. He should be offloaded at least every two hours. At one time, he had four wounds including his ear. On 03/26/19 at 1:56 PM, the resident was observed lying on his back with his heels resting on the mattress. During an interview on 03/26/19 at 1:57 PM, Staff J, RN, stated the resident was turned every hour because he was so fragile. During an interview on 03/27/19 at 8:21 AM, Staff I, Nurse Manager, reviewed the resident's skin care plan and confirmed there were multiple conflicting directives to staff on skin interventions including heel protection, getting him up in the chair and turning. Staff I stated care plans were important and she would revise it. Staff I was asked about the resident not observed out of his bed on any occasion all days of the survey, the resident's heels were often resting directly on the mattress and he was not repositioned frequently. She provided no additional information was provided. The resident was not observed to be out of bed on any occasion on all days of survey. The resident admitted [DATE] with no skin issues. The facility had no process in place to prevent pressure ulcer development for Resident # 42 who was dependent on staff for all care and positioning. This is a repeat citation from 12/13/17 survey. Reference: (WAC) 388-97-1060 (3) (b)

Based on observation, interview and record review the facility failed to provide timely and adequate dental services for one of three residents (1) reviewed for dental services. This failure caused harm to Resident 1 who experienced tooth decay, gum inflammation, increased dental pain which affected her ability to enjoy her favorite foods and a caused decreased in her quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had dysphagia (difficulty swallowing) and required feedings through a tube placed into her stomach. The resident did, however, eat small amounts of food for pleasure. Review of the quarterly Minimum Data Set assessment dated [DATE], identified the resident had mouth/facial pain, difficulty/discomfort with chewing and obvious/likely cavity's/broken teeth, required total assist with eating and had no cognitive impairment. Review of the care plan, with the last review date of 06/28/18, revealed Resident 1 was at risk for oral health or dental care problems. The care plan requested an urgent dental consult, which was initiated on 01/18/18. Current care plan interventions directed staff to monitor the resident for mouth pain, inflammation and bleeding. The Respiratory Therapist (RT) and Licensed Nurse (LN) were to provide oral hygiene/mouth care twice daily. Review of the medical record showed no evidence the facility addressed the care plan problem dated 01/18/18 for an urgent dental consult. Review of the physician order [REDACTED]. Review physician fax communication form dated 03/28/18, requested to have the residents teeth evaluated. The resident had inflamed gums, tarter and noted tooth decay. The facility documented the resident would be seen by a visiting dental company on 04/03/18. Review of visiting dental company note dated 04/03/18, showed the resident had red irritated gums, four missing teeth, medium levels of plaque and calculus. The recommendation was for oral hygiene cleaning and to follow up with a dentist. Review of the medical record showed the facility did not follow up on the visiting dental company's recommendation for the resident to be seen by a dentist. Review of a visiting dental company noted dated 05/10/18, showed the resident's main complaint was having difficulty eating food. The resident was identified to have cavities on the posterior upper and lower teeth, had hot/cold sensitivity and had tooth sensitivity to sweets. The recommendation was to do a [MEDICATION NAME] rinse twice daily and limit sweets. Review of a physician progress notes [REDACTED]. The physician documented the resident had gingivitis secondary to poor dentition and poor teeth cleaning. The physician agreed with the visiting dental company recommendations. Review of a faxed communication form dated 05/22/18, showed SS referred the resident to a hospital's Advanced General Dental (AGD) Clinic. Review of a nursing assessment dated [DATE], showed the resident had obvious or likely cavities, broken natural teeth, mouth or facial pain and discomfort or difficulty with chewing. There was no further documentation or follow up from nursing to address the resident's oral pain/concerns. Review of a SS note dated 07/03/18, showed a hospital's School of Dentistry would not accept the resident due to her respiratory needs. Staff A then made another call to the hospital's AGD clinic, which was already done on 05/22/18. Review of a visiting dental company noted dated 07/09/18, showed the dental hygienist documented upper left pain reported by the resident, the resident had moderate gingivitis, had peridontitis, had gum recession, and noted inflammation and bleeding with brushing. There was visible tooth decay present (on teeth 29, 31, 19, 18 and 10-14). The resident needed to be referred to a dentist for teeth decay and pain. Review of a SS note dated 09/05/18, showed Staff A continued to schedule a dental appointment to a hospital's AGD clinic. The resident's caseworker, from another agency, provided the necessary referral paperwork from the hospital's School of Dentistry for the resident to be seen. Staff A documented the interdisciplinary team at facility was completing the referral paperwork and would send to the clinic when completed. In a phone interview on 09/13/18 at 1:00 PM, the resident's caseworker, from another agency, stated she had contacted Staff A at the facility on 05/01/18 requesting the resident be set up with an appointment to a hospital's dental clinic as she qualified for care through the DECOD clinic related to her diagnosis. The DECOD clinic worked with resident's who had tracheostomies or were ventilator dependent. The caseworker stated on 08/29/18, she found out an appointment had not been made yet at DECOD clinic. The caseworker stated she sent another e-mail to Staff A and the facility's administrator with an application for the hospital's DECOD clinic and requested Staff A assist the resident to fill out the application. The caseworker stated on 09/05/18, Staff A stated she still had not filled out the DECOD clinic's application but stated it would be done that day (on 09/05/18). On 09/13/18, Staff A sent a faxed application to a hospital's Dental Education in Care of Persons with Disabilities (DECOD) clinic. Review of a physician order [REDACTED]. In a phone interview on 09/14/18 at 3:22 PM, Resident 1's friend, who visited the resident frequently, stated they had been trying to get her dental issues addressed for about 7 months. We were told by the staff that no dentist would see her in the area because of her [MEDICAL CONDITION]. The [MEDICAL CONDITION] isn't that big a deal, it just needs to be suctioned once in a while, I can do that. I go with her to her appointments to do that. In an interview on 09/17/18 at 9:15 AM, Staff C, Licensed Nurse (LN), stated the resident does have a dental appointment today. Staff C stated the resident started having dental pain a few months ago, but could not remember exactly when it started. Staff C stated the resident's dental pain was not constant and hurt sometimes when she ate or when providing oral care. Staff C stated the LN's and Respiratory Therapy provided oral care to the resident. On 09/17/18, the resident was seen by a community health center dentist (close to the facility). The dentist recommended the resident be seen by a hospital's DECOD clinic (to the same clinic that was referred on 09/13/18). At 12:00 PM, Resident 1 stated she had a dental appointment at the Community Health Clinic. Resident 1 stated she had been waiting to see a dentist for 7 months and that one of her teeth turned brown . about 7 months ago .now I have 3 more teeth turning black. My teeth were hurting so I had the staff look and take a photo for me so I could see. I think one of the Respiratory Therapist (RT) saw it first and tried to brush it off but couldn't. He told the nurse about it. When my teeth first started hurting I told the head nurse who said she would let Staff A know. That was about 5 months ago. I check in with her every other week and she always says she is waiting for a call back or paper work. My teeth hurt when brushing, eating, drinking and sometimes will just throb .sometimes a sharp pain. I just try and avoid the side where my teeth are black when I eat. I want to go to the hospital's dental clinic because that is where I have always gotten all my care (for other health concerns). I know they are more experienced working with people like me, they know my limitations. The administrator set up an appointment with the Community Health Clinic, I am worried about going to this clinic, they will probably just want to pull them out. A dentist did come and see me here, but she told me I should see a dentist in the community because she doesn't normally do the kind of work I need in house. During an observation on 09/17/18 at 1:00 PM, Staff B, RT, performed oral hygiene to the resident. Staff B brushed the resident's teeth, administered her medicated rinse, and suctioned the secretions. There was bleeding from the gums noted during the treatment. The resident had her eyes closed and facial grimacing was observed during the treatment, especially when the left upper teeth were being brushed. On the resident's left upper mouth, there was a tooth with brown discoloration and three teeth with black discoloration observed at their bases. The resident's gums were reddened. The resident stated after the brushing that really hurts when they brush back there. The resident went on to state that those teeth were really sensitive, especially with cold things. Staff B confirmed the resident received daily oral care from both RT and LNs. At 1:25 PM, Staff D, RT, stated he had first noted the spot on her tooth several months ago and she complained of pain at that time. Staff D stated this was reported to a couple of nurses but did not recall documenting the resident's pain, the spot on her tooth or who it was reported to. At 3:00 PM, the resident and her friend, who accompanied her to the appointment this day (09/17/18), stated the Community Health Clinic said they could not help her there. All they said was the teeth would maybe have to be pulled and that she would need to go to a hospitals dental clinic for care. The clinic wrote a referral to the hospital's DECOD clinic. In an interview on 09/18/18 at 9:00 AM, the Administrator stated that Staff A was aware what the facility has done to meet Resident 1's dental needs. The Administrator was aware there was a referral made to a hospital's DECOD clinic and would be looking into it. At 9:30 AM, Staff E, Nursing Assistant (NA), stated she worked with the resident and provided morning care which included washing the resident's face/hands, providing personal care (dressing) and transferred the resident into her wheelchair. Staff E stated she did not provide oral care because the nurses and RTs did that. At 10:45 AM, Staff A stated she was first made aware of the resident's dental issues in (MONTH) and started to work on it. Staff A stated she sent a referral to a hospital's AGD clinic in May, and then started to fax twice weekly to follow up on the referral. Staff A stated she spoke to the hospital's AGD clinic around (MONTH) .that's when they told me they couldn't do the work for the resident because they couldn't meet her respiratory needs. It was like playing phone tag or ping pong ball with them. I didn't do a good job of documenting the contacts I made. The resident's caseworker, from another agency, had e-mailed me the first of (MONTH) about getting her into the hospital's Dental Clinic which is what I tried. Staff F, Resident Care Manager (RCM), even talked to them last week but didn't get anywhere. I got the application for the DECOD clinic from her caseworker at end of (MONTH) and got it faxed to them on 09/13/18. I will see if I have any other documentation of my contacts. No further documentation was provided. During a joint interview on 09/18/18 at 11:45 AM, Staff G and H, NAs, stated they worked occasionally with the resident doing AM care, but did not do oral hygiene. At 12:40 PM, Staff I, LN, stated she had been working with the resident for the past two months and she has had issues with the left upper side of her mouth (teeth). Staff I stated the resident was on routine pain medications and that seemed to help the resident with her dental pain. At 1:05 PM Staff F, RCM, stated I have not spoken to the (hospital's) dental clinic. When asked about the care plan focus problem of dental pain and the need for an urgent dental referral, initiated on 01/18/18, she replied I can't speak to that, I don't know who initiated that. In summary, the facility failed to aggressively pursue adequate and timely dental services to meet the resident's special needs. By failing to contact the appropriate hospital's Dental Clinic and not reaching out to other agencies for assistance in locating a dental clinic that could meet her needs, Resident 1 experienced a deterioration in her dental status including increased tooth decay, gum inflammation and oral pain which affected the quality of her daily life. Reference: WAC 388-97-1060(2)(c), (3)(j)(vii)

Based on observation, interview, and record review, the facility failed to accurately and comprehensively assess smoking safety and provide the necessary supervision/monitoring for 1 of 1 resident (20) who smoked. The facility failed to recognize the danger of smoking materials for Resident 20 who was observed to have ashes and burn holes on her clothing/blanket while smoking. The likelihood of serious injury [MEDICAL CONDITION] to unsafe smoking, constituted a situation of immediate jeopardy (IJ) on 12/05/17. In addition, the facility failed to assess, evaluate and provide necessary supervision/monitoring for 2 of 8 residents (35 and 58) with assistive and safety devices (wheelchair) and (bed alarms) reviewed for accident hazards, supervision and devices. The facility failed to maintain and monitor devices to ensure that they were in good working condition to prevent avoidable accidents. These failed practices resulted in a substantial injury/harm, and pain to Resident 58 and Resident 35. Findings included: RESIDENT 20 Resident 20 was admitted to the facility in April 2015 with [DIAGNOSES REDACTED]. In a review of the most recent Minimum Data Set (MDS) Assessment, dated 09/27/17, identified the resident as having intact cognition, and used an electric wheelchair independently inside and outside the facility. The facility identified the resident as being able to smoke cigarettes independently. In a review of Resident 20's Smoking Evaluation completed on 05/01/17 showed, the resident was able to smoke independently and follow the facility's smoking policy. Subsequent quarterly evaluations were conducted (the most recent evaluation was on 10/26/17), and the resident continued to be identified as being able to independently smoke safely. In a review of Resident 20's Care Plan, initiated on 01/14/15, showed that the resident may smoke independently per smoking assessment and the resident clothing has had burn holes prior to coming to the facility. Interventions included: Assess resident after smoking if there is any problem occurred for safety. The resident was observed several times at the facility's designated smoking area. She was observed smoking cigarettes alone without wearing any protective sheet or smoking apron except her own personal blanket. The resident was known to go off the facility property and smoke cigarettes during regular hours and outings. In a joint observation with another surveyor on 12/05/17 at 11:00 AM, the resident was observed smoking in the facility courtyard. She was covered with her personal blanket and was able to light the cigarette independently. The resident was not able to use her left hand due to weakness and because of a soft splint in place. Resident smoked 2 cigarettes during the observation and was observed to have ashes drop to her blanket, shoes and wheelchair while she was smoking. The resident was unable to remove the ashes from her blanket until she finished smoking and free up her right arm. There was no staff around to supervise the resident, no available smoking apron, and the resident stated that she was not aware if an apron was even offered to her or not. There was no observation of a staff member that assessed or checked the resident after smoking as written in the resident care plan. In an interview with the resident at 11:30 AM, the resident stated I am fine. Those ashes normally get on my blanket when I smoke, especially when it is windy. The resident also reported she had burn holes in her clothes. The resident said the holes on the blankets were from embers dropped from her cigarettes, and that she had not burned herself. The resident showed her blanket to the surveyor and two to three burn holes measuring approximately ½ to 1 centimeter (cm) in size were observed. The resident stated No one checked me after I smoke. Never in my time here. In an interview at 11:45 AM, Staff D, Certified Nursing Assistant (CNA), was asked if she knew about Resident 20's blanket cover, and the cigarette burn holes. Staff D stated she was not aware of the burn holes, and that the resident was an independent smoker. Staff D further stated that the resident goes out to smoke anytime she wants, even out in the community, and she was not aware of any unsafe smoking activity. Staff D was not aware of the care plan intervention that a staff member had to check the resident after smoking. In an interview at 12:03 PM, Staff A, Licensed Practical Nurse (LPN), was asked if she knew about Resident 20's cigarette burn holes on her blanket. Staff A denied any knowledge and stated She is an independent smoker. She was assessed by nurses and managers to be an independent smoker. Staff A added she never used an apron. I believe she is safe to smoke alone. I don't assess her, no. She had some clothes in the past with burn holes, I remember. In an interview at 2:30 PM, Staff I, Resident Care Manager (RCM), stated, We are a non-smoking facility. We only have one smoker and she is an independent smoker. Staff I stated that the facility had done a smoking assessment with Resident 20 and deemed her an independent smoker and that the care plan reflected the assessment. In another observation at 3:09 PM, the resident had just came back from smoking. Ashes were still noted on the resident's personal blanket. The resident was observed to give her cigarettes and lighter to Staff A. The resident proceeded to her room without being checked by any staff member. There was no observed assessment completed by any staff member. In an interview at 3:16 PM, Staff G, Administrator, stated, I am not aware of the resident's unsafe smoking. We are not a smoking facility and she was the only one remaining. Staff G further stated We will immediately do an assessment and follow our process to address this safety concern. RESIDENT 58 Resident 58 was admitted to the facility in July 2017 for rehabilitation therapy. [DIAGNOSES REDACTED]. In a review of the resident's MDS Assessment, dated 07/21/17, showed the resident had cognitive impairments, and required one person assist with ambulation, toileting and transfer. In a review of the resident care plan dated 07/17/17, showed the resident to be at risk for falls related to a recent hospitalization , [MEDICAL CONDITION] and collapse, [MEDICAL CONDITION], poor safety awareness, and history of falls. Interventions included a Pressure sensitive alarm for safety to bed at all times. Remind resident to use call light when attempting to ambulate or transfer. Monitor for and assist toileting needs. In a review of the facility nursing assessment dated [DATE] showed, the resident needed extensive assistance for locomotion and was not steady to move from seated to standing position, and walking. In a review of the facility incident log on 12/12/17 at 2:15 PM revealed, the resident fell on [DATE] near her bathroom. In a review of the facility incident investigation completed by Staff B, Resident Care Manager (RCM), dated 10/22/17 showed, Resident 58 was found on the floor lying on her right side after attempting to get up from bed and tried to walk to the bathroom pushing her WC as a walker and fell . Preventative measures in place prior to the fall included: wander guard, frequent checks and pressure sensitive alarm. In a review of the incident investigation root cause/conclusion stated Resident/patient has impaired/decline in cognitive function or impaired thought processes related to a condition r/t Dementia. The conclusion further stated The pressure alarm was in place but did not sound. It appears that somehow the cord that attaches the pressure mat to the alarm box somehow disconnected from the alarm box. I am unable to determine why the cord detached. In an interview with Staff B, on 12/13/17 at 9:10 AM, stated, We are not sure what happened. She was confused. She needed one person assist and was frequently checked. She also had an alarm but didn't work at that time. Staff B further stated that the nursing staff monitored the resident and the functionality of the alarm used. According to Staff B, the monitoring were documented in PCC (Point Click Care) electronic record, Medication Administration Record (MAR), and Treatment Administration Record (TAR). In a review of the resident MAR and TAR for the month of July 2017, showed no evidence of staff monitoring the resident and/or staff monitoring the pressure alarm or proper placement and functionality. In a follow-up interview with Staff B at 10:30 AM, stated, We added the actual documentation for monitoring after the fall and the care plan was also updated. Staff B further stated that the facility had no routine preventative maintenance to monitor or assess the functionality of the resident pressure alarm prior to the incident. Further review of the facility medical record for Resident 58 revealed an event summary report dated 10/22/17: Resident 58 had complain of pain to her right hip that was treated with Tylenol. Resident continued to complain of pain to her right hip after being medicated. Resident 58 daughter was notified of the situation and requested to transfer the resident to the emergency room for further evaluation. In a review of the hospital records dated 11/07/17 showed, Resident 58 had suffered a fractured right leg. In a review of the most recent MDS, dated [DATE] revealed, the resident had significant decline in condition, requiring more help and assistance with activities of daily living, and now not able to walk. In a review of Resident 58 MAR for November and December 2017, showed the resident continued to experience moderate to severe pain on her right leg on a regular basis. During an observation on 12/11/17 at 11:45 AM, Resident 58 was observed screaming in her room while being attended by staff. Resident was grimacing and was guarding her right leg while the staff attempted to reposition and move the resident in bed. Another observation at 2:30 PM, Resident 58 once again was calling for help and verbalizing pain, ouch, aw, while grimacing and being transferred from bed to wheelchair by 2 staff members. In an interview with the resident on 12/12/17 at 2:55 PM, resident complained of constant pain and reported she was not able to sleep because of severe pain. In an interview with Staff B, at 3:30 PM, stated, we are monitoring and addressing her pain. The Doctor and the Nurse Practotioner were both notified. In an interview with Staff F, Maintenance Director, on 12/13/17 at 8:32 AM, confirmed that the facility had no regular routine preventative inspection to monitor alarms, and if they were properly working. According to Staff F, nursing monitor the function of each alarm every shift. The facility was not clear on how frequent the resident should be checked and/or supervised. The facility also failed to ensure that a routine preventative inspection was in place to monitor devices/alarms for functionality to minimize risk of avoidable accidents. RESIDENT 35 Resident 35 was admitted to the facility in December 2016 with [DIAGNOSES REDACTED]. In a review of the facility nursing assessment dated [DATE] showed, the resident needed extensive assistance from staff and was not steady to move from seated to standing position. In a review of the resident's most recent MDS assessment, dated 10/25/17, identified the resident to have cognitive impairment, and needed one person assistance from staff for bed mobility, transfer, and uses wheelchair for locomotion in unit. In a review of the resident care plan dated 11/01/17 identified the resident to be at risk for repeated falls related to his medical conditions, poor safety awareness and history of repeated falls in the past. Interventions included to check resident frequently and to remind resident to use call light when attempting to ambulate or transfer. In a review of the facility incident log on 12/12/17 at 11:15 AM showed, Resident 35 had a fall on 03/19/17 which resulted in an abrasion to the right hip. In a review of the facility incident investigation completed by Staff A dated 3/19/17 showed, the resident wheelchair brake was loose and was not working at the time of incident. The summary and conclusion of the investigation stated Old wheelchair replaced with a new wheelchair and working locks on both sides of the wheelchair. In an interview with Staff A on 12/13/17 at 8:10 AM, stated, she was not able to recall the details of the incident but she remembered that Resident 35's old wheelchair brake was not functional at the time of the incident, which caused the resident to fall. Staff A was not aware if Resident 35's old wheelchair was routinely inspected and maintained by the facility to avoid such accidents. In an interview with Staff E, Physical Therapist/Director, on 12/13/17 at 8:20 AM, stated, Therapy was responsible for assigning assistive devices to residents. According to Staff E, the nursing staff will report any concerns related to assistive devices to the therapy team or maintenance. Staff E further stated there was no routine preventative inspection that she was aware of to monitor wheelchair brakes if they were in good working condition except when the staff reported any concerns or issues with the device. In an interview with Staff F on 12/13/17 at 8:32 AM, he confirmed that the facility had no regular routine preventative inspection to monitor wheelchairs if they were properly working and if in good working condition. In an interview with Staff G and Regional Corporate Nurse on 12/13/17 at 12:45 PM confirmed that the facility had no routine preventative inspection to check wheelchairs prior to the incident, and now being addressed and reviewed thru the facility's quality of care rounds and quality assurance program. Reference: (WAC) 388-97-1060 (3)(g)

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 an immediate jeopardy (IJ) situation related to unsafe smoking, harm for 6 residents, and placed the other residents at risk for diminished quality of life and related complications. Findings included: 1. The Administration failed to ensure an accurate assessment and supervision was in place for resident who smoked. The Administration failed to recognize the danger of smoking materials and the likelihood of serious injury [MEDICAL CONDITION] to smoking which constituted an immediate jeopardy (IJ) situation. Refer to F689 - Free of Accident Hazards/supervision/devices 2. The Administration failed to ensure resident was free from physical restraints. The Administration failed to comprehensively assess/monitor the need of physical restraints, document ongoing re-evaluation for the need of the restraint, and to ensure least restrictive interventions were attempted prior to use of the restraint. This failed practice caused harm to the resident, diminished quality of life, feelings of sadness, seclusion and imprisonment. Refer to F604 - Right to be free from Physical Restraints 3. The Administration failed to ensure that the facility policy was followed and appropriate interventions were in place to prevent development of pressure ulcers to residents. These failure caused harm to the residents when they developed avoidable facility acquired pressure ulcers. Refer to F686 - Treatment/Services to Prevent/heal Pressure Ulcer 4. The Administration failed to ensure that appropriate care and services were provided to maintain and avoid loss of bowel and bladder functions to the resident. This failed practice caused harm when the resident's bowel and bladder function declined from always continent, to frequently incontinent, and eventually resulted to development of severe fungal rash, moisture associated [MEDICAL CONDITION] and pain. Refer to F690 - Bowel/Bladder Incontinence, Catheter, UTI 5. The Administration failed to ensure an accurate assessment was completed and interventions were reviewed and revised as needed to prevent significant weight loss to residents. These failure caused harm, and placed the residents at significant risk for decline in nutritional status and related complications. Refer to F692 - Nutrition/Hydration Status Maintenance 6. The Administration failed to ensure that effective pain management was in place, reviewed/revised as needed for a resident with a terminal illness. This failure caused harm to the resident by not alleviating the resident's pain and compromised the resident's quality of life during the end of life period. Refer to F697 - Pain Management 7. The Administration failed to ensure that adequate monitoring and safety measures/interventions were in place related to potential side effects or adverse reactions for resident receiving high risk medications (anti-coagulant/blood thinner). This failure caused harm to the resident who had signs and symptoms of internal bleeding and compromised the resident's quality of life and care. Refer to F757 - Drug Regimen is Free from Unnecessary Drugs

Based on observation, interview and record review, the facility failed to implement identified interventions to prevent pressure ulcers in 2 of 4 residents (58 & 11) reviewed for pressure ulcers. Failure to: float the resident's heels, to follow facility policy for assessing pressure ulcer risk, and to apply heel protectors when it was documented they were applied, caused harm to Resident 58 when she developed a stage 3 pressure ulcer on her heel. Additionally, failure to aggressively provide pressure relieving interventions for Resident 11 caused harm when he developed pressure ulcers under his [MEDICAL CONDITION] ties and the back of his head. Findings included: Review of the facility skin policy titled Skin Integrity Care Delivery Process, dated 01/02/14, revealed: Risk Factor Guide: specific risk factors included Impaired/Decreased mobility or function, Bed mobility problem . Cognitive impairment, Leaves 25% or more of food uneaten, .Recent surgery (THR) (total hip replacement) Risk Assessment tool (Braden Scale .) to be done on admission/re-admission, weekly x 4, . Wound measurements were to be taken in length, width, and depth. Report all information from Skin Integrity Report. Review of the facility's heel pressure ulcer policy titled Prevention and treatment of [REDACTED].#1 site of pressure ulcer breakdown, as with any pressure ulcer, the best way to prevent or treat a pressure ulcer is to eliminate or minimize pressure, risk factors associated with heel pressure ulcers include immobility, decreased sensation, nutritional decline and poor circulation, an air mattress is not enough to prevent and/or treat a heel pressure ulcer, as the optimal way to prevent and/or treat a heel pressure ulcer is to float or suspend the heel off of any surface, the primary intervention should be a type of heel off-loading, not an air mattress. RESIDENT 58 The resident readmitted to the facility in November 2017 with [DIAGNOSES REDACTED]. Review of her Minimum Data Set (MDS) assessment, dated 11/14/17, revealed she had severe cognitive impairment, required extensive assist of 2 staff for bed mobility, transfers, toilet use, and personal hygiene. The MDS also indicated she had a lower extremity functional limitation of range of motion, and she had no pressure ulcers. Review of a Nursing Assessment, dated 11/07/17, revealed: impaired judgment/insight, nonpalpable pedal pulses (unable to feel feet pulses), nutrition that is probably inadequate, completely immobile - does not make even slight changes in body position by self, Bedfast - confined to bed, lower extremity impairment on 1 side, no pressure ulcers. Review of Braden pressure risk assessment documentation revealed the resident had 3 recent admissions and the facility did only 1 Braden assessment for each admission, not weekly after each admission, which was facility policy. The Braden done on 11/07/17 revealed the resident was at High Risk for pressure ulcers. Review of a Braden Scale risk assessment dated [DATE] which was done after the heel pressure injury, revealed the facility had coded the resident as high risk for pressure injury. The facility coded the resident was Bedfast (confined to bed), Completely Immobile (Does not make even slight changes in body or extremity position without assistance). Review of a Skin Check, dated 12/03/17, revealed the resident had no new skin injury/wounds identified and had no pressure ulcers. Review of a Change in Condition Evaluation, dated 12/04/17, revealed the resident had a new skin issue on right heel possible caused by shear/friction. 4cm (centimeter) length open area. No width or depth documentation was done. Review of an undated Skin Integrity Report, revealed only a 4 cm length assessment was done. No width or depth documentation was done. The wound was documented to be a Skin Tear. Review of a nurse practitioner Progress Note, dated 12/04/17, revealed resident had a new skin tear to heel, 4 cm with flap intact, high risk for malnutrition as PO (oral) intake remains poor. Interventions completed to change pressure relieving mattress, bridge heels in bed, cushion boots bilaterally, dressing changes in right heel until healed. Awaiting labs in AM to determine severity of malnutrition. No width or depth documented. Review of an occupational therapy treatment encounter note dated 12/04/17, revealed heels offloaded due to new skin breakdown. Review of a wound consult report, dated 12/05/17, revealed NEW pressure ulcer, right heel, same side as surgical intervention, treatment recommendation is for aggressive offloading . Initial wound measurements are 5.5 cm length x 6 cm width x 0.1 cm depth. Review of an investigation report titled Event Summary Report, dated 12/04/17, revealed the facility considered the pressure ulcer an Event : self-inflicted injury, caused by shearing/friction when resident's heel brushed against the bed. Review of the resident's care plan, print date 12/12/17, revealed an intervention, dated 07/17/17, to Float heels with pillows while in bed, and to Utilize positioning devices as appropriate to prevent pressure over bony prominences. Review of the clinical record revealed no documentation the facility had routinely floated the resident's heels when she was in bed, until after she had already sustained a heel pressure ulcer. In an interview on 12/12/17 at 9:48 AM, Staff I, Registered Nurse (RN)/Resident Care Manager (RCM), stated if heel floating was on the care plan, it should have been documented that it was done on the Treatment Administration Records (TARs). In an interview at 2:04 PM, the resident's daughter was asked if staff had been floating her mother's heels prior to the heel pressure injury. The daughter stated staff had at times elevated the resident's legs due to swelling, but she did not think the heels were floated. Review of the July - December 2017 TARs revealed the facility had not documented the resident's heel were being floated per the care plan until after the resident sustained [REDACTED]. In an interview at 1:13 PM, Staff N, Nurse Practitioner, was unable to provide documentation the resident's heels had been floated prior to the heel pressure injury, as per the care plan. She stated if heel floating was on the care plan, then it should have been done. Staff N stated she did not think the resident had a pressure injury, she stated it was a skin tear. Staff H, RN, stated she did not know why there was no documentation the resident's heels had been floated until after the heel injury. Review of a Point of Care document Preventative skin care (protectors heel/elbow): reflecting care from 11/13/17 - 12/11/17, revealed staff had documented applied every day during that time period. In an interview on 12/13/17 at 9:20 AM, Staff O, Licensed Practical Nurse, was asked which protectors staff were documenting they had applied to the resident. Staff O, stated she did not know of any protectors that were being applied back in November. She stated she thought it had to do with comfortable positioning of the resident's arms and legs. In an interview at 9:25 AM, Staff P, Nursing Assistant Certified, stated she was sure there were no elbow or heel protectors used back in November. She said she didn't think the resident ever had elbow protectors, and did not have heel protectors until just this month. She said she thought that documentation was for positioning because they had put pillows under the resident's arms because she was a fall-risk. In an interview at 9:32 AM, Staff B, LPN/RCM, stated that P(NAME) protector documentation was for comfortable positioning of the resident and that no protectors were used until the heel protectors were implemented after the heel pressure injury. She did not know what staff were documenting they had applied. In an interview at 11:25 AM, the resident was deemed not-interviewable. In an observation on 12/11/17 at 12:39 PM, the resident was lying in bed wearing yellow non-slip type socks in which blood had seeped through the sock onto the bedding in the area of the right heel. After the sock and dressing were removed, there was an open wound that covered the entire bottom of the right heel and it was very red and oozing blood. The wound was cleaned and treated, and a dressing was applied. In summary, the resident had multiple risk factors: advanced age ([AGE] years, cognitive impairment (dementia), immobility (from a [MEDICAL CONDITION]), pain (from a [MEDICAL CONDITION]), generalized muscle weakness, impaired nutrition, and was assessed to be at risk for pressure ulcers. The facility care planned that she have her heels floated when in bed, but this was not documented as done until after she sustained a heel pressure injury. Additionally, the facility made a provision for protectors (heel/elbow) to be applied, but this intervention was not implemented. Finally, facility staff failed to follow their own facility policy to perform weekly pressure risk assessments for 4 weeks after admission. These failures caused harm to the resident when she sustained a stage 3 heel pressure injury. RESIDENT 11 Resident 11 was admitted to the facility in May of 2016 with [DIAGNOSES REDACTED]. The resident readmitted to the facility on [DATE] after a 2 week hospitalization in a Long Term Acute Care Hospital (LTAC) for more intensive wound management as the resident developed several facility acquired pressure ulcers since the original admission in 2016. These ulcers were located on bilateral hips, tailbone and buttock. On readmission, the resident had a Brief Interview for Mental Status score of 0, as documented on the 08/30/17 Social Services assessment. The resident's care plan documented the resident remained in a persistent vegetative state and required 2 person total assist for toileting, personal hygiene, and bed mobility. Transfers required 2 person total assist with a mechanical lift. WOUND CLINIC PROGRESS NOTES 03/03/17: new wound noted on left head. The wound is documented in the note as a traumatic wound but the wound bed is 100% eschar (dead wound tissue). The wound measurements were 1.5 cm x 1.5 cm with no measurable depth. 04/17/17: new posterior neck wound was noted. 04/24/17: the posterior neck wound was an unstageable pressure injury with the wound bed 100% slough (dead yellow tissue). The wound measurements were 1cm long x 1cm wide x 1cm deep. Recommendations included aggressive offloading of all pressure wound areas, low air loss mattress, heel protectors. 05/30/17: posterior neck wound resolved. 07/03/17: there is a new pressure ulcer on the occiput (back of head) today that I believe could be due to positioning. 07/17/17: debrided some loose eschar (dead tissue) from scalp wound. 07/24/17: changing dressing procedure to left head wound. 08/14/17: resident is now on 4-6 weeks of antibiotic treatment for [REDACTED]. Scalp wound debrided. 08/29/17: readmitted from long term acute care hospital with a new occipital/scalp wound and left heel deep tissue injury. 09/19/17: there is another new scalp wound present for evaluation today from the pillow. Discussed with the resident care manager about speaking to the physical therapist about better cushioning for the patient's head to help mitigate the pressure 09/26/17: occipital wounds slowly healing. 10/03/17: occipital pressure wound debrided (removing dead tissue). Had discussion with nursing about need for finding ways to reposition the patients head to help offload pressure to his scalp. He had a C-shaped neck pillow with zipper that was being used which may in part be contributing to pressure load. This was discarded today. 10/10/17: resolved area at crest of occiput. 10/24/17: New wound, pressure to the back of his neck, related [MEDICAL CONDITION]. Patient is severely contracted at the neck. Recommend dressing and placement of ABD pad (large soft padded dressing). Also, recurrent wound to scalp noted. Posterior neck wound is an acute Stage 3 pressure injury. 11/14/17: posterior [MEDICAL CONDITION] pressure wound resolved. Head wound measurements as follows: 1) lateral head wound is an unstageable full thickness skin and tissue loss. It measures 1.7cm length x 3.2cm width x no measurable depth. The wound bed is100% slough. 2) back of head at top is an unstageable pressure injury obscured by full-thickness skin and tissue loss. The wound measurements are 1.5cm lentgh x 1.3 cm width with no measurable depth. Review of the Skin Integrity Report for June-November 2017 revealed documentation of a pressure wound on the back of the head. It further documented the wound was present on admission, however, there was no documentation in the wound clinic or nursing progress notes to support that the resident had the head wound when he readmitted on [DATE]. Additionally, the report documented an in-house acquired pressure wound to back neck from neck (trach) ties. PROGRESS NOTES 02/28/17: new wound on left side of head. Central supply to order a new neck pillow. 04/17/17: documented a new wound to the neck. No documentation was found identifying pressure relieving measures were put in place under the [MEDICAL CONDITION] ties. 06/21/17: documented that during the skin check there were no new wounds but has a previous start to come back, will keep head off the L occipital (back) region using neck pillow, scab like area about 2.5 cm x 3 cm will have wound team take a look. 08/02/17: documented a couple of wounds to his head, got permission (from family member) to shave his head. New orders for wound care. There was no documentation of off-loading the pressure to the resident's head. 08/28/17: documented the resident was readmitted from LTAC with previous pressure ulcers including a left lateral occiput and a new left occipital wound. 09/13/17: Staff N, Nurse Practitioner, documented a follow up visit for muscle tightness and [DIAGNOSES REDACTED] with range of motion and positioning changes. The muscle relaxant [MEDICATION NAME] was initiated to attempt to decrease tone and improve positioning. 09/22/17: documented a new wound to the occiput below occipital crest. There was no documentation of pressure relieving devices being used for the posterior head found in the progress notes. 10/09/17: Staff N documented the patient with ongoing difficulty positioning and protection from skin breakdown. Increase difficulty with neck flexion backwards. Nursing with attempts to position head forward with use of pillows. 10/24/17: documented moisture associated skin damage on posterior neck. (wound clinic nurse documenting this breakdown as pressure related). 11/02/17: documented physical therapy is currently working with the resident on positioning and will start to get out of bed on 11/02/17. In addition, a pressure relieving dressing has been implemented along with a pressure relieving device being ordered. CARE PLAN 05/24/16: the focus problem was identified as resident at risk for skin breakdown as evidenced by a persistent vegetative state, limited mobility and history of pressure ulcers. Interventions included: apply barrier cream; reposition resident every 2 hours, float heels while in bed, pressure redistribution surfaces to bed as per protocol; utilize positioning devices as appropriate. No resident specific measures for positioning or pressure relieving devices were documented at that time. 08/30/17: the focus problem of actual skin breakdown related to limited mobility with residents multiple pressure ulcers including the left lateral occiput stage 3 ulcer added. 10/12/17: Occipital crest resolved 11/07/17: Occipital crest wound reopened Interventions included: 01/28/17: Dolphin/Flapcair LAL mattress to bed 11/13/17: Allevyn dressing utilized for back of head pressure relief 11/13/17: Foam pillow for pressure offloading of back of head Review of the clinical record revealed an Interdisciplinary Care Plan initiated by the respiratory therapy team. It documented the open area to the posterior neck under [MEDICAL CONDITION] on 10/25/17. Interventions included to apply an ABD pad under [MEDICAL CONDITION] and to change pad daily and as needed if soiled. The neck pressure wound was not addressed in the nursing care plan. Review of the physician's orders [REDACTED]. [MEDICATION NAME], for muscle [DIAGNOSES REDACTED], was ordered on [DATE] and [MEDICATION NAME] (muscle relaxant) was added on 11/01/17. Review of the clinical record also revealed physical therapy did an initial evaluation and plan of care on 08/10/17 for abnormal posture. The goals were to decrease overall tone and increase cervical flexion to improve positioning. Wound care was observed on 12/12/17 at 11:10 AM with the wound care team consisting of the wound clinic nurse practitioner and Staff I, Resident Care Manager. Two open pressure areas were observed on posterior head. One on the lower left occipital area and one at the crest of the occipital area which had undermining. The wound clinic nurse stated that the wounds were finally starting to heal. The wound clinic nurse was observed measuring the wounds, which had decreased in size from the previous week. When she was asked what caused the wound on the top of his head she replied it was probably the foam pillow we were using. He has so much tone he is constantly pushing backward. They are finally starting to heal though. We are packing the top wound and using the Allyven foam dressing on the lower occiput wound. Therapy is also now working with him for positioning. I think that is really helping too. Staff I, Resident Care Manager,stated the neck wound is now healed and the ABD pad is still being used to prevent further breakdown. In an interview on 12/07/17 at 8:40 AM, Staff KK, Registered Nurse (RN), stated we are now using a special dressing on his head wounds which is cushioning and then a special foam pillow with a cut-out where the wound is so it is suspended. We also have him on a every 2 hours turn schedule and his specialized mattress. In an interview on 12/08/17 at 10:08 AM Staff H, RN stated the new type of pressure distribution dressing to his head wound seemed to be helping. She was not sure when it started to be used. In an interview on 12/08/17 at 2:46 PM Staff II, Respiratory Therapist Director, stated the respiratory therapists changed the [MEDICAL CONDITION] ties once a week and as needed, but most residents got them changed twice week. He did develop a wound under the ties so we started to put an ABD pad under the ties after it opened several weeks ago. You'd have to ask nursing if it is getting better. In an interview on 12/11/17 at 9:56 AM, Staff KK stated when the resident first admitted he had no wounds on his head. We just used a regular pillow, a turn schedule, and low air loss mattress with him. When he developed the wound on his head we tried a u-shaped pillow which helped at first but then it got worse so we went to a special foam pillow. Now we have also added the special dressing with foam that helps redistribute the pressure on his head. Therapy is also working with him now. In an interview on 12/12/17 at 8:25 AM, Staff E, Physical Therapy Director, stated physical therapy was now seeing him 3 times a week for his neck contracture and bed positioning. We also have gotten him a tilt in space wheelchair with a special head support to keep pressure off the head wound. He has such abnormal tone and has had minimal response to the medication changes. In an interview on 12/13/17 at 8:24 AM, Staff I stated the posterior neck wound care was coordinated with respiratory therapy. It was pretty superficial and opened and closed several times in the past. We now keep an ABD pad under the ties. It should be on the care plan but since the problem resolved it dropped off. When he came back from the hospital in August his hip ulcer was better but he came back with a new pressure ulcer on his head in addition to the one he developed here. We have been working on those head wounds for a while. We have an algorithim for initiation of pressure relieving equipment. If they come in with no skin issues they are on a standard mattress. If they develop a Stage 2 ulcer we place on a low air loss mattress. If the ulcers worsen we go to a mattress like a flap type. This resident is on a dolphin (advanced) mattress now which seems to be working. It is heartening to see he can heal despite is comorbidities. The head wound is difficult, we have tried different pillows, medications for his tone, and physical therapy for positioning and [DIAGNOSES REDACTED]. It is now starting to respond to treatment. Looks like we are finally on the right track, I wish we had gotten on the right track sooner with him. In summary, the resident presented with multiple risk factors, including persistent vegetative state, diabetes, impaired mobility, incontinence, and increased muscle [DIAGNOSES REDACTED]/tone creating an abnormal posture. The resident was assessed to be at risk for developing pressure ulcers. He first developed a left head wound on 03/03/17 which the wound clinic documented was traumatic, however, the wound bed was 100% eschar and a neck pillow was ordered at that time. He then developed an unstageable pressure wound under his [MEDICAL CONDITION] tie on 04/17/17. There was no documented evidence of pressure relieving attempts being initiated at that time. The wound subsequently healed but the resident developed another pressure wound under the tie on 10/24/17. The wound clinic nurse documented the resident had developed a new pressure ulcer on the back of his head due to positioning on 07/03/17 and then he developed another pressure ulcer on the back of his head on 09/19/17 from his pillow. No documentation was found in the progress notes or care plan addressing offloading pressure to the back of the head until 10/09/17, 11/02/17, and 11/13/17. The care plan was not updated with interventions for the head wounds until 11/13/17. Additionally, physical therapy was not referred for positioning issues until 08/10/17 and muscle relaxant medications were not ordered until 09/15/17. This delay in instituting aggressive pressure relieving measures in a timely manner resulted in harm to the resident when he developed 2 Stage 3 pressure ulcers to the back of his head and one unstageable and one Stage 3 pressure ulcer under his [MEDICAL CONDITION] ties. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to comprehensively assess and monitor the need of physical restraints (wander guard) for 1 of 2 residents (27) reviewed for physical restraints. In addition, the facility failed to obtain consent in the language the resident was able to read/understand, to document ongoing re-evaluation for the need of the restraint, and to ensure least restrictive interventions were attempted prior to use of the restraint. This failed practice caused harm to resident in the form of: diminished quality of life, feelings of sadness, seclusion and imprisonment. Findings included: Resident 27 was admitted to the facility in December 2016 with [DIAGNOSES REDACTED]. In the review of the Minimum Data Set ((MDS) dated [DATE] indicated resident had only moderately impaired cognition. In the review of resident current care plan for discharge goals showed the resident, family and facility were in agreement for him to move to a lesser care setting and the facility Social Worker was searching for an assisted living facility. In the review of resident's current care plan initiated on 10/13/17 for the wander guard stated: Resident/Patient is at risk for elopement related to: Resident/Patient has made one or more attempts to leave the facility during his stay or previous stays in this or other facilities, Alcohol/Smoking-seeking behavior. Interventions noted in Care Plan were as follows: Monitor resident activity every shift and Encourage resident/patient participation in activity preferences. In the review of resident's current care plan for impaired communication stated, The resident has impaired communication as evidenced by language barrier. Speaks and understands minimal English. Primary language is Korean. The goal in the care plan states Resident will use alternative method of communication using interpreter line as needed daily. The interventions to staff for communication with the resident stated Provide preferred (aka, primary) language interpreter services, as indicated. In the review of the investigation report provided by the facility Administrator titled RMS Event Summary Report elopement of resident 27 on 10/13/2017 summarized the event as follows: Resident was wearing street clothes, pants, sweater and jacket with shoes on and Hat. Ambulatory using front wheel walker independently. Stable per baseline. No signs of any acute respiratory distress noted. Denies pain and discomfort. The summary of the interview with the resident stated, Resident reported that he want to go to Wal-Mart to buy cigarette and come back to the facility. Resident was able to identify and elaborate to staff his intention. The corrective action on the report identified that a Wander Guard to resident at all times for safety. Educate/encourage resident to notify nursing if he want anything in particular from the store and resident will need to sign out with family if he decides to go out for any reason, and MD has to be notified. In a review of the Speech Therapy Progress Report from 10/30/17 through 11/14/17 services to trial and train strategies to increase patient's ability to follow safety recommendations revealed, education on use of both English and Korean for increased comprehension, recall and problem solving for safety. It went on to state Patient was able recall safety recommendations with 80% accuracy given min (minimum) cues and 100% accuracy given moderate cues. In the review of the facility policy titled Communication with Persons with Limited English Proficiency (LEP) stated, When translation of vital documents is needed, locations will work with Language Line to ensure that accurate oral translation of written materials is provided. In the review of the progress notes from 09/01/17 through 12/07/17 showed multiple entries from licensed nursing staff that described the resident as alert and oriented able to make needs known. In an entry dated, 10/20/17 Resident sad to wear wander guard. Talked with the administrator, now we have to find a solution. There were no entries found in the progress notes of resident exit seeking prior to or after the incident recorded on 10/13/17 when the resident left the facility to go to Walmart. In the review of the flow sheet note book on the medication cart for the resident; there was no behavior monitoring sheet for the resident in the book. During the survey there were multiple observations of the resident sitting near a window adjacent to the facility dining room. Resident was observed ambulating independently using his front wheel walker between his room and this location daily. There were no observations of resident attempts to exit building during the survey period. In an interview with Resident 27 on 12/05/17 at 9:42 AM he stated, he was not allowed to leave the building without permission from the staff. Resident stated he did not agree to have the bracelet (wander guard) on his arm, and he was not given a choice. It was against his will to have it, and he feels trapped and imprisoned here. In a second interview with the resident on 12/08/17 at 12:50 PM, the paperwork was reviewed regarding his wander guard. The resident was not able to read the document named Restrictive Device Consent written in English. Resident indicated that was his signature at the bottom of the page, but stated he did not know what he had signed. It was explained to him that he signed the consent for the wander guard, and pointed to the device on his wrist; he shook his head side to side and said, Oh, I didn't know that was what it meant, no one told me what I was signing. The resident further stated that the alarm goes off when he goes near the front door. The resident stated that he liked to go outside on the property to get fresh air. The resident stated that he was not able to get fresh air anymore, and he requested please help me, I don't want this on me, I don't like it, it makes me sad. In an interview with Staff X, Recreation Director, on 12/08/17 at 1:36 PM, she stated that Resident 27 was wearing a wander guard because he left the facility to go to Walmart by himself. Staff X stated when they put it on initially, he pointed to it, and I am not sure what he said, but he looked at it as if confused. When asked if the facility involved her with any interventions to help prevent resident from leaving the facility alone, she stated they asked me to call his family on the phone to see if they could come to the facility on ce a week and take him shopping. When Staff X was asked, did the facility ask you to include the resident in the facility shopping activities or take him outside? Staff X responded, No. In an interview with Staff Y, Social Service Director on 12/11/17 at 2:17 PM. she stated, I think he is totally appropriate to go to an assisted living, which is a lesser care setting. I am not sure why they made the decision to put a wander guard on him, I am not aware of anymore exit seeking attempts. In an interview with Staff B, Resident Care Manager on 12/11/17 at 2:37 PM, she stated the resident was wearing a wander guard because he left the facility to go to Walmart. Staff B stated, nursing was not monitoring this resident for behaviors, they were monitoring on the Medication Administration Record [REDACTED]. When asked if there were any reports of resident exit seeking since the incident that occurred on 10/13/17, Staff B stated I have no reports that he has exit seek since. In an interview with Staff E, Physical Therapy/Director on 12/11/17 at 3:25 PM, she stated, therapy did not make a recommendation for wander guard, but to assess for his safety when out in the community. When asked if she was aware of any exit seeking attempts since the Walmart incident, she stated I am not aware, but resident was found in the downstairs of the facility. When asked if he had been told that he was not allowed downstairs, Staff E responded I don't know. In summary, the facility did not ensure that the resident was informed of the physical restraint in a language that he understands and alternatives to restraint use. There were no documented interventions or less restrictive alternatives attempted and shown to be ineffective prior to use of the wander guard. Additionally, the facility failed to monitor and document ongoing re-evaluation of the need for the restraint. Reference: (WAC) 388-97-0620 1(a)(b) 2(d) 3(b) 4(a)(b)(c)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sample residents (20) reviewed for bladder and bowel functions received appropriate care and services necessary to maintain and avoid loss of bowel and bladder functions. This failed practice caused harm to Resident 20 when her bowel and bladder function declined from always continent, to frequently incontinent, and eventually resulting to severe fungal rash, moisture associated [MEDICAL CONDITION] and caused pain. Findings included: RESIDENT 20 Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In a review of the resident admission assessment on 12/05/17, the facility identified the resident as continent of bowel and bladder. In a review of the most recent Minimum Data Set (MDS) Assessment, showed the resident urinary continence as frequently incontinent, and bowel continence as occasionally incontinent. The resident was identified needing 2 person assistance from staff for bed mobility, transfer and toileting task. In a review of the facility's most recent comprehensive nursing expanded assessment, dated 09/27/17, showed the resident was incontinent of bowel and bladder, not currently on a toileting program, and no trial of toileting program has been attempted since urinary and bowel incontinence was noted. In a review of the resident care plan showed, the resident was occasionally incontinent of urine and bowel, with potential for improved control or management of urinary/bowel elimination related to decreased functional mobility. Interventions included; assist the resident to the toilet at scheduled times, upon rising, before meals, at bedtime and as needed, and provide verbal cues and physical assistance as needed. In a review of the resident bladder pattern from 11/07/17 to 12/06/17, showed the resident was always incontinent of bladder. In a review of the resident elimination pattern from 11/08/17 to 12/07/17, showed the resident was occasionally continent of bowel. In an interview with Resident 20 on 12/05/17 at 1:50 PM, resident was asked How long have you had bladder and/or bowel incontinence?, and to describe how you were involved in developing your care plan for improving and maintaining her continence. The resident stated, I am incontinent of both. No, no one here discussed anything to address my bowel and bladder functions that I can remember. The resident was asked, Do you know what the plan is to improve your continence, and what type of interventions are being provided? The resident responded, No. I called them when I need to go, but most of the time cannot get here on time. Resident added, most of the time, I will have accidents. But I wear briefs. Another questions was asked. What happens when you ask assistance to go to the bathroom? How do the staff respond to you if you have can't make it to the bathroom in time? and, Has your incontinence impacted your involvement in activities, mood, or ability to function? The resident stated They will just clean me. It will take them about 45 minutes to an hour sometimes to respond because they will go on breaks. I sometimes have to go in my brief. The resident further stated, she felt bad, and it was humiliating for her to urinate and had bowel movement in her brief. The resident reported, she ended up with rash, painful sores to her bottom/peri area because of incontinence. The resident stated, the staff are putting powder and cream to her buttock area, and she was also taking pain medication every night to manage the pain. In a review of the resident Physician order [REDACTED]. For severe fungal rash. In a review of the resident Care Plan showed the resident had an actual skin breakdown related to incontinence, limited mobility: MASD (Moisture Associated Skin Damage) to buttock. In a review of the resident Medication Administration Record [REDACTED]= 10mg dose) by mouth everyday at bedtime for pain. During an observation at 3:09 PM, the resident just came back from smoking. The resident had urine odor coming from her wheelchair. The resident was asked when the last time she was toileted, the resident stated I wasn't toileted. They changed my brief this morning. During an observation on 12/06/17 at 10:30 AM, the resident was still in bed. The resident turned her call light on. Staff A, Licensed Practical Nurse (LPN), and Staff C, Certified Nursing Assistant (CNA), responded and answered the call light at 10:34 AM. The resident requested to get up in bed, and she was assisted to her wheelchair. In an interview with Staff C at 11:05 AM, stated, the resident was incontinent of bowel and bladder. We just clean the resident in bed every morning. She wears brief. Sometimes we toilet her, but she is usually incontinent. Staff C was asked if the resident was on a toileting program, Staff C responded, No. In an interview with Staff A at 11:10 AM, stated, Resident 20 is incontinent. She was changed in bed today, I put the cream on her after the aide cleaned her. Staff A was asked if the resident was currently on a toileting program. Staff A responded, No. When asked if the resident will benefit for a toileting program, Staff A responded, Yes. In a follow-up interview with the resident at 1:30 PM, the resident stated I can still feel the urge to urinate or defecate. They just need to help me, and get here on time. Who wants to urinate and defecate on their pants? In an interview with Staff B, Resident Care Manager (RCM), at approximately 2:00 PM, stated, the resident was incontinent of bowel and bladder. It was very difficult for the staff because Resident 20 had her own routine. Staff B further stated The resident will call for help when she needed to go the bathroom, and that was the only time they will toilet her. According to Staff B, the resident often will refuse help from staff when offered. When asked if a trial of toileting program and bowel retraining program was recently initiated, Staff B stated, No. There was no documentation the facility had identified, comprehensively and accurately assessed, or treated/addressed Resident 20's bladder and bowel incontinence which resulted in the development of MASD, severe fungal rash, feeling of self humiliation and pain. Resident 20's bowel and bladder incontinence issues had been care planned, but there was no documentation in the medical record that the facility had attempted, initiate or considered a trial for bowel and bladder retraining to further improve or restore continence. In addition, there was no documentation in Resident 20's medical record from admission to 12/07/17 that a facility physician, or a specialist had identified, assessed, or provided any treatment or services to achieve or maintain as much normal bowel and bladder function as possible for Resident 20. Reference: (WAC) 388-97-1060 (2)(a)(iii)

Based on interview and record review, the facility failed to reassess, report and provide effective pain management for 1 of 3 residents (51) with end [MEDICAL CONDITION] and on Comfort/ Palliative care. This failure caused harm to the resident by not alleviating the resident's pain during routine tasks such as repositioning and peri-care. Additionally this failure compromised the resident's quality of life during the end of life period. Findings included: The National Institute of Aging (www.nia.nih.gov) defines comfort care as care that helps or soothes a person who is dying. The goals are to prevent or relieve suffering as much as possible and to improve quality of life by reducing physical discomfort such as pain, breathing problems and fatigue. Resident 51 admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. Interviews conducted and review of the clinical record showed the resident was placed on Comfort Care on [DATE] as a result of [MEDICAL CONDITION] progression. The interviews and clinical record also showed the resident had a significant increase in pain as a result of [MEDICAL CONDITION] and became nonverbal one to two weeks before he expired. Record review of the facility's policy titled Palliative and/or End of Life Policy stated, Staff will provide supportive care to minimize symptoms and/or allow the patient to die with grace, dignity and comfort in accordance with his/her wishes. The policy also stated to develop a patient centered care plan may address, but is not limited to: pain, respiratory symptoms and psychosocial needs. Record review of the facility's policy titled Pain Management dated [DATE] stated the following: 1. The purpose of the policy stated, To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat and evaluate pain. 2. To design a plan of care to achieve an optimal balance between pain relief and preservation of function in accordance with patient directed goals. 3. If a patient has a change in pain status, complete a pain evaluation (electronic) 4. Patients who have unstable pain management will be indicated on the 24hr Summary Report. 5. The care plan will be evaluated for effectiveness until satisfactory pain management is achieved a. Contact the physician/APN/PA to report findings and obtain revised treatment orders. b. Revise the care plan as indicated. Review of the resident's Minimum Data Set (MDS), dated [DATE], showed the resident scored 15 on the Brief Interview for Mental Status (BIMS) and was verbally able to make his needs known. The MDS showed he was able to ambulate with a walker with 1 person assist. As previously mentioned, progress notes reviewed indicated the resident was placed on Comfort Care on [DATE]. The resident had a rapid decline in function/cognition, became bedridden and non-verbal 10 days prior to his death on [DATE]. However a Significant Change MDS was not completed to identify needs in accordance with his decline and comfort care status up until his death. Review of the Care Area Assessment (CAA), identified causes for the resident's pain. However, sections to describe the residents pain, frequency and intensity (how often it occurs, how long it lasts, time or situation of onset) or acceptable/baseline levels of pain were not summarized or completed. Additionally, sections on non-verbal indicators for pain such as (frowning, grimacing, moaning, groaning or guarding) were not summarized or completed. Review of the residents care plan to address pain dated [DATE], stated goals for pain as the Resident will achieve acceptable level of pain control x90 days. Interventions included the following: 1. Evaluate pain characteristics, quality, Severity, location, precipitating factors 2. Advise resident to request pain medication before pain becomes severe 3. Monitor for non-verbal signs/symptoms of pain and medicate as ordered. 4. Complete pain assessment per protocol. Review of the clinical record did not show any revisions made to the care plan to address the resident's decline in function, cognition, increased pain levels and comfort care needs. Review of the progress notes from [DATE] to [DATE] showed the resident had an increase in growth on the left side of his neck where [MEDICAL CONDITION] was located. The progress notes also showed the resident was medicated for pain in his back where he had unhealed pressure ulcers on multiple occasions. However the progress notes did not show any communication to a Physician or a qualified provider the resident was still having significant pain during repositioning and peri-care or the current pain regimen was ineffective. Review of the Medication Administration Record (MAR) for the month of November, showed the resident received 2 doses of [MEDICATION NAME] (Narcotic Pain Medication) from [DATE] to [DATE]. However, the MAR showed he received 24 doses of the medication from [DATE] to [DATE]. The December MAR showed the resident received 6 doses of the [MEDICATION NAME] and 9 doses of [MEDICATION NAME] (another narcotic pain medication added on ,[DATE]). The MAR showed his pain levels ranged from ,[DATE]- ,[DATE] on the pain scale. (0 for the least pain and 10 being the most). In an observation on [DATE] at 12:36 PM, during care being provided by the Respiratory Therapist (RT), the resident was observed guarding his neck area with his hands, was restless and was trying to speak with facial grimacing while pointing to his neck area. In an interview on [DATE] at 1:25 PM, the resident's wife stated the resident was getting pain medication and was able to communicate pain through facial expressions. She stated the resident was in so much pain all the time and grimaced with any ROM. The staff eventually stopped doing any range of motion (ROM) exercises because of the pain. When she was asked where she thought the pain was coming from, she stated from [MEDICAL CONDITION]. She also stated the resident did not get up for this reason. At 1:49 PM, Staff Q and Staff R, Nursing Assistants (NA), stated the resident had not gotten up in his wheelchair or received ROM for 2 weeks since the neck tumors had grown significantly and also due to extreme pain. Staff Q and Staff R stated the resident was having extreme pain during peri-care and repositioning in bed. In an interview on [DATE] at 10:52 AM, Staff T, Licensed Practical Nurse (LPN), stated the resident was getting up with Physical Therapy (PT) and doing other activities up until about 2 weeks. Staff T stated the resident recently had been having continuous pain even after taking the medication because of [MEDICAL CONDITION] which had spread. He stated he had communicated this with the Doctor. When he was asked if communication with the Doctor was documented he said Yes. No documentation of this could be found in the clinical record. At 11:40 AM, Staff U, Medical Doctor (MD) was asked if he was aware the resident was having significant pain during daily tasks and he stated he was not aware. He continued to state in a loud voice Nobody told me until today. They did not tell me! I wrote an order to give the resident as much pain medicine as he wants. In an interview on [DATE] at 1:56 PM, Staff N, Nurse Practitioner (NP), stated the goal was to keep the resident stable such as preventing shortness of breath, anxiety and pain management. For any additional concerns with resident's pain, she stated she relied on staff to notify her. Staff N stated the increase of the tumors on his neck were painful to the touch and it was reported to her he was having pain when using the Hoyer lift and repositioning. In an interview at 2:14 PM, Staff T, LPN, stated the resident was having pain during peri-care or when being repositioned. When he was asked if the residents increase in pain during the last week of the resident's life was communicated, he stated the NP was not in the facility and stated he reported to Staff U, MD, about the resident's pain the day before the resident passed away. Summary The progress notes showed the resident started having an increase in his pain on [DATE] as shown by the increase in the number of pain medications given and recorded on the MAR. This is around the same time the note stated the resident had increase in the size of his neck tumors. It was not until 14 days later, another Narcotic pain medication was added, however, did not provide effective pain relief as observations made, interviews from staff reported the resident was having extreme pain with peri-care and repositioning. The facility did not follow their policy on revising the care plan as needed to identify goals/ interventions for comfort care which included effective pain management. The facility also failed to notify a Physician or qualified professional regarding the resident's ineffective pain regimen, therefore adequate pain management was never achieved until the day before the resident died . Reference: (WAC): [DATE] (1)

Based on observation, interview and record review, the facility failed to ensure 3 of 5 residents (51, 20, 49) were free of unnecessary drugs due to lack of monitoring and care planning, use of an inappropriate medication to treat dry skin, and lack of assessment for safe self-administration of medications. This failure caused harm to Resident 51 who experienced unrecognized signs of symptoms of bleeding while receiving an anticoagulant (blood thinning) medication and staff did not respond appropriately or consult with the resident's medical providers. Findings included: Manufacture recommendations regarding the use of [MEDICATION NAME] (blood thinning medication) stated the drug was contraindicated if there were signs and symptoms of bleeding such as black tarry stools, coffee ground emesis (vomit that is indicative of bleeding) and hemorrhagic [MEDICAL CONDITION] ([MEDICAL CONDITION] caused by bleeding and diagnosed by low hemoglobin). Indications for the use of the drug were that it was typically used to prevent the formation of blood clots. Recommended dosing to prevent [MEDICAL CONDITION] (blood clots in the veins) was recommended at 40mg once a day until the risk of blood clots was reduced. RESIDENT 51 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The progress notes showed the resident was able to make his needs known until he became non-verbal due to the increased growth of [MEDICAL CONDITION]. Review of the Minimum Data Set (MDS) assessment, dated 11/08/17, identified the resident taking an anti-coagulant, however review of the Care Area Assessments (CAA) showed the anticoagulant was not identified. No summaries or recommendations regarding the medication use, monitoring or safety precautions for the resident were completed. Review of the resident's care plan dated 11/01/17 showed goals for the use of the medication; interventions to include monitoring, safety precautions and reporting were not developed for the duration of the residents stay. He passed on 12/07/17. Review of the Medication Administration Records (MAR) showed the resident was administered the medication [MEDICATION NAME] via injections twice daily from 11/01/17 to 11/20/17 at 60mg per administration. The medication was held on 11/21/17. Review of the progress note dated 11/04/17 showed the resident had an episode of coffee ground emesis. The note showed the doctor was made aware, with no new orders given. Further review of the progress note dated 11/21/17, showed the medication was held due to bleeding in the resident's [MEDICAL CONDITION] with the MAR indicated [REDACTED]. Review of the resident's lab reports from 11/06/17 to 11/22/17 showed the residents Hemoglobin had dropped from 9.1 to 7.2 during this period. The same lab reports reviewed showed normal ranges for Hemoglobin at 13.2 - 17.0. Review of the entire progress note showed these abnormal lab values were not reported to a physician or qualified professional with no interventions during the time the resident was administered the blood thinning medication. In an observation on 12/04/17 at 12:39 PM, dried blood was observed on the resident's neck area, and an intravenous line on his right arm showed signs of dried blood under the transparent dressing. In an interview on 12/11/17 at 2:08 PM, Staff N, Nurse Practitioner, was asked what the plan was to address the resident's low hemoglobin, she stated she was trending the resident's hemoglobin and there was no concern at this time. When asked if there were any concerns with any bleeding the resident may have had, she stated no concerns were reported to her. In an interview at 2:23 PM, Staff T, Licensed Practical Nurse (LPN), was asked what was done when a resident was on a blood thinner and had signs and symptoms of bleeding. He stated they would hold the blood thinner and call the doctor. He stated the resident did not have any signs and symptoms of bleeding, did not know of any bleeding events, and that critical labs were reported to the MD. In an interview at 2:30 PM, Staff I, Registered Nurse (RN), was asked what was done when a resident on a blood thinner was suspected of bleeding. Staff I stated the nurse would assess and notify the doctor. She stated she would hold the next dose until further orders and notify the family. Staff I stated she could not recall any signs and symptoms of bleeding the resident may have had. In a joint review of the chart she was asked if the resident was taking any blood thinners. She stated the resident was on [MEDICATION NAME] for [MEDICAL CONDITION] (to prevent blood clots in the vein) that was discontinued on 11/22/17. Upon further review of the chart, she stated the resident had bleeding and bloody secretions from his [MEDICAL CONDITION]. Staff I was also asked what she would do if a resident had coffee ground emesis, she stated based on her nursing judgment, she would hold the blood thinner until she spoke to a provider for further guidance. When she was asked what kind of monitoring should be done for a resident on [MEDICATION NAME], she stated she would monitor for bleeding and any resident on anticoagulant therapy should have an anticoagulant care plan. When she was asked what goals and interventions should be in place for anticoagulant therapy, she stated I would monitor vital signs, active bleeding and lab results. When asked if the resident had an anticoagulant care plan, she looked in the computer, could not find any care plan and stated it should have been put in place upon admission. In a follow up interview on 12/13/17 at 12:20 PM, Staff I was asked if she thought the blood thinner should have been held when the resident had coffee ground emesis. She stated Well I can't speak of what the ARNP rationale was at the time, so I can't speak of why the medication was not held. When asked if she thought the medication should have been held, Staff I refused to comment. In a joint review of the chart with Staff I, it showed the Nurse Practitioner (NP) was notified. However, review of the NP notes showed there was no documentation of the resident's coffee ground emesis, the abnormal hemoglobin lab results, interventions to address bleeding, or the abnormal Hemoglobin lab results. Summary Indications for the use of the [MEDICATION NAME] were clearly justified, however when the resident 1st presented with signs and symptoms of bleeding, the medication was not held and consultation to a physician or qualified professional did not occur and may have contributed to further bleeding through his [MEDICAL CONDITION]. Furthermore, the resident experienced a significant decrease in his hemoglobin which would have also warranted holding the medication until further consultation with a physician or qualified professional. An anticoagulation care plan was not developed. An anticoagulation care plan would have included goals and interventions for the medication and would have better directed staff on what kind of monitoring was needed and what to do in the event of an adverse reaction. RESIDENT 20 In a review of the resident's Physician order [REDACTED]. In a review of the resident's MARs and Treatment Administration Records, for November and December 2017, showed the resident received the [MEDICATION NAME] Powder twice a day. In a review of the resident's skin care plan, revealed, Resident has actual skin breakdown related to shear/friction risks, impaired sensation, moisture/excessive perspiration, incontinence, limited mobility, MASD (moisture associated skin disorder) to buttock, MASD under breasts, psoriasis rash to face, raised [MEDICAL CONDITION] in groin, abdominal fold, back, and bottom. The care plan was initiated on 01/14/15 and last reviewed/revised on 01/20/16. In an interview with the resident at approximately 11:00 AM, the resident stated, she had psoriasis, and she believed that was the reason why she was getting the powder applied to her skin. The resident stated, I really don't know the reason why I am getting an antifungal powder. In an interview at approximately 2:10 PM with Staff H, Regional Nurse Consultant/Infection Control Nurse, stated, The Treatment order was not appropriate. [MEDICATION NAME] should not be used for dry skin. Refer to F684 - Quality of Care for more information. RESIDENT 49 Resident 49 was admitted to the facility in October 2017 for rehabilitation therapy following a hip surgery. In a review of the resident's most recent MDS assessment, dated 11/03/17, showed the resident had intact cognition. In a review of the resident's Physician order [REDACTED]. During an observation on 12/11/17 at 9:19 AM, the resident was observed to have a small plastic container of the artificial lubricating eye drops at her bedside table. There were also two prescription bottles observed at the bedside, labelled Aspirin. Both the prescription bottles, and the eye drops were uncovered and not secured, mixed with other clutter (newspaper, personal purse, and fruit bowl). The resident was observed to self-administer the eye drops during this observation. In an interview with the resident at the time of the observation, the resident stated, she kept her eye drops and two bottles of Aspirin with her at bedside. I am not allowed to keep any prescription medications at bedside. Aspirin and eye drops are ok I think, they don't care about that. The Resident further stated, I take 1 or 2 Aspirin tablets when I need to. In a review of the resident's clinical assessments from admission to 12/11/17, showed no clinical assessments, or care planning completed for the resident to keep and manage own medications at bedside. In an interview at approximately 10:00 AM with Staff B, Resident Care Manager (RCM), she stated she was not aware that Resident 49 had medications at bedside. Staff B further stated, I will take care of it as soon as possible, call the doctor and follow-up with the resident and the nurse. Reference: (WAC) 388-97-1060 (3)(k)(i)

Based on observation, interview and record review, the facility failed to comprehensively assess and revise interventions as needed to prevent significant weight loss/gain for 2 of 5 sampled residents (35 and 20) reviewed for nutritional status and weight loss. These failure caused harm, and placed the residents at significant risk for decline in nutritional status and related complications. RESIDENT 35 Resident 35 was admitted to the facility in December 2016. [DIAGNOSES REDACTED]. In a review of the most recent Minimum Data Set (MDS) assessment, dated 10/25/17, showed the resident needed 1 person extensive assistance from staff with eating. In a review of the resident care plan, showed the resident required limited assistance for set up and assist for all meals. Resident was identified as at nutritional risk related to [MEDICAL CONDITION], Cognitive Deficit, and Gastro[DIAGNOSES REDACTED] Ulcer. Interventions included: Offer alternate food choices if < (less than) 50% consumed at mealtime. In a review of the resident's Weight Summary showed the following weights: 12/21/16: (admission) 142.8 pounds (lbs.) 02/18/17: 144.7 lbs. 05/18/17: 136 lbs. 06/17/17: 134.5 lbs. 07/17/17: 135.2 lbs. 08/18/17: 135 lbs. 09/17/17: 132 lbs. 10/17/17: 123.5 lbs. 11/17/17: 120 lbs. 12/06/17: 117 lbs. The resident weight on 06/17/17 was 134.5 lbs. The resident weight on 12/06/17 was 120 lbs. A loss of 14.5 lbs. in 6 months, a 10.78% loss of body weight. The resident's weight continued to decline. The weight on 12/06/17 was 117 lbs. which totaled a significant weight loss of 17.5 lbs. from 06/17/17 to 12/06/17, a 13.01% loss of body weight. In a review of the Nursing Assessment Expanded completed on 07/25/17, showed the resident had obvious or likely cavity or broken natural teeth, and had multiple upper and lower teeth were broken and decayed, Dental consult requested. In a review of the Dental Care Plan initiated on 12/20/16, showed the resident to have dental caries, chipped teeth, and inflamed gums. In a review of the dietary assessment, dated 07/25/17, completed by Staff L, Registered Dietician (RD) stated, the resident weight had progressively increased since admission, and that the resident appetite has been good. Staff C documented Resident 35 was not nutritional risk. In a review of the Speech Therapy Notes dated 07/26/17 identified the resident to had mild oropharyngeal dysphagia, and skilled Speech Therapy services were recommended. Resident continued working with Speech Therapy until 08/08/17. In a review of the Speech Therapy Notes dated 08/08/17, showed the resident required aspiration precautions, and the resident was able to eat food with diet consistency of puree solids with nectar thick liquids with no signs and symptoms of aspirations, and the resident was able to perform the task with moderate cues. In a review of the ARNP (Advanced Registered Nurse Practitioner) note dated 10/01/17, stated, During meals found difficulty managing fluids with notable coughing when neck flexed backward. The ARNP also documented that there was a significant concern related to body positioning as it affected adequate swallowing, and management of oral secretions. In a review of the ARNP note dated 10/17/17, stated Today, noted with high risk of aspiration as found with inability to initiate swallowing, holding both food and liquid in the mouth. Cued to initiate swallow, noting some throat movement but mouth remaining full of breakfast. In a review of the Nutrition and nursing notes dated 10/17/17, showed the ARNP had requested a care conference to discuss the resident decline and inability to consistently initiate swallowing, and the risk of aspiration. In a review of the care conference notes, dated 10/18/17, attended by the resident family member (son), nursing representative/staff, and social services, stated IDT discussed res (resident) change in condition with res son. ST (Speech Therapist) provided education in regards to res inconsistent swallowing and the safety of this. NSG (nursing), and SW (social worker) reviewed res AD (advance directives-POLST (physician's orders [REDACTED]. In a review of the Nursing Assessment Expanded completed on 10/25/17, identified the resident had obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, and was coughing or choking during meals or when swallowing medications. In a review of the dietary assessment, dated 10/25/17, completed by Staff L, Registered Dietician, stated, the resident weight had progressively increased since admission. The resident's diet was downgraded due to the resident holding/pocketing food and increased risk of aspiration. Son was made aware of the risk of aspiration and he wants to continue to let pt (patient) take PO (by mouth). He has signed a risk and benefit form. Staff C also documented that the resident was eating 25-50% of meals with supplements, and that weight loss maybe unavoidable with advancement of the resident disease and dysphagia. However, section c of the dietary assessment identified, the resident had no swallowing issues and no deficit was noted. In a review of the nutrition notes dated 11/01/17, identified resident to have significant weight loss, and further weight loss may be unavoidable due to worsening dysphagia. Family was not interested in nutrition support at this time, ARNP is aware. In a review of the Physician order [REDACTED]. an order for [REDACTED]. In a review of the Speech Therapy notes dated 12/05/17, stated, resident to have severe oropharyngeal dysphagia, decreased mastication strength. Premature spillage of secretions and bolus noted intermittently, which appears to increase as meal progresses 2/2 fatigue, increasing aspiration risk. Notes further stated, Pt (patient) able to eat approximately 25% prior to significant holding, suspect 2/2 (secondary to) fatigue. In a review of meal monitors for November 2017 to December 2017, showed the resident was consuming approximately 25-75% of meals, with rare consumptions of 100%. Review of snacks offered other than meals was documented as not applicable. In an interview on 12/07/17 at 2:05 PM Staff D, Certified Nursing Assistant (CNA), was asked on how the facility identify concerns with oral intake and weights, Staff D stated, If the CNA has concern with resident meal or fluid intake, they will notify the nurse. Then the nurse will monitor and the RD will be notified also. For Resident 35, he had serious swallowing problems. He choked and cough with his liquids, but not his food. It just takes time. In an interview at approximately 2:10 PM, Staff A, Licensed Practical Nurse (LPN), was asked how the facility identified concerns with oral intake and weights. Staff A stated, We monitor them. The meal monitor for example, if they are eating less than 50%, we report to the dietician and the nurse practitioner. Staff A further stated, Resident 35 had issues with swallowing, and that the resident choked mostly with his liquids. Staff A confirmed that the resident was not on any nutritional supplement. According to staff A, Resident 35 was just recently seen by Speech Therapy. In an observation on 12/08/17 at 12:15 PM, the resident was observed in the dining room during lunch. Resident was able to take small bites, and drink his fluids with assistance from staff. The resident was observed to cough 2 times during this meal observation. Resident consumed approximately 25% of his meal. There was no supplements, or alternatives given to the resident. The resident went straight to bed after lunch. In an interview at 1:05 PM with Staff B, Resident Care Manager (RCM), stated, I am not aware of any supplements ordered for the resident. There was no order for it, and he is on comfort care. Staff B showed the resident POLST form that was marked as DNR (do not resuscitate), comfort measures only, and no artificial nutrition by tube. According to Staff B, the resident was not in palliative care or hospice care, just comfort care, as marked in the POLST. Staff B was asked if there was a discussion made between the facility and the resident representative to consider having consultation with a specialist, or have a study done to rule out the pathology of the resident swallowing issues, assess the resident oral cavity for sores, and pain, or comprehensive medication review that may have caused the resident to pocket his food, Staff B responded No. In a review of the resident care plan, it showed no evidence of comfort care approaches, interventions or goals. In a follow-up interview Staff B stated, They haven't made the comfort care official yet. In an interview with Staff L on 12/13/17 at 9:04 AM, stated, Resident 35 was in comfort care. He was on magic cup supplement back in October and we just stopped it around November. Staff L further stated the facility have tried most nutritional interventions, especially with his fluids but not with his meals. According to Staff L, We have not enhanced his meal or fortified it, because we are limited on what we can do here. I can check with the higher ups and see if that is something we can do here. In a follow-up interview at 9:45 AM, Staff L stated that she confirmed with administration that fortifying food, and enhancing meals is something they can do. Staff L further stated, I guess we have not tried everything, we can try these approaches in the future. The last documented weight in the clinical record dated 12/06/17 was 117 lbs. There were no further documentation in the clinical record to follow up on the resident concerns of weight loss. The resident continued to lose weight, and there was no documentation in the clinical records that a thorough assessment, consultations, or follow-up were made to address and rule out the root cause of swallowing/chewing concerns for Resident 35. Further review of the resident medical records showed no further interventions or documentation in the clinical record that any additional noninvasive/ non-aggressive nutritional interventions were either discussed and/or attempted for the resident. There was no clear documentation that the resident was on either comfort/palliative care, and/or hospice. RESIDENT 20 Resident 20 was admitted to the facility in April 2015 with [DIAGNOSES REDACTED]. In a review of the most recent Minimum Data Set (MDS) assessment identified the resident as having intact cognition, and was independent with eating, and required only set up help from staff. A review of the resident's Weight Summary showed the following weights: 02/10/17: 280.0 pounds (lbs.) 03/13/17: 247.4 lbs. 04/17/17: 249.8 lbs. 05/22/17: 286.4 lbs. 06/06/17: 250 lbs. 08/09/17: 275.5 lbs. 08/17/17: 275 lbs. 11/12/17: 275 lbs. The resident weight on 02/10/17 was 280 lbs. The resident weight on 03/13/17 was 247.4 lbs., a loss of 32.6 lbs. in 32 days, and 11.64 % loss of body weight. The resident's weight abruptly increased to 286.4 lbs. on 05/22/17, then dropped again to 250 lbs. on 06/06/17. The resident's most recent weight was 275 lbs. A significant weight gain of 15 lbs., and a 10 % gain in body weight. In a review of the dietary assessment, dated 03/27/17, completed by Staff L, Registered Dietician (RD) stated, Pt (patient) is not always compliant w/ (with) weight checks. A re-weight was requested in February however pt refused. Unclear if Feb (February) weight is accurate. She is noted to have refused some meals recently. Staff C documented Resident 20 was not nutritional risk, and that there was no concerns identified. In a review of the subsequent dietary assessment, dated 06/27/17 and 09/27/17, showed the resident was not always compliant with weight checks, and the weight from May 2017 was most likely an error. Interventions included: The facility will request a recheck of weight because of the resident history of non-compliance with diet. The note further stated, the resident was noted to have refused some meals mostly during breakfast. Resident was documented to not have any weight loss or gain, and that there was no concerns identified. In a review of the ARNP note dated 03/16/17, showed no mention of weight changes/concerns to the resident. Subsequent ARNP notes dated 06/14/17, 06/16/17, 08/22/17, 08/28/17, and 09/25/17, showed no weight concerns. In a review of the ARNP note dated 11/19/17, identified resident to be at 275 lbs., and a weight warning was triggered, Warnings: +7.5% change, False. The weight warning was not followed up on, or discussed in the note. In a review of the nutrition progress notes dated 03/27/17 and 06/27/17, stated No Concern(s) identified. In a review of the Weight change note dated 09/19/17, completed by Staff L, showed a weight warning indicating a 7.5% change. The note stated Pt. is triggering for weight fluctuations. - Requested nursing obtain an updated weight to evaluate. Pt does not appear to have any significant weight changes. Appetite has been good and stable. Will continue to follow. Further review of the weight records revealed the resident weight was not obtained until 11/20/17. In a review of meal monitor for November 2017 to December 2017 showed resident consistently refused breakfast, and occasionally ate 25 to 75% of lunch and 75-100% of dinner. In a review of the Physician order [REDACTED]. During multiple observations on 12/04/17, 12/05/17, 12/06/17, and 12/07/17, resident did not eat or have breakfast. Resident stayed in bed until approximately 10:00 AM to 11:00 AM. In a review of the resident care plans and clinical records on 12/05/17, identified the resident was at nutritional risk: weight gain/loss r/t (related to) excessive caloric intake and limited mobility aeb (as evidenced by) diet recall, weight record. The nutrition care plan focus and interventions were initiated on 04/07/15 and revised on 05/18/15. In an interview on 12/07/17 at 2:05 PM, Staff D, was asked how the facility identified concerns with oral intake and weights, Staff D stated, If the CNA has concern with resident meal or fluid intake, they will notify the nurse. Then the nurse will monitor and the RD will be notified also. Staff D stated that she was not aware of any weight changes for Resident 20. In an interview at approximately 2:10 PM, Staff A, was asked how the facility identified concerns with oral intake and weights. Staff A stated, We monitor them. The meal monitor for example, if they are eating less than 50%, we report to the dietician and the nurse practitioner. Staff A further stated, she was not aware of any weight problems with Resident 20. In an interview with Staff L on 12/08/17 at 10:07 AM, stated, the weight loss for Resident 20 was not addressed because the resident refused a re-weigh. Staff L further stated, We did not addressed the other weight changes either because I assume the weight was an error. When asked, if the care plan needs to be updated, Staff L responded, yes, and Staff L was not sure why the care plan was not updated. In an interview with the resident's attending Physician (MD), stated, he was not sure if he was notified regarding the resident weight loss and gain. MD reviewed previous notes and stated, Resident 20's weight loss or gain was not addressed in my notes. MD confirmed that the resident was not on a physician prescribed planned weight loss or gain. Reference WAC: 388-97-1000 (1)(b)(2)(k) - 1060 (3)(h)

Based on observation, interview and record review, the facility failed thoroughly assess and monitor equipment related devices in relationship to skin integrity for 2 of 2 residents (3 & 4). Failure to follow the facility policy on skin integrity management, resulted in harm for Resident 3 who developed an avoidable pressure ulcer (PU), deterioration of pressure ulcers and placed Resident 4 at risk of deterioration of a pressure ulcer due to inadequate pressure relief. Findings included: The facility's policy for Skin Integrity Management indicated staff are to continually observe and monitor patients for changes and implement revisions to the plan of care as needed to manage skin integrity. The policy directed Licensed Nurses (LNs) to perform skin assessments on admit, complete skin integrity reports (ISRs) upon identification of altered skin integrity, weekly, and with anticipated decline of wound. The policy directed staff to perform daily monitoring of wounds or dressing for presence of complications or declines and document. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments and determine the need for support surfaces. The policy directed staff to review the care plan weekly and revise as indicated. RESIDENT 3 Resident 3 was admitted on [DATE] and was dependent on staff for all care needs, had a history of [REDACTED]. Resident 3 admitted with her own specialized wheelchair (PWC) that had a head support and control arrangement. The Minimum data set (MDS) assessment dated [DATE] documented Resident 3 was dependent on two person assistance for bed mobility and transfers. The MDS assessment indicated upon admission indicated she had three pressure ulcers (PS), one Stage 1 pressure ulcer (A stage I pressure ulcer presents as a localized area of superficial reddening of the skin, or skin discoloration), and two Stage 2 PU (Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed). The respiratory therapy's admit note dated 7/11/17 documented Resident 3's back of the neck had sore/small cut, and that the Licensed Nurses (LN) performed dressing changes around and under [MEDICAL CONDITION]. The Care Plan dated 7/11/17 directed staff to observe skin condition with activity of daily living (ADL), to use extreme caution while assisting, monitor skin prior and after transfer from bed to PWC and PWC to bed. The care plan revealed that she required 2 person assist for transfer and bed mobility. The initial nursing assessment indicated Resident 3 was chair fast and could not bear her own weight and needed assistance into the PWC and she was frequently observed to slide down in her chair or bed. The initial assessment documented skin issues around the back of her neck due [MEDICAL CONDITION] and referred to the Skin Integrity Report (SIR) form for measurements. The SIR form dated 7/11/17 documented redness back of neck which measured 24 centimeter (cm) by 2 cm in size. The skin surrounding the redness was described as being healthy. Another SIRs dated 7/11/17, revealed the resident had two Stage 2 pressure ulcers from the medical device. The location of the first Stage 2 pressure ulcer was on the back of her neck (mid-posterior). The pressure ulcer measured 2 cm by 1 cm in size and the wound bed contained 100% [MEDICATION NAME] (tissues that is primarily involved in protecting the underlying structures) The second pressure ulcer was on the left side of the neck. This pressure ulcer measured 3 cm by 3 cm in size with drainage and the wound base contained 100% [MEDICATION NAME] tissue. The next measurements on the SIRs were completed on 7/18/17. The back of the neck pressure ulcer measured 2 cm by 2 cm in size with drainage and the PU on the left side of the neck measured 3 cm by 2 cm in size. The next measurement of the back of neck pressure ulcer was documented as being measured on 8/7/17. The PU measured 2 cm by 2.1 cm in size with 100% [MEDICATION NAME] in the wound bed. The next assessment on the ISR form dated 8/14/17 for the back of the neck pressure ulcer documented the wound base was less (75%) [MEDICATION NAME] tissue and had bloody drainage. The documentation revealed no measurements for the wound. After the second PU on the left side of the neck was measured on 7/18/17. There was no assessment or measurements until 8/14/17. The 8/14/17 only described the wound base ([MEDICATION NAME]) and there were no measurements documented to evaluate the size of the wound. On 8/25/17 a SIR form documented a new pressure area located on the back of the head (occipital). The SIR documented that the occipital pressure ulcer measured 0.5 by 0.4 in size, the wound bed contained [MEDICATION NAME] tissue and the surrounding tissue was inflamed. Resident 3 was referred to the wound specialize team on 8/29/17 The wound specialist note dated 8/29/17 documented that the facility reported Resident 3 spends very long periods of time in her PWC and assessed 3 Stage 3 pressure areas (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss) as follows: The pressure ulcer on the back of the neck had deteriorated. The pressure ulcer was now a Stage 3 pressure ulcer. The pressure ulcer measured 1 cm by 3 cm by 0.1 cm in size and the wound bed contained 51-75 % slough and had moderate amount of sero-sanguineous drainage and the surround tissue of the wound had maceration (moisture). The other pressure ulcer on the neck (left side) had also deteriorated to a Stage 3 pressure ulcer. The wound bed contained slough and measured 0.5 by 2.5 cm by 0.1 cm in size with drainage and maceration around the wound. The facility's acquired pressure area on the occipital area (back of head) identified on 8/25/17 and measured 0.5 cm by 0.4 cm had deteriorated. The wound measured 4 cm by 5 cm by 0.1 cm in size and the wound contained 51-75 % slough (Slough is necrotic/avascular tissue & is usually light colored, soft, moist, & stringy (at times). The skin around the pressure ulcer (periwound) was excoriated, macerated and erythemic (red). The wound specialist's recommendation/orders (8/25/17) were to provide a supportive wheelchair cushion for off-loading and only up in chair for a limited amount of time and to reposition every 2-3 hours. On 9/5/17 the wound specialist assessed the 3 pressure ulcers. The two pressure ulcers on the neck now had adipose (fat) tissue exposed and the skin around the wounds were with maceration. The third pressure ulcer on the occipital area wound bed contained eschar (dead tissue) and with redness and maceration around the wound. The wound specialist also directed respiratory therapy to apply pads and [MEDICAL CONDITION] due to the pressure from [MEDICAL CONDITION] use. The respiratory therapy plan of care was updated on 9/5/17 to ensure pressure relief was provided after the pressure ulcers on the neck revealed deterioration. During an interview on 9/12/17 at 9:33 AM, the respiratory therapist stated last week the procedure regarding securing Resident 3'[MEDICAL CONDITION] was changed due to the need to provide pressure relief. Prior to changing, the method of securing [MEDICAL CONDITIONS] and the use of shoe laces which Resident 3 wanted to be tight around the neck upon admission to the facility. A facility event summary report dated 8/25/17 documented Resident 3 had a new-in house acquired pressure ulcer to the occipital (back of head) related to the head rest of her PWC not properly functioning. The report note indicated Resident 3 had a specialty electric wheelchair with a head rest to support her neck and head when she was out of bed and that the pressure ulcer on the occipital area was due to not being provided pressure relief by repositioning or changing positions when in her PWC. The facility event summary report dated 8/25/17 also revealed the 2 pressure ulcers on the neck were from [MEDICAL CONDITION] being secured with shoe strings that Resident 3 requested to be very tight which lead to worsening of the 2 necks wounds. During an interview on 9/12/17 at 2:15 PM the facility's Corporate Nurse, stated the pressure ulcer on the occipital area was caused by the pressure of the head rest of the PWC and that the Licensed Nurses (LNs) did not complete weekly wound assessments and or revise the plan of care to ensure pressure relief from [MEDICAL CONDITION] around the neck or interventions to prevent an avoidable pressure ulcer on the back of her head. During an interview and review of the SIRs on 9/12/17, she stated weekly assessments were not completed in order to evaluate wound deterioration or need for pressure relief measures. On 9/12/17 at 9:50 AM, Resident 3 was observed in bed with the head of bed in an elevated position. She stated the pressure ulcers on her neck had gotten worse but last week additional changes were made to ensure padding (ABD) under [MEDICAL CONDITION] and loosening [MEDICAL CONDITION] and shoe lace. She stated when admitted on [DATE], the skin around the neck was red and a duoderm dressing was used. Resident 3 also stated [MEDICAL CONDITION] would get wet during showers and staff did not immediately remove the soiled/wet ties around neck. RESIDENT 4 Resident 4 was admitted [DATE] and the nursing assessment documented he had limited mobility of upper and lower extremities, ventilator dependent with a [MEDICAL CONDITION] and had no pressure ulcers. The progress nursing notes revealed Resident 4 required frequent suctioning of the [MEDICAL CONDITION] due to secretions and had a medication patch to decrease the amount of secretions. The initial Care Plan dated 8/8/17 under risk for skin breakdown, admitted with Stage 2 pressure ulcer to mid anterior neck as a result of pressure from [MEDICAL CONDITION] flange (neck plate). Interventions included daily skin observation and report abnormalities and to have LNs perform weekly skin assessments. The Skin Integrity Report (ISR) dated 8/8/17 documented a Stage 2 medical device pressure ulcer which was present on admission to the facility. However, not until 8/15/17 (7 days later) was the pressure ulcer measured and assessed. The pressure ulcer measured 2 centimeter (cm) by 2.5 cm by 0.1 cm in size with serosanguinous drainage and healthy tissue surrounding the wound. The wound base was described as 100 % pink shallow opening. A nursing note dated 8/12/17 documented Resident 4 required two person assist with bed mobility and transfers and that RT (respiratory therapy) routinely checked on resident ([MEDICAL CONDITION]). Another nursing note entry dated 8/15/17 revealed that LNs were to apply a special dressing ([MEDICATION NAME]) every three days or as needed (prn) for the Stage 2 medical device pressure ulcer. A nursing note entry dated 8/25/17 documented a skin check was performed and indicated skin breakdown on [MEDICAL CONDITION]. There was no documented evidence in regard to the wound size or description or whether there was improvement or decline in the Stage 2 pressure ulcer. Another nursing note entry dated 9/1/17 documented Resident 4's skin breakdown was related to moisture Associated skin Damage (MASD) on neck area below his [MEDICAL CONDITION]. There was no measurement of the MASD area. The next ISR entry (5 weeks after initial measurements) documented that the wound specialist was assessing the pressure ulcer (9/5/17). The wound specialist's note dated 9/5/17 documented that the neck (trach site) pressure ulcer measured 2.6 cm by 2.2 cm by 0.1 cm in size, had deteriorated to a Stage 3 pressure and had moderate amount of serosanguinous drainage. The recommendation was to watch carefully for oversaturation of the dressing and change it if so and ensure pressure relief/offloading. On 9/12/17 at 3:40 PM observation Resident 4's pressure ulcer was observed with Licensed Nurse and the wound specialist. During this observation Resident 4'[MEDICAL CONDITION] against the pressure ulcer. Prior to the wound assessment respiratory therapy suctioned [MEDICAL CONDITION] to heavy secretions. The secretions were noted to create moisture on the wound. The wound specialist informed the respiratory therapist that pressure relief measures were needed to avoid pressure that [MEDICAL CONDITION] placing on the pressure ulcer. The pressure ulcer measured 2.6 centimeter (cm) by 2.4 cm in size with 100 % granulation of the wound bed. Resident 4's wife voiced concern regarding the delay in healing of the pressure ulcer from the [MEDICAL CONDITION]. The wife informed the wound specialist the [MEDICAL CONDITION] was new (June 2017) and asked the wound specialist about the healing progress of pressure ulcer. The wound specialist informed Resident 4 and wife that the appliance (trach) has caused the pressure ulcer and respiratory therapy needs to evaluate the pressure that [MEDICAL CONDITION] putting on the wound. Even though Resident 4 had increased secretions from [MEDICAL CONDITION] and was identified to have a pressure ulcer related to a medical device the facility did not initiate pressure relieving until 9/12/17 when the wound specialist discussed the need for evaluating how [MEDICAL CONDITION] still causing pressure. Reference: (WAC) 388-97-1060

Based on observation, interview and record review, the facility failed to consistently monitor, implement preventive measures, evaluate treatment(s) and revise the plan of care for 2 of 3 sample residents (3,4) who were at risk for skin breakdown. Failure to ensure interventions to avoid pressure resulted in the development of a pressure sore on a former resident's heel, Resident 3 and possible delay for healing Resident 4's coccyx/buttock pressure sores. Findings include: The facility's skin integrity management policy, dated 12/08/14, read: The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. RESIDENT 3: Prior to Resident 3's admission to the facility, the vascular surgeon's history and physical, dated 9/17/15, documented the [MEDICAL CONDITION] cannot heal because of oste[DIAGNOSES REDACTED] and insufficient blood supply of the left foot. The note indicated she would lose foot if surgical revascularization was not performed. The resident agreed to revascularization surgery for [REDACTED]. Resident 3 was admitted to facility on 10/3/15 after surgical intervention for a non-healing diabetic (DM) foot ulcer on the ball of her left foot. After her DM foot ulcer surgery on the ball of the left foot, she was not to put weight (NWB) on the ball of her left forefoot. To assist with the healing of the DM foot ulcer post operative wound site a wound vac was used. Resident 3's [DIAGNOSES REDACTED]. The initial admission nursing skin assessment, dated 10/3/15, revealed Resident 3 had no pressure sores on her heels of both feet. The plan of care, dated 10/3/15, directed nursing to monitor skin for breakdown, redness, and decrease sensation. A Physical Therapy note, dated 10/5/15 , documented that a wheelchair was adjusted to fit her needs with an elevating L (left) leg rest for wheelchair (w/c). The skilled therapy notes from 10/5/15 to 10/12/15 documented no weight bearing on the ball of her left foot (surgical area) upon admission, she was to be non-ambulatory. The skilled therapy notes documented Resident 3 was able to perform a pivot transfer with WB (weight bearing-putting all weight on heel) through the heel with supervision, and able to propel her wheelchair independently in the facility. Resident 3 was admitted to the hospital for a gastrointestinal evaluation on 11/11/15 and returned on 11/19/15. The nursing re-admit assessment, dated 11/19/15, documented Resident 3 had no pressure sores on her heels. The Treatment Administration Record (TAR) for December documented that Resident 3 was able to put weight on the ball of her left foot and only WB on heel (weight on left heel) for transfers which was dated 11/19/15. The Nutritional Assessment, dated 11/27/15, documented Resident 3 weighed 204 pounds, had [MEDICAL CONDITION] of her lower extremities, poor intake and had no pressure sores. The Minimum Data Set (MDS) assessment, dated 1/14/16, indicated Resident 3 required one person assist with bed mobility, transfers and toileting. The MDS documented she had a [MEDICAL CONDITION] and was at risk for skin breakdown. The MDS did not document the pressure ulcer on her left heel which had been identified on 12/14/15. The care plan directed staff to observe skin condition with activities of daily living (ADL) every day. However, there was no directive regarding skin prevention for her heels such as off loading heels while in bed. The TAR for December 2015 indicated Licensed Nurses (LNs) had applied an elastic wrap (ace) to lower extremities for swelling ([MEDICAL CONDITION]) which was documented as being removed at noon and reapplied at 5:00 p.m. everyday. According to the January TAR the resident continued to have ace wraps applied to the lower extremities until 1/8/16. The facility skin integrity report, dated 12/14/15, documented Resident 3 developed a left heel wound which measured 4 cm by 2.4 cm in size. The wound bed was described as containing 50% eschar (necrotic/dead ) tissue and 50% [MEDICATION NAME] appearance. The wound had minimal serous drainage. The LN documented the pressure ulcer as UN (unstagable). The following week, the wound bed contained 100% necrotic (dead) tissue. The Advanced Nurse Practitioner's late entry note, dated 12/14/15, documented Resident 3's left heel pressure/deep tissue injury (DTI). Review of the Wound Consultant (WC) Notes were: -12/11/15, documented no pressure ulcer to left heel. The WC only described the skin condition on the ball of the left foot (surgical site) and documented the healing of the plantar (ball) wound may be delayed due to Resident 3's impaired mobility and diabetes. There was no documented observation of the skin on the left heel. -12/21/15, Left Heel Stage 2 pressure ulcer which measured 4 cm by 3 cm in size and wound bed 100% epithelizlization. The periwound skin exhibited dry/scaly, [DIAGNOSES REDACTED] (redness.) The recommendation was boot for foot and heel protector. A facility fax, dated 2/17/16, from the WC read: Resident 3 developed an ulcer on her left heel noted on rounds 12/21/2015 and described as having been caused by her using her left heel to propel herself in her wheelchair. She was encouraged and reminded on weekly rounds thereafter not to traumatize her heel in this way. Additional WC notes as followed: -12/28/15, Left Heel 3.8 cm by 3cm in size with 100% eschar in wound bed. -1/4/16, Left heel wound bed with 100% eschar. The vascular consult, dated 1/6/16, indicated Resident 3's surgical site on the bottom (plantar) of her left foot had healed, however she now had a pressure ulcer on her left heel. The consult informed Resident 3 that she was at risk to have an amputation if the pressure ulcer on her left heel does not heal. The 1/11/16, the WC documented the left heel is a necrotic tissue (unstageable) Pressure Ulcer which measured 3.5 cm by 2.5 cm in size with serous drainage. The wound bed was 80% eschar, 20% slough (dead tissue). Periwound no [DIAGNOSES REDACTED] but dry callus formation. On 2/12/16 at 11:20 a.m., during an interview with the skilled therapist (PT), she stated she had evaluated Resident 3 for the fitting of an offloading boot on 12/25/15 due to her left heel pressure sore. PT stated the resident was scared about losing her leg and went ballistic about possible below knee [MEDICAL CONDITION] (BKA) if the left heel pressure ulcer did not heal. On 2/11/16 at 9:03 a.m., the Director of Nursing stated Resident 3 would self propel in her wheelchair using her feet. On 2/23/16 at 1:50 p.m., the Director of Skilled Therapy stated Resident 3 had no sensation in her foot and preferred to stay in bed and was not interested in therapy. The Therapy Director stated she had observed Resident 3 digging her left heel straight into floor, she was a foot propeller when she used her wheelchair. After identification of the left heel pressure ulcer on 12/14/15, a physician's orders [REDACTED]. The TAR for January 2016 revealed the resident was able to touch down weight bearing to the left forefoot (surgical site) and weight bearing for transfer only to left heel. (start 11/19/15). The revised care plan, dated 12/27/15, after the developement of the pressure ulcer on the left heel indicated she required extensive assistance for transfers, assist of one person with wheelchair to toilet with left boot/shoe on to off load heel. Weight bearing only for transfers which was dated 10/9/15. Even though staff had observed Resident 3 use her left heel to propel about the facility in her wheelchair, had knowledge of her medical condition, there was no documented evidence that they recognized the need for frequent monitoring of her heels or wheelchair adjustments/use of foot rests to eliminate pressure on the heel. Resident 3's plan of care had not been updated or revised to ensure pressure relief on the heel was provided until after the development of an unstageable/deep tissue injury was noted on 12/14/15. RESIDENT 4: Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated 7/13/15, documented Resident 4 had MASD (Moisture Associated Skin Damage), no pressure sores, weighed 286 pounds, had required maximum assistance of 2 staff for bed mobility and toileting. The resident had a urinary catheter on admit. The nursing admission assessment form and admit nursing note, dated 7/6/15, documented Resident 4 had red, excoriation with open areas on her buttocks and required 3-4 people for bed mobiltiy . The Plan of Care, dated 7/6/15, included interventions for pain and skin breakdown on coccyx, buttocks related to limited mobility and incontinence with instruction for staff to 1)assist with turning and reposition in bed every 2 hours, 2) a pressure redistribution surfaces to bed, 3) ultra absorbent pads under backside, 4) reposition every 2 hours and 5) provide pericare/incontinent care as needed. The facility's skin integrity reports documented that on 8/26/15 the left sacrum had an unstageable wound which measured 2.2 centimeters (cm) by 1.9 cm in size. The wound base contained slough (dead tissue) and the wound had drainage. The WC evaluated resident 4's sacral pressure ulcer on 8/27/15. The WC documented the pressure ulcer on the left sacrum was necrotic tissue (unstageable) pressure ulcer. The ulcer measured 1 centimeter (cm) by 1.5 cm in size and had moderate drainage. The wound bed contained 70 % slough (dead tissue) and the surrounding tissue (periwound) was macerated (moist). The weekly skin integrity reports from 8/27/15 to 12/21/15 revealed the wound continued to have moderate drainage with the surrounding tissue being macerated (moisture). The wound bed contained slough (dead tissue). The Wound Consultant (WC) note, dated 11/16/15, included the plan to ensure aggressive off-loading of pressure ulcer areas at all times and a low air-loss mattress (LAL). The Plan of care revealed she had received a specialty mattress/low air loss-LAL on 12/23/15 due to unresolved breakdown of skin. On 2/11/16 at 1:25 p.m., Resident 4 was observed in bed with the head of bed elevated approximately 30 degrees. The low air loss-LAL (specialty mattress) was in place. The resident stated she was unable to be reposition onto her left side due to prior surgeries. Resident 4 stated prior to getting the new mattress (LAL), her buttock hurt and she felt the bars of the bed. During an interview with the DNS on 2/12/16 at 3:00 p.m.,he stated the facility had changed Resident 4's mattress in December 2015, but had not considered evaluating the treatment plan or revised the plan of care when the WC documented Resident 4 should have aggressive offload of her pressure ulcer. Even though the resident was dependent on staff for repositioning and was at risk for pressure ulcer develpment, needed tissue off loading to assist with wound healing, there was no documented evidence that the plan of care was changed in regard to change in turning and repositioning more than 2 hours, to meet the individualized needs of Resident 4.

Based on interview and record review, the facility failed to provide the necessary supervision for two of two residents (1,2) who were dependent on staff for all care needs. Failure to ensure adequate assistance was provided during repositioning in bed resulted in harm for Resident 1 who fell out of bed, sustained a laceration(s) to his head which required activation of the emergency system (911) and placed Resident 2 at risk for possible injury. Findings include: RESIDENT 1: Resident 1 was admitted to the facility July 2014 due to with respiratory failure. Resident 1 had a tracheotomy and was ventilator dependent for life support and received 100% nutritional support through a gastrotomy tube. The care plan indicated he was dependent on staff for care. The resident was on several medications which may effect the clotting of blood (Plavix and aspirin). The Minimum Data Set (MDS) assessment, dated 1/17/16 revealed Resident 1 required 2 staff assist with bed mobility and toileting needs and weighed 199 pounds. The nursing notes documented Resident 1 required 2 person extensive assistance with care. The MDS documented he had experienced no falls since his admission to the facility (2014). The Current Care Plan and Kardex used by Nursing Assistants (NACs) revealed Resident 1 was dependent on staff for bed mobility and toileting needs. The nursing notes from 12/1/15 to 1/19/16 revealed Resident 1 was alert and non verbal, had a tracheotomy and was ventilator dependent and fed by gastrostomy tube. The notes indicated his family was involved in his care and decision making. The facility's investigative report, dated 1/19/16, documented NAC rolled Resident 1 toward her when she removed an incontinent brief; the resident's weight shifted and he fell to the ground from his bed. The NAC was by herself when Resident 1 rolled out of his bed. The report documented Resident 1 sustained a laceration to his forehead, bridge of nose and forearm. The report indicated pressure was applied to his lacerations and when the bleeding continued, the facility activated the emergency system (911). The investigative report documented that the 911 staff assessed Resident 1 and recommended transfer to the hospital emergency room (ER) for evaluation due to the bleeding. When the family was notified about the fall with injuries, they declined transfer to ER. The investigative report documented when the resident was on the floor, she was away from the ventilator cart/circuit and had required manual bagging with 100% oxygen. The skin integrity report, dated 1/19/16, a lac (laceration)/skin tear to left forehead which measured 4 centimeter (cm) by 0.2 cm in size, a skin tear on nose bridge and a 5 cm by .02 cm skin tear to his left forearm. The physician's note, dated 1/19/16, document Resident 1 had a fall during care and a laceration to right forehead and bridge of his nose. One 2/4/15 during an interview with the Acting Director of Nursing (DNS) he verified Resident 1 had fallen out of bed, rolled out of bed, when a nursing assistant was providing care and repositioning the resident. On 2/11/16 at 10:10 a.m., Licensed Nurse (Staff A) stated that residents who have tracheotomies and are dependent on a ventilator require 2 staff assist when they are repositioned in bed at all times 2 staff need to be there. LN A stated definitely need 2 , you can not handle both the resident and the equipment, the ventilator tube(s) would disconnect from the ventilator. On 2/23/16 at 11:00 a.m., during an interview with a NAC (Staff B ) she stated there is always 2 staff required to assist residents who are connected to ventilators. Staff B stated one person needs to support the tubing of the ventilator while the other staff ensure resident safety. On 2/23/16 at 10:50 a.m., the respiratory therapist (RT) verified 2 staff members are always required to assist any resident who has a trach on ventilatory support. The RT stated one staff needs to support the circuit (tubing) connected to ventilator and the other staff would support the resident. Resident 2: Resident 2 was admitted ,[DATE] to the facility with [DIAGNOSES REDACTED]. The MDS assessment, dated 1/15/16, revealed Resident 2 required maximum assistance of 2 staff for bed mobility, transfers and toileting. The MDS documented she was 68 inches in height and weighed 258 pounds. The Plan of Care and Kardex, revised 1/28/16, informed staff that she required 2 person extensive assistance with bed mobility. The nursing progress notes revealed Resident 2 had a fall on 12/26/15 when she slid out of bed trying to reach for something. Resident 2 sustained an injury. She had swelling to her left eye brow area which measured 2 cm by 4/5 cm in size. A physician's note, dated 12/28/15, documented that Resident 2 had lack of coordination and a history of falls. The physician's note alerted staff to encourage patient to turn gently in bed to avoid shifting of weight too quickly as she is on a pressure relieving mattress. During an interview on 2/11/16 at 9:40 a.m., Resident 2 stated she had experienced 2 falls since her admission to the facility. She stated when one tiny NAC was assisting with personal care and repositioning her in bed, the NAC was unable to keep her from falling out of bed. She stated there should have been two staff assisting in cleaning me up, but there was only one. Review of the facility's Investigative Report, dated 1/30/16, indicated Resident 2 was alert, able to make her needs known and required assistance with bed mobility. The report revealed that only one nursing assistant was providing care when Resident 2's weight shifted and both feet slid off of the bed as she held onto her upper side rails on her bed. The one NAC called out for help. The report documented that it took 3 staff to lift Resident 2's legs back onto her bed. During an interview on 2/11/16 at 1:15 p.m. with the DNS, he stated Resident 2 was hanging onto her side rail and both of her legs were on the ground. The Nursing Assistant (NAC) had to call out for help. The DNS verified that during the incident there was only one NAC who was assisting Resident 2 with repositioning and toileting. During an interview on 2/11/2016 at 12:50 p.m., the Resident Care Manager (RCM) she verified Resident 2 required 2 person assistance for bed mobility. Failure to ensure 2 person assist was provided to prevent accidents resulted in Resident 1's fall from the bed with head lacerations and placed Resident 2 at risk for injury.

Based on observation, interview and record review, the facility failed to provide care and thoroughly monitor two of two sample residents (1.2). Failure to provide necessary treatment resulted in harm for Resident 2 who acquired a scalp abcess and the failure to consistently monitor a cardiac condition resulted in harm for Resident 1 who experienced unnecessary chest pain, a delay in medication treatment and death. Findings include: RESIDENT 2: Resident 2 was dependent on staff for all care needs including re-positioning and turning, and personal hygiene. The quarterly Minimum Data Set (MDS) assessment, dated [DATE] indicated the resident required 2 person physical assistance with bed mobility, transfers, personal hygiene and bathing. The MDS documented he received ointments/medication for his skin treatment. During a interview on [DATE] at approximately 2:30 p.m., a family member voiced frustration and anger regarding the care for Resident 2. He stated the staff at the facility had not used the special shampoo for his scalp and staff shaved his head due to the crusty green buildup on the scalp. He stated an abscess on the back of his head had developed and it was draining and painful for Resident 2. He also stated the skin around the feeding tube ([DEVICE]) was red and there was drainage. On initial rounds on [DATE] at 4: 00 p.m., Resident 2 was observed on a stretcher getting ready to be transferred to the hospital per the family request for evaluation. Resident 2's scalp was red and and a fifty cent piece sized wound with drainage was observed of the left side of his head. The skin around his [DEVICE] site and the left abdomen was red and there was no dressing around the [DEVICE] site. The physician note, dated [DATE], documented Resident 2 had chronic seborrhea and dandruff which has been addressed with anti-dandruff shampoos twice a week and trying to keep it under control. On [DATE] at 5:03 p.m., Resident 2's physician was interviewed and he stated the resident received a special shampoo twice a week for his scalp. Review of the Medication Administration Records (MARs) for August, September, October and [DATE] indicated a medication shampoo was to be used as needed for skin/scalp issues. There was no documented evidence that the shampoo was used in the four month period. The physician note, dated [DATE], indicated that Resident 2 had an abscess which initially was noticed by staff the day prior ([DATE]). The area (abscess) was the size of a quarter and was described as a cystic area on the back of his head. Within 24 hours, the abscess increased in size and started to drain. The MARs for [DATE] documented, care had been provided to the [DEVICE] site during the day shift ([DATE]). There was no documented evidence regarding the redness or drainage around the [DEVICE] site or abdomen even though [DEVICE] site care was documented as provided for Resident 2. An interview at 4:45 p.m., Licensed Nurse B stated the policy for [DEVICE] care was to cleanse around the site and document if there are any abnormal drainage and to notify the physician regarding signs of irritation and or drainage. Resident 2's emergency room note for [DATE] documented that Resident 2's skin around the [DEVICE] site was [DIAGNOSES REDACTED] (redness) with some purulent drainage. Resident 2 was dependent on staff and unable to verbalize his needs, the staff failed to provide the ordered shampoo to prevent a decline in his skin condition. The staff also failed to provide skin assessments and dressing change around the [DEVICE] site. RESIDENT 1: Resident 1 was admitted to the facility following cardiac surgery on ,[DATE]. Resident 1's POLST/CPR form revealed the resident had requested to be a full code/ full treatment. The care plan revealed Resident 1 was at risk for cardiovascular symptom or complications related to cardiac surgeries and stroke. The Care Plan indicated Licensed Nurses (LNs) were to assess and monitor chest pain, report to physician and monitor his apical pulse. Resident 1 was readmitted to the facility on [DATE] at 1250. The re-admit nursing note documented he denied shortness of breath (SOB) or chest pain (CP). He was placed on alert for monitoring. On the evening shift of [DATE], Resident 1 complained of CP. The severity of his CP was described as being a 6 on a 0 to 10 scale (0-being no pain and 10 being worse pain). He had described his CP as being sharp. The LN administered [MEDICATION NAME] for the CP and documented recheck in 5 minutes and indicated the resident had no more pain. A second [MEDICATION NAME] was administered at 8:40 p.m., for CP with an intensity of 7. There was no further documentation of monitoring after the administration of second dose of [MEDICATION NAME]. During the night shift ([DATE]), the LN documented Resident 1 was restless all night, c/o (complained of) CP under left arm and middle of chest and had profuse sweating. The Resident received one dose of [MEDICATION NAME] at the beginning of night shift. The LN documented vital signs were monitored every hour to evaluate pain consistency. The note revealed the LN had talked to patient to calm down because he started throwing things, in order to get attention. The LN documented the resident was given a narcotic pain medication ([MEDICATION NAME]) at 4:00 a.m., however there was no documented assessment or monitoring of vital signs. Even though the Resident 1 experienced CP, restlessness, profuse sweating and was administered [MEDICATION NAME] and a narcotic medication, there was no documented evidence the LN had thoroughly monitored the resident's condition. A faxed statement from the LN who provided care on the night shift ([DATE]) was obtained by the Director of Nursing which indicated the LN had not documented hourly vital signs. The day shift, dated [DATE], documented the resident complained of chest pain twice. The note documented [MEDICATION NAME] was effective and a second nitro was administered at noon due to chest pain. On [DATE], the physician assessed Resident 1. Resident 1 received additional nitrogylcerin for chest pain of ,[DATE] midsternal, sharp and ordered additional dose of cardiac medications and various tests (EKG, chest x-ray). The additional cardiac medications were administered on [DATE], however there was no documented evidence Resident 1's condition was consistently monitored after administration of the additional medication. Even though the resident had a change in cardiac medications ([DATE], day shift), there was no documented evidence Resident 1's condition was consistenty monitored during the evening shift other than an entry on the Pain Management flow sheet which documented severe/horrible back pain at 8 p.m. A night shift nursing note entry, dated [DATE], revealed the resident received narcotic medication at 1:00 a.m., and [MEDICATION NAME] at 2:30 a.m. for chest pain. At 4:00 a.m., Resident 1 was found non-responsive and 911 was called. Resident 1 was pronounced dead at 4:30 a.m.

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 sample residents (129) reviewed for urinary function received the appropriate care and services necessary to restore her bladder function. This failed practice resulted in harm to Resident 129 when her urinary function declined from always being continent, to occasionally incontinent, to frequently incontinent, and eventually requiring emergency evaluation and treatment at a hospital for unidentified [MEDICAL CONDITION]. Findings include: Resident 129 Resident 129 was admitted to the facility in August 2014 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, dated 9/26/14, the resident did not have any cognitive impairments. The MDS also indicated Resident 129 required extensive assistance of facility staff for transfers and toileting. In an interview on 10/27/14 at 11:39 a.m., Resident 129 stated she was continent of urine prior to admission to the facility. She was observed to be wearing an adult attends (incontinent brief). Resident 129's Admission Nursing assessment dated [DATE] indicated the resident was continent of urine. Additional information provided by the facility indicated Resident 129 had been using a bedside commode at a nursing facility she lived at prior to this admission. The admission MDS dated [DATE] listed Resident 129's urinary function as "occasionally incontinent." The MDS indicated no "trial of toileting program had been attempted since urinary incontinence was noted in this facility." An MDS dated [DATE] listed Resident 129's urinary function as "frequently incontinent." The MDS indicated no "trial of toileting program had been attempted since urinary incontinence was noted in this facility." Resident 129's physician admission assessment dated [DATE] did not include any urinary system notes regarding urinary function. Resident 129's physician progress notes [REDACTED]. physician progress notes [REDACTED]. Staff Q, Pharmacist, notified the facility via consultation report on 9/22/14 that "resident has lots of meds (medications) - probably too many." Staff Q's rationale for recommendation included "...urinary incontinence" as one of the risks of the side effects of her medications. Staff O, facility doctor, declined the recommendation and wrote "defer to her PCP (Primary Care Provider)." In an interview on 10/27/14 at 2:13, p.m., Staff F, Licensed Nurse (LN), stated that the residents PCP did not come to this facility to treat residents and the recommendation had not been forwarded to any other physician. Facility documentation revealed that on the morning of 10/26/14 at 6:00 a.m., Resident 129 was "moaning, crying, and complaining of sharp pain on her left abdomen." At 9:30 a.m., the facility gave Resident 129 [MEDICATION NAME] (a narcotic pain medication) 10 mg by mouth for complaints of 10/10 (severe) abdominal pain. At 11:39 a.m., Resident 129 was admitted to the Emergency Department with a complaint of "diffuse abdominal pain for the duration of 2 days." While at the hospital Resident 129 had an extensive emergency department workup that included a Computerized Tomography scan of her abdomen and pelvis that showed a "distended appearance of the bladder." A urinary catheter was inserted and one liter of urine was removed which resulted in "complete resolution of her pain." The emergency department physician's final impression was "[MEDICAL CONDITION]," with "possible medication side effects as a cause." Resident 129 returned to the facility the same day. In a review of Staff O's, (facility doctor), physician progress notes [REDACTED]. The physician progress notes [REDACTED]. In an interview on 10/27/14 at 9:30 a.m with Staff F and Staff S, LN's, Staff S stated the facility had not been monitoring Resident 129 for [MEDICAL CONDITION] prior to her emergency department admission. Staff F was then asked if the facility was monitoring for medication side effects from Resident 129's MS ([MEDICATION NAME]) Contin, [MEDICATION NAME], or [MEDICATION NAME], all of which have "[MEDICAL CONDITION]" listed as a potential side effect, she answered "no." Review of Resident 129's Psychotherapeutic Medication Informed Consent for the two antidepressants [MEDICATION NAME] and [MEDICATION NAME], disclosed "[MEDICAL CONDITION]" as an adverse reaction of these two medications. The form also stated "Two/more medications in the same drug class simultaneously may increase the risk of side effects/adverse reactions." Resident 129 signed this form. There were also signature blocks for the Physician/Mid-level Provider and Licensed Nurse signatures, however, both of those signature blocks were blank. Resident 129's nursing care plan initiated on 9/7/14 stated "complete an incontinence assessment at intervals according to policy and procedure." In an interview on 10/27/14 at 2:13 p.m., Staff F, LN, was asked if a comprehensive bladder assessment had been performed on Resident 129 since her admission (8/29/14) to the facility, she answered "no, but we will do one today." As of 10/29/14 this assessment had not been done. Resident 129's nursing care plan (dated 9/7/14) stated "encourage resident to use toilet upon awakening, after meals, nightly, and PRN (as needed)." In an interview on 10/29/14 at 9:33 a.m., Staff U, Nursing Assistant - Certified, was asked if she ever offered resident to get up to the bedside commode, she answered "no, because the resident is alert." Staff U was asked if Resident 129 ever refused to get up to the bedside commode, she answered "no." In an interview on 10/29/14 at 9:22 a.m., Resident 129 was asked if anyone had offered to assist her up to the bedside commode yet that day, she answered "no." When asked when was the last time she had been up on a bedside commode, Resident 129 answered "over 3 days ago." When asked how often she urinates, Resident 129 answered, "I feel like I trickle all day." Resident 129's nursing care plan (dated 9/7/14) stated "respond promptly to the residents' request to use the toilet." In an interview on 10/22/14 at 11:31 a.m., Resident 129 stated "I'm afraid to get on the commode because I've sat on it for over an hour before someone could help me off, sometimes it takes a half an hour for my call light to be answered." In an interview on 10/27/14 at 11:39 a.m., Resident 129 said she was not incontinent of urine before being admitted to the facility. She then stated she was "lying in urine right now" because only 1 nursing assistant came to change her and it takes 2. Resident 129 said she urinated in a brief because they (the facility) did not get her up frequently enough. Resident 129's nursing care plan stated "monitor output for odor, color, consistency, and amount." In an interview on 10/29/14 at 8:21 a.m., Staff F was asked where the facility was documenting Resident 129's urinary output, color, consistency, and amount, she said "we're not." Staff F immediately entered a nursing order in the computerized charting system to initiate urinary output monitoring. At 8:21 a.m., Staff F was asked if Resident 129's attending physician had assessed the resident for potential causes of her [MEDICAL CONDITION], she replied "I don't know." When Staff F was asked if Resident 129's physician had assessed the residents' medications for possible causes of [MEDICAL CONDITION], she replied "I don't know." On 10/29/14 at 9:41 a.m., Resident 129's urinary incontinence documentation was jointly reviewed with Staff F. From 10/16/14 to 10/29/14 facility documentation indicated Resident 129 had been incontinent of urine 33 times. Staff F, LN, was unable to provide urinary frequency or incontinence information from admit to 10/15/14. In an interview on 10/29/14 at 10:33 a.m., Staff F, LN, was asked if Staff O, Resident 129's attending physician, was aware of resident's urinary incontinence. She answered "I don't know." On the afternoon of 10/29/14, Staff O, facility doctor, wrote a physician's orders [REDACTED]." Resident 129 was on 4 medications ([MEDICATION NAME], MS Contin) that had [MEDICAL CONDITION] as a side effect, there was no documentation the facility was monitoring for [MEDICAL CONDITION]. The resident ended up being admitted to the emergency department for emergency assessment and treatment, the emergency department physicians final impression was "[MEDICAL CONDITION] - with possible medication side effects as a cause." There was no documentation the facility had identified, assessed, or treated Resident 129's [MEDICAL CONDITION] which resulted in emergency hospitalization for assessment and treatment. Resident 129's urinary incontinence issues had been care planned, but there was no documentation in her medical record they had been implemented. After the facility identified Resident 129's urinary incontinence, there was no documentation they had considered potential causes for the incontinence. From admission to the facility (8/29/14) to 10/25/14, there was no documentation of any communication between facility nursing staff and Resident 129's physician regarding Resident 129's urinary incontinence. There was no documentation in Resident 129's medical record from admission to 10/28/14 that a facility physician had identified, assessed, or provided any treatment or services to achieve or maintain as much normal urinary function as possible for Resident 129. Refer to:483.25(1)(i)(iii)(iv)(v), (2)(i)(ii) F329 Unnecessary Drugs 483.60(c)(2) F428 Drug Regimen Review .

Based on observation, interview, and record review, the facility failed to evaluate, document and communicate to the resident, his physician and Power of Attorney (POA) acute changes in the condition of wounds for 1 of 2 residents (1). This failure resulted in harm for Resident 1 as evidenced by the worsening of his wounds, hospitalization and subsequent surgery. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment, dated 06/03/13, indicated that the resident was severely impaired in his cognition. Resident 1 had a significant history of vascular compromise as evidenced by prior vein graph surgeries in 2003, 2007 & 2008. In addition the [DIAGNOSES REDACTED]. The resident was discharged on [DATE], after the podiatrist requested he be sent to the hospital for treatment of [REDACTED]. The facility's policy on "Skin Integrity Management", with a revision date of 10/01/10, was reviewed. The policy instructed staff to perform weekly skin evaluations, to monitor for any signs of decline in wound status and document daily and adjust the plan of care, as indicated. Staff were to document any conditions or factors that may have potential to delay or impede healing including diabetes and [MEDICAL CONDITION]. The policy further directed staff to notify family and/or health care decision maker of status and to provide appropriate education regarding risk factors, wound status, wound goals, patient goals. The "Skin Integrity Management" policy included care plan instructions to consider the resident's specific, individual risk factors; refer to the risk assessment and to include approaches to stabilize or improve co-morbidities and interventions limiting the effects of risk factors. On 07/23/13 at 11:30 a.m., the corporate regional nurse (Staff B stated that the facility also used the Lippincott Manual of Nursing Practice for guidelines for diabetic foot care. The Lippincott Manual of Nursing Practice included the following: Inspect the feet carefully and daily Bathe the feet daily in warm water, massage the feet with an absorbable agent, and avoid injuries to the feet If an injury occurs - wash the area with soap and water, cover with a dry sterile dressing without adhesive and wear white cotton socks (dye in colored socks and wool may serve as irritants when skin is already irritated.) On 06/27/13 Resident 1 complained to facility staff of right foot pain. He reported that his pain level was a 7 out of 10 indicating that he had "Severe/Horrible" pain (per the facility pain sheet) that day. Staff C documented in the progress notes that skin tears were discovered on the 1st and 2nd toes on the resident's right foot. The second toe had serosanguineous drainage (fluid that was yellowish with small amounts of blood) and had about 50% granulation tissue (usually occurs at day 3 to 4 of normal healing stages) and was about 50% purple / bruise. On the same day, Staff C sent a fax to the physician describing the injuries and informing the physician that the areas had been cleansed with normal saline and were covered with a band aid. Staff C also requested the physician order [REDACTED]." The facility fax did not inform the physician that the resident was a diabetic or that he had a history of [REDACTED]. From 6/27 to 7/1/13 the resident received dressing changes at least 2 times daily. There was no evidence facility staff were performing ongoing assessment and monitoring of the resident's wounds, evaluating the resident's response to treatment and providing ongoing notification of the status of the resident's wounds to his physician and POA. On 07/01/13 Staff C documented on the skin integrity report that the surrounding tissue around the 2nd toe was inflamed and the wound edges were macerated (The softening and breaking down of skin resulting from prolonged exposure to moisture which can increase the risk of infection and prolong healing). On the same day, Staff C sent a fax to the physician that stated the resident had a current order for triple antibiotic ointment for his right second toe. The big toe was not healing so Staff C asked the physician for an order to clean the toe with normal saline, apply triple antibiotic ointment and cover with a gauze or band aid and the treatment was set up to be once a day. Staff C did not inform the physician that the toe had maceration or that the toe was inflamed. Again staff did not remind the physician of the resident's [DIAGNOSES REDACTED]. There was no documentation the facility spoke with the resident or notified the POA about the status of the wounds or the change in the treatment. On 07/03/13 the resident's physician saw the resident. Neither the resident's progress note nor the physician's note indicated the resident's wounds were observed by the physician and that the physician had been notified by staff of the status of the resident's wound. The physician wrote the resident was lying on his bed and the toe was covered with a band aid on his left toe (wrong foot). The physician's "assessment" was that the resident had "[MEDICAL CONDITION]" and the "plan" was to "monitor." From 07/03/13 to 07/05/13, again there was no evidence facility staff were performing ongoing assessment and monitoring of the resident's wounds, evaluating the resident's response to treatment and providing ongoing notification of the status of the resident's wounds to his physician and POA. On 07/06/13 Staff C wrote on a fax to the physician that the resident was a diabetic and had non-healing wounds on the right foot. Another "new area" had developed that was deep purple on the 1st toe of the right foot. The "new area" on the 1st toe was mostly slough (The dropping off of dead tissue from living flesh), with serous (thin watery serum substance) drainage. The area was deep purple in color measuring 1.5 x 1.5 cm. The second toe was also dark purple measuring 1.4 x 1 cm and the capillary refill was greater than 3 seconds (normal would be less than 3 seconds). There was no documentation about the inflammation but Staff C requested a wound consultation and the physician agreed. There was no documentation that the resident or the POA was notified of the new area of breakdown. Staff C did not inform the physician about the status of the inflammation that had been on the toe prior. An appointment for a wound consultation was made for 07/16/2013; for 10 days later. There was no documentation that Staff C contacted the physician to discuss other alternatives for treatment since the wound specialist could not see the resident for 10 days. There was no documentation that the facility discussed the appointment with the resident or the POA was aware. The resident and POA were denied the opportunity to research other alternatives. On 07/08/13 the podiatrist was in the facility. There was no evidence that the facility requested the podiatrist make the resident a priority so he could be seen that day. On 07/9/13 the resident was seen by the podiatrist and the description of the resident's right foot was documented. The documentation showed the resident had mild ankle [MEDICAL CONDITION], and the big toe toward the center had a black area measuring 0.9 X 0.5 centimeters (cm). The underneath of the toe had an ulceration that measured 2 x 1.5 cm in diameter. The base was dark in color of grey/black. The second toenail was loose and there was ulceration at the area of the nail bed that measured 1.5 x 1.5 cm. The base was filled with necrotic green slough and there was 5 cm of [DIAGNOSES REDACTED] (reddening of the skin) surrounding the open area. There was also a red linear streaking area going along the top of the right foot 5 cm in length as well. The Podiatrist's assessment was that the resident had "ulcerations with [MEDICAL CONDITION]" of the right foot and "early gangrenous changes." The podiatrist recommended that the resident be sent to the emergency room to be started on intravenous antibiotics. The podiatrist felt the wound clinic appointment was too far out and that the resident needed be seen by the hospital vascular staff. Resident 1 was transported to the hospital on [DATE]. On that same day the hospital history and physical confirmed that the resident had full thickness black gangrene and right forefoot [MEDICAL CONDITION] that was positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus bacteria). On 07/19/13 at 2:30 p.m., the resident's POA was interviewed. She stated the facility "never" told her about the injury to the toes on the resident's right foot. She did not learn about the injury until 07/09/13 when the resident was being sent to the hospital. The POA stated if the family had known about the injury, they would have taken the resident to his own physician who had managed the resident diabetes prior to his admission to the nursing home. On 07/22/13, Resident 1's care plan was reviewed and revealed no intervention for prevention of injury to the resident's feet, no instruction to staff regarding ongoing assessment and monitoring of the resident's feet and what staff should be looking for.

Based on observation, interview and record review, the facility failed to reevaluate pressure relief and /or preventive measures to prevent the development of avoidable pressure ulcers for 3 of 7 Residents (1,2, 3). Failure to identify and develop a plan of care resulted in the development of an avoidable pressure ulcers for Resident 1 with pain and the development of a bone infection for Resident 3. Findings include: The facility's policy, "Skin Care & Pressure Ulcer Management Program" read: Regardless of any residents' total risk score: the licensed nurse (LN) and interdisciplinary care team are responsible for reviewing each risk factor and its potential causes and implementing preventive strategies, as applicable. A resident scores low risk but develops a pressure ulcer (sore). The care plan should reflect interventions, as appropriate. In this situation, it is important for the nurse to document what happened and why it happened. Definitions from Center Medicare Services (MDS) RAI version 3.0 mannual: A pressure ulcer (sore) is any lesion caused by unrelieved pressures that results in damage to the underlying tissue (s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers (sores). Eschar is described as thick, lethery, frequently black or brown in color, necrotic (dead) or devitialized tissue. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy. Serous drainage or exudate is watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage. Stage 2 Pressure sore- partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. Unstageable Pressure ulcers related to suspected Deep Tissue Injury-(DTI) -puple or maroon area discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. DTI requires vigilant monitoring because of the potential for rapid deterioration. Such monitoring should be reflected in the care plan. RESIDENT 1: Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 2/11/13, documented Resident 1 required 2 person assistance for bed mobilty and one person assistance for transfers and was at risk for skin breakdown. The plan of care to prevent skin breakdown due to his immobility directed staff to observe his skin every shift for potential skin breakdown and to apply protective /preventive barrier cream to his skin every shift. Review of the nursing notes from 1/21/13 to 2/24/13, indicated Resident 1 experienced left leg/ankle pain, had a flare up of gout which was treated with steroids ([MEDICATION NAME]), frequently remained in bed and had a decrease in his appetite. A nursing note, dated 2/13/13, documented Resident 1 had a fluid filled blister on his left outer heel which measured 4.3 centimeters (cm) by 3 cm in size. The Advanced Nurse Practitioner (ARNP) note, dated 2/13/13, confirmed the resident had a fluid filled blister on his left heel and requested a test to determine if he had adequate blood flow to his foot. The ARNP documented there was poor blood flow to his feet. Even though the Licensed Nurse (LN) discovered the pressure sore on his left heel, a fluid filled blister, there was no documented evidence the plan of care was updated to include pressure relieving interventions when identified on 2/13/13. Review of the Pressure Ulcer documentation form, dated 2/19/13, indicated the LN completed the form 6 days after the ulcer was observed on 2/13/13. The LN documented a fluid filled blister measured 3 centimeters (cm) by 3 cm on the left heel. Was painful and a dressing would be applied to " relieve pressure". A 2/19/13 nursing note entry indicated the resident's pressure sores on both of his heels were painful and the resident required pain medication. The MDS, dated [DATE], indicated Resident 1 required 2 persons to assist him with his bed mobility and had developed 2 pressure sores. The Registered Dietitian (RD) note, dated 2/20/13, revealed Resident 1 had a weight loss of 10 pounds (#). On 2/15/13, his weight was 98#. There was no documented evidence, the RD had been notified regarding the pressure sores on both heels. The RD ordered health shakes and the goal was to promote weight gain due to his weigh loss. Another Pressure Ulcer Documentation Form , dated 2/19/13, was completed for the right heel. It was described to be a deep tissue injury (DTI) which measured 3 cm by 1 cm in size. Review of a revised care plan, dated 2/13/13, indicated the LNs were to apply skin prep to the left heel blister (Stage 2 pressure sore). There was no documented interventions regarding pressure relief measures for the pressure sores on both heels. Resident 1 was discharged on [DATE] to an Adult Family Home (AFH). There was no documented assessment regarding the condition of his pressure sores on both his heels or whether the pressure sores had improved or were healed. The AFH's wound assessment note, dated 3/2/13, documented the pressure sores on both heels were unstagable pressure sores. The wound beds contained dry eschar (eschar-dead tissue). The dry eschar on his left heel measured 3 cm by 4 cm in size and the eschar on his right heel measured 2.5 by 3 cm in size and the pressure sores were painful. On 5/6/13 at approximately 11:15 a.m., LN K who provided care for Resident 1 stated he required frequent positioning in bed and that when a pressure sore was identified, the nurse should measure the pressure sore, complete a change of condition (COC) form to alert the physician and notify the RD when a pressure sore is identified. On 3/5/13, Resident 1 visited his physician in the community. According to his physician's note, a specialized pillow for pressure relieve was prescribed due to his pressure ulcers. During an interview with the Director of Nursing on 5/6/13 at 11:00 a.m., she stated Resident 1 had "fluid filled blisters of both heels" and the LNs were to apply skin prep to the pressure sores and then cover them. The DNS stated LNs were to monitor the resident's feet and reposition him every 2 hours. She stated Resident 1 had vascular impairment of his lower extremities according to the 'ABI' test performed on 2/14/13, after the pressure sore(s) had developed. She stated his pressure sores may have been from his shoes he wore during skilled therapy and confirmed the shoes were "restrictive". She stated his shoes were removed after the pressure sores developed. On 5/10/13 the DNS, facility administrator and corporate nurse consultant were interviewed by telephone. They stated the resident exhibited repetative movement of his feet against the mattress. The facility was aware of resident behaviors that placed him at risk of friction and pressure sores. The facility failed to evaluate the need for and implement pressure relieving measures/devices when pressure sores were observed, and continued to worsen, on both heels. RESIDENT 2: Resident 2 was admitted from the hospital on 2/2/13 with [DIAGNOSES REDACTED]. The nursing assessment, dated 2/2/13, indicated he was at risk for the development of pressure sore(s). The admit nursing assessment documented the skin on his inner aspect of the right heel and the outer aspect of the left heel were red. The hospital's History and Physical note, dated 2/2/13, revealed Resident 2 had diabetes, and ankle pain with swelling. This note revealed Resident 2 had used boots for his feet, an air mattress and needed to be turned and positioned for avoid skin breakdown. The Minimum Data Set (MDS) assessment, dated 2/9/13, revealed Resident 2 was cognitively impaired, required two person assist for bed mobility and transfers, and had no pressure sores. The Plan of Care (POC) revealed Resident 2 required two person assist with bed mobility and a mechanical lift was used for his transfers. The POC directed staff to inspect and monitor his feet for redness, [MEDICAL CONDITION], and any open areas or injury. The POC did not indicate the resident used specialty boots for pressure relieve when in bed. The Treatment Administration Record (TAR) for February 2013 documented Licensed Nurses (LNs) were to float heels with pillows when in bed and to reposition him from side to side every two hours. Review of the nursing notes, dated 2/11/13, documented he had developed pressure sores on both heels. A Change of Condition (COC) form documentation read: " Dark blisters like areas on bil (both) heels, using SAGE boots when in bed". The blister on his right heel measured 6 centimeters (cm) by 3.5 cm in size. His left heel had two blisters. One blister was 2 cm by 2.5 cm in size and the other blister was 5.4 cm in size. The physician's visit note, dated 2/13/13, verified Resident 2 had developed pressure sores/ blisters on both of his heels. The physician ordered a specialty bed. Even though the physican and COC form documented Resident 2 had pressure sores, described as blisters, the facility's Pressure Ulcer Documentation Forms, dated 2/11/13, described these pressure sores on both heels as deep tissue injuries (DTI). Even though the LNs documented on the TAR for February 2013 that resident's heels were floated with pillows every shift, 3 pressure sores developed and when the facility identified the pressure sores, they were dark blisters on both heels. There was no documeted evidence the facility had evaluated whether floating his heels was an appropriate intervention for Resident 2. Review of the clinical record revealed Resident 2 was transferred to the hospital on [DATE] due to a change in his level of consciousness. He returned to the facility on [DATE]. The re-admit nursing assessment notes for 2/22/13, documented his right heel was covered with black eschar, necrotic tissue, and his left heel contained black boggy tissue and the medial side of his left heel was also covered with black eschar. The Treatment Administration Record (TAR) for April and May 2013 revealed the staff were to continue to float his heels. During an interview on 5/6/13 at 1:45 p.m., the Director of Nursing (DNS) stated sage boots were cotton boots and did not provide pressure relieve. She stated when the resident was transferred to the hospital on [DATE], he did not have SAGE boots or any order for the boots. The DNS stated that even though staff were to float Resident 2's heels, he would not keep his heels raised off the pilow or positioned to avoid pressure on his heels. On 5/6/13 at 8:38 a.m., during an interview with LN M, she stated Resident 2's heels are delicate and need to be floated. She stated Resident 2 frequently pulled his legs up and down on the surface of his bed, which rubbed his heels against the mattress's surface. LN M stated LNs need to make sure his heels are floated to avoid pressure. On 4/25/13 at 1:00 p.m., the resident was observed in bed. Both heels rested on top of his pillow and the heels were not floated. The family member was visiting and stated the resident moves his feet up and down in bed and rested his heels on top of his pillow rather than keeping his heels off the bed or pillow surfaces. On 4/17/13 at 9:25 a.m the resident was observed in bed. His specialty mattress was set on firm, both heels had dressings around them. Both heels were in contact with the surface of the bed. At 10:15 a.m., the resident remained in the same position, with his heels in contact with the bed surface. On 5/6/13 at 8:35 a.m., and at 1:05 p.m., Resident 2 was observed seated in his wheelchair. Both of his feet were swollen and he had cloth booties on. Both of his heels rested directly against the foot rest of his wheelchair. On 5/6/13 at 1:08 p.m., the resident's heels were observed with LN C. The outer aspect of his left heel had an unstagable pressure sore. The wound base contained 80% yellow slough (dead tissue) and the tissue surrounding the wound was dark red/purplish color. The skin of his right inner aspect of the heel was a reddish discoloration. LN C verified his heels were to be floated with the use of a pillow to avoid pressure on his heels. On 5/10/13 the DNS, facility administrator and corporate nurse consultant were interviewed by telephone. They stated the resident also exhibited repetative movement of his feet against the mattress and wheel chair. Even though the resident had developed pressure sores (blisters) on both of his heels on 2/11/13 which deteriorated during his hospital stay from 2/14 to 2/19/13, the facility failed to assess and reevaluate pressure relieve measures or take into account the resident's condition when they had knowledge Resident 2 did not keep his feet floated with a pillow when he was bed. RESIDENT 3: Resident 3 was admitted to the facility on [DATE]. The quarterly nursing assessment, dated 2/1/13, documented the resident had no wounds, and had contractures of his ankles, hands, arms and knees. The quarterly Minimum Data Set (MDS) assessment, dated 2/4/13, documented Resident 3 had no pressure sores or any [MEDICAL CONDITION] on his feet. On 4/25/13 at 11: 45 a.m., 2:10 p.m. and 3:30 p.m., the resident was observed in his tilt in space wheelchair with the footrests in the elevated position. A specialty boot (Rooke) was on his left foot. Record review indicated the resident was seen by a podiatrist on 1/3/ 13 and no open area were noted on his feet. On 4/25/13, the restorative aide (RA# O) verified Resident 3 received ROM exercises 7 days a week. She stated when she performs these passive ROM exercies on his lower extremities it was easier to perform them when he is in his bed. Review of the shower sheet documentation for Resident 3 revealed he had not received his bathing/shower on 2/9/13, 2/13/13 or 2/16/13. Review of the Plan of Care, dated 7/12, indicated the resident used a tilt-n-space chair when out of bed, body lotion was to be applied every evening at bedtime to extremities and a preventative skin barrier lotion was to be applied to the skin every shift due to his immobility, incontinence and cognitive impairment. Review of the Treatment Administration Record (TAR) for February 2013, documented weekly skin assessments had been performed on February 7 and 14th , the Licensed Nurse (LN) documented his skin was intact and had no pressure ulcers. Two days later, 2/16/13, Resident 3 was assessed to have a black area on his left outer side of his foot which measured 1 cm by 0.5 cm in size. Another entry read: " Black pressure area which measured 1.5 cm by 1.5 cm in size and there was small amount of clear liquid drainage". The faciltiy ' s Pressure Ulcer Documentation form, dated 2/16/13, documented the new identified skin issue was unstagable and the wound base contained 80% eschar with periwound [MEDICAL CONDITION] and tenderness. The wound measured 1.5 by 1.5 cm in size. Review of the faciltiy's investigative report, dated 2/16/13, documented Resident 3 was unable to communicate his needs, was bed/chair bound and unable to make simple body movement by himself. The report documented when the nursing assistant (NAC) changed his sock, she noticed a dark colored skin breakdown on his left foot and reported it to the nurse (LN). The LN verified the wound as an unstagable pressure ulcer on the bottom of his left foot. The investigative report concluded the pressure sore was related to inappropriate size/length of wheelchair. The MDS assessment, dated 3/27/13, documented the resident's pressure sore on his left foot was unstagable. The wound base contained slough/eschar (dead tissue) and measured 2.0 centimeters (cm) by 2.0 cm in size with no depth. On 4/7/13, the resident had a MRI of his left foot. The MRI test result read: "Ulcer adjacent to the fifth metatarsal head with osteo[DIAGNOSES REDACTED] of the fifth metatarsal head". By 4/16/13, the MDS documented the wound base still contained eschar and was 1.8cm by 1.8 cm in size with a depth of 0.3 cm. On 5/6/13, the Director of Nursing (DNS) stated Resident 3's ROM program had been discontinued on 2/11/2013. The DNS stated Resident 3 had scraped his foot against his tilt in space foot rest device which caused pressure. She stated when he pushes and extends his leg, and the bottom of his foot scraped against the foot rest. The physical therapy (PT) evaluation, dated 2/20/13, indicated Resident 3 was pushing his left foot into the foot plate of his chair which exerted pressure on the bottom of his left foot and required improved lower extremity aligment to prevent pressure to the bottom area of his foot. Even though staff were aware of the resident's contractures and extending his feet against the foot plate of the wheelchair, there was no documented evidence interventions were in place to avoid pressure to the bottom of his foot for a resident who was dependent on staff for all his care needs and unable to verbally communicate to staff.

Based on observation, interview and record review, the facility failed to evaluate and follow the plan of care to prevent the development of sores for 1 of 4 residents (Resident 1) who was identified to be at risk for skin breakdown. Failure to evaluate and follow-up on skin issues for Resident 1 resulted in actual harm and the development of sores. The facility did not provide a supportive pillow for neck positioning for Resident 2. Findings include: The facility's policy on "Skin Care & Pressure Ulcer Management Program", dated 9/11, read "managing pressure ulcers, ...uses the Assess, Plan, Implement & Evaluate ("APIE") approach to care giving. The program relies on standards of practice that focus on two aspects of care: 1) Prevention of pressure ulcer development,..and 2) Treatment that uses a standardized approach to promoting healing and preventing infection when skin breakdown occurs". The policy also directed staff to perform weekly skin evaluations, to monitor daily and communicate skin issues with nursing assistants, access and evaluate pressure redistribution treatment, wound pain, individualized repositioning and monitoring and whether incontinent products wick away moisture or if appropriate for the prevention of skin breakdown. RESIDENT 1: Resident 1 was readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 12/9/12, documented the resident had no cognitive impairment, required extensive assistance of two people for his bed mobility and transfer, was incontinent of urine and bowel and had no pressure sores. Resident 1's plan of care (POC) revealed staff were to apply a barrier cream after each incontinent episode and to keep his skin clean and dry and to report any open areas to Licensed Nurses (LN). The LNs were to perform weekly skin assessments. On 2/1/13 at 8:45 a.m., the resident was observed seated in his wheel chair. At 10:50 a.m., incontinent care was observed after an incontinent episode of both urine and bowel. When the Nursing Assistants (NAs) wiped between the resident's upper groin/inguinal area and scrotum, he grimaced and stated it " burns" and "hurts". On 2/1/13 at 10:55 a.m., after incontinent care was provided, the resident's skin was assessed with [REDACTED]. The open area on his right upper thigh/groin measured 11 centimeter (cm) by 5 cm in size and its wound base contained granulation tissue measuring 5.5 cm by 0.8 cm in size. The LN stated that the granulation tissue was "eschar". Another pressure sore area was noted along his brief line which measured 4.3 cm by 1cm in size and contained 50% slough in its wound base. The periwound areas of both open areas were tender. When the NAs wiped the areas, the Resident stated it was "painful". During this skin assessment with LN A, two new open pressure sores were identified along the brief line on the right ischial area of his right buttock where the brief compressed against his skin. One pressure sore measured 2cm by 1 cm in size and the other sore measured 1cm by 1cm in size. The wound bases contained granulated tissue. His left inguinal area had an open area which measured 10cm by 0.1cm and the wound base was red granulated tissue. His scrotal area had two open sores. One area measured 2.4cm by 2.3 cm in size with 50 % slough in the wound bed. The other open area on his scrotum was the size of a dime and had a red wound base. After the LN applied medicated creams to these open areas, the NACs were unable to properly secure his brief. The brief was ill fitting and the elastic portion of his brief was in direct contact with the open areas on his upper thigh/groin area and ischial region. The brief exerted pressure and irritation along the skin areas of his inner thigh area and along the ischial areas of the buttocks where the open pressure sores were located. Review of the Treatment Administration Record (TAR) for December 2012 indicated that the LNs were to apply an antifungal cream twice a day to "skin folds and buttocks area, and D/C (discontinue) diaper when in bed to decrease skin breakdown". In addition to the twice a day application of an antifungal cream, the LNs were to apply [MEDICATION NAME] ointment twice a day to the groin which was started on 12/3/12. Review of the TAR for January 2013 revealed the LNs were to perform weekly skin assessments. The January 2013 TAR revealed no skin assessment had been documented for 1/21/13. The January 2013 TAR also read: " cleanse scrotum area, put pillow case underneath scrotum area to heal skin tear. Apply barrier cream around it. Change pillow case each time patient is soiled or as needed (PRN ). Due to the skin tear on the scrotum , the LNs were to apply barrier cream for every shift. During an interview on 2/1/13 at 12:25 p.m. NAC(NAC F) stated the skin breakdown on his right upper groin area was present last week and had informed the LN. She stated she also reported the open area "yesterday" to the LN. NAC F stated the LN "gave her cream to put on the opened area from the medication cart. The NAC stated she was not aware the resident's brief was to remain off when he was in bed and had not applied pillow cases under his scrotum as she felt it "was not appropriate". During an interview on 2/1/13 at noon, the Resident Care Manager (RCM A ) stated that according to the resident's treatment plan of care, the LNs were to apply two different creams twice a day, an antifungal cream and [MEDICATION NAME]. RCM A stated the facility's policy for skin prevention was to have NACs apply a cream "Remedy" after each incontinent episode. She verified there was no documentation to inform the NACs that Resident 1 was not to use a incontinent brief when he was in bed. Review of the facility's "Skin Condition Documentation Form", dated 1/30/13, documented he had a skin tear on his scrotum which measured 3cm by 2cm in size and had a small amount of exudate. The wound base was documented to have 75% slough, was painful and the surrounding skin had erythemia and was tender. Another "Skin Condition Documentation Form", dated 1/31/13, documented the resident had excoriation on his scrotum. The excoriated area was measured as 0.5 cm by 0.5 cm in size. The nursing notes, dated 1/30/13, documented the resident had a skin tears on the scrotum. Another entry documented he had multiple wounds. Another entry for 1/30/13 read: "scrotal blister x1 =2x3 cm and R (right) thigh x1 3 by 3 cm. The following day, the entry for 1/31/13, read R thigh x1= 2 by 2 cm. this AM sites scabbed over". Even though the Nursing Assistant had informed the LN regarding the open area on his groin, there was no documentation on a "Skin Condition Documentation Form" to monitor the open areas. Even though the LNs were applying routine creams twice a day, the open area was not recognized until the surveyor assessed the resident's skin with LN on 2/1/13. During the time, the open area on his inner thigh/groin measured 11cm by 5 cm in size which was painful for the resident and newly identified areas on his ischial area were noted and his open areas on his scrotum contained slough. RESIDENT 2: Resident 2 was admitted to the facility on [DATE] with a [MEDICAL CONDITION] muscle wasting disease. The resident lacked trunk (upper body) control and was dependent on staff all her care needs. Resident 2 was identified to be at risk for skin breakdown due to her immobility and to keep pressure off her ear, to prevent the re-development of the pressure sore. The staff were to place a supportive neck pillow around her neck to keep pressure off her ears. The staff was to observe every shift for sign and symptoms of skin breakdown, redness/discoloration or O/A (open area). Observation on 2/1/13 throughout the day, the resident was observed in bed with the head of her bed elevated. There was no supportive pillow around her neck to relieve the re-developed pressure sore on the outer area of her left ear. On 1/29/13, the Director of Nursing (DNS) stated the pressure area on Resident 2's ear was from the pressure and irritation from her glasses. On 2/1/13 at approximately at 2:55 p.m., LN D was asked about the supportive neck pillow. The pressure relief pillow was not in place and her neck pillow was located in the bottom of her closet which was soiled without a pillow case. The re-developed pressure sore on her left ear was on the outer aspect of the ear. When the resident's glasses were put on the Resident , the hard ware of her glasses did not rest against her ear. Review of the facility's "Pressure Ulcer documentation Form", the pressure sore on the left ear was assessed on 1/14/13 as Stage 2 Pressure Sore (Stage 2- partial thickness skin loss involving epidermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) with maceration. It measured 1cm by 1cm in size and by 1/26/13 the pressure sorre contained slough. Interivew on 2/1/13 with the Resident Care Manager (RCM T) stated the resident's pressure sore developed in 2011 and the plan of care was to reposition the resident and to use a pillow to relief pressure on her ear.

Based on interview and record review, the facility failed to maintain dignity for 6 of 19 sample residents (5, 6, 8, 12, 17 and 18.) Failure by staff to speak and interact with respect resulted in psychological harm for Resident 8 who was tearful after a care conference and again when she recalled the incident more than 6 weeks later, stating she felt "they don't care about me." Failure to provide personal hygiene services as needed resulted in Resident 5 feeling "greasy" and "unclean;" Resident 6 feeling "angry" and "not important;" and residents 12, 17 & 18 not receiving necessary services. Findings include: 1. Resident 8 readmitted in March 2012 after replacement of an obstructed feeding tube. Her [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) assessment, dated 01/12/12 identified anxiety as a new diagnosis. Her MDS assessment, dated 02/03/12, identified depression as a new diagnosis. All MDS assessments since admission in November 2011 identified her recall and memory as intact. On 04/03/12 Resident 8 reported several staff members had spoken inappropriately to her. In February 2012, Licensed Nurse (LN) D told her to "shut up" when the resident was speaking with a family member on the telephone in her room. She was upset by the comment and reported it to Staff F, who assisted the resident to complete a grievance form. Since then, Resident 8 had not received any follow-up for that grievance. She became tearful as she recalled the incident and felt "the staff doesn't care". Again in February, Staff I told her to "go back to your room" in a loud tone of voice in front of other residents and staff at the Nursing Station when Resident 8 reported her call light had not been answered and there was not enough staff in the facility. On 03/27/12, Resident 8 attended a care conference with facility staff and the Resident Advocate (RA). Staff I stated the facility knew Resident 8 telephoned the State Hotline with a complaint about the facility care. Resident 8 became tearful. She felt "intimidated" by Staff I's comment. On 04/06/12 at 1:51 p.m., the RA reported Staff I spoke at Resident 8 rather than with her at the care conference. The RA observed this behavior of speaking at residents rather than with them for the past couple of months by Staff I. 2. Resident 5 was admitted in April 2010 with [DIAGNOSES REDACTED]. Her most recent MDS assessment, dated 01/28/12, identified she required one person assist with personal hygiene. Her memory and recall ability were intact (15/15 points on the memory assessment). On 03/14/12 at 1:50 p.m., Resident 5 reported she felt concerned as she sometimes received showers weekly rather than twice weekly as scheduled. She needed the showers twice weekly as the staff washed her hair during the shower. Her hair had a " greasy feeling " if she did not shower twice weekly. No one from the facility staff had informed her why she did not receive showers twice weekly. She thought it was "not right" to have showers as scheduled. She felt "not important". Review of the shower records for Resident 5 revealed she did not receive showers twice the week of March 3, 2012. 3. Resident 6 was admitted in 2005 with [DIAGNOSES REDACTED]. Her MDS assessment, dated 03/02/12, identified she could not move her arms or legs. She required mechanical lift assistance for transfer and two person assistance for dressing and showering. Her recall and memory were intact. On 03/14/12 at 9:02 a.m., Resident 6 reported things were "not going well here recently." She was scheduled for showers twice weekly. The routine was to have the shower in the morning about 10:30 a.m. on the shower day. She explained it required extended amounts of time and staff as they had to use the mechanical lift and get her out of bed, into the wheelchair, and down to the shower room. When she returned to her room, they used the mechanical to return her to her bed. She had very dry skin and they applied lotion to her body when she was back in bed. The staff dressed her and transferred her into her wheelchair for meals and her activities of the day. Recently, she "had to refuse a couple of showers" as the staff failed to arrive at the routine morning time for the shower. Staff arrived about 11:30 a.m. on those days; the time she goes to lunch. She had to "make a choice of lunch or shower." She was hungry and chose to go to the dining room for lunch. She felt "not important" as she "had to choose to eat then" or she "would not have been able to get my meal". Resident 6 could not feed herself; she relied on staff to feed her. There would not have been anyone there to feed her if she went to the dining room after a shower. Additionally, the staff knew she showered earlier in the morning when she got up. When they asked her about a shower at 11:30 a.m., she was already out of bed, dressed, groomed and seated in her wheelchair. They must use the lift, place her in bed, undress her, use the lift and place her in the wheelchair for transport to the shower. That process required time. She would arrive in the dining room too late for lunch. There was no staff later in the day to give her a shower as it required so much staff assistance. Resident 6 felt "angry, upset and frustrated." They knew she showered in the morning when she first awakened. That was her routine. Staff were not following the schedule. She was "frustrated". She did not think she should have to "choose between eating a meal and getting a shower." Additionally, Resident 6's son visited most Sundays, arriving about 11:0 a.m. routinely. He waited to visit when she was not yet up and dressed, ready for his visit. She reported he sat in the hallway until "they finally get me ready. They manage to get others ready who have family that visit regularly, but they can't seem to have me ready for my son on Sundays. I don't like that. It is not right. It feels like they don't care about me or whether I am ready for my family on time. When you have company, you like to be ready for them." 4. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/16/12 at 10:15 a.m. the resident was observed to be lying in bed with his call light on. He stated that he was "swimming in his own filth." He stated that it takes staff "forever to get help around here. When they don't come I will turn my TV up full blast to make them come." It makes me so "angry to know that I have to depend on them for assistance and then they don't come when you need them." The resident waited for over a half hour and did not receive assistance until 10:45 a.m. On 4/16/12 at 2:00 p.m., Staff I stated that the facility only uses male staff per the residents request, yet Staff I did not reveal how the facility was going to met the needs of the resident in a timely manner if he only wanted male staff. 5. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her MDS dated [DATE] indicated the resident was cognitively intact and needed extensive assistance of two people for transferring and toileting. On 4/16/12, Resident 18 stated that staff seems to "disappear and don't answer call lights. When I have to use the restroom I become uncomfortable and I dribble. I have not had a accident but it hurts right here (pointing to her bladder area) when I have to go and no one comes." 6. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/16/12 at 10:15 a.m. the resident was observed alone in her room, sitting in her wheel chair with her head hanging over a waste basket wrenching. She requested a cold wet wash cloth. The Investigator went to the nursing station to request assistance for the resident. An annoucement was heard over the loud speaker requesting a housekeeper to go to Resident 12's room. There were four staff members at the nursing station, the RCM, a Licensed Nurse, the Dietary Manager and one NA. The NA went to Resident 12's room, but the Licensed Nurses did not respond. On 4/16/12 at 10:50 a.m., Resident 12 stated, that she didn't know why she became sick. A staff member came into her room, but then left her alone and did not return. The LNs did not come to her room the NAs did though. Resident 12 also stated that she felt one RN treated her like she was "a piece of meat a couple of nights ago." She also went on to say that when she puts her call light on staff would enter the room and provide assistance to her roommate, turn off the light, because she is in the first bed. Staff would leave the room without asking her if she needed assistance. Then she would have to yell at them to come back and assist her. She stated that it is "very frustrating" when you need help and can't get it. Resdient 12 who was the Resident Council president stated that call lights and medication delivery is still a continuing problem. She asked the nurse to "please" bring her medications so she would not have to ask for them.

Based on interview and record review, the facility failed to maintain physical well being for 1 of 19 sample residents (4.) Failure to identify, assess, monitor, care plan and treat Resident 4's infection in a timely manner resulted in harm of skin deterioration with suppurating skin wounds and blisters. Findings include: Resident 4 was admitted in February 2012 for rehabilitation after a fall which resulted in a fractured arm. He had chronic [MEDICAL CONDITION] and a history of [MEDICAL CONDITION] Resistant Staphylococcus Organisms (MRSO) for which he took [MEDICATION NAME] as a [MEDICATION NAME] antibiotic. His Minimum Data Set (MDS) assessment, dated 03/01/12, identified he was a two person assist for turning and repositioning in bed. The hospital "Patient Transfer Summary" form, dated 02/24/12, was completed at the hospital before transfer and admit to the facility later that day. It noted he had a skin tear on this right forearm and sutures at two lacerations on the outer aspect of his left lower leg. No other skin issues were identified. At the facility, his "Nursing Admission Assessment" form, dated 02/24/12, was blank for the skin assessment section. Physician admission orders [REDACTED]. The first weekly skin assessment was scheduled for Friday, 02/25/12. It was documented as "x", an indication it was not performed. On 04/04/12 at 9:26 a.m., Licensed Nurse (LN) A reported a weekly skin assessment should be done as ordered. In this case, the admission skin assessment was blank. The night LN "should have done something or put it on the 24 hour report if she could not get it done". LN A was unaware Resident 4 had sutures in the left lower left when admitted . She stated the sutures "should be identified for location and they should be listed on the Treatment Administration Record (TAR). LNs should monitor their condition and any symptoms of infections." Any LN could and "should contact the physician and find out when and who should remove the sutures." Review of the TAR revealed no evidence of identification or documentation of any sutures in the left lower leg for symptoms of possible infection. There was no indication the physician was notified presence and removal of the sutures. LN A reported the LNs "should have done all of that. They did not follow the process." On 03/14/12 at 3:01 p.m., a family member reported Resident 4 complained of pain in his legs and left hip about a week after admission. On 03/01/12 the family member was concerned pain relief medications "were being used to cover a problem." On 03/22/12 at 2:44 p.m., Licensed Nurse (LN) C reported she performed the wound treatments for residents in the facility. She initially assessed the legs of Resident 4 on 02/29/12. On that date, she identified and documented five skin wounds for Resident 4 - one on the right forearm, three on the left leg and one on the right leg. She had no information why she documented these five wounds were present at admission as she did not see him until 02/29/12, 5 days after he admitted , and she did not have any facility admission skin assessment to review. LN C thought she saw him on 02/29/12 because one of the other LNs had left her a note asking her to see him. When she saw Resident 4, she was concerned about the "swelling in his legs." She did not start a care plan and she did not know who should evaluate and create a care plan for the skin conditions/wounds. Additionally, LN C did not know who did the skin assessments, monitoring or notification to physicians and families. LN C commented she documented only on the "Skin Condition Documentation" form. She noted it was not adequate for "all the categories" she needed to document. She had not considered or utilized other documentation avenues. Although she did the skin treatments, she did not know where assessments were documented. She had not sought or reviewed any skin assessments. LN C was not aware a wound culture from the left leg was sent for culture of possible infection on 03/04/12. She initiated formal wound treatment, including wrapping, to the " blisters and weeping areas " of both lower legs each day on 03/07/12. She documented on the TAR for March 2012 that she started this treatment beginning on 03/05/12. She had no information for the discrepancies of dates in her documentation. She stated she "did not know the system and process for all of this." Review of the clinical record of Resident 4 revealed a FAX document sent to the physician of Resident 4 on 03/04/12. The FAX read Resident 4's left lower leg was "very swollen and dark, painful to touch, [MEDICAL CONDITION] 4+ pitting." Pitting [MEDICAL CONDITION] defines as observable swelling of body tissues due to fluid accumulation that "pits" or indents when a finger is pressed against the skin. 4+ indicates the impressions of 4 fingers remain visible when the skin is depressed by touch. There was also a wound, 4 centimeters (cm) x 3 cm x 0.2 cm on the front of the leg with "minimal drainage". The physician ordered a culture from the left leg wound to assess whether an infection was present and what antibiotics the infection would respond to (sensitivity). The facility staff obtained and sent a wound specimen for culture and sensitivity (C&S) on 03/04/12 but failed to complete the required labeling and requisition data. The facility sent a fully detailed request and labeled specimen again on 03/05/12. On 03/07/12 the facility received the final C&S results from the laboratory. Resident 4 had an infection, [MEDICAL CONDITION] Resistant Staphylococcus Aureas,[MEDICAL CONDITION], in his leg wound. Resident 4's physician ordered antibiotics by mouth. Review of the "Skin Condition Documentation" forms revealed documentation of five wounds; each identified as present at admission. Each documented on weekly. The left leg posterior wound was described as having "large serous" amounts of drainage for both weekly entries 02/29/12 and 03/06/12. Additionally, the entry for 02/29/12, noted the presence of "[MEDICAL CONDITION]". The left and right leg wounds had pain identified as present each week. None of the five wounds had evidence of notification to the physician or family. The notification of change section was blank on all five wound records. Updating the care plan was also blank for all five wounds. Additionally, there was no evidence of documentation of a care plan for the skin wounds, no evidence of on-going assessments and monitoring of the skin wounds. The nursing notes lacked documentation of observations or notifications to the family of Resident 4's skin changes and wounds. On 04/06/12 at 1:51 p.m., the Resident Advocate reported a family member phoned her on 03/05/12 as the family member "thought something was not right" for Resident 4. The Resident Advocate met Resident 4 and his family on 03/07/12 in the resident's room. Resident 4's legs were "puffy and swollen; they had wraps on them. The family member wanted to see what his legs looked like as earlier that day the facility told her Resident 4 had an infection,[MEDICAL CONDITION], in his legs. But the wraps were already changed in the day time." The Resident Advocate recalled the family member was not able to visit any earlier in the day as she worked. She told the family member she "would meet her there on Friday evening and we would have them unwrap his legs". The Resident Advocate went to the facility on Friday, 03/09/12 and met with the family member. The Resident Advocate spoke to LN C and requested removal of the leg wraps. LN C explained she had already changed the wraps earlier in the day. LN C told the Resident Advocate "they were fine". LN C declined to remove the wraps. The Resident Advocate phoned Staff J. Staff J phoned to the Nursing Station and requested another LN remove the leg wraps on Resident 4's legs so the family and Resident Advocate could see the legs. A LN came into his room and removed the wraps while LN C stood at the doorway watching. "When the wraps were removed I saw his legs. They were huge, really swollen and puffy. The family member told me he had stitches on the outside of the left leg - they looked like black holes. I could not tell that there were any stitches there...his legs were purple/red color, no white/normal color on his legs. The toes were purple too. He had three large blisters on the left foot with yellow drainage oozing out of them. It dripped onto the floor. The LN told us to be careful and not step in it. LN C did not say anything; she just turned and walked away. The family member closed the door when the other LN left the room. She told me she wanted to call 911 and I agreed with her". The Resident Advocate stated Resident 4 was taken to the hospital, where she visited him the next day, 03/10/12. She saw his legs that day. "Parts of his toes were back to normal color and parts of them were still purple. I could see the stitches on the outside of the left leg. They looked like stitches. It was like night and day, the difference. His skin looked much better." Review of the hospital records, dated 03/09/12, revealed the physician of the emergency department documented Resident 4's chief complaint as "[DIAGNOSES REDACTED] (redness), swelling, drainage from wound." Resident 4's legs were "marked a dark red angry [DIAGNOSES REDACTED] to both extremities from the knees to the feet." The physician documented "patient is ill appearing." The nursing assessment noted "both legs are weeping. The left foot has blisters, swelling to both legs. Legs are a dark red/purple. Painful to touch. Open area on left lateral calf. Signs of infection, swelling, skin temperature is warm, skin moisture is moist." The physician ordered and started intravenous antibiotics in the emergency department. Resident 4 was admitted to the hospital. See F 157 - notification of change in condition for additional details.

Based on observation, interview and record review, the facility failed to have sufficient qualified nursing staff to safely provide and supervise care for residents with complex health care needs. The care provided was not supervised in a manner to provide consistency in therapeutic approaches to avoid actual harm. Staff did not have sufficient knowledge to prevent significant medication errors, adequately assess, evaluate or document information needed to formulate effective and timely interventions for skin care. Failure to prevent significant medication errors, provide timely medical evaluation and treatment, and accurate/timely pain management, resulted in harm for Residents and place all other residents at risk for potential or actual harm. Findings include: 1) Nursing services failed to ensure there was sufficient qualified staff to safely provide a proactive medication administration system with the role and responsibility to prevent significant medication errors. Refer to 42CFR 483.25(m)(2), F-333 - Residents Free of Significant Med Errors 2) Nursing Services failed to ensure qualified licensed nursing staff accurately assessed, planned and provided skin care to prevent skin breakdown and recognized the need for prompt medical evaluation and treatment for [REDACTED]. Refer to: 42 CFR 483.25, F-309, Quality of Care 42 CFR 483.25(c), F 314 - Pressure Sore 3) Nursing Services failed to ensure qualified licensed nursing staff provided residents with timely care related to: responding to call lights, feeding and toileting needs. Lack of staffing Random residents were asked if they felt there was enough staff available to ensure care was provided and assistance they needed without having to wait a long time. During an observation on 6/6/11 at 8:30 a.m., lights were observed to be on for room [ROOM NUMBER] & 116. There were no staff members in the area. The two lights were observed to be on for 20 minutes, before a staff member began to respond. In an interview on 6/6/11 at 11:30 a.m., Resident 4 stated that she has to wait for everyone else in the dining room to be served before she gets to eat and "sometimes I am hungry." In an interview on 06/06/11 at 2:23 p.m., Resident 3 stated "they are not well staffed. My feeling is after 9 at night." In an interview on 06/06/2011 at 3:35 p.m., Resident 82 stated "it is very hard to get help after 10:00 at night, recently all the shifts have new staff - the mornings are hard related to getting up, cleaned, dressed and ready for breakfast." In an interview on 06/07/2011 at 9:23 a.m., Resident 217 stated "Evening shift needs more aides, during meals, the nursing assistants hand out trays, so they do not have time to help to go to the bathroom. That is inappropriate and should not happen, but this happens at every meal." In an interview on 06/07/2011 at 10:13:52 a.m., Resident 21 stated she does not "know of any pattern, but does have to wait for long times, sometimes up to an hour." In an interview on 06/07/2011 at 2:43 p.m. Resident 2 stated she wanted to have a shower twice weekly as scheduled but they are "short staffed when they pull someone to do the showers for the residents on the respiratory unit. Weekends are often short staffed, they don't want the residents to know - but we have to wait about 30 minutes on the weekends for a call light response." In an interview on 06/07/2011 at 3:04:32 p.m. Resident 239 stated she had been "wondering if they have enough qualified staff at night shift. The nurse last night was terrible. They didn't know how to get the bubbles out of her IV or get it started. She had to leave and come back. She finally had to get another nurse to help with the IV." In an interview on 06/07/2011 at 3:54 p.m. Resident 99 stated "sometimes I feel like their responses are delayed. It is mostly on nights. By in large I think they try, there is just not enough of them." In an interview on 06/07/2011 at 4:10:06 p.m., Resident 25 stated "I get a shower when the staff has time. They are so busy and I am not the only one on the floor so I try to make it convenient for them. It works both ways, if you don't complain then things run smother." In an interview on 06/08/2011 at 9:42:42 a.m. Resident 235 stated "the weekends and evenings are slow." In an interview on 06/08/2011 at 10:07 a.m., Resident 54 stated he wants to go outside "they don't have the staff to do that" and on weekends his showers were put off. In an interview on 6/10/11 at 2:55 p.m. the DNS stated "No I don't have enough staff" for the restorative program. In an interview on 6/13/11 at 9:50 a.m., Resident 115 stated that "there is not enough staff here. And not enough that speaks English. It is hard to communicate with them." He stated it is not one shift in particular but during the weekends it is really bad. In an interview 06/13/11 at 3 p.m., Resident 203's family member recalled the resident's brief and his bed linens were "soaking wet" on more than one occasion when they visited. In an interview on 6/14/11 at 12:30 p.m., Resident 85 during the day he waits 10 minutes for call light response. On nights it takes from 30 minutes to 2 hours. That is the worst because "I can't breathe well and I need help clearing my airway" The resident stated "They are short" staffed. In an interview on 6/14/11 at 11:00 am Resident 52 stated that during the night it could "take up to an hour" before the call lights are answered. "I can get up on my own now, but when I couldn't, I wet my bed. It made me so angry and frustrated because we pay a lot to be cared for." She went on to say that she felt there was "not enough staff because no one comes when you need help." Refer to 42 CFR 483.15(a), F 241 - Dignity Unqualified Staff Failed to have qualified staff for the overall monitoring of residents, to assess, plan treatment and implement interventions for complex medical care. In an interview on 6/14/11 at 12:22 p.m. the DNS stated she did not know where "as needed" psychoactive medications and pain medications should be documented. She stated she would have to go check on that. The DNS was unable to answer the question. In an interview and record review on 6/14/11 at 5:48 p.m., Resident 1 had two Abnormal Involuntary Movement Scale assessments were reviewed. The Regional director of clinical operations (RDCO) stated one of the assessments was inaccurate. When asked why the LNs documented inaccurately on the AIMS tests. The RDCO stated that she cannot say why one nurse assessed at a zero and one is a one. "One nurse may have liked" the the zero versus the number one. She cannot speak to why they assessed the resident wrong the way they did. In an interview on 6/9/11 at 9:10 a.m., LN 5 was asked where the Nursing Assistant's document the care they had provided. LN 5 was unable to provide an answer. She stated she would have to ask LN 1. LN 1 did not provide the answer but went to get the DNS to answer. In an interview on 6/9/11 1:45 pm the DNS stated the direct care LNs do not know how to measure wounds. They do not know how to consistently measure wounds. In an interview on 6/9/11 2:15 pm LN 6 was asked the procedures of the facility skin program. LN 6 stated that "in the most part skin documentation is in the MARs" but the DNS does some of the monitoring. In an interview on 6/9/11 3:30 pm the RDCO was asked for the skin care policy the RDCO stated that the facility followed a book, "Potter & Perry." A copy of the pages was requested and the RDCO stated it was just "normal standard of care". She then began to talk about the procedure. She was informed the nurses on the floor were unable to tell me what they do when a pressure ulcer is found. The RDCO also stated that the direct care LNs had been trained on pressure ulcers in December of 2010, then again on 4/11/11. The RDCO stated the facility had identified there was an inconsistency of pressure ulcer measuring. The RDCO could not provide an explanation as why the direct care floor nurses were still doing assessments if the facility identified them to be unqualified to accurately assess. She also stated the DNS needed further training. In an interview on 6/14/11 at 12:22 pm the Director of Nursing Services DNS stated she was unaware of where staff would document interventions, but she would check on it and get back to the survey team. In an interview on 6/14/11 at 12:32 the Regional director of clinical operations (RDCO) stated that documentation for psychoactive medications interventions and responses should be documented on the front of the MARs where the codes are listed, at the bottom of the sheets. She reviewed the MARs with the surveyor stated the licensed nurses were not documenting. A Record review with the DNS on 6/9/11 at 1:45 pm showed there were two different skin sheets with different documentation. The DNS stated "where did you get that from." She stated "I don't know why because I am the one who does the skin measurements. The LNs do not know how to measure wounds." The DNS was unable to provide an explanation what why her measurements were so much different from what was on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"do not know how to consistently measure wounds." On 6/15/11 a "Medication Error report" was requested from the DNS. A review of the report on 6/16/11 showed the LN who made the transcription error completed the "medication error report" on 6/15/11, 7 days after discovery of the error. The report was incomplete and not completed in a timely manner.

Based on observation, interview and record review, the facility failed to ensure 11 of 26 sampled residents (2, 4, 52, 75, 115, 203, 217, 222, 224, 248 and 300) were treated in a dignified/respectful manner. Failure to ensure staff respond to requests for pain medications; provide feeding, dressing and toileting assistance in a manner to enhance dignity and individuality caused residents unrelieved pain, anger, frustration & embarrassment. Findings include: Interviews were conducted on 6/6 - 6/16/11 during the course of the survey. Residents voiced concerns including slow responses to call lights, delay in receiving pain control medication, showers not being received per their preferred schedules, and not being fed in a timely manner. 1. Resident 300 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had chronic pain and was receiving pain medications. In an interview on 6/13/11 at 1:35 pm Resident 300's family member stated the resident had to wait up to a half hour for her call light to be answered and then had to wait another hour to get her pain pill. When the resident's pain gets, "out of control it is hard to get her comfortable again." The family member indicated this had happened since Resident 300 had been in the facility. The resident agreed with what the family member stated. The family member also stated she had observed the roommate (Resident 248) who had the same problem with call light response, when she needed to get up and go to the bathroom. She could not wait for staff so she would get up alone to toilet. 2. Resident 224 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]." dosage of pain medication. In an interview on 6/07/11 at 9:51 a.m. Resident 224 stated he had to wait long periods of time for pain medications especially on evenings. When he had to wait too long the pain was difficult to control. He stated he has had to wait a half hour to 3 hrs to get his pills. When he finally received his pain medication, especially on the evening shift, he would say to them, "Gee, it's about time." He said he felt like he shouldn't have wait and it is so difficult to predict when the pain would return to request more medication. 3. Resident 222 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS assessment dated [DATE] indicated the resident was cognitively intact and needed a two person extensive assistance with toileting but was she was continent of bowel and bladder. In an interview on 6/06/11 at 3:30 p.m. Resident 222 stated, in a raised angry tone, that when she needed help to go to the bathroom, staff would not come right away. "I peed down my legs a couple of times waiting for staff to help. I had never in my life wet myself, it is a helpless feeling." She was unable to take a shower to clean up after these incontinence episodes. She stated that bathing was more according to the facility schedule. The resident did not feel it was acceptable or healthy to have only 2 showers per week especially when someone had soiled themselves. She was constantly worried of body odor, so she bathed at the sink while sitting in her wheel chair to stay clean. She had never "felt so dirty" as she did now that she was in the nursing home. 4. Resident 248 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She needed a one to person extensive assistance with her toileting but she was continent of bowel and bladder. The resident was at high risk of injury if ambulating without assistance. In an interview on 6/16/11 at 9:15 am, Resident 248 stated she was not supposed to be up walking alone because of her surgery, but it took staff up to an hour to answer her call light. Sometimes staff would come in and ask her what she wanted and then they would turn around walk out and not come back. "I had to get up and go to the bathroom. I couldn't make it and right in front of the sink I peed all over the floor. I just hated that, It was so embarrassing." She never knew if staff would come to answer the call bell. She expressed fear and worry that staff would not answer her call bell when she needed assistance to the bathroom. 5. Resident 52 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS assessment dated [DATE] indicated the resident needed a two person extensive assistance with toileting and but she was continent of bowel and bladder. In an interview on 6/14/11 at 11:00 am Resident 52 stated that during the night it could take up to an hour before the call lights are answered. "I can get up on my own now, but when I couldn't, I wet my bed. It made me so angry and frustrated because we pay a lot to be cared for." She went on to say that she felt there was "not enough staff" because no one comes when you need help. 6. Resident 75 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS assessment dated [DATE] indicated the resident was moderately impaired with his cognition and needed one to two persons provide total assistance with all of his ADLs except eating. During an observation of care on 6/7/11 at 8:58 am, two nursing assistants (NA)s assisted Resident 75 to lie down on a specialized pressure reducing bed. After NA 1 and NA 2 had the resident back in bed NA 1 pulled his pants down to check his attends. After checking his attends NA 1 left his pants pulled down around his knees and lower legs, covered him up with two blankets and left the room. In an interview on 6/7/11 at 1:55 pm, NA 1 stated that they left Resident 75's pants pulled down so that they could change him easier. The NAs did the same thing for Resident 115. During an observation of care on 6/10/11 at 1:15 pm, NA 3 and NA 5 assisted the resident back to bed. After they checked the resident NA 3 pulled his pants up before covering him with his blanket. In an interview on 6/10/11 at 1:15 pm, NA 3 stated that some staff members leave Resident 75's and 115's pants down because it was easier to change their briefs. NA 3 stated "I pull their pants up" but others leave them down for the oncoming shifts. That way their pants are already down. In an interview on 6/16/11 8:01 am The Director of Nursing Services stated that it was not facility practice that resident's pants were left down around their legs. 7. Resident 115 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS assessment dated [DATE] indicated the resident was cognitively intact and was dependent on staff for all ADLs. In an interview on 6/13/11 at 9:57 am Resident 115 stated that staff left his pants down but he was unsure why he guessed it was easier for staff. He also stated that he did not consistently get showers as scheduled and he stated "I do not like that." Leaving the resident's pants down for staff convenience placed these residents in an undignified state. During a record review on 6/13/11 including the Activity of Daily Living form and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 8. Resident 203 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS assessment dated [DATE] indicated the resident was in a comatose state and needed a two person total assistance with toileting. In a family interview on 06/07/2011 at 1:52 p.m. Resident 203's family member stated the family had concerns for the resident and timely attention to his care needs. He was often wet when they visited him. Sometimes there was an odor of urine in the room when they visited. The family was tearful as she recalled visiting the resident in such a condition. On 06/13/11 at 3 p.m., another family member recalled the resident's brief and his bed linens were "soaking wet" on more than one occasion when they visited. The family knew Resident 203 would not want his family to see him in that condition. As a reasonable person, no one would want visitors when they had urinated and it had soaked through their brief, clothing and bed linens. 9. Resident 217 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS assessment dated [DATE] indicated the resident was cognitively intact and needed a two person extensive assistance with toileting and was on a bowel toileting program. In an interview on 06/07/2011 at 9:23 a.m. Resident 217 stated "Evening shift needs more aides, during meals, the nursing assistants hand out trays, so they do not have time to help residents go to the bathroom. That is inappropriate and should not happen, but this happens at every meal." During an observation on 6/6/11 during the breakfast meal call lights were observed to be on in hallway where room [ROOM NUMBER] was. There were no staff members in the area. Two lights were observed to be on for 20 minutes. 10. Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS assessment dated [DATE] indicated the resident was cognitively intact and needed a one person total assistance with eating. During a dining room observation on 6/6/11 at 11:25 am, Resident 4 was already sitting in the dining room along with 6 other residents. At 11:30 am there were 4 residents who were already eating while others could look on. They were part of a progressive feeding program. There were two staff members assisting those 4 residents and no other staff. At 11:35 am the meal cart with trays was delivered to the dining room. There were 3 staff members in the dining room, but no one began to serve the trays and no one was serving coffee or interacting with the residents. At 11:40 am a second cart arrived to the dining room. Three different staff members were in the dining room including the Director of Nursing Services (DNS). No one at that time was serving meals from the first cart. At 11:45 am the DNS began to serve meals along with other 2 other staff members. Staff members continued to serve all of the other residents until 11:58 when Resident 4 was served her food and assisted to eat. In an interview on 6/13/11 at 1:15 pm Resident 4 stated that her meal service was better now than it used to be. It used to be even worse before, but "I have to wait until everyone is served before they get to me. Sometimes I am really hungry too but I have to wait." The facility created an atmosphere that resulted in the resident having to settle for waiting long periods of time to be assisted with eating. 11. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 6/7/11 at 2:43 pm Resident 2 stated that she has no feelings in her extremities and had to be fed by staff. Her and Resident 4 are the last ones to be fed at every meal. She had to wait to be fed until everyone else receives their meal. There is one woman that sits at her table that the family comes in to feed her and the other gentleman can sometimes feed himself.

Based on observation, interview and record review, the facility Administration failed to monitor and effectively administer services to attain and/or maintain resident highest level of function and optimal well-being. Failure to assess for sufficient qualified staffing and address staff knowledge to meet resident needs resulted in harm for residents with skin issues and placed residents with restorative needs at risk for failure to reach the highest level of function and a decrease in quality of life. Findings include: 1. The Administrator failed to ensure that all residents were treated with respect and dignity. Failure to respond to requests for pain medications in a timely manner caused uncontrolled pain; Failure to ensure residents were feed timely manner; Failure to ensure residents were dressed / undressed and responded timely for requests to toilet. Refer to 42 CFR 483.15(a), F 241 - Dignity 2. The Administrator failed to ensure the facility implemented written skin policies and procedures and failed to provide training to attain sufficient qualified staff to assess, monitor, care plan, treat, and evaluate skin conditions of residents. This failure demonstrated that the facility's Administration skin program was ineffective, resulted in harm for two residents and placed all residents at risk for delay in identification, treatment and evaluation of skin issues. Refer to: 42 CFR 483.25(c), F 314 - Pressure Sore 42 CFR 483.20, F272 - Assessments 42 CFR 483.25, F309 - Quality of Care 3. The Administrator failed to ensure the facility provided training for the Director of Nursing Services (DNS) who oversaw the Restorative Program for residents in a timely manner. The DNS reported she and been in charge of the Restorative Program for over a year and had no training for the role. This failure resulted in delay of care plan development and on-going evaluation of restorative program exercises for residents. The facility failed to implement their policy for care planning and assessment of goals for residents on restorative programs. Without sufficient care planning, including measurable goals and individualized interventions, residents were placed at risk for decreased range of motion and mobility. Additionally, lack of sufficient numbers of qualified staff to provide daily restorative exercises to all identified residents placed those residents at risk of lack of mobility and diminished range of motion. Refer to 42 CFR 483.25(e)(2), F318 - Range of Motion 4. The Administrator failed to ensure incidents were thoroughly investigated or allegations of abuse were reported to the appropriate entities as required. No action was taken to protect residents from further potential abuse. Refer to 42 CFR 483.13(c)(1)(3), F 225 - Investigate/Report Allegations/Individuals 5. The Administrator failed to ensure the facility provided adequate supervision and maintained an environment that was as free as possible from accident hazards for 1 resident and also failed to provide enough supervision to prevent resident to resident altercations. This failure resulted in harm for one resident related to repeated falls with injuries and created an atmosphere of fear for another resident. Refer to 42 CFR 483.25(h), F 323 - Accidents and Supervision 6. The Administrator failed to ensure the facility provided qualified staff to provide supervision, assess residents and document outcomes. Refer to 42 CFR 483.30(a), F 353 - Sufficient Qualified Staff 7. The Administrator failed to ensure Social Services provided advocacy so residents could reach their highest psychosocial level, were discharged appropriately and prevented inappropriate us of psychoactive medications. Refer to: 42 CFR 483.12(a)(3)(2), F 202 - Admission, Transfer, Discharge 42 CFR 483.12(a)(4)-(6), F 203 - Notice before Discharge 42 CFR 483.15(g), F 250 - Social Services 42 CFR 483.25(l), F 329 - Unnecessary Drugs

Based on observation, interview, and record review, the facility failed to ensure 2 of 3 sampled residents (108 & 193) reviewed, did not develop a pressure ulcer during their stay at the facility. Failure to ensure care and services were consistently provided, resulted in harm for Resident 108 & 193 who developed painful and avoidable pressure ulcers on their heels. Findings include: The facility's skin policy named the "War on Wounds" program directed staff that on admission a "Skin at Risk Assessment" was to be completed and a preliminary skin care plan would be developed and implemented. Interventions should include repositioning at least every 2 hours, routine observation of skin, application of lotion to dry skin. A full body audit would be completed by a licensed nurse at least weekly and documented on the "Weekly Licensed Skin Check" form. The C.A.R.E. process indicated that the Interdisciplinary team reviews resident weekly to evaluate the plan of care and the overall clinical condition (including potential complications) in relation to pressure ulcer healing. Treatment changes are documented on the resident's care plan. Resident 108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her MDS assessment dated [DATE] indicated the resident did not have any skin breakdown. On 4/23/11, hospital staff documented on the "discharge report" the resident was at a moderate risk to develop pressure ulcers. Hopital staff also documented the resident's skin, skin temperature and capillary refill were within normal limits. On the day of admission, 4/23/11, the facility completed an initial nursing assessment. The assessment indicated the resident's skin was clear. It was determined that she was at moderate risk for skin breakdown, related to the "Norton Plus Pressure Ulcer Scale" (a standardized assessment form that determines a risk score). The facility developed a care plan dated 5/3/11 with goals that the resident would not develop any skin breakdown. Interventions included: Apply protective / preventive cream every shift. Assist the resident to turn and reposition every 2 hours as needed. Keep the resident's skin clean and dry. Use pressure relieving devices as ordered (there were no oders for devices on admit) and complete weekly skin assessments. Documentation by the Director of Nursing (DNS) on 5/19/11 on a "Pressure Ulcer Documentation Form" indicated that a 6 centimeter (cm) X 5 cm, stage 2 blister was discovered and the resident was having associated pain from the blister. There was no documentation of any follow up until the next day, when the floor nurse documented in the progress notes. The DNS did not document that she contacted the physician, there was no documented care plan developed and no documented interventions were put into place at that time. The night nurse documented in the progress notes the resident had a fluid filled blister on her left heel. The skin was intact, but it was painful to touch. The night nurse documented that she initiated an intervention of bridging the resident's lower legs on a pillow to releive pressure. There were no measurements or description of the wound documented. On 5/20/11 the Resident care manager (RCM) documented on a different "Pressure Ulcer Documentation Form" than what the DNS documented on. The RCM documented the measurements of the raised fluid blister was 2.5 cm x 2.5 cm. There was no other documented description of the blister in the progress notes and the form was not compltely filled out. The RCM also documented in the progress notes at 10:00 am the Physician, Dietician and Physical Therapy were contacted. After the wound was discovered there was no documentation of an analysis as to why the wound had occured. On 6/6/11 the Regional Director of Clinical Operations (RDCO) documented in the progress notes a "Skin / wound assessment and summary:" On 6/9/11 at 3:20 pm the RDCO stated that she wrote the summary without visually assessing the resident even though she documented the "resident was observed with 6 cm x 5 cm intact blister ....Blister is dark purple (old blood)." An observation of the resident's pressure ulcer was done on 6/9/11 at 10:40 am with LN 8. The resident was lying on her back and had a boot on her left foot. There was a pillow under leg that was flattened and not elevating the boot. The resident had a large black blister on her left heel. The LN measured the area and stated the wound looked different from the last time she had visualized the area. She stated the wound measured 3.6 cm x 4.5 cm. At 12:30 pm the resident was observed up in her wheel chair with her feet resting on the floor. The blister / heel had contact with the boot. A record review with the DNS on 6/9/11 at 1:45 pm showed there were two different skin sheets with different documentation. One set of sheets was kept in the DNS' office and The DNS stated "I am the one who does the skin measurements. The LNs do not know how to measure wounds." The DNS was unable to provide an explanation why her measurements were so much different from the skin sheets that were in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"do not know how to consistently measure wounds." Record reviewed revealed there were two separate documents for wound assessments, one kept in the DNS office and one in the clinical record. When the records were reviewed they were difficult to follow and contradictory to each other. Pressure ulcer Documentation forms: The DNS documented the wound measuremented on: 5/19/11, 6 cm x 5 cm Stage 2 intact blister 5/26/11, 6 cm x 5 cm Stage 2 intact blister 6/2/11 5.6 cm x 4.8 cm Stage 2 intact blister reabsorbing 6/9/11 5.2 cm x 4.8 cm Stage 2 intact blister reabsorbing 6/16/22 4.8 cm X 3.9 cm with 100% eschar (Thick dry black dead tissue) The Floor nurses documented the wound measurmented on: 5/20/11 length 2.5 x 2.5 cm raised fluid blister 5/27/11length 2.4 cm x width 2.3 cm fluid blister 6/3/11 length 2.1 cm x width 2.2 cm fluid blister 6/9/11 the wound measured 3.6 cm x 4.5 cm fluid blister On 6/10/11 LN 8 stated the DNS removed the measurment flow sheets out of the MAR. In an interview on 6/9/11 at 2:15 pm, the RCM stated "in the most part skin documentation is in the MARs, but the DNS does some of the monitoring." In an interview on 6/9/11 at 3:30 pm the Regional director of clinical operations RDCO corporate nurse, stated when asked for a pressure ulcer policy that the facility follows Potter & Perry for care of pressure ulcers. The RDCO stated the facility "followed normal standards of care." She also stated that floor staff had been trained on pressure ulcers in December of 2010 and then again on 4/11/11 with a inservice that included the wound program, measuring and staging sheets. The RDCO stated the facility had identified the DNS needed further training and there was an inconsistency of pressure ulcer measuring. The RDCO could not provide an explanation as why the floor nurses were still doing assessments if the facility identified there were unqualified nurses to accurately assess wounds. In addition she stated as soon as a pressure ulcer was found that a plan of care was developed, a chart note was written and risk factors were developed. In an interview on 6/10/11 at 10:05 am The RDCO stated the facility thought the reason there was a variation in measurements was because when the RCM first measured the area it was at the very beginning of development and was flat. Whereas depending on the time of day from the [MEDICAL CONDITION] the fluid sac filled up and the wound became bigger because of the fluid buildup. An observation on 6/10/11 at 1:30 pm the Resident was lying in bed with eyes closed. On 6/10/11 at 2:20 pm the resident's daughter informed the surveyor that after we had spoken, the SW came and informed her that when the resident converts to Medicaid they now will be able to keep her in the facility because there will be a bed available on the other side of the building. On 6/11/11 at 3:10 p.m. the DNS stated that documentation is only done if there is something out of the ordinary. The facility only documents to exception. On 6/20/11 the DNS submitted a written statement indicating the resident had a .....decrease in capillary refill of the toes both when dependant and elevated even though the hospital on discharge indicated it was within normal limits. Based on these factors preventative measures were placed. Resident received a pressure reducing mattress upon admission and a pillow was place under her calves to bridge her heels. (Per documentation, the pillow was not started until after the wound was discovered.) 2. Resident 193 was readmitted in May 2011 with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS) assessment, dated 06/06/11, identified his short-term and long-term memory and recall abilities were intact. The hospital transfer, dated 05/20/11, documented Resident 193 had right heel eschar, a hard crust of dark colored skin. The facility documented a right heel pressure ulcer as unstageable and measuring 2.8 centimeter (cm) by 2.3 cm with eschar Observation on 06/09/11 at 08:20 a.m. found Resident 193 seated in a wheelchair. He wore non-skid socks on his feet, which were not elevated. He stated he wished he had a dressing on his right heel. At 10:13 a.m., his right heel rested against the flip flops he wore on his feet. This position applied direct pressure to the heel. His feet were not elevated. At 1:12 p.m., Resident 193 stated he had only the flip flops to wear on his feet and he had sores both feet before. He stated the staff did not place pillows under his feet to keep his heels on the direct contact with the bed. Observation at that time with Licensed Nurse (LN) 4 found Resident 193 had both heels in direct contact with the bed. Neither heel was elevated. The right heel had dry eschar, measured as 1.8 centimeters (cm) x 1.2 cm. The eschar was surrounded by reddened skin tissue. The presence of eschar defines the pressure ulcer as unstageable. The entire right foot was [MEDICAL CONDITION] (swollen). LN 4 stated Resident 192 was unable to lift his right foot by himself. When LN 4 lifted the resident's right foot, the resident was observed to be guarded and requested his leg be lowered because of discomfort. The left heel was boggy and non-blanchable, non-blanchable [DIAGNOSES REDACTED] of intact skin meets the definition of Stage I pressure ulcer. At this time, LN 4 outlined the left heel area with a marker and measured the size, 2 cm by 2.5 cm in size. At 2 p.m., while the surveyor was sitting at the nursing station LN 4 explained to the next shift oncoming LN how to document each heel on a separate form when she what to do about the two areas. . At 3:30 p.m., Resident 193 was observed lying in bed. Both heels were in contact with surface of mattress. No pillows were under either heel; neither leg was elevated. Resident 193 ' s care plan identified impaired skin integrity related to pressure ulcer. Interventions included a sage (soft) boot to be placed on the right foot and likes right foot elevated on pillow in bed. The Regional Director of Clinical Operations (RDCO) stated that on the evening of 06/09/11, a skin assessment was completed for Resident 193. The facility documented the left heel was intact and skin prep was applied. Additional review of the clinical record found no evidence of nursing documentation of the assessment on 06/09/11 at 1:12 p.m. or initiation of monitoring of the left heel. There was no update to the care plan at that time. The care plan update, dated 06/10/11, read " soft left heel, but intact. Added heel lift on bed. " The care guide, a form used by the Nursing Assistants to care for residents, read: pressure sore to heel - without clarifying which heel(s) or how to relieve the pressure on the heel(s). On 06/10/11 at 8:15 a.m., Resident 193 was observed in bed - -eyes closed, the left heel was not elevated. The right heel was also in direct contact with the surface of the mattress. A pillow lay at the foot of the bed. On 6/13/11 at 9:40 a.m., LN 4 reported she did not initiate and document a form to monitor Resident 193 ' s left heel. She did not document the assessment of the left heel or initiate interventions to address the skin issue of the left heel. A nursing note, dated 06/13/11, as an addendum to 06/09/11, noted an area of the left heel was slow to blanch. At 10:00 a.m. the surveyor informed facility administration and the RDCO LN 4 did not complete documentation of skin assessment on heels and updated the resident's care plan. The RDCO stated "things are out jointed."

Based on observation, interview and record review, the facility failed to perform and document accurate assessments for resident physical and mental conditions. Affected were three sampled residents with known change in condition (108, 193, and 197). Failure to assess Residents 108, 193 and 197 for skin condition resulted in harm of mulitple areas of skin breakdown. Findings include: 1. Resident 108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her MDS assessment dated [DATE], indicated the resident did not have any skin breakdown. On the day of admission, 04/23/11, the facility completed an initial nursing assessment. The assessment indicated the resident's skin was clear. It was determined that she was at moderate risk for skin breakdown, related to the "Norton Plus Pressure Ulcer Scale" (a standardized assessment form that determines a risk score). Documentation by the Director of Nursing (DNS) on 05/19/11 on a "Pressure Ulcer Documentation Form" indicated that a 6 centimeter (cm) X 5 cm, stage 2 blister was discovered and the resident was having associated pain from the blister. There was no documentation of an assessment of the pain associated with the blister. The night nurse documented in the progress notes the resident had a fluid filled blister on her left heel. The skin was intact, but it was painful to touch. There was no documented assessment of the pain. On 6/6/11 the Regional Director of Clinical Operations (RDCO) documented in the progress notes a "Skin/wound assessment and summary:" On 6/9/11 at 3:20 p.m. the RDCO stated that she wrote the summary without visually assessing the resident even though she documented the "resident was observed with 6 cm x 5 cm intact blister ....Blister is dark purple (old blood)." Record reviewed revealed there were two separate documents for wound assessments, one kept in the DNS office and one in the clinical record. When the records were reviewed they were difficult to follow and contradictory to each other. Pressure ulcer Documentation forms: The DNS documented the wound measuremented on: 5/19/11, 6 cm x 5 cm Stage 2 intact blister 5/26/11, 6 cm x 5 cm Stage 2 intact blister 6/2/11 5.6 cm x 4.8 cm Stage 2 intact blister reabsorbing 6/9/11 5.2 cm x 4.8 cm Stage 2 intact blister reabsorbing 6/16/22 4.8 cm X 3.9 cm with 100% eschar (Thick dry black dead tissue) The Floor nurses documented the wound measurmented on: 5/20/11 length 2.5 x 2.5 cm raised fluid blister 5/27/11length 2.4 cm x width 2.3 cm fluid blister 6/3/11 length 2.1 cm x width 2.2 cm fluid blister 6/9/11 the wound measured 3.6 cm x 4.5 cm fluid blister On 6/10/11 LN 8 stated the DNS removed the measurment flow sheets out of the MAR. 2. Observation of Resident 193 on 06/09/11 at 1:12 p.m., found him seated in his wheelchair with both heels directly in contact with the floor. His left heel was boggy with surrounding rubor (redness). Licensed Nurse (LN) 4 outlined the heel area with a marker. Resident 193 complained he had a history of [REDACTED]. At 3:30 p.m. Resident 193 lay in bed with both heels in contact with the surface of the mattress. There were no pillows on the bed to elevate his feet and keep the heels from touching the mattress. On 06/10/11 at 8:15 a.m., Resident 193 lay in bed, eyes closed, and his left heel against the surface of mattress. A pillow lay at the foot of the bed. When asked, LN 4 reported she failed to initiate a flow sheet for Resident 193's left heel or record the assessment. On 06/13/11 at 10:00 a.m. the surveyor notified facility administration and the Regional Director of Clinical Operations (RDCO) that LN 4 did not complete documentation of skin assessment of Resident 193's heels and update his care plan. The RDCO stated, "things are out jointed'. Review of the clinical record revealed no assessment documentation or care plan for the left heel skin condition identified on 06/09/11. 3. Resident 197 was admitted in March 2011 with his skin intact. Observation of Resident 197's skin occurred on 06/09/11 at 09:13 a.m. by the surveyor and LN 2. LN 2 reported the skin on the coccyx area was "discolored, with reddened purple blanches." He stated the wound bed had granulated (healing) tissue and no dead tissue. The surrounding area had slough - small and moist purplish part and the periwound has eschar, "white color." The surveyor noted ruborous discoloration of both buttocks, wound base with red granulated tissue, and periwound maceration. A moderate amount of sero-sanginous drainage with odor was present. The area measured 2.2 centimeters (cm) length by 2.0 cm and 3 cm depth. Review of the resident's clinical record revealed he was initially seen at the Wound Clinic for treatment of [REDACTED]. Treatment orders from the clinic were not consistently followed or documented. The extended wound area of the buttocks with maceration was not reassessed and monitored after the resident was seen by the Wound Clinic and consulting surgeon.

Based on observation, interview, and record review, the facility failed to monitor and evaluate acute changes in condition for two residents. Failure to monitor, assess, and evaluate Resident 197's open skin wound resulted in harm of extended skin breakdown. After consultation and treatment at the wound clinic, the facility failed to follow the orders of the wound clinic. Failure to document neurological changes for Resident 159 after an unwitnessed fall placed her at risk of unmonitored and unidentified potential changes in condition. Findings include: 1. Resident 197 was admitted in March 2011 with [DIAGNOSES REDACTED]. The admit physician's orders [REDACTED]. He had no skin breakdown. The Minimum Data Set (MDS) assessment, dated 03/10/11, documented Resident 197 required two persons for bed mobility and transfers. The Care Area Assessment (CCA) for pressure sores documented Resident 197's skin would be observed every shift for potential skin breakdown and weekly skin assessments would be completed. The admission nursing assessment, dated 03/10/11, documented Resident 197 had no skin breakdown. He was chair bound and his mobility was very limited. The pain assessment identified moderate pain to the buttocks (area circled on the form). Observation of Resident 197 on 06/06/11 at 09:30 a.m., found Resident 197 unable to use the trapeze bar on his bed to lift his buttocks for pressure relief. The resident stated when he arrived at the facility in March 2011; he was over 400 pounds and could not pull himself up in the bed using his feet. On 06/08/11 and 06/09/11 at about 2:30 p.m., observation found him supine in bed. The bed was in a jack-knife position which did not permit pressure relief to the coccyx region. Observation of Resident 197's skin occurred on 06/09/11 at 09:13 a.m. by the surveyor and LN 2. LN 2 reported the skin on the coccyx area was "discolored, with reddened purple blanches." He stated the "wound bed had granulated tissue, a healing tissue, no dead tissue. The surrounding area had slough, small and moist purplish part and the periwound has eschar, white color." The surveyor noted ruborous discoloration of both buttocks, wound base with red granulated tissue, and periwound maceration. A moderate amount of sero-sanginous drainage with odor was present. The area measured 2.2 centimeters (cm) length by 2.0 cm and 3 cm depth. LN 2 cleansed the wound with normal saline and taped only a soft absorbent dressing. Although Resident 197 had no skin breakdown on admission, review of the Treatment Administration Record (TAR) for March 2011 revealed Resident 197 had an open skin area on 03/17/11 and 03/25/11. There was no documentation regarding the type of open area, its location, size or description of the wound. The TAR read: "monitor skin condition s/s of infection @ (at) L (left) buttock." The April 2011 TAR indicated Resident 197 had an open area according to the documented weekly skin assessments. The LNs documented "O" for open skin area for each of the five weekly skin assessments of April 2011. The TAR also read: monitor L buttock every day until healed. There was no other documentation in the clinical record or care plan with interventions and goals. Not until 04/29/11 was the open area measured when the facility's "Non-Pressure Wound and Skin Condition Documentation" form was initiated. Review of the form revealed Resident 197 had multiple areas of skin breakdown on that date. In addition to the left buttock area, the resident ' s right buttock also had an open area. Both areas measured 0.5 centimeters (cm) by 0.5 cm in size, had no drainage, but the skin tissue that surrounded both open areas had redness. Review of the May 2011 TAR noted open skin areas on all four weekly skin assessments. Not until 05/12/11 were the open areas assessed. Documentation on that date indicated the open area(s) measured 3 cm by 1.5 cm in size and both areas had a large amount of serous drainage with odor. Even after the area(s) were documented to have drainage, no further size measurement was completed until 16 days later on 05/29/11. Resident 197 was referred to and initially seen at the wound clinic on 05/19/11. Per the wound clinic, the wound then measured 4.5 cm in depth and had a "deep wound infection". The wound clinic ordered the facility LNs to cleanse/irrigate the wound with normal saline, pack it with [MEDICATION NAME], then cover the site with a large soft dressing that should be changed twice daily. In addition, the resident required an antibiotic medication and additional medication due to the wound infection. The clinic recommended a surgical consultation for the wound. If Resident 197 could not be seen by a surgeon, he should return to the wound clinic on 05/24/11. Although Resident 197 was not seen by a surgeon until 05/27/11, review of the clinical record revealed no evidence Resident 197 returned to the wound clinic by 05/24/11 as ordered. When the surgeon saw Resident 197 he documented the skin wounds were "coccygeal decubites-NOT pilonidal" and recommended Resident 197 "avoid sitting!!". The surgeon ordered wet to dry dressings, changed 2-3 times daily. If there was not improvement, a plastic surgeon should be consulted. On 06/10/11 the Regional Director of Clinical Operations (RDCO) reported the "Non-pressure Wound and Skin Condition Documentation" form, dated 04/29/11' was not accurate. The documentation for the wound, dated 04/29/11, was for the left and right buttocks and the 05/12/11 measurements were for the coccygeal open area. The RDCO stated there was no further assessment of the open areas of the buttocks. After reviewing the facility's documentation record for measuring a wound, the RDCO reported, she found no indication as to what wound(s) was/were being monitored. The documentation "was incomplete, very confusing". The RDCO stated the treatment for [REDACTED]. The clinic ordered packing of the wound because of the drainage. Therefore; LNs should pack the wound. Review of Resident 197's clinical record revealed no evidence of documentation the LNs were packing the coccygeal open area. The LNs were only placing a soft dressing over the extended open area which caused maceration around the wound. The facility did not provide the treatment (packing of the wound) that the wound clinic had instructed them to do. The treatment sheet did not instruct the LN how to cleanse the wound. The lack of implementation of physician orders [REDACTED]. Unrelieved pressure to the buttocks and lack of oxygenation contributed to the skin maceration and possibly resulted in delayed wound healing. Resident 197's TAR documented open areas without thorough assessment of the actual wound and this may have delayed appropriate treatment and care plan development. There was no indication the facility had evaluated the resident's current care plan for pressure relief even after the resident was seen by the wound clinic and surgeon. On 05/19/11 the wound clinic identified the coccygeal open area as a pilonidal cyst with abscess formation. There was no documented evidence the facility assessed the wound and developed a care plan for the cyst with abscess after Resident 197 was seen by the wound clinic and the surgeon. The care guide, a document used by the nursing assistants when delivering care, did not indicate where any skin breakdown was located when it instructed staff to "reposition" the resident. 2. Resident 159 was admitted in December 2010 with [DIAGNOSES REDACTED]. She elected to receive palliative [MEDICAL CONDITION] and possible [MEDICAL CONDITION]. The nursing admission assessment, dated 12/22/10, identified she was alert and oriented. She had an abnormal gait and muscle weakness. She used a walker and required one person assistance. On 01/02/11 she was found on the floor in her room. Her speech was slurred and her pupils were unresponsive to light. She went to the hospital for evaluation and returned to the facility that same day. The hospital noted no injury. The facility's policy for post-fall documentation indicated the Licensed Nurse (LN) would updated the care plan, follow the resident via the 24 hour report x72 hours, follow up with the physician as needed to provide updated, and to continue to follow the resident every shift for the next 72 hours, and document findings and resident condition in the interdisciplinary progress notes. On 06/13/11 the RDCO reported if a resident is unable to tell you how they fell and did not hit their head, no neurological checks were needed. However, she expected neurological checks to be performed for an unwitnessed fall as Resident 159 had. A fall risk assessment should also be completed for the resident. On 06/13/11 the DNS provided information on the resident's neurological assessment and reported there was no neurological evaluation. On 06/14/11 at 10:00 a.m. LN 2 stated the policy was when a resident fell , the resident was placed on alert charting for 72 hours. If a fall was unwitnessed, alert chart must be performed together with the neurological assessment. LN 2 reported LNs used the " neuro sheet " to document neurological assessment. Record review revealed no nursing documentation until 01/03/11, which indicated Resident 159 was ambulating and working with skilled therapy. LNs documented Resident 159 had stable vital signs and her neurological signs were within normal limits. There was no evidence of documentation on the neurological flow sheet to evaluate the resident's pupils, hand grips, or levels of consciousness for a resident who had an unwitnessed fall on 010/2/11 with neurological changes.