Every finding on record at Good Samaritan Health Care CTR

Based on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk for transmission of COVID-19 were consistently implemented in the areas of proper donning (putting on), use of, and doffing (taking off) personal protective equipment [(PPE) equipment worn to minimize exposure to hazards that can cause injuries], providing readily available PPE for 3 of 5 teams (Team 4, Team 2, and Team 1), and cross contamination during catheter care for 1 of 4 Residents (Resident 71) reviewed for infection control. These failures placed the residents at risk for transmission of communicable diseases, illness, and death. Findings included. Review of the Centers for Disease Control and Prevention (CDC) guidance titled, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 06/03/2020, showed PPE must be donned correctly before entering the patient area and must remain in place and worn correctly for the duration for work in the potentially contaminated areas. PPE must be removed in a sequence that prevents self-contamination. PPE includes an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles with edges that are designed to form a seal around the nose and mouth), face shield or goggles (eye protection), clean, non-sterile gloves, and a gown. Donning PPE includes performing hand hygiene, putting on an isolation gown, an N95 mask (ensuring the mask extends under the chin with both the mouth and nose protected), perform a seal check while wearing the N95 mask (a procedure performed each time a mask was put on to ensure the N95 mask is properly seated on the user's face, creating a tight seal against potential air leaks), eye protection, and gloves over the cuff of the gown. To doff PPE, remove the soiled gloves and gown, and dispose in a trash receptacle. Exit the resident room and perform hand hygiene. Remove the eye protection and remove and discard the N95 mask. Perform hand hygiene before donning a new face mask (a loose-fitting disposable mask that creates a barrier but does not offer filtration). Review of a policy titled Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised 05/08/2025, showed healthcare personnel that enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID-19) infection should wear an N95 mask, gown, gloves, and eye protection. Proper Use/Readily Available PPE Team 4 During an observation on 09/15/2025 at 12:19 PM, Staff F, Nursing Assistant (NA), donned a gown, eye protection, gloves, and an N95 mask placed over their face mask. Staff F obtained a meal tray and entered a COVID-19 positive resident room. At 12:20 PM, Staff F exited the resident room carrying two plate covers. They were wearing the same gown, eye protection, and N95 mask over their face mask. Staff F removed their soiled gloves, performed hand hygiene, donned clean gloves, and entered a second COVID-19 positive resident room with a meal tray. Staff F exited the resident room at 12:24 PM, wearing the same face mask. Staff F placed the plate covers on the meal cart and performed hand hygiene. A second observation at 12:43 PM showed Staff F exiting a COVID-19 positive resident room with a soiled gown, eye protection, and N95 mask over their face mask. They walked down the hall, still wearing the soiled PPE and double mask, and donned clean gloves. They entered a COVID-19 positive resident room, still wearing the soiled PPE, and placed the resident's meal tray on the over the bed table. Staff F cut the residents' food on their plate, walked to the door, removed their gown, gloves, and N95 mask, and placed them into the trash inside the resident room. Still wearing their soiled face mask, Staff F obtained a disinfectant wipe from the PPE cart outside the resident's room, wiped their eye protection, and walked back into a second COVID-19 positive resident room to discard the disinfectant wipe. A concurrent observation and interview on 09/15/2025 at 12:43 PM, showed Staff H, Housekeeper, standing at their housekeeping cart outside of a COVID-19 positive resident room, wearing a gown, gloves, and N95 mask. Staff H stated they were going into the room to clean. Staff H stated they were not required to wear eye protection if there was none available on the PPE cart (located outside the resident room). Observation of the PPE cart showed there was no eye protection on the cart. An observation on 09/16/2025 at 8:29 AM, showed Staff I, Licensed Practical Nurse (LPN), preparing medications at their cart outside of a COVID-19 positive resident room. Staff I donned a gown, eye protection, clean gloves, and placed an N95 mask over their face mask. Staff I entered the COVID-19 positive resident room, handed the medication cup containing pills to the resident, placed a cup of water on the bedside table, then picked up the cup of water and handed it to the resident. Staff I took the medication cup and empty water cup from the resident and placed them in the trash. They removed their soiled gown, gloves, and N95 mask in the resident room, and exited wearing their soiled face mask and eye protection. Staff I performed hand hygiene, removed their soiled eye protection and placed it on top of a box of gloves that was sitting on the PPE cart outside of the COVID-19 positive resident room. Staff I donned a glove on their right hand, obtained a disinfectant wipe from the drawer of the cart with the gloved hand, and picked up the soiled eye protection with their bare left hand. They used the gloved hand to clean the eye protection then threw away the glove and disinfectant wipe in the medication cart trash. During a concurrent observation and interview on 09/16/2025 at 8:57 AM, Staff I pointed to a printed sign posted at the Team 4 nurses' station and stated they followed the CDC guidelines for proper use of PPE in a COVID-19 positive resident room. Staff I stated wearing an N95 mask over their face mask was not the process for proper PPE use. They stated they did not want to wear the soiled N95 mask in the hallway and there were no face masks on the PPE carts located outside of the COVID-19 positive rooms. Staff I stated the face masks were located at Team 4 nurse's station. A concurrent observation and interview on 09/16/2025 at 9:01 AM, showed Staff J, NA, exit a COVID-19 positive resident room with a meal tray. Staff J was wearing a soiled gown, gloves, eye protection, and N95 mask over their face mask. Staff J stated one of the nurses told them they could go from one COVID-19 positive resident room to another COVID-19 positive resident room wearing the same soiled PPE. During a combined interview on 09/16/2025 at 10:53 AM with Staff B, Director of Nursing Services (DNS)/Infection Preventionist (IP), and Staff C, Assistant DNS/IP, Staff B stated the proper PPE required when entering a COVID-19 positive resident room included donning an N95 mask, gown, gloves, and eye protection. Staff C stated it was not the process to wear an N95 mask over a face mask. During an interview on 09/16/2025 at 4:25 PM, Staff A, Administrator, stated all staff had recently received education on the proper use of PPE in COVID-19 resident rooms. Staff A stated the staff did not follow the process for PPE use. Team 2 During an observation and concurrent interview on 09/16/2025 at 8:31 AM, showed Staff F, NA, prepared to enter a COVID-19 positive resident room. Staff F was wearing a face mask and an N95 mask over the top of the face mask. Staff F were donning a second N95 mask over the top of the two masks. Staff F stated they did not realize they already had an N95 mask on and removed one of them. Staff F stated they were not trained to wear a face mask with an N95 mask; however, they preferred to wear both at the same time. During an observation and concurrent interview on 09/16/2025 at 8:35 AM, Staff M, Laundry Aide, stated they were entering a COVID-19 positive resident room to deliver some clean linens. Staff M was wearing a face mask and donned a gown, without securing the gown ties behind their neck or back, donned gloves and entered the room. Staff M handed the resident the clean linen and adjusted the residents' heater. As Staff M leaned over to adjust the heater, the gown fell completely forward away from their body. Staff M proceeded to the residents sink and placed the used linen on top of the resident's toiletry bin, removed their gown and gloves, washed their hands for five seconds and gathered the used linen, exited the room, and proceeded down the hall. Staff M stated they were required to wear a gown, gloves and a mask when they entered a COVID-19 positive resident room and did not know which mask they needed to wear or if they needed eye protection. Staff M asked Staff F, NA, which masks they were required to wear for a COVID-19 positive room and were told they were to wear an N95 mask. Staff M stated they did not wear an N95 as there were none available in the PPE bin. Staff M further stated they did not know how to secure or remove linen from a COVID-19 resident room. During an observation and concurrent interview on 09/17/2025 at 12:00 PM, Staff L, LPN, wore a face mask (not the required N95 mask) and a disposable face shield with a foam headband. Staff L donned a gown and gloves and entered a COVID-19 positive resident room. Upon Staff L's exit from the room, they doffed the gown, face mask and removed the disposable face shield and wiped the face shield with a disinfectant wipe. Staff L showed the face shield read single use, and proceeded to use a disinfectant wipe and placed it back on. Staff L stated their process was to clean and reuse the face shield and were unsure if it was the correct process. During an observation and concurrent interview on 09/19/2025 at 11:46 AM, showed a bin at Team 1,2 and 3 nurses' station with a bin that contained three different types of eye protection goggles. Staff B stated they had instructed the staff to clean the eye protection goggles with a disinfectant wipe prior to placing them into the bin. Staff B stated that was the process they followed and was unsure if that was the correct instructions for each type of eye protection goggles in the bin. Staff N, Inservice Director LPN, stated the face shields with a foam headband were for single use and then disposed of. Team 1 During an observation and interview on 09/15/2025 at 9:20 AM, Staff Q, NA, entered an identified COVID-19 positive room. Staff Q donned PPE including a gown, googles, gloves and placed an N95 mask over their face mask. At 9:40 AM Staff Q exited the COVID-19 identified room after removing their PPE in the room including their N95 mask however they did not change or discard the face mask. Staff Q continued to wear the contaminated face mask going in and out of non-COVID-19 rooms. Staff Q stated their process was to cover the face mask with the N95 mask to save time and resources, further explaining that was what the nurses had told them to do. During an observation on 09/16/2025 at 8:41 AM, Staff O, LPN, entered a COVID-19 positive room wearing a gown, goggles, gloves and an N95 mask over their face mask. At 8:50 AM, Staff O exited the room after discarding their PPE however continued to wear their face mask. Staff O stated their process was to not remove their face mask after exiting a COVID-19 positive room I feel like I am better protected, and I do not want to be exposed if I take off my face mask. Additionally, Staff O stated there was no room in the PPE carts located outside of COVID-19 positive rooms to store extra face masks for staff to change into after exiting COVID-19 positive rooms. Resident 71 Review of the resident's medical record showed the resident was admitted with diagnoses including, history of a stroke (blood supply is cut-off from a part of the brain), urinary retention (inability to completely empty the bladder can be the result of a stroke) and history of prostrate cancer. Review of the comprehensive assessment dated [DATE] showed Resident 71 had moderately impaired cognition, required substantial assistance for personal hygiene and had a retention catheter [a soft flexible tube inserted into the bladder through the urethra (tip of the penis) that stays in place to allow continuous drainage of urine into a collection bag]. Record review of Resident 71's Treatment Administration Record dated September 2025, showed the resident had a treatment for an antibiotic cream to be placed around the tip of their urethra related to a rash. During an observation on 09/17/2025 at 9:44 AM, Staff O, LPN, entered the room with two small plastic cups containing ointments. Staff O applied ointment from one of the cups to the resident's bottom including the rectal area and around their testicles. Staff O then obtained the other cup of ointment and stated it was an antibiotic treatment for Resident 71's urethra rash. Staff O did not perform hand hygiene or change their contaminated gloves prior to applying the antibiotic ointment to the tip of the resident's urethral opening. During an interview on 09/19/2025 at 8:35 AM, Staff B, DNS, stated it was not the facility's practice to use contaminated gloves when applying ointment to the urethra area and the nurse should have changed their gloves prior to completing the treatment.

Based on observation and interview, the facility failed to ensure medications and vaccines were properly stored for 1 of 3 medication rooms (Team 4 medication room) and medications were properly labeled for 2 of 5 medication carts (Team 1 and Team 4 medication carts) reviewed for medication storage. This failure placed the residents at risk of receiving expired medications, experiencing compromised or ineffective medications and vaccines and negative health outcomes. Review of the policy titled, Storage of Medications, dated 01/01/2020, showed medications and biologicals were stored safely and properly, and expired medications were removed from supply and destroyed by the facility. The facility should maintain and monitor the refrigerator that stores vaccines at least twice daily per Centers for Disease Control (CDC). Additionally, when a medication vial was initially opened, the nurse would place a sticker on the medication and enter the open date and the new date of expiration per the manufacturer's guidance. Review of the U.S. Food and Drug Administration's (USFDA) Information Regarding Insulin Storage, dated 09/19/2017, showed insulin contained in vials supplied by manufacturers may be used up to 28 days once opened. Review of the CDC guidance titled, Vaccine Storage and Handling, dated 04/03/2024, showed to ensure safety of vaccines, the refrigerator must have a reliable temperature monitoring device with the recommended use of a recording device called a digital date logger (DDL-a device that records temperatures at least every 30 minutes). The guidance further showed when a DDL was not used, the facility should monitor and record the vaccine refrigerator temperature at a minimum of twice daily. Team 4 Medication Room During an observation on 09/18/2025 at 9:20 AM, showed the medication refrigerator contained 2 vials of Apisol (solution used for tuberculosis sensitivity test) and Pneumococcal vaccines. The medication refrigerator temperature log showed the temperature for the refrigerator was to be checked and documented twice daily. Review of the temperature logs showed: February 2025; 21 missed temperature documentation,March 2025; 25 missed temperature documentation,April 2025; 26 missed temperature documentation,May 2025; 20 missed temperature documentation,June 2025; 19 missed temperature documentation,July 2025; 25 missed temperature documentation,August 2025; 26 missed temperature documentation,September 2025;14 missed temperature documentation. A continued observation of the medication refrigerator showed a collection of water on top of a locked medication container in the refrigerator on the top shelf. Underneath the locked medication container was a white towel that was soaked in water with a reddish/brown tint. The freezer in the top section of the medication refrigerator showed a buildup of ice and a 3-inch by 2-inch area of reddish/brown on the base of the freezer. The refrigerator showed three medication boxes were wet and expired. During a concurrent interview on 09/18/2025 at 9:40 AM, Staff B, Director of Nursing Services, stated the medication refrigerator should be checked each shift, medications should be removed when expired and they were unaware of the water in the refrigerator. Medication Carts During an observation and concurrent interview on 09/18/2025 at 9:44 AM, the Team 4 medication cart showed a vial of insulin that was dated 8/19. Staff I, Licensed Practical Nurse (LPN), stated the vial of insulin was good for 30 days once the vial was opened. During an observation and concurrent interview on 09/18/2025 at 9:51 AM, with Staff L, LPN, showed the Team 3 medication cart containing the following medications; One vial of insulin with no open date, and a handwritten expiration date of 10/13;One vial of insulin with no open date, and a handwritten expiration date of 09/02.One vial of insulin with an open date of 09/08 and a handwritten expiration date of 10/27;One insulin pen with an open date of 9/14/25 and no expiration date; One insulin pen with no open date and an expiration date of 9/30. Staff L stated there were discrepancies on what staff were to label when the vials and pens were opened. Staff L stated pharmacy had provided stickers to use that had open date, expiration date and initials of who opened the medication, and they were inconsistently used. During a concurrent interview on 09/18/2025 at 10:13 AM, Staff C, Assistant Director of Nursing Services/Infection Preventionist, stated insulin was good for 28 days once it was opened. Staff B stated the staff should be putting the open date and their initials on the stickers provided for the medications. Staff B stated the medication refrigerator should be monitored and temperature recorded twice daily as there were vaccines stored in the refrigerator and the process was not followed. Reference WAC: 388-97-1300(2)

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) [an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions] Level II assessment [a more in-depth screening, to identify whether nursing home services were needed and if specialized mental health services were required] was completed for 1 of 5 sampled residents (Resident 58), reviewed for PASARR services. This failure placed the resident at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs. Findings included . Review of a policy titled, Pre-admission Screening and Resident Review WA (PASARR), revised 06/2024, showed individuals identified with a positive screen, require a PASARR Level II referral for evaluation and determination prior to admission to the facility. Resident 58 Review of the medical record showed Resident 58 was admitted to the facility on [DATE] with diagnoses including heart failure, anxiety, and depression. The 09/06/2025 comprehensive assessment showed Resident 58 required assistance of one to two staff members for activities of daily living. Resident 58 had an intact cognition. Record review of Resident 58's Level I PASARR dated 07/29/2025 showed a Level II evaluation was required. During an interview on 09/18/2025 at 10:19 AM, Staff E, Social Services Director, stated the process for completing the PASARR review included auditing the Level I's for accuracy. They stated they sent for a Level II if indicated. Staff E stated they had sent for Resident 58's Level II evaluation on 07/30/2025. They stated they had not received a Level II evaluation for Resident 58 and had recently completed an audit on all outstanding Level II referrals. Staff E stated after the audit, they followed up with an email to the reviewer to see where the Level II evaluations were. Staff E stated they did not make a notation of follow-up in Resident 58's medical record and did not have a follow-up email for Resident 58. During an interview on 09/18/2025 at 10:40 AM, Staff B, Director of Nursing Services, stated Staff E had training on the process for completing PASARR Level I and II referrals. They stated Staff E should have sent Resident 58's PASARR Level I for a Level II evaluation and followed up on it. Staff B stated the process was not followed for completing PASARR Level II's. Reference: WAC 388-97-1915(2)

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice [(ABN) a notification that provides an estimated cost of continued services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] as required for 1 of 3 residents (Resident 32) reviewed for beneficiary notification. This failure placed the resident at risk for their inability to make informed financial and care decisions related to their continued stay.Findings included . Resident 32 Review of the medical record showed Resident 32 was admitted to the facility with diagnoses including anxiety disorders, arthritis, and heart failure. The 09/10/2025 comprehensive assessment showed Resident 32 required supervision/moderate assistance of one staff member for activities of daily living. The assessment also showed Resident 32 had a moderately impaired cognition. Review of the medical record showed Resident 32 was covered by Medicare Part A (insurance that covers skilled nursing care after a qualifying hospital stay) until 06/01/2025, with their first non-covered day as 06/02/2025. Review of an ABN dated 06/02/2025, showed an incomplete form that had no selections marked for the cares they had received and would no longer receive under Medicare Part A, and an estimated cost of $729.89 per day/item or service. The ABN showed Resident 32 signed the form on 06/06/2025. During an interview on 09/18/2025 at 10:13 AM, Staff D, Business Office Manager, stated the form should indicate which services would be continued and should have been provided to Resident 32 when they received their notice of non-coverage on 05/27/2025. Staff D stated they completed audits on the ABN forms to ensure they were accurate and provided on time. Staff D stated they should have pulled Resident 32's ABN during the audits. During an interview on 09/18/2025 at 10:34 AM, Staff E, Social Services Director, stated the ABNs were issued to residents the same day as the notice of non-coverage. They stated the ABN provided to Resident 32 was not complete. They stated the process for presenting a completed ABN to Resident 32 was not followed. During an interview on 09/18/2025 at 10:43 AM, Staff B, Director of Nursing Services, stated the ABN should have been completed, with no blank areas, and Resident 32 should have been notified of the change in coverage on the same day the change occurred. Reference: WAC 388-97-0300(1)(e)(5)

Based on interview and record review the facility failed to accurately assess and manage the diagnosis of congestive heart failure (CHF, a weakened heart condition, in which the heart doesn't pump blood as effectively as it should, and causes fluid build-up in the feet, arms, lungs and other organs) according to physician orders for 1 of 3 sample residents (Resident 1) reviewed for the management of CHF. This failure placed the resident at risk for fluid overload, respiratory complications, and exacerbation of (worsening of) heart failure. Findings included.Resident 1Resident record review showed Resident 1 was admitted to the facility on [DATE] with diagnoses including CHF, chronic obstructive pulmonary disease (COPD, is a lung condition caused by damage to the airways that limit airflow), and atrial fibrillation (A-fib, an irregular and often very rapid heart rhythm that can lead to blood clots in the heart.) Review of the 10/30/2025 comprehensive assessment showed Resident 1 was cognitively intact, had shortness of breath and received continuous oxygen therapy (a treatment that delivers extra oxygen to the lungs when the level of oxygen in the blood is too low.) Review of Resident 1's 10/24/2025 care plan showed the resident had altered cardiovascular status due to their A-fib and CHF with interventions for nursing to monitor as needed any changes to lung sounds, cough, edema (extra fluid trapped in the body's tissues often caused by conditions such as heart failure. The extra fluid/swelling can affect any part of the body but is more likely in the legs and feet), and changes in weight. Record review of a facility reported incident dated 11/03/2025 showed Resident 1's Representative (RR1) stated the facility staff were neglecting the resident's health needs and requested Resident 1 be transported to the hospital. Review of Staff C's, Registered Nurse (RN), 11/03/2025 witness statement showed RR1 stated they had concerns about Resident 1's weight gain and swelling and wanted Resident 1 sent to the hospital. During a telephone interview on 11/14/2025 at 1:15 PM, RR1 stated they were very concerned Resident 1 was having fluid overload due to swelling they noted to Resident 1's abdomen, ankles and feet. RR1 stated they reported their concerns to the nursing staff during visits leading up to 11/03/2025 and felt nothing was being done. Record review of a 10/24/2025 physician order on Resident 1's October 2025 and November 2025 Medication Administration Record (MAR) showed furosemide 20 milligram (mg) tablet (a diuretic/water pill used to treat fluid retention/edema associated with heart failure) was ordered as needed for CHF if Resident 1's weight increased by 2 pounds in one day or if leg swelling developed. Further review of the MARs showed the diuretic/water pill was not administered to Resident 1. Record review of a 10/24/2025 physician order on Resident 1's October 2025 and November 2025 MARs showed an order for daily weights and to notify clinician for weight gain of two or more pounds in one day or five pounds or more in five days. Resident 1's weight on 10/25/2025 was 184.2 pounds and their weight was 189.6 pounds on 11/03/2025 (an increase of 5.4 pounds since admission.) Review of Staff B's, Director of Nursing (DON), investigation conclusion dated 11/10/2024 showed staff obtained Resident 1's daily weight with no weights above two pounds in one day (1.8-pound increase was noted on October 29, 2025) as ordered by the physician. Staff B did not document the presence or absence of leg swelling as part of their review that staff followed the physician's orders. During an interview on 11/14/2025 at 2:20 PM, Staff D, Licensed Practical Nurse (LPN), stated they entered Resident 1's daily weight in the MAR and watched for a two pound or greater increase. They stated Resident 1's weight never went about two pounds in a day and the as needed furosemide was not given. When Staff D reviewed the furosemide order, they stated they were not aware the order also referred to the presence of leg swelling as an indication to give the as needed diuretic medication. They stated they had not specifically assessed or documented the presence or absence of Resident 1's leg/ankle/foot swelling during their stay. During an interview on 11/14/2025 at 2:35 PM, Staff E, RN, stated they were the nurse present when Resident 1 was transferred to the hospital on [DATE]. They stated they were aware RR1 had concerns about Resident 1's weight gain during their stay; however, they did not recall RR1 having concerns about any specific edema or swelling to Resident 1's legs. Staff E stated they did not monitor Resident 1's feet for edema and did not notice the resident's feet on 11/03/2025 prior to being sent to the hospital. During an interview on 11/14/2025 at 4:30 PM, Staff B, DON, stated the staff did not monitor and document Resident 1's legs and feet for swelling. Staff B stated they were not aware the resident's diuretic order also included leg swelling as an indication to give the medication and not just the weight gain. Reference: WAC 388-97-1060(1)-(3)

Based on interview and record review, the facility failed to ensure the Minimum Data Set [(MDS) assement tool] accurately reflected the status for 6 of 7 sampled residents (Resident 32, 84, 79, 3, 29 and 96) reviewed for accuracy of assessments. This failure placed the residents at risk for unidentified and/or unmet care needs. Findings included . <Resident 32> Review of Resident 32's medical record showed the resident admitted to the facility on [DATE] with diagnoses including left hip fracture and heart failure. The comprehensive assessment dated [DATE], showed Resident 32 required moderate assistance with their transfers and activities of daily living (ADLs). Review of the 5-day MDS assessment, dated 07/03/2024, showed section N, Medications, indicated Resident 32 was taking an anticoagulant (medication used to prevent and treat blood clots by interfering with the bloods ability to form clots). Review of Resident 32's physician orders showed the resident was prescribed clopidogrel bisulfate [an antiplatelet (medication used to stop specific blood cells called platelets from sticking together and forming a clot)] ordered 06/27/2024, and was not receiving any anticoagulant medications. <Resident 84> Review of Resident 84's medical record showed the resident admitted to the facility on [DATE] with diagnoses including lung cancer and stroke. The comprehensive assessment, dated 08/27/2024, showed Resident 84 required substantial assistance with their transfers and ADLs. Review of the 5-day MDS assessment, dated 08/27/2024, showed section N, Medications, indicated Resident 84 was taking an anticoagulant medication. Review of Resident 84's physician orders showed the resident was prescribed aspirin (an antiplatelet medication) ordered 08/21/2024, and was not receiving any anticoagulant medications. <Resident 79> Review of Resident 79's medical record showed the resident admitted to the facility on [DATE] with diagnosis including heart disease. The comprehensive assessment dated [DATE], showed Resident 79 required moderate assistance with their transfers and ADLs. Further review of the comprehensive MDS assessment, dated 07/27/2024, showed section N, Medications, indicated Resident 79 was taking an anticoagulant medication. Review of Resident 79's physician orders showed the resident was prescribed clopidogrel bisulfate (an antiplatelet medication) ordered 07/21/2024, and was not receiving any anticoagulant medications. <Resident 3> Review of Resident 3's medical record showed the resident admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and heart failure. The comprehensive assessment, dated 08/02/2024, showed Resident 3 required substantial assistance with their transfers and ADLs. Further review of the comprehensive MDS assessment, dated 08/02/2024, showed section N, Medications, indicated Resident 3 was taking an anticoagulant medication. Review of Resident 3's physician orders showed the resident was prescribed clopidogrel bisulfate (an antiplatelet medication) ordered 07/12/2024, and was not receiving any anticoagulant medications. <Resident 29> Review of Resident 29's medical record showed the resident admitted to the facility on [DATE] with diagnoses including bipolar disorder (a brain disorder that causes changes in a person's mood, energy, or ability to function), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of worry, nervousness, or unease). The comprehensive assessment, dated 10/28/2023, showed Resident 29 required substantial assistance with their transfers and ADLs. Review of the MDS assessment, dated 10/28/2023, showed section A, indicated the Pre-Admission Screening and Resident Review (PASRR) did not reflect that Resident 29 should be considered and/or assessed by the state level II PASRR process (a process to evaluate the need for additional support services for residents who have serious mental illness and/or intellectual disability). Further review of the medical record showed Resident 29 had a completed PASRR, dated 09/27/2018, which indicated a PASRR level II should be completed. <Resident 96> Review of Resident 96's medical record showed the resident admitted to the facility on [DATE] with a primary diagnosis of a fractured left hip. The comprehensive assessment, dated 08/14/2024, showed Resident 96 required substantial assistance with their transfers and partial assist with ADLs. Review of the 5-day MDS assessment, dated 08/14/2024, showed section A indicated Resident 96's discharge status was to a critical access hospital. Review of the resident discharge summary, dated 09/06/2024, showed the resident had discharged to home with family. During an interview, on 10/07/2024 at 2:37 PM, Staff J, Resident Care Manager/ Licensed Practical Nurse, stated Resident 96 had discharged from the facility to home with family. Staff J stated, yes I do the resident discharges. Staff J reviewed the MDS assessment and stated, I sure did .I marked the discharge to the hospital; the resident went home with his family. During an interview, on 10/04/2024 at 2:03 PM, Staff C, Assistant Director of Nursing Services (ADON) acknowledged that the medications were coded incorrectly on the MDS assessments for Residents 32, 84, 79, and 3, and did not reflect the residents' status accurately. Staff C stated, it appears that we need to do some education with our Resident Care Managers. During an interview, on 10/04/2024 at 2:11 PM, Staff B, Director of Nursing Services, stated the expectation was the resident assessments were to be accurate. Additionally, Staff B stated they were aware of the MDS discrepancies and Staff C would be providing education to the Resident Care Managers and making the corrections immediately. Reference: WAC 388-97-1000 (1)(b) 43280

Based on interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma informed care complete with identified experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience) for 1 of 3 residents (Resident 47) reviewed for trauma informed care. This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Review of the facility's policy titled, Trauma Informed Care, revised October 2022, showed the purpose was to .ensure that residents who are trauma survivors receive culturally competent, trauma-informed care .in order to eliminate or mitigate (to make less severe or painful) triggers that may cause re-traumatization of the resident. The policy showed the facility promoted an environment of healing/recovery rather that practices or services that may inadvertently (without knowledge or intent) re-traumatize a resident and Examples of Trauma: Prolonged family violence .Assault/Abuse-including sexual/physical/emotional .Characteristics: Detailed memories, Reliving the event .Misperceptions (a wrong or incorrect understanding or interpretation)/overreactions .sleep disturbance . Additionally, the policy showed residents would be screened and assessed for a history of trauma, potential triggers identified, development/implementation of a care plan with preventative interventions and routine review a resident's care plan would be performed to ensure trauma informed care was being provided. <Resident 47> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including heart failure, depression and insomnia (sleep disorder that makes it hard to fall asleep, stay asleep, or get enough sleep). The 07/24/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. During an interview on 10/01/2024 at 11:27 AM, Resident 47 stated that Staff I, Nursing Assistant (NA), was rough and impatient when providing cares to them, was sometimes nice, but then other times was the opposite of nice. Resident 47 stated they reported this to Staff F, Charge Nurse, a month and a half ago. The resident stated they were worried about Staff I's mental state (an emotion or condition that greatly influences an individual's thought processes at a moment in time) and how it was up and down. Resident 47 stated they were afraid sometimes because Staff I's treatment toward them was unpredictable and Staff I's mood swings reminded Resident 47 of their significant other who was an alcoholic and had mood swings. Resident 47 stated they did not think that Staff I would physically abuse them like their significant other had, but Staff I's unpredictable mood swings triggered those traumatic memories. Review of Resident 47's medical record showed no trauma informed care assessment had been completed for the resident. Review of Resident 47's care plan, dated 06/05/2023, showed the resident had a history of physical abuse as a child and a plan for the resident's trauma history was developed. No potential triggers were identified. Review of a progress note, dated 10/02/2024 at 9:30 AM, showed Staff E, Social Service Assistant (SSA), interviewed Resident 47 and documented, Follow up with resident regarding care concerns per resident no issues or concerns. Does not want a particular NAC in (Resident 47's) room however reports no abuse or neglect just personal preference. Will continue to monitor and follow as needed. During an interview on 10/02/2024 at 11:44 AM, Staff K, NA, stated they knew Resident 47 had a history of an abusive parent but was not aware of any potential triggers for the resident. During an interview on 10/02/2024 at 12:36 PM, Staff E, SSA, stated they had just followed up about a specific NA that Resident 47 did not want to care for them anymore earlier in the morning. Staff E stated when they had interviewed Resident 47 that morning, they understood the issue to be that Staff I and Resident 47's personalities did not mix well. Additionally, Staff E stated Resident 47 had a previous roommate that would yell/hit themselves and that would make Resident 47 upset. During an interview on 10/02/2024 at 12:47 PM, Staff D, Social Service Director and Staff E, stated Resident 47 had a history of verbal and physical abuse from the resident's parents. Staff D stated they had not completed a trauma informed care assessment on Resident 47 because we knew about (Resident 47's) trauma from 2019, but was not aware of the resident ever being married. Additionally, Staff D stated they had never assessed Resident 47 for potential triggers regarding their traumatic history. During an interview on 10/02/2024 at 1:07 PM, Staff H, NA, stated they remembered hearing Resident 47 was married and their significant other was physically abusive toward Resident 47. Staff H stated the resident's parent was also verbally abusive. Staff H stated they did not convey any information on the resident's traumatic events to any other staff because the resident's trauma history was already known. During an interview on 10/02/2024 at 1:35 PM, Staff F, Charge Nurse, stated Resident 47 expressed concerns about a night shift NA that was rude/rushed when providing cares two to three months prior. Staff F stated Resident 47 had a history of parents that were not good to the resident and a significant other that was also not good, .rude verbally maybe. Staff F stated they were not aware of any potential triggers for Resident 47 traumatic history. During an interview on 10/02/2024 at 10:15 AM, Staff B, DNS, stated the facility's process for trauma informed care with residents was to complete a trauma informed care assessment, which identify traumatic events in the resident's history, any possible triggers that would make them relive the traumatic event, and interventions to prevent that from happening. Staff B stated that Resident 47 should have had a trauma informed care assessment that identified/care plan the residents potential triggers. Staff B stated Resident 47's perception of Staff I's mental state being up and down could be a potential trigger of the resident's trauma from their abusive significate other, and the correct process was not followed. Reference: WAC 388-97-1060(3)(e)

Based on interview and record review the facility failed to ensure implementation of their abuse prohibition policy/procedures components of resident protection, identification, reporting and investigating for 1 of 3 residents (Resident 47) reviewed for abuse/neglect. This failure placed the resident at an increased risk for unidentified abuse/neglect, retaliation from the alleged perpetrator and the potential for continued exposure to abuse and/or neglect. Findings included . Review of the State Operations Manual, Appendix PP, dated 08/08/2024, the Code of Federal Regulations 483.12 (b)(1), F607, The Facility must develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of residents property, showed that in order to .provide protections for the health, welfare and rights of each resident residing in the facility . the facility must develop and implement components of screening, training, prevention, identification, investigation, protection and reporting/response. Review of the facility's policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised October 2022, showed The purpose of the policy was to prevent, identify, report and investigate abuse, neglect and exploitation. The policy showed that to protect resident and keep them safe the alleged perpetrator would be immediately suspended, and a trusted person would stay with the resident in an area where they felt safe. Additionally, to identify abuse, facility staff were to monitor suspicious occurrences, patterns or trends that may constitute abuse. <Resident 47> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including heart failure and depression. The 07/24/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. During an interview on 10/01/2024 at 11:27 AM, Resident 47 stated that Staff I, Nursing Assistant (NA), on the night shift was rough and impatient when turning and providing care to them. Resident 47 stated they were unsure of the date happened a month and a half ago, but had informed Staff F, Charge Nurse, about Staff I roughly moving and turning them during cares. Resident 47 stated that Staff F informed the resident about how they talked with the night shift staff member, and they were no longer allowed to come into the resident's room. Resident 47 stated (Staff I) took care of me this week and (Staff I) was nice but sometimes comes back in a different mood and I'm afraid (Staff I) might do it again (referring to Staff I being rough and impatient with turning/providing cares to Resident 47). Record review of the facility staffing schedules/room assignments for September and October 2024 showed that Staff I was working the night shift and assigned to care for Resident 47's on 09/29/2024, 09/30/2024, and 10/01/2024. During an interview on 10/02/2024 at 12:13 PM, Staff G, Licensed Practical Nurse, stated Resident 47 had allegation of rough handling during cares against Staff I and that investigations had been conducted. Staff G stated Staff I was not supposed to be going into Resident 47's room when they were working. Staff G stated Staff I had been going into Resident 47's room even though they were told not to. Additionally, Staff G stated that Staff E, Social Service Assistant (SSA), was investigating Resident 47's continued concerns about Staff I not being allowed into the resident's room. Review of a progress note on 10/02/2024 at 9:30 AM showed, Staff E, SSA, interviewing Resident 47. Staff E stated, Follow up with resident regarding care concerns per resident no issues or concerns. Does not want a particular NAC in her room however reports no abuse or neglect just personal preference. Will continue to monitor and follow as needed. During an interview on 10/02/2024 at 12:36 PM, Staff E, stated they followed up about a specific NA that Resident 47 did not want to care for them anymore. Staff E stated they followed up after concerns were conveyed to them by Staff H, NA, who had received the concern from Resident 47 the morning of 10/02/2024. Staff E stated when they had interviewed Resident 47 that morning, they understood it as Staff I's and Resident 47's personalities did not mix well. During an interview on 10/02/2024 at 1:07 PM, Staff H, NA, stated that Resident 47 made a comment to them the morning of 10/02/2024 about not having night shift NA, Staff I, come into their room anymore. Staff H stated Resident 47 made allegations Staff I would wake (Resident 47) up at all hours of the night and bruised the resident's arm with turning and was bossy with the resident. Staff H stated Resident 47's concerns had been ongoing and that Staff I was sometimes nice and then would sometime be rough with turning and cares towards the resident. Staff H stated the allegations against Staff I had been ongoing for about a month and a half, and that the resident's original allegation, of rough handling with turning/bruising the resident's arm by Staff I, had already been investigated by nursing staff. Additionally, Staff H stated now it was just a grievance from Resident 47 to not have Staff I care for or enter the resident's room. During an interview on 10/02/2024 at 1:35 PM, Staff F, Charge Nurse, stated Resident 47 had concerns about a night shift NA that was rude and rushed when providing cares. Staff F stated, it's been a few months since the resident had conveyed their concerns and that Staff I was not supposed to be going into Resident 47's room. Staff F stated they had informed Staff B, Director of Nursing Services (DNS), who came and talked with Resident 47. During an interview on 10/02/2024 at 10:15 AM, Staff B, DNS, stated they were unaware of the Resident 47's allegation of abuse regarding Staff I rough handling with turning/cares that were made. Staff B stated they had completed an investigation into skin complications in July 2024 but was not made aware of the resident allegations from any their staff at that time. Staff B stated Resident 47's statements were allegation of abuse that should have been reported, investigated and that Staff I should have been taken off the schedule to protect Resident 47 when the facility became aware of the abuse allegations. Staff B stated the correct process for protection of the resident from abuse and identification of potential abuse was not followed. Reference: WAC 388-97-0640(2)(a)

Based on interview and record review, the facility failed to report allegations of potential abuse and/or neglect to the State Agency, for 1 of 3 residents (Residents 47), reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect, and the potential continued exposure to abuse and/or neglect. Findings included . Review of the facility's policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised October 2022, showed The purpose of the policy was to prevent, identify, report and investigate abuse, neglect and exploitation. The policy showed that to protect resident and keep them safe the alleged perpetrator would be immediately suspended, and a trusted person would stay with the resident in an area where they felt safe. Additionally, to identify abuse, facility staff were to monitor suspicious occurrences, patterns or trends that may constitute abuse <Resident 47> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including heart failure and depression. The 07/24/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. During an interview on 10/01/2024 at 11:27 AM, Resident 47 stated that Staff I, Nursing Assistant (NA), was rough/impatient when providing cares to them and they had received bruises from Staff I's rough care. Resident 47 stated they had informed Staff F, Charge Nurse, that Staff I was roughly turning them during cares. Additionally, the resident stated, I told (Staff I) they were going to hurt somebody (referring to the way that Staff I was rough when providing cares) and (Staff I) said, well it might be you. Review of the facility incident log for March through September 2024 showed that Resident 47 allegation of abuse towards Staff I had been logged or reported to the State Agency. During an interview on 10/02/2024 at 12:13 PM, Staff G, Licensed Practical Nurse, stated Resident 47 had allegation of rough handling during cares against Staff I and they thought that the reporting and investigating into the resident's allegation had already been completed. During an interview on 10/02/2024 at 1:07 PM, Staff H, NA, stated Resident 47 had made previous allegations that Staff I would wake the resident up at all hours of the night, bruised the resident's arm with turning and was bossy with the resident. Staff H stated Resident 47's concerns had been ongoing and that some nights Staff I was nice but then other nights the staff was rough with turning and cares towards the resident. Staff H stated they thought the resident's allegation of abuse had already been reported by nursing staff. During an interview on 10/02/2024 at 1:35 PM, Staff F, Charge Nurse, stated that Resident 47 had concerns about a night shift NA that was rude and rushed when providing cares. Staff F stated, it's been a few months since the resident had conveyed their concerns and did not remember Resident 47 stating that Staff I was rough when turning and caring for them. Staff F stated they had reported it to Staff B, Director of Nursing Services (DNS). During an interview on 10/02/2024 at 10:15 AM, Staff B, DNS, stated they were unaware of the Resident 47's allegation of abuse regarding Staff I's rough handling with turning/cares that were made. Staff B stated Resident 47's statements were allegation of abuse that should have been reported and they were unsure of why they were not informed by facility staff. Staff B stated the correct process was not followed and they would be reporting Resident 47's allegation of abuse to the State Agency. Reference: WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to conduct a thorough investigation into an allegation of abuse for 1 of 3 residents (Resident 47), reviewed for abuse and neglect. This failure placed the residents at risk for unidentified abuse, unmet care needs, and the potential for continued exposure to abuse and/or neglect. Findings included . Review of the facility's policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised October 2022, showed The purpose of the policy was to prevent, identify, report and investigate abuse, neglect and exploitation. The policy showed that all alleged incidents of abuse were to be thoroughly investigated in order to determine what occurred and would begin as soon as the incident was identified and the alleged victim protected. <Resident 47> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including heart failure and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The 07/24/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. During an interview on 10/01/2024 at 11:27 AM, Resident 47 stated that Staff I, Nursing Assistant (NA), was rough/impatient when providing cares to them and they had received bruises from Staff I's rough care. The resident stated they had informed facility staff about the incident but could not remember the exact date that the incident occurred. Review of the facility incident investigation log for March through September 2024 showed no investigation into Resident 47's allegation of abuse towards Staff I had been completed. During an interview on 10/02/2024 at 12:13 PM, Staff G, Licensed Practical Nurse, stated they were aware of Resident 47's allegation abuse. Staff G stated that Resident 47 alleged that Staff I treats (Resident 47) rough when providing cares/turning the resident. During an interview on 10/02/2024 at 1:35 PM, Staff F, Charge Nurse, stated that Resident 47 had concerns about a night shift NA that was rude and rushed when providing cares. Staff F stated that it had been two to three months since the resident had conveyed their concerns. Staff F stated they had reported Resident 47's concerns to Staff B, Director of Nursing Services (DNS). During an interview on 10/02/2024 at 10:15 AM, Staff B, DNS, stated they were not made aware of Resident 47's allegation of abuse regarding Staff I's rough handling when turning/providing cares. Staff B stated Resident 47's statements were allegation of abuse that should have been investigated right after the allegations were made. Staff B stated the correct process was not followed and Resident 47 should have been protected by removing Staff I from the schedule pending an investigation. Reference: WAC 388-97-0640(6)(a)

Based on interview, and record review the facility failed to ensure residents received treatment and services in accordance with professional standards of practice regarding monitoring of their cardiac status (issues related to the functioning of the heart). This included daily weights and physician notification of weight changes greater than three or more pounds (ibis, a unit of measure) in a 24-hour period for 1 of 2 residents (Resident 1) reviewed for quality of care. These failures placed residents at an increased risk for unidentified complications and a deterioration in their health status. Findings included . <Resident 1> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including; congestive heart failure (a condition in which the heart does not pump blood as well as it should), diabetes (a condition that causes elevated blood glucose) and history of a cerebral vascular accident (lack of blood supply to an area in the brain which results in brain damage). Review of the most recent comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance from staff for activities of daily living such as toileting, dressing, transferring between surfaces and mobility. Record review of Resident 1's October 2024 physicians orders showed an order dated 06/12/2024 in which the resident was to have daily weights to monitor their cardiac status. The order included instructions to contact the physician if the resident had a weight gain of three lbs or greater in a 24-hour period. Review of Resident 1's July 2024 medication administration record (MAR) showed nine missed daily weights on 07/01/2024, 07/02/2024, 07/08/2024, 07/09/2024, 07/10/2024, 07/11/2024, 07/19/2024, 07/23/2024 and 07/30/2024. Additionally, on 07/25/2024 the resident had a documented weight of 160 lbs and the following day on 07/26/2024 their weight was 165 lbs which was a greater than three lbs of weight gain in 24 hours. Review of Resident 1's progress notes (PN) dated 07/26/2024 showed that the physician had not been notified of the weight gain. Record review of Resident 1's August 2024 MAR showed seven missed daily weights on 08/14/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/26/2024, 08/28/2024 and 08/31/2024. Further review showed on 08/29/2024 the resident's weight was 162 lbs. and on 08/30/2024 the resident's weight was 166 lbs. which was greater than three lbs. of weight gain. Review of the PN dated 08/30/2024 showed that Resident 1's physician had not been notified of the resident's greater than three lbs. of weight gain. Record review of Resident 1's September 2024 MAR showed their daily weights had been missed seven times during the month on 09/01/2024, 09/05/2024, 09/09/2024, 09/14/2024, 09/15/2024, 09/28/2024 and 09/29/2024. Further review showed the resident's weight on 09/27/2024 was 157 lbs. and the next documented weight was on 09/30/2024 which was 164 lbs. showing seven lbs. of weight gain in three days. Record review of the PN dated 09/30/2024 showed Resident 1's physician had not been notified of the weight gain or an assessment of the resident's cardiac status completed. Review of Resident 1's October 2024 MAR showed the resident had currently missed daily weights three times on 10/01/2024, 10/05/2024 and 10/06/2024. Further review showed the weight on 10/04/2024 was 160 lbs and on 10/07/2024 the resident's weight was 165 lbs indicating five lbs of weight gain over several days. Review of the residents PN dated 10/10/2024 showed the physician had not been notified of the weight gain or an assessment of the resident's cardiac status completed. During an interview on 10/07/2024 at 9:14 AM, Staff M, Registered Nurse, stated the physician should have been called for the weights that showed a three lbs. or more of weight gain. Staff M stated they had not contacted the physician related to Resident 1's weights but probably should have or at least had re-weighs completed to verify the accuracy of the data. During an interview on 10/07/2024 at 9:30 AM Staff N, Licensed Practical Nurse/Charge Nurse stated Resident 1's weight should have been completed daily and if the resident's weights showed an increase of three or more lbs. then the physician should have been notified. Reference: WAC 388-97-1060(1)

Based on interview and record review the facility failed to ensure that 1 of 5 residents (Resident 1) reviewed for unnecessary medications, had an acceptable indication for use for a psychoactive medication (a class of medication that affects brain activity of mental functioning and behavior). Resident 1 was prescribed an antipsychotic medication (a psychoactive medication primarily used to treat psychosis with a high risk for adverse side effects [ASE's]) with no acceptable mental health diagnosis or identified individualized target behaviors to justify the use of an antipsychotic. This failure placed Resident 1 at increased risk for deterioration in their mental and physical health status. Findings included . Record review of a facility policy titled, Behavior Management/Psychotropic Medication Overview, dated 10/2022 showed, .When psychotropic medications are ordered, an appropriate diagnosis must have been obtained .Behavior monitoring will be documented when an antipsychotic medication is ordered .Psychotropic medication use will be reviewed at least quarterly to determine appropriateness of continued use . Record review of an Alzheimer's Society 2024 guidance showed, antipsychotic drugs are used to treat people who are experiencing severe agitation, aggression or distress from psychotic symptoms such as hallucinations or delusions and; antipsychotic drugs do not help with other behaviors such as: Distress and anxiety Repetitious vocalizations Social withdrawal Possible negative effects of antipsychotics include: Drowsiness or confusion Shaking, unsteadiness and reduced mobility Worse than usual dementia symptoms Higher risk of infection (in the chest or urinary tract) Higher risk of fall with fractures Higher risk of blood clots and stroke <Resident 1> Review of the resident's medical record showed they were admitted to the facility on [DATE] with mental health diagnoses including dementia without behavioral disturbances or psychotic features, anxiety (a feeling of worry, nervousness, or unease) and depression (a mood disorder that causes a feeling of sadness and loss of interest). The most recent comprehensive assessment, dated 09/18/2024, showed the resident was cognitively intact with anxiety and moderate depression. The assessment did not identify that the resident had issues with psychosis. Review of Resident 1's physician orders, dated October 2024, showed the resident was taking several psychoactive medications including an antidepressant medication used to treat their depression, an antianxiety medication used to treat their anxiety and an antipsychotic used to treat their anxiety. There was no diagnosis or an associated behavior documented in the medical record to show that an antipsychotic medication was clinically indicated for use. Record review of Resident 1's August 2024 through 10/06/2024 behavior monitor flow sheets (a sheet that provides documentation of identified target behaviors associated with the resident's mental health diagnoses) showed the resident's identified behaviors were sadness and hopelessness related to depression, worrying and ruminating (to think consistently and for a long period about something) related to anxiety. The sheets did not identify any behaviors associated with psychosis to justify the use of an antipsychotic medication. Further review of the resident's behavior monitor flow sheets for August and September 2024 showed the resident had no documented behaviors related to sadness, hopelessness, worrying or ruminating. The resident's most current behavior monitor flow sheet dated 10/01/2024 to 10/06/2024 also showed no documented behaviors had occurred. Record review of Resident 1's psychoactive medication review meeting, dated 09/19/2024, showed the resident was unaware of when they were started on the antipsychotic. The review showed the diagnosis for the use of the antipsychotic was anxiety and dementia. The targeted behaviors were identified as sadness and hopelessness. There was no other clinical indication or justification for the use of Resident 1's antipsychotic medication. During an interview on 10/04/2024 at 11:36 AM, Staff D, Social Services Director, stated Resident 1 was admitted to the facility on several psychoactive medications including an antipsychotic. Staff D stated they were unable to find a provider note for the use of Resident 1's antipsychotic except for a diagnosis of anxiety. Staff D was asked if there were identified target behaviors that would justify the use of an antipsychotic medication and they replied no. Reference: WAC 388-97-1060 (3)(k)(i)

Based on interview and record review, the facility failed to provide copies of personal and medical records, as required, to 1 of 3 residents (Resident 1), reviewed for resident rights. This deficient practice placed residents at risk of not having access to their complete medical history, potentially affecting their ability to make informed decisions, and violated their resident rights. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses of muscle wasting, contusion (bruise) of the scalp, and repeated falls. Review of the comprehensive assessment completed on day of discharge, dated 12/04/2023, showed Resident 1 had intact cognition and required set up and supervision assistance with personal cares. Review of record requests received by the facility showed a written request, dated 07/29/2024, was submitted to the facility on behalf of Resident 1 by a local attorney's office. The records request included a Consent for Release/Exchange of Confidential Information, signed by Resident 1 and a letter that outlined the time frame, the category of records, the preferred method of receiving the records (electronically) and the e-mail address to submit them to. The records request was received via fax machine and was delivered to the facility on [DATE] at 2:30 AM. Review of a statement dated 08/29/2024, from Staff D, Medical Records Assistant, showed they received a records request on 07/30/2024 for Resident 1. Staff D's statement showed they informed Staff A, Administrator and Staff C, Medical Records Director, by e-mail of the record request and began gathering some of the records. During an interview, on 08/29/2024 at 1:40 PM, Staff C stated the facility received a records request for Resident 1 on 07/30/2024, and they received a follow-up phone call from the requesting attorney's office on 08/08/2024. Staff C stated a clarified list of requested records was discussed and they confirmed the records were to be sent electronically. Staff C stated the phone call ended, and they realized they had not confirmed the e-mail address to send the records to. During the same interview, Staff C stated they attempted to contact the local attorney's office to confirm the recipient's e-mail address on 08/16/2024 but was unsuccessful. Staff C stated they were still waiting for the local attorney's office to confirm the recipient e-mail address, and as of 08/29/2024 (22 working days later), no requested records had been submitted. During an interview, on 08/29/2024 at 2:45 PM, Staff A stated they were aware the facility received a records request for Resident 1 but was unaware that the request had not been responded to. Staff A stated they expected record requests to be responded to in a timely manner and did not consider 22 working days to be timely. Staff A stated they were unaware the facility had a response time requirement for record requests. Reference: WAC 388-97-0300 (2)(a)(b)

Based on interview and record review, the facility failed to maintain their Respiratory Protection Program (RPP) for N95 respirator masks (a respiratory protective device designed to filtrate airborne particles by achieving a very close facial fit) initial and annual fit testing for 4 of 5 staff (Staff D, E, F, and G) reviewed for infection control practices during a COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) outbreak. This deficient practice placed residents and staff at continued risk of exposure and spread of COVID-19 during an active outbreak. Findings included . Review of guidance from the Washington State Department of Health titled Respiratory Protection Program for Long-term Care Facilities, showed the N95 respirator protected the user when the seal around the person's nose and mouth was tight enough to prevent the respiratory hazards from leaking into their breathing space. The N95 respirator would need to be tested before using and annually after that. Review of the facility policy titled, Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic, revised on 05/08/2023, showed staff entering a resident room who was suspected or confirmed positive for COVID 19 should use a National Institute for Occupational Safety and Health (NIOSH) approved N95 respirator, and respirators should be used within a RPP that included medical evaluations, fit testing, and training. Review of the undated facility document titled Outbreak Investigation Form, showed the current and active COVID-19 outbreak started on 05/28/2024 when a staff member tested positive, and as of 07/01/2024, a total of 17 residents and 21 staff members had been infected. Review of staff personnel records on 07/01/2024 showed the following: Staff D, Licensed Practical Nurse (LPN), was hired on 04/23/2024 and completed the medical evaluation and N95 fit testing on 07/01/2024 (68 days after hire and 34 days after outbreak began). Staff E, LPN, was hired on 05/30/2024 and completed the medical evaluation and N95 fit testing on 06/20/2024 (21 days after hire and 23 days after outbreak began). Staff F, Nursing Assistant (NA), was hired on 05/30/2024 and completed the medical evaluation and N95 fit testing on 06/26/2024 (27 days after hire and 29 days after outbreak began). Staff G, Restorative Aide, was hired on 11/29/2022 and there were no records of N95 fit testing completed in 2024. Review of the Nursing Department staffing schedule for June 2024, showed Staff D, E, F, and G worked in a capacity that required the use of an N95 respirator. During an interview, on 07/01/2024 at 12:50 PM, Staff C, Staff Development Director (SDD), stated they had been hired approximately three weeks prior, and was currently responsible for staff N95 fit testing. Staff C stated the facility's policy was to complete fit testing upon hire and annually, and they were aware the facility was behind on fit testing schedules. During an interview, on 07/01/2024 at 01:20 PM, Staff A, Administrator and Staff B, Director of Nursing stated the expectation was for staff to be fit tested for N95 respirators upon hire and annually. Staff A acknowledged staff fit testing had not been completed as expected. Reference: WAC 388-97-1320 (1)(a)(2)(a)

Based on interview and record review, the facility failed to prevent an avoidable accident when COVID 19 reagent solution (a chemical used in a test to determine if a person has COVID 19 [infectious disease by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death]) was used as an eye drop for 1 of 1 resident (Resident 2) reviewed for accidents and hazards. This deficient practice placed residents at risk for unnecessary exposure to chemicals and potentially harmful outcomes. Findings included . <Resident 2> Review of the medical record showed Resident 2 admitted to the facility on [DATE] with diagnoses of pelvic fracture, head contusion (a deep bruise caused by a direct blow to the body), and bladder infection. Review of the comprehensive assessment, dated 03/24/2024, showed Resident 2 was cognitively intact and required the assistance of one person for activities of daily living (ADLs). Review of the facility's incident reporting log showed a medication error incident occurred to Resident 2 on 03/23/2024 at 5:00 PM. Review of the facility's incident document, dated 03/23/2024, showed Staff E, Registered Nurse (RN), had Resident 2's prescribed eye drops and a dispensing bottle of COVID 19 reagent solution at Resident 2's bedside. The document showed Staff E noticed they instilled drops of the COVID 19 reagent solution into Resident 2's eye in error when Resident 2 began complaining of a burning sensation. Review of Staff E's witness statement, documented on 03/27/2024, showed they initially took Resident 2's prescribed eye drops to their bedside to administer them. Staff E's statement showed they returned to the medication cart to get other supplies and noticed a similar looking bottle (COVID 19 reagent) on the top of the cart. Staff E stated they mistook the similar looking bottle for Resident 2's prescribed eye drops and took the bottle with them back to Resident 2's bedside. Staff E's statement showed they proceeded to administer Resident 2's eye drops using the incorrect bottle. During an interview, on 06/04/2024 at 2:03 PM, Staff F, Consultant Pharmacist, stated that COVID 19 reagent solution was considered a chemical, not a medication, and was not meant to be put in the body. Staff F stated items, such a COVID 19 reagent solution, that were packaged similarly to medications, should not be stored on a medication cart. During an interview, on 06/04/2024 at 3:05 PM, Staff B, Director of Nursing (DON), stated COVID 19 reagent solution should not be stored on the medication cart, and Staff E did not follow the facility's policy for administering medications. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when physician's orders were not implemented timely for 1 of 2 residents (Resident 1) reviewed for medication administration. This deficient practice placed residents at risk for adverse side effects and an overall decline in medical condition. Findings included . <Resident 1> Review of the medical record showed Resident 1 readmitted to the facility on [DATE] with diagnoses of osteomyelitis (infection in the bone) to the left foot, diabetes mellitus (a disease that a disease that impairs the body's ability to process sugar in the blood), and peripheral vascular disease ([PVD] circulation disorder caused by narrowing, blockage or spasms in the blood vessels of the legs and feet). Review of the comprehensive assessment dated [DATE] showed Resident 1 had moderately impaired cognition, required the assistance of one person for personal cares, hygiene, dressing, and the assistance of two people for transfers and bed mobility. During an interview, on 06/03/2024 at 11:06 AM, a Resident Representative (RR) stated the purpose of Resident 1's admission to the facility was to receive intravenous ([IV] a medical technique that administers medications directly into a person's vein) antibiotic therapy for their osteomyelitis which was managed by an Infectious Disease (ID) physician specialist. The RR stated Resident 1 had around the clock care at home and would be returning home once the IV antibiotic therapy was completed. Review of the Medication Administration Record (MAR) for May 2024 showed Resident 1 admitted to the facility with orders for Ampicillin-Sulbactam ([brand name Unasyn] an antibiotic medication used to kill the infection causing bacteria)-three grams ([g] a unit of measure) IV every six hours for 15 days. The MAR showed the administration times were 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM, and the last dose was administered on 05/26/2024 at 5:00 AM. Review of the medical record showed Resident 1 was seen by the ID specialist, on 05/22/2024 at 1:40 PM, and returned with a visit summary that gave orders to continue IV Unasyn for 3 more weeks. Further review of the visit summary document showed it had been signed by Staff C, Charge Nurse. During an interview, on 06/04/2024 at 12:26 PM, Staff C stated the Charge Nurse job duties included processing physician orders, coordinating care with outside providers, discharge preparations, and participating in care conferences. Staff C stated they were the Charge Nurse on 05/22/2024 and their signature was on Resident 1's visit summary document to indicate that they had reviewed the document. Staff C stated they recalled briefly reviewing the visit summary document but missed the directions to continue Resident 1's IV antibiotics. During an interview, on 06/04/2024 at 2:43 PM, Staff D, Resident Care Manager (RCM) stated they were working as the Charge Nurse on 05/28/2024 and was following up on the status of Resident 1's IV access site. Staff D stated it was at that time they discovered that Resident 1's IV antibiotics had discontinued, on 05/26/2024 after the 5:00 AM dose was administered, despite orders to continue for three more weeks. Staff D stated they notified Staff B, Director of Nursing, right away. Review of the facility's incident reporting log showed an incident of other nature occurred to Resident 1 on 05/28/2024 at 9:30 AM. The incident log entry showed Resident 1 sustained no injuries from the incident and it was not reported to the State Agency. Review of the facility's incident investigation, dated 05/28/2024, showed the continuation order for Resident 1's IV antibiotics was not processed and placed on the MAR resulting in medication errors. The investigation summary showed Resident 1 had missed a total of seven doses of IV antibiotics, equaling seven medication errors. During an interview, on 06/04/2024 at 2:03 PM, Staff F, Consultant Pharmacist, stated in treating a serious infection, such as osteomyelitis, it was important to maintain regular levels of the antibiotic in the body. Staff F stated this was done by administering the antibiotic medication at timed intervals, and even one missed dose could impact a resident's medical condition. Staff F stated that seven missed antibiotic doses for the treatment of Resident 1's osteomyelitis was a significant medication error. During an interview, on 06/04/2024 at 3:05 PM, Staff B stated they recognized the incident for Resident 1 on 05/28/2024 as a medication error, but did not feel it rose to the level of being a significant medication error. Reference: WAC 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to ensure residents who had personal fund accounts established, received accrued interest on those accounts or accurate statements for 11 of 18 residents (Residents 1, 4, 5, 12, 21, 29, 32, 33, 50, 51, and 183) reviewed for personal funds. This failed practice caused residents not to receive or have access to monies owed to them. Findings included . Review of the facility's policy Resident Trust Account, dated 01/2023, showed the facility would provide a secure bank account that earns interest for residents. The policy further showed the trust accounts would be reconciled within two days of receiving the monthly bank statement and at that time interest would be posted to the resident's accounts. Review of the resident's printed statements and lists of trust accounts, provided by Staff D, Business Office Manager, who had personal funds accounts established, showed 11 current residents and one discharged resident with balances greater than $50.00 and no interest income had been earned or applied to the accounts. Review of a the most recent trust interest transaction list, dated 09/30/2022, showed that was the last time interest had been accrued for nine of the 11 residents (Residents 1, 4, 5, 12, 21, 32, 33, 50, and 183). During an interview, on 08/14/2023 at 11:00 AM, Staff D stated they had noticed they had not received a trust batch (a statement they received from the bank showing each accounts accrued interest) since 09/2022. Staff D contacted the bank via email on 08/08/2023 to discuss why the personal funds accounts had not gained interest since 09/2022 and they had not received a response. During an interview on 08/14/2023 at 11:18 AM, Staff A, Administrator, stated all trust accounts were interest bearing accounts and acknowledged awareness that the accounts were not accruing interest. During an interview, on 08/15/2023 at 8:32 AM, Staff D stated they had received an email response from the bank, they continued to work on why the interest had stopped accruing, and there had not been a resolution. WAC Reference: 388-97-0340 (3)(a)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Four medication errors were identified for 3 of 14 residents (Residents 6, 27 and 52) observed during 25 medication administration opportunities that resulted in an error rate of 16%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects. Findings included . <Resident 6> Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses including lung disease and muscle weakness. The 07/14/2023 comprehensive assessment showed the resident required limited assistance of one staff for activities of daily living (ADLs). The assessment also showed the resident had an intact cognition. Review of the physician's orders, dated 12/08/2021, showed that the resident's Methadone (a [narcotic-a medication that has a numbing, calming and sedative effect] medication used for chronic pain and pain medication withdrawal) was to be administered two times a day, once in the AM and once in the PM. The resident's electronic medication administration record (eMAR) showed that the resident had already received their AM dosage. An observation on 08/11/2023 at 12:10 PM, showed Staff F, Licensed Practical Nurse (LPN), removed a blister pack card (a cardboard card with foil on the back to hold single doses of a medication) for the resident's Methadone. Staff F removed a single dose from the blister pack and placed it into a medication cup. They reviewed the medication order then placed the medication back into the blister pack and taped the back of the blister pack closed. They returned the blister pack to the medication drawer. During an interview on 08/11/2023 at 3:33 PM, Staff B, Director of Nursing Services (DNS), stated that narcotics that had been removed from the blister pack and placed into a medication cup were to be destroyed and two nurses should sign off the destruction on the narcotic log. Staff B further stated that staff were not to tape the medication back into the blister pack. During an interview on 08/15/2023 at 9:29 AM, Staff F stated that their practice was to place the medication back into the blister pack and tape it closed when they obtained the wrong medication. <Resident 27> Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular heartbeat), hypertension (high blood pressure), and depression. The 06/14/2023 comprehensive assessment showed the resident required extensive assistance of one staff for ADLs. The assessment also showed the resident had a severely impaired cognition. Review of the physician's order, dated 06/07/2022, showed that the resident's Atorvastatin (a medication used to treat high cholesterol) dose was to administer 10 milligrams (mg) once a day. During a concurrent observation and interview on 08/11/2023 at 8:39 AM, Staff H, LPN, obtained a blister pack of Atorvastatin 40 mg from the medication cart and stated that they would use a pill cutter to divide the pill into four parts to make a 10 mg dose. Staff H then used a pill cutter to cut the medication into the four parts and used a white plastic spoon to remove a cut piece of medication and placed it into a medication cup. During an interview on 08/22/2023 at 11:49 AM, Staff C Assistant Director of Nursing (ADON), stated that staff were not to cut up medications without permission from the pharmacy. The process would be to send the medication back to the pharmacy for repackaging. Staff C further stated that some medications were not able to be divided as the accuracy of the dosage may not be correct. During an interview on 08/15/2023 at 10:52 AM, Staff N, Pharmacist, stated that the process for medications that needed to be cut for dosages would be performed at the pharmacy, placed into blister packs, and delivered to the facility to administer to the residents. <Resident 52> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including diabetes (a group of diseases that results in too much sugar in the blood). The 06/20/2023 comprehensive assessment showed the resident required extensive assistance of one staff for ADLs. The assessment also showed the resident had an intact cognition. Record review of a 07/25/2023 physician's order showed the resident was to receive insulin glargine (a long-acting insulin), 19 units, twice a day via pen-injector (insulin pen). A second physician's order showed the resident was to receive Humalog insulin (a short/fast-acting insulin), three units before meals via pen-injector. During a concurrent observation and interview on 08/11/2023 at 3:59 PM, Staff G LPN showed Staff G attach the disposable needles to both prefilled insulin pens and use the dial on the pens to adjust to the ordered dosages. Staff G administered the insulin doses to the resident without priming the insulin pens prior to injection. Staff G stated they forgot to prime the needles and they are supposed to prior to administering insulin pens to ensure the resident receives the proper dosage. During an interview on 08/15/2023 at 9:40 AM, Staff B Director of Nursing Services, stated that Staff G did self-report the medication error as they were to prime the insulin pen needles prior to administering. Reference (WAC) 388-97-1060(i)(k)(ii)

Based on observation, interview, and record review, the facility failed to ensure resident's personal refrigerators; 1. were free of expired foods, 2. temperatures were being monitored and maintained within acceptable standards of practice, and 3. cleaning schedules were followed for 4 of 4 residents (Resident 4, 5, 51, and 31) reviewed for safe food handling practices. This failed practice put residents at risk for being exposed to a food-borne illness (Illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and decreased quality of life. Findings included . Review of the facility's policy, titled Resident Room Refrigerators/Resident Food, dated [DATE], showed temperatures of the refrigerators were to be checked and documented on the temperature log twice weekly by the housekeeping staff. The housekeeping staff were also responsible for the disposing of expired food. The policy further showed, food items that required refrigeration should have been kept in air-sealed tight containers and dated. Lastly, the policy showed, .Acceptable Temperature Range: 41 degrees F [Fahrenheit, a type of temperature measurement] & below, and if the refrigerator was not functioning properly, the maintenance department was to be called immediately. <Resident 4> Review of the resident's electronic health record (EHR) showed, the resident admitted to the facility on [DATE] with diagnoses to include heart and respiratory failure. The comprehensive assessment, dated [DATE], showed Resident 4's cognition was moderately impaired, and required extensive staff assistance for their activities of daily living. During a concurrent observation and interview, on [DATE] at 12:09 PM, Resident 4 stated their Resident Representative (RR) would bring them in soda pop and at times food to have direct access to. Resident 4 had a mini-refrigerator in their room and contained five-7.5 fluid ounce cans of diet soda pop, and one 32-ounce bottle of yellow Gatorade (a brand of sports drink). The racks of the refrigerator had black, fuzzy soiled areas, and two thermometers located on the top shelf. One thermometer read 32 degrees F and the other thermometer read 40 degrees F. Resident 4 stated they did not have a cleaning schedule or temperature log located anywhere in the room, and they didn't know who was responsible for monitoring/cleaning the refrigerator. During an interview, on [DATE] at 9:56 AM, Staff GG, Housekeeper (HSK), stated it was the responsibility of the family to clean the refrigerators and take care of them, unless they ask us to clean them, then we will. During an interview, on [DATE] at 11:38 AM, Staff JJ, HSK, stated housekeepers were responsible for wiping the refrigerators down daily, but had never checked temperatures. An observation on [DATE] at 10:24 AM, the refrigerator was the same as it was on [DATE], and there were no temperature logs or cleaning schedules. On the same day, at 1:45 PM, the thermometers in the refrigerator showed 32- and 40-degrees F. <Resident 5> Review of the resident's EHR, showed the resident admitted to the facility on [DATE] with diagnoses to include heart failure and chronic pain. The comprehensive assessment, dated [DATE], showed the resident's cognition was intact and required the assistance of one staff bed mobility, transfers, toilet use, personal hygiene, dressing, and walking. An observation on [DATE], at 10:08 AM, showed Resident 5 had a mini refrigerator in their room, the refrigerator thermometer read 44 degrees F and the freezer thermometer read 20 degrees F. There were no cleaning schedules or temperature logs and the refrigerator contained: four single-serve containers of yogurt, one peach yogurt that expired on [DATE]. three single-serve containers of Sherbet, one raspberry that expired on [DATE]. a plastic sandwich bag that contained more than 10 round slices of summer sausage and had the date of [DATE]. The package showed no expiration date and was not in its original packaging more than 10-individually wrapped slices of yellow cheese, no expiration date and not in the original package they came in. An observation on [DATE], at 11:51 AM, showed the same foods as listed on [DATE]. The freezer thermometer read 24 degrees F and the refrigerator read 47 degrees F. There was a temperature log posted on the left side of the refrigerator. The log showed the initials of KM at 10:30 AM on the dated column for the 1st . The log showed no specific month, and temperatures had not been logged in the temperature columns. An observation on [DATE] at 12:17 PM, showed the refrigerator contained the same foods as observed on [DATE] and [DATE], and there were six slices of summer sausage left in the plastic bag. The thermometer in the refrigerator showed 46 degrees F and the freezer showed -16 F. The temperature log showed no changes and no temperatures. <Resident 51> Review of the resident's EHR, showed the resident admitted to the facility on [DATE] with diagnoses to include heart failure and respiratory failure. The comprehensive assessment, dated [DATE], showed the resident's cognition was moderately impaired. An observation on [DATE] at 10:39 AM, showed Resident 51 had a mini refrigerator in their room. The refrigerator contained; four yogurts, one of them expired on [DATE] (lemon burst flavor), an opened bottle of juice, and five protein drinks. There was a temperature log posted to the front of the refrigerator that showed the time of 7:33 AM entered in the column dated for the 13th , but no specific month, initials or temperatures were documented on the log. The refrigerator did not have a thermometer. <Resident 31> Review of the resident's EHR, showed the resident admitted to the facility on [DATE] with diagnoses to include diabetes and stroke. The quarterly comprehensive assessment, dated [DATE], showed the resident's cognition was intact and independent with activities of daily living. An observation on [DATE] at 2:48 PM showed Resident 31 had a mini refrigerator in their room, the refrigerator had no thermometer, and the freezer had no thermometer. There were no cleaning schedules, and the temperature log had a date of ,d+[DATE] without a specific year of when it was placed on the refrigerator. There were no temperatures or signatures of monitoring on the temperature log. During a concurrent interview and observation on [DATE] at 11:12 AM Resident 31 stated no-one takes care of it, I do it myself when asked about their mini refrigerator. The temperature log taped on the refrigerator had a date of ,d+[DATE] without a specific year of when it was placed. There were no temperatures or signatures of monitoring on the temperature log. During an interview on [DATE] at 12:01 PM Staff FF, Housekeeper, stated that they were to check the resident refrigerators daily. Also, they had to wipe them out with bleach or disinfectant (a chemical liquid that kills bacteria). Additionally, that they just found out today they had to check the temperatures of the refrigerators. An observation on [DATE] at 9:55 AM, showed Resident 31's refrigerator still without monitoring of the temperature or a verifying signature that the check has been done. The temperature log still had the date of ,d+[DATE] with no specific year. An observation on [DATE] at 8:32 AM showed, Resident 31's refrigerator continued with the date of ,d+[DATE] without a specific year. The temperature log continued without monitoring of temperatures or verifying signatures. During an interview, on [DATE] at 10:33 AM, Staff B, Director of Nursing Services, also present was Staff A, Administrator, stated they were not made aware the refrigerators were not being cleaned and temperatures had not been obtained or monitored. Staff B further stated it was the responsibility of the housekeepers to clean the refrigerators, monitor and document temperatures. Reference: WAC ,[DATE] (3)

Based on observation, interview, and record review the facility failed to implement effective infection control practices for 2 of 4 dining rooms (West and Rehab Dining Rooms), reviewed for appropriate infection control practices during meal serve out. This failure placed residents at risk for infectious diseases and a diminished quality of life. Findings included . <West Dining Room> During an observation on 08/07/2023 at 11:50 AM , Staff W, Nursing Assistant, (NA), entered the [NAME] dining room and poured beverages for residents. Staff W did not wash their hands prior to serving beverages. Staff W also cleaned up a coffee spill and without performing hand hygiene continued to make drinks and serve them to the residents (Residents 9, 28, 36 and 78). Staff W assisted residents entering the dining room to their places at the tables. Staff W helped the residents with their clothing protectors and adjusted residents sitting in their wheelchairs for more upright positioning. Staff W did not perform hand hygiene after touching the residents and their equipment. Observation on 08/07/2023 at 12:20 PM showed the meal cart with the residents' lunch trays arrived at the [NAME] dining room. Staff W began passing trays without having performed any hand hygiene. Staff EE, NA, joined Staff W and began passing out and setting up the residents' lunch trays. Staff EE also did not perform hand hygiene prior to passing out the residents' meal trays. Observation on 08/07/2023 at 12:28 PM, showed Staff W sat down at table one in the [NAME] dining room. A resident sitting at the table dropped their fork on the floor and stated, five second rule. Staff W obtained the fork from under the table and returned it to the resident without cleaning it or replacing it with another fork. The resident continued eating with the same fork that had fallen on the floor. <Rehab Dining Room.> During an observation on 08/09/2023 at 11:29 AM, in the Rehab Dining Room showed Staff BB, NA, put on gloves without performing hand hygiene. Staff BB sat down at a table and crossed their arms which placed the gloves they were wearing on their bare skin. Staff BB readjusted their positioning and used the arms of the chair they were sitting in to stand up. Staff BB while still wearing the same contaminated gloves, passed out the residents' meal trays and set up their food items. Continued observation of Staff BB showed them assist a resident to wipe their mouth, and with the same contaminated gloves adjusted a resident's straw and clothing protector. Observation on 08/10/2023 at 11:30 AM, showed Staff BB, wearing gloves, brought lunch trays to the Rehab Dining Room, and began setting up the residents' meals by removing lids and setting up silverware and napkins. Staff BB sat by a resident and assisted them with their meal providing verbal cuing and hands on assistance. Resident 28 stated I'm ready to leave Staff BB assisted another resident to remove their clothing protector and pushed them into the hall. Staff BB then returned to the dining room and continued to assist them with their meal. Staff BB did not change their gloves or perform hand hygiene. During an interview on 08/14/2023 at 12:45 PM, Staff B, Director of Nursing Services, stated that staff were expected to perform hand hygiene and change their gloves prior to serving food or after contamination. Reference WAC 388-97-1320(1)(c)

Based on observation, interview and record review, the facility failed to ensure pain was managed effectively for 1 of 6 residents (#1) reviewed for pain management. This failed practice resulted in actual harm to Resident #1, who experienced intermittent severe pain due to delays in receiving pain medication. Findings included: Resident #1. Per the medical record the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was not currently in the facility as she had been readmitted to the hospital on [DATE]. Review of Resident #1's nursing admission note dated 9/28/18 at 4:14 PM stated the resident arrived to the facility at 3:20 PM and was alert and oriented to person, place, time and situation. The resident required extensive assistance with transfers and mobility and expressed the current pain level to be a 3 on a scale of 1-10 (with 10 being the most severe pain) at rest and a level 8 to 10 with movement. Review of a pain assessment completed on 9/28/18 at 5:21 PM showed the resident reported pain over the past 5 days as almost constant and severe to the low back and left leg which made it hard to sleep and limited her day to day activities. The resident reported that pain medication assisted most to relieve her pain. Review of the hospital and transfer records showed Resident #1 was ordered the narcotic pain medication [MEDICATION NAME] 10 mg. (milligrams) to be given every 4 hours as needed and the muscle relaxant [MEDICATION NAME] 4 mg. to be given every 8 hours as needed for pain control. The hospital Medication Administration Record [REDACTED]. on 09/28/18 at 1:47 PM for pain at a level 6 prior to transferring to the facility. The next facility progress note was on 09/28/18 at 8:00 PM which stated Resident #1 received one [MEDICATION NAME] 10 mg. tab for a pain level of 9, over 6 hours after her last dose at the hospital. A follow up progress note at 8:37 PM stated the pain medication was effective with a pain level of 3. The next medication administration for an [MEDICATION NAME] 10 mg. tab was on 09/29/18 at 07:45 AM for a pain level of 9, almost 12 hours after the last dose. A follow up progress note at 10:04 AM stated the pain medication was reduced to a pain level of 4. On 10/23/18 at 2:05 PM in an interview with Staff A, Registered Nurse (RN), who admitted Resident #1 to the facility, stated she recalls attempting to pull the ordered narcotic for the resident from the facility Omnicell (a machine in the facility that holds back-up and emergency medications and supplies) but there was none available. Staff A did not recall what time she attemped to do this though remembered she passed on the information to the medication nurse on duty. Staff A stated that the facility had been having trouble getting medications from the pharmacy based out of Portland and had switched to the Spokane pharmacy the first week of (MONTH) which had improved services. Staff A stated they had been using the Portland pharmacy for approximately 1 year. Staff A further stated it was common to call the pharmacy for orders and authorizations to be able to give narcotic medications and be put on hold for up to 45 minutes before you spoke to a pharmacy representative for your request. Staff A stated it could then be hours before you actually heard back from the pharmacist to process the order. Staff A stated you could have the medication authorization forwarded to a local satelitte pharmacy but it still took several hours because of having to wait for the pharmacist authorization. Staff A stated the process does go faster when the medication is available to give in the Omnicell but the pharmacy frequently did not refill the medications to the Omnicell timely. On 10/23/18 at 2:45 PM, in an interview with the Director of Nursing (DNS), she stated the facility was having issues with the Portland pharmacy delivering medications timely prior to switching to the Spokane pharmacy. The DNS stated she was unaware Resident #1 did not get her pain medication timely and was not notified by staff that there was not a supply to pull from the Omnicell on the day of admission. The DNS was also unaware the resident complained of uncontrolled pain during the first few days after admission. On 10/22/18 at 2:30 PM during an interview with Resident #1's Physician, he stated that he had not been notified of the resident's uncontrolled pain and was first notified of this concern on 10/02/18. The physician stated he added additional pain medication to control Resident #1's pain at that time. On 10/23/18 at 10:40 AM, in an observation and interview with Resident #1 at the hospital, the resident was observed lying in bed with multiple IV's administering fluid and medications. The resident was alert and oriented to her condition and previous stay at the facility and was agreeable to share concerns. Resident #1 stated she was in considerable pain on arrival to the facility and believed pain medication was first requested at approximately 5:00 PM. She stated she was told that it would be several hours as the facility did not have the type of pain medication that was ordered in the facility and the pharmacy would be unable to deliver it until later in the evening. Resident #1 stated she requested that her surgeon or another physician be called for a different medication the facility did have and was told that the surgeon had gone home for the day and the facility Medical Director was unavailable to change the order. The resident stated at some point she requested to be sent back to the hospital for pain control and was told that the medication would be available shortly. She stated it was approximately an hour later before the medication was brought and she was in excruciating pain by that time. Resident #1 then explained that she was so exhausted that she slept for several hours before waking in severe pain throughout the night. She stated she could not recall if pain medication was requested or not, but knew she did not receive anything more for pain until almost 8:00 AM the following morning. Resident #1 stated throughout the weekend she had to request pain medication to receive it and was never in control of the pain until she was seen by the Physician on 10/02/18 when the narcotic pain medications were increased. The resident stated the Physician changed her pain medication orders again the next few days and she felt her pain was in better control from then until her discharge to the hospital on [DATE]. Review of the facility medication administration sheets from 09/28/18 to 10/02/18 showed the resident frequently had very high levels of pain despite having an order for [REDACTED].>* 09/28/18, 8:00 PM for a pain level of 9 * 09/29/18, 7:45 AM for a pain level of 8, 11:47 AM for a pain level of 8, 4:02 PM for a pain level of 3 and 8:30 PM for a pain level of 8. * 09/30/18, 12:21 AM for a pain level of 8, 4:30 AM for a pain level of 8, 4:20 PM for a pain level of 8 and at 8:30 for a pain level of 8. * 10/01/18, 12:51 AM for a pain level of 8, 4:47 AM for a pain level of 8, 12:27 PM for a pain level of 8 and 8:28 PM for a pain level of 7. * 10/02/18, 12:45 AM for a pain level of 5, 6:45 AM for a pain level of 10 and 11:31 AM for a pain level of 8. In addition, even though the [MEDICATION NAME] 4 mg was ordered every 8 hours as needed for muscle relaxation and spasms, it was only given 5 times between 09/28/18 and 10/02/18. Review of the Physical Therapist (PT) notes showed Resident #1 was seen on 9/29/18 at 7:37 PM for an evaluation. The PT documented the resident was alert and oriented, the plan of treatment was discussed and the resident consented to treatment. In addition, the PT stated the resident complained of severe back pain stating it was currently at a pain level of 8 at rest and a 10 with movement. On 10/01/18 at 5:20 PM, the PT documented he had to terminate the treatment session early due to neuopathic pain and he took the resident to the nurse to recieve pain medications. The PT noted that the resident's pain limited all of her functional mobility and her level of pain was currently described as sharp and shooting to her back and left leg, at an intermittent level of 5 at rest and a 9 with movement. Review of the Occupational Therapist (OT) notes showed Resident #1 was seen on 10/01/18 at 11:07 AM for an evaluation. The OT documented the plan of care was discussed and the resident described her pain at that time as a 9 at rest and a 9 with movement. The resident described her pain as constant, intermittent at times and shooting to her left back, buttock and upper leg. On 10/02/18 at 9:48 AM the PT assistant documented the residents pain as a 10 and stated that nursing gave pain medications. Review of the Nursing progress notes dated 09/28/18 through 10/01/18 showed that the Physician was not notified of continuous pain levels of 8 on a scale of 1 to 10. On 10/23/18 in an interview with Staff B, RN, Resident #1's Case Manager, she stated she was not made aware of Resident #1's pain levels until 10/02/18 at the residents care conference with the resident and her family. Reference WAC 388-97-1060(1)

Based on interview and record review facility failed to provide necessary care and services that included identification, monitoring and treatment of [REDACTED].#1) in a sample admitted without pressure ulcers. This failure caused harm to Resident #1 who developed a stage 4 pressure ulcer on the coccyx (tailbone) and an unstageable pressure ulcer on the left heel approximately two months after admission to the facility. Findings include but are not limited to: The definitions for stages of pressure ulcers are as follows: (from The National Pressure Ulcer Advisory Panel (NPUAP)) Stage 1 pressure ulcer: An observable, pressure-related alteration of intact skin, defined as an area of persistent redness or blue, purple hues. Stage 2 pressure ulcer: Partial thickness loss of dermis (inner layer of two main layers of skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough. This ulcer may also present as an intact or open/ruptured serum-filled blister. Stage 3 pressure ulcer: Full thickness skin loss involving damage / death of subcutaneous tissue that may extend down to, but not through, underlying connective tissue. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage 4 pressure ulcer: Full thickness skin loss with extensive destruction, tissue death, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and tunneling also may be associated with stage 4 pressure ulcers. Unstageable: Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present. The anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed and should be classified as unstageable. Resident #1. Record review revealed the resident was admitted on [DATE] for rehabilitation after surgical repair of a fractured left ankle and on 11/08/16 she was sent to the emergency room to rule out osteo[DIAGNOSES REDACTED] (bone infection) of the sacrum/coccyx among other things. On 12/05/16 at approximately 4:40 p.m. a collateral contact stated Resident #1 entered the facility with a broken ankle in the beginning of September and left in the first week of November with a really bad bed sore all the way down to the bone. The 09/08/16 comprehensive assessment indicated the resident was cognitively intact and required extensive assistance from two staff to change positions in bed. The skin section of the assessment identified the resident was at risk for pressure ulcers and had no current ulcers. There were no preventative measures marked such as pressure reducing device for the bed or chair. Review of progress notes indicated the resident had a splint to immobilize her left ankle until 09/28/16 when Staff Member F, the Rehab/Skin Licensed Nurse (LN), wrote (Resident #1) has a full cast to her left ext(remity) from her ortho(pedic) appointment. On 10/01/16 Staff Member C, a LN, documented the resident required one (staff) assist for bed mobility and was up in (the) chair most of the day. On 10/02/16 Staff Member C documented the resident had a small superficial open area on coccyx that we have been applying thick barrier cream to (was observed). (Per NPUAP definition this was a Stage 2.) A comprehensive assessment dated [DATE] signed by Staff Member E, a MDS coordinator, indicated in the skin section that Resident #1 had one stage 2 pressure ulcer with treatment marked as pressure ulcer care; however, there were no pressure reduction devices marked for the bed or chair. Review of the October physician orders [REDACTED]. On 10/12/16 the Registered Dietitian (RD) wrote skin note: cast on left lower leg and a surgical incision . Also the same day, Staff Member D, the wound nurse, wrote in a skin/wound note: left lower leg cast, CMS (color, movement, and sensitivity) is good in her toes and lower leg. (There was no mention of the resident's stage 2 coccyx pressure ulcer.) On 10/30/16 a progress note by Staff Member C revealed the following (the resident) has chronic wound on bottom that appears to be getting deeper and tunneling. We had been putting barrier on it and keeping her on her side as much as possible which she has been compliant with. I put a [MEDICATION NAME] over the area to protect the skin. The 60 day comprehensive assessment dated [DATE] indicated the resident had one stage 3 pressure ulcer with dimensions of 1.0 centimeter (cm) long and 1.0 cm wide and 0.1 cm deep with pressure ulcer care and a pressure reducing device for the bed. Per information provided by the Director of Nurses, a scratch note written by a supply staff dated 10/25/16 read place overlay next to Resident #1's name. However, there was no documentation in the resident's record in October what day and what type of mattress was placed on the resident's bed. Review of the Treatment Administration Record for the months of September, October and November 2016 included the following order dated 09/08/16 check skin. Indicate (+) if new condition present and (-) if no new skin condition present. The order was set for Thursdays on day shift and between 09/08/16 and 11/08/16 the documentation indicated (-) by the Staff Member G, a LN and designated team leader. Progress note review revealed the following documentation in the first week of November, 2016: On 11/02 at 4:50 p.m. Staff Member H, the unit charge nurse, documented wound was cleansed with saline and packed with calcium arginate and covered with foam. 11/02 at 6:17 p.m. Staff Member I, a LN, documented air bed arrived today. Dressing in place to bottom. The Initial Skin Ulcer Assessment by Staff Member D dated 11/07/16 revealed Resident #1 had a facility acquired stage 4 pressure ulcer. It was described by the LN as an open coccyx wound . noted to have a white bed; this was hard and appears to be sacral bone. Measurements are 1.5 cm x 1.4 cm x 1.0 cm. Next to this open wound is a smaller stage 2 which is 0.5 cm x 0.8 cm x 0.2 cm in depth. The plan of treatment was to call the Director of Nursing, recommend the physician assess and the resident should be assessed at the wound center as soon as possible. A skin/wound note by Staff Member H dated 11/08/16 revealed (the resident) has a new wound to her left heel. It is black about ½ (inch) around and then red around it. Width is 1 ¼ inch and length is 1 inch. Heel pad applied and elevate her heels. On 11/08/16 Resident #1 was sent to the emergency room to rule out osteo[DIAGNOSES REDACTED] (bone infection) of the sacrum/coccyx. Per review of hospital records, the resident arrived in the emergency roiagnom on [DATE] for evaluation of low blood pressure and [MEDICAL CONDITION] (blood infection). The resident was treated in the hospital for nine days and discharged to a different long term care facility. Review of the facility's Skin at Risk Program dated 11/2015 included the following statements: An appropriate treatment order will be obtained from the resident's physician and implemented when a pressure ulcer is identified. The Initial Ulcer Assessment will be initiated for each ulcer identified and wound monitoring order added to the resident treatment record as appropriate. Development of stage 1 or greater pressure ulcer will be documented on an Incident Report and investigated. On 12/08/16 at 9:20 a.m. Staff Member J, a Nursing Assistant (NA), stated she provided direct care to Resident #1 during her stay. The NA reported that the resident had a regular blue mattress, preferred to stay in bed when not at therapy, would turn from side to side but preferred to be on her back. She stated she regularly applied barrier cream to the resident's bottom, both before and after the break in the skin and was not aware of any other treatment. She also recalled that the residents coccyx wound was present several weeks before she got the air mattress. On 12/08/16 at 9:45 a.m. Staff Member G, a LN, stated when a nursing assistant reports a new skin issue on a resident, we (the nurses) are supposed to assess the area and start an incident report so we can figure out the cause. She stated she did not write an incident report for Resident #1's wound. The LN also recalled the resident wanted to be in bed all of the time and did not like to sit in the wheel chair and was compliant with positioning on her sides; however, she was not a fan and preferred her back. On 12/08/16 at 10:00 a.m. Staff Member H, a LN, stated she started on Team 4 as the charge nurse in mid-October and recalled seeing Resident #1's pressure ulcer a couple weeks later with the wound nurse, Staff Member D. A skin/wound note dated 11/09/16 by Staff Member D indicated he assessed the resident's wound and performed a dressing change on 11/01/16. On 12/08/16 at 10:20 a.m. Staff Member C, a LN, stated she only worked weekend shifts at the facility. She thought the resident's initial superficial opening on her coccyx was known because there was a treatment for [REDACTED]. On 12/08/16 at 11:35 a.m. Staff Member D, the wound/skin nurse, stated he worked at the facility part time twice a week. He stated he recalled looking at Resident #1's skin integrity related to her cast; however he was not aware of her coccyx wound until the beginning of November. On 12/08/16 at 11:45 a.m. Staff Member B, the Director of Nurses, stated she was not aware of the resident's coccyx pressure ulcer until the beginning of November and there was no investigation to determine the cause.

Based on record review and interview, the facility failed to ensure 1 of 5 sampled residents (#2) was free of significant medication error(s). Resident #2 experienced actual harm related to the medication error(s) and associated serious side effects. The resident received too much [MEDICATION NAME], a medication prescribed to treat [MEDICAL CONDITION] Disorder, resulting in medication toxicity. Findings include but were not limited to: Resident #2: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident received her food, fluids, and medications through a gastrostomy tube and she was not to have anything by mouth. Physician orders, dated 3/28/16, documented the resident was to receive [MEDICATION NAME] 225 milligrams (mg) daily (in the morning) and [MEDICATION NAME] 150 mg at bedtime through her feeding tube for treatment of [REDACTED]. The resident's care plan documented the resident was receiving [MEDICAL CONDITION] medication therapy and was at risk for complications of medication usage for the medication used for treatment of [REDACTED]. Monitor medication usage and side effects per facility protocol and PRN. A 3/31/16 lab test noted the resident's [MEDICATION NAME] level was 0.6 with a reference range of (0.5-1.5). Another lab test on 4/05/16 documented the resident's [MEDICATION NAME] level was 0.4 (low). The lab sheet contained an entry that a call was made to the resident's previous health care provider to identify the resident's previous (historical) [MEDICATION NAME] dose. A 4/05/16 social service entry documented the resident had scored 14 of 15 on a cognitive test, indicating she was cognitively alert. Review of the 4/06/16 physician's orders [REDACTED]. A nursing entry on 4/08/16 noted the resident had a fever of 101.4 degrees Fahrenheit. The resident received oxygen and two antibiotics to treat the pneumonia. On 4/09/16 the resident was noted to be less oriented than she had previously been. A 4/11/16 social service entry noted the resident scored 9 of 15 on the same cognitive test. Her score had dropped by 5 points. The resident was not aware of the month or day of the week and she had stated she had trouble concentrating on things. A 4/11/16 nursing entry documented the resident had ice at her bedside and she had drunk the water used for her oral care the day before (indicating non-compliance with her treatment plan and putting herself at risk for aspiration due to her unsafe swallow). The following day, on 4/12/16, a nursing entry by Staff Member E, a Licensed Nurse (LN), stated the resident's oxygen levels continued to drop despite the oxygen administration. She had tremors as well. Per the entry, a [MEDICATION NAME] level was planned. A 4/13/16 morning nursing entry by Staff Member E documented the resident was very confused and anxious. Her tremors had increased from her upper body to her lower body. There was bright blood as a result of the resident tugging at the feeding tube. The resident was unable to verbalize her needs, mummble (sic) and slurred speech. The physician was notified. Staff were directed to send the resident to the hospital for an evaluation. Hospital records on 4/13/16 revealed the facility had sent the resident to the hospital emergency department (ED) for an evaluation of her respiratory distress and out of concern she might have dislodged her gastric feeding tube. The emergency department records noted the resident had some tremors with occasional twitching motions of the extremities and what was termed as a partial complex [MEDICAL CONDITION] while in the hospital ED. A lab study review did not locate documentation of a [MEDICATION NAME] level at the hospital. The resident was sent back to the facility. According to a 4/13/16 afternoon nursing entry by Staff Member F, a LN, the facility received a call from the lab reporting a critical [MEDICATION NAME] level of 2.8. The physician was notified and he provided an order to increase the resident's water intake (through her gastric tube) and staff were to hold the [MEDICATION NAME]. Additionally, on 4/13/16, a medication error was identified. The resident had received extra daily [MEDICATION NAME] doses. Review of the 4/2016 MAR indicated [REDACTED]. A 4/13/16 nursing assessment documented the resident's oxygen saturation level was very low, at 54% on 2 liters of oxygen. The oxygen was turned up and the oxygen saturation increased to 87%. The resident continued to have slurred speech and tremors. The 4/14/16 day shift nursing entry by Staff Member F documented the resident had upper extremity tremors and slurred speech. A 4/15/16 nursing entry at 8:20 a.m. documented the resident was disoriented and had x 3 (3 episodes of ) [MEDICAL CONDITION] activity within 2 minutes. On 4/15/16 the Physician examined the resident and documented the resident had toxic levels of [MEDICATION NAME] (per the 4/11/6 lab study) and the medication was discontinued (on hold). The Physician also documented the resident had a change in mental status, tremors, and ? [MEDICAL CONDITION]. On 4/15/16 the resident was sent to the hospital again and was hospitalized for [REDACTED]. Review of the 4/13/16 facility Medication Error Report revealed that as a result of the medication error(s) the resident's speech was more slurred than at baseline and she had more tremors. On 4/27/16 Staff Member E was interviewed at approximately 12:02 p.m. Staff Member E stated the resident had a lot of co-morbidities. The resident had aspiration pneumonia and her oxygen levels were dropping. She was trying to get ice and water to drink (an unsafe behavior). Resident #2's cognition was impaired at that time. She had increased tremors and partial [MEDICAL CONDITION]. Staff Member E had looked up the potential side effects of [MEDICATION NAME] and many of the resident's symptoms were listed as potential medication side effects. The side effects had included mental confusion, tremors, and [MEDICAL CONDITION]. The resident's family member was initially hesitant to send her to the hospital on [DATE] as the other trips to the hospital emergency department had not resulted in hospitalization . Staff Member E stated she had talked to the family member and offered another hospital and he agreed. The LN stated, I was scared for her life.

Based on observation, interview and record review the facility failed to ensure that 5 of 5 current residents (#'s 12, 72, 111, 138, 264) and 1 of 1 previous resident (#35), reviewed for pressure ulcers, did not develop avoidable pressure ulcers and/or worsening pressure ulcers on their coccyx and/or feet. This failure caused pain, discomfort, health complications and/or increased health care costs. Further, this resulted in harm and a finding of sub-standard care for Residents #'s 72, 111, 138, 264 and 35, admitted to the facility without a pressure ulcer, who developed pressure ulcer(s) subsequent to admission, and for Resident #12 whose pressure ulcer worsened after admission. Findings include but are not limited to: Definitions: Description of Pressure Ulcers from the facility's Resident Assessment Instrument (RAI), version 3.0, manual (taken from The National Pressure Ulcer Advisory Panel (NPUAP)): Stage 1 pressure ulcer: An observable, pressure-related alteration of intact skin, defined as an area of persistent redness or an area with blue, purple hues depending upon skin coloring. Stage 2 pressure ulcer: Partial thickness loss of dermis (inner layer of two main layers of skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough. This ulcer may also present as an intact or open/ruptured serum-filled blister. Stage 3 pressure ulcer: Full thickness skin loss involving damage / death of subcutaneous tissue that may extend down to, but not through, underlying connective tissue. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Unstageable: Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present. The anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed and should be classified as unstageable. General Findings: On [DATE] at 11:00 a.m., Staff Member L, a Physical Therapist (PT), stated it was a nursing decision as to what device was used for pressure reduction or relief if the resident was not receiving physical or occupational therapies. There were catalogues available in the therapy office for the nurses to review the products and place an order for [REDACTED]. [DATE] at 2:00 p.m., the Director of Nursing (DNS) stated there were daily meetings with managers, including the Rehabilitation Director. At that time, it would be asked if therapy could benefit a resident, a therapy evaluation would be requested from the physician. The nurses had known to let the DNS know if there were any skin issues. If the resident had started with a pressure ulcer on admit, then nursing judgment was used for care and treatment. If the pressure ulcer was a Stage 2 or above, then an air mattress was to be ordered. If a resident was 'at risk' for a pressure ulcer, but there was no open area, then standard care was performed, such as turn and reposition every two to three hours. Weekly skin rounds by the nurses were documented on the treatment record. On [DATE] at 12:00 p.m., the Medical Director stated she was not an expert on the air mattresses, including what setting to put them on. That would be specific to the resident such as their weight and diagnoses. The physician did not specifically assess the resident and the needed setting of the mattress. On [DATE] at 3:00 p.m., Staff Member Q, a Licensed Nurse (LN), stated she was a fairly new nurse and was not comfortable with assessing ulcers. She stated if she saw something unusual on the skin, she would ask the DNS or another nurse to assess a skin issue with her. She stated that since she started at the facility about two years ago, she had no training on how to assess a wound. During the same interview, Staff Member HH, a LN, stated she had no wound assessment training that she could remember. 1) Resident #111. admitted on [DATE] with [DIAGNOSES REDACTED]. Also, [MEDICAL CONDITION] (paralysis) and left sided pain were documented in the admission profile/assessment. The admission skin assessment revealed the resident was at high risk for skin breakdown. The admission comprehensive assessment dated [DATE] documented there were no unhealed or previous pressure ulcers. The care plan identified the resident was totally dependent on staff for bed mobility. The care plan identified on [DATE] a coccyx ulcer had progressed to stage 3. The plan dated [DATE] identified that stage 3 and stage 2 pressure ulcers had developed on the right lateral foot. Physician notes on [DATE] identified an outer left ankle scab fell off. However, the care plan did not contain a revision related to that pressure ulcer on the ankle. An air mattress to reduce pressure on the skin was ordered for the bed on [DATE], after the resident developed a stage 3 coccyx ulcer and a left ankle ulcer from pressure. On [DATE] at approximately 3:00 p.m., the resident was observed in bed on her back with her knees bent and lying to the right side. The lateral right side of her right foot was in a sock and her foot was laying on the air mattress. On [DATE] at 11:00 a.m., Staff Member Q, a Licensed Nurse (LN), stated the resident did not have pressure ulcers on admit. The most advanced stage of the pressure ulcer on her coccyx was staged at a level 3. On [DATE] at 10:00 a.m., the resident was in bed on her back with her legs bent at her knees and leaning slightly to the left side with one pillow supporting her knees. Her left lateral foot was lying on the mattress with a quilted boot in place. The air mattress was on at a medium setting. Pressure Ulcer - Coccyx: On [DATE] at 11:25 a.m., Staff Member Q changed the resident's dressing on her coccyx pressure ulcer. Staff Member Q stated the ulcer was staged at a 3, but was healing. The open area was circular with dark pink/red tissue surrounding and a whitish colored center taking up most of the opening. When asked, the LN stated she thought the center was slough. She cleansed the area and placed a dressing over it per physician orders. Family Member A observed the wound treatment. She stated the resident had no ulcers when at the previous nursing home; she stayed in bed much more than here. The wheelchair did not belong to the resident but to the previous nursing home. It was observed to have a padded high back and a standard seat cushion. Family Member A stated the resident had been up for long periods of time during the day and it caused her bottom to break down. She stated the wheelchair cushion was the one that came in the wheelchair originally. Pressure Ulcers Right Lateral and Mid-lateral Foot: On [DATE] at approximately 11:45 a.m., Staff Member Q changed the dressings on the resident's right foot. She stated they were not pressure ulcers but calluses that had come off when they put the dressing on and there was moisture. She was not sure what caused the calluses to form. An ulcer was on the the right side of the right mid-foot with another ulcer above. Both were open areas that were cleansed and a dressing applied. Standard quilted boots were placed on her feet for padding. Family Member A, watching the procedure, stated the resident had been in another facility where the daughter would use a special lotion on the resident's skin, including her feet, almost daily. It was not until she was admitted to this nursing home that she developed the ulcers on the side of her right foot. When asked if she had calluses on her feet, the Family Member said no. She again stated that she daily lotioned the resident's feet and legs and she did not have any issues with her feet when she was transferred here. Pressure Ulcer Left Outer Ankle: On [DATE] at approximately 11:50 a.m., Staff Member Q removed the resident's padded foot/ankle boots to observe a reddened, but healed, area on the left ankle. The LN stated the resident had suddenly developed an open ulcer which now was healed and required no treatment. She stated did not know what caused the ulcer. On [DATE] at approximately 11:50 a.m., Family Member A stated that the cause of the left ankle ulcer was the way the resident was positioned in the wheelchair. Her feet would slide down between the foot pedals and rub. She pointed out the resident's wheelchair now had a padded sling-like device to hold the feet which extended across the foot pedals and upward to between the legs of the wheelchair. She stated after the ulcer on her ankle and her foot developed, she found the sling in a magazine, bought it, and put it on the resident's wheelchair. The staff had tried to put a gait belt across to position the feet, which just did not work. On [DATE] at 11:30 a.m., Staff Member EE, a nursing assistant (NA), stated the resident usually liked to lay in bed on her right side. On [DATE] at 10:45 a.m., the resident was lying in bed on her back with her knees bent to the right side in a contracted position; her right foot was on it's right side with a quilted 'boot' and sock on her foot/ankle. The air reduction air mattress was on at a medium setting. On [DATE] at 2:00 p.m., the Director of Nursing (DNS) stated the resident received an air mattress, a padded mat against wall (to protect her knees), quilted 'boots' to protect the heels; to offload (pressure) the heels. It's nursing judgement to decide what to do for pressure reduction and to determine when to throw away the stock supply of the heel protectors if they were worn out. On [DATE] at 3:00 p.m., the resident was in bed with her legs laying to the right side and her feet positioned on their right sides. The quilted 'boots' were in place over socks. She was not aware what type of pressure reduction the 'boots' provided. Staff Member Q noted the pressure setting for the air mattress was on medium, but did not know what the setting should be; just that it is on. Neither she nor Staff Member Q were aware that they could attempt to find other types of pressure reduction devices in the therapy department. Staff Member Q stated she thought that there should be information on the air mattresses for the nurses to have as a resource; to know if the mattress was in proper working order and what settings were appropriate for each resident's specific needs. When it was pointed out by the surveyor to both of the LNs that the resident had a sheet, draw sheet and incontinent pad under her, both acknowledged that was not indicated for an air mattress as it would decrease the effectiveness. On [DATE], the resident was lying on top of the bed quilt and incontinent pad with the mattress covered with a sheet, when Staff Member II, a nursing assistant, entered the room at approximately 3:15 p.m. He was asked about the bed linen under the resident. He stated that it depended if it was an air mattress or not; some mattresses you wanted the resident right on top of the mattress and not separated with sheets and things. He pulled back a corner of the quilt and sheet to point at the mattress. He did not identify it as an air mattress nor re-position the resident to ensure the effectiveness of the air mattress. On [DATE] at 10:00 a.m., the resident was positioned completely on her right side with mulitple pillows in place to reduce pressure on coccyx and feet. At 10:45 a.m., the Regional Nursing Director for the facility stated he had bought 20 pillows last night for proper positioning of residents and reducing pressure. He stated the quilted 'booties' were not sufficient for pressure relief/reduction. On [DATE] at 2:30 p.m. the resident was positioned on her left side with pillows to decrease pressure on her coccyx. However, on [DATE] at 9:30 a.m., the resident was positioned slightly on her right side with one pillow under her back; her back rested on the pillow. There were no pillows between her knees for further support which were contracted and lying to the right side. Her feet had quilted 'boots' in place. Two pillows were laid at the foot of the bed but not in use. (At 11:00 a.m., the resident remained in the same position.) On [DATE] at 12:00 p.m., the physician stated she did not think callouses would have formed on the side of the resident's foot and, after reviewing her physician notes, she stated she had not made note of them in her observations. The last observation was on [DATE], and she had not needed to address the resident's ulcers on the side of her right foot because there were none. On [DATE] at 12:30 p.m., Family Member B stated the resident did not have skin problems before coming to the facility. He described that her feet would be down between the foot pedals which caused the rubbing on the feet - ankle and sides. She ended up with open areas because of that, which was why the family bought the special sling device to prevent the rubbing. Although nursing documentation in the progress notes on [DATE], assessed the foot wound beds with a little slough, the stage of the ulcer was not revised to 'un-stageable' as the depth of the wound was not visible. The resident, with contractures of the upper and lower extremities and dementia, was not mobile without total assistance and did not move her legs and feet without assistance. admitted to the nursing home with no pressure ulcers, she developed four areas of pressure - two on her right foot, one on her coccyx, and one on her outer ankle, all of which were assessed at stage 2 and 3. The facility failed to provide timely treatment and care that would prevent the ulcers' formation. This included understanding the proper settings for the pressure reduction air mattress, proper linen usage to allow the mattress to provide pressure reduction, proper positioning techniques to alleviate pressure to the vulnerable pressure points at risk for breakdown, and training of Licensed Nurses for pressure ulcer assessments. 2) Resident #12. admitted [DATE] with [DIAGNOSES REDACTED]. A Social Service progress note dated [DATE] revealed she was cognitively intact. The admission nursing 'note' revealed the resident was totally dependent for bathing (the facility protocol was to bathe twice a week) and extensive assistance for other activities of daily living, including bed mobility and toileting. Review of the bath schedules revealed the resident had three baths between [DATE] and [DATE]; a total of 3 baths in 15 days. (She should have had 4 baths in that amount of time per the bath scheduled routine of the facility.) The [DATE] admission comprehensive assessment (MDS) identified a stage 2 unhealed pressure ulcer was present on admit. The 'Skin and Ulcer Treatment' portion of the assessment identified there were no pressure reduction devices for the chair or bed, and no turning/repositioning program in place. The care plan dated [DATE] identified a stage 2 pressure ulcer on the coccyx with a revision on [DATE] identifying progression to a stage 3. The goal was for the ulcers to heal. The interventions included an air mattress to the bed initiated on [DATE] for which settings and function were to be monitored. (However, there were no directions on mattress settings for this specific resident.) Further, the assessment of fragile skin was addressed, but no interventions were developed for the resident with a Body Mass Index (BMI) of greater than 40 (classification as morbidly obese.) The [DATE] progress note: Pressure ulcer wound to coccyx is worsened - noted to be deeper stage 3, moderate serous drainage, with odor, wound bed with 30% slough, small area with black soft eschar, wound pain noted. On [DATE] at 3:00 p.m., the resident was on her back on a bed with an alternating pressure mattress. She stated she did not get out of bed including for meals. On [DATE] at 10:00 a.m., the resident was lying in bed on her back with the functioning alternating pressure mattress on a medium setting. On [DATE] at 10:45 a.m., Staff Member EE, a nursing assistant (NA), provided incontinent care, changing the incontinent brief. After turning on her side, the resident's incontinent brief was noted soiled with stool and urine. The resident stated twice that when she pees [MEDICAL CONDITION] skin. After cleansing her with wash cloths, wet with water only, and placed in a plastic bag containing mulitple cloths, the resident was readied for placement of an incontinent brief. The surveyor asked for closer observation of the coccyx area where there had been a pressure ulcer. When Staff Member EE lifted her skin folds exposing her rectal area, stool was still present. Staff Member EE noticed it and then requested more wash cloths from Staff Member NN, a nursing assistant, who entered the room to assist Staff Member EE. After further cleansing and placement of the incontinent brief, the resident was transferred via the mechanical lift to a wheelchair. The wheelchair contained a padded seat but the resident's thighs and hips were snug against the sides of the chair. She reported that her right side was hitting a bar and Staff Member EE obtained a small sheet he folded and placed between her skin and the bar. Staff Member EE stated the pressure ulcer on her backside was now healed. He said he had been told by other nursing assistants that the resident was too hard to get out of bed so she usually was not up in her wheelchair. He stated he had thought getting her out of bed might help heal the ulcer and had started getting her out of bed for about two hours at a time; her bottom got better. Staff Member EE stated he had gotten the wheel chair out of a storage room to use. He was not aware who would assess the wheelchair for proper fit; she was not receiving rehabilitation therapy. On [DATE] at 3:00 p.m., Staff Member Q stated that the resident had gone back to bed around 12:45 p.m. She looked at the air mattress controls and said it was not on; it must have become unplugged when the resident went back to bed. The LN plugged the bed back in and then looked at the controls noting the static mode was on with the setting at medium. She said she was not sure what the mode should be put on, the auto control or the other setting. She stated she did not know where the setting should located for this resident (from low to high). They don't give us any information or the books on the mattress. On [DATE] at approximately 3:15 p.m., Staff Member HH stated she did not know either where the settings should be located. Staff Member HH and Staff Member Q both observed the resident was laying on a sheet, draw sheet and incontinent pad, over the air mattress. They both acknowledged that was not indicated for an air mattress as it increased the pressure on the resident's body. On [DATE] at 9:45 a.m., the resident was positioned on her back with the a draw sheet only underneath. The alternating pressure mattress noted direction taped on the device stating keep setting on medium but there was no directions for what mode should be in place: static, alternating, or auto firm. The mode was on static (not alternating air pressure). At 1:30 p.m., the resident's mattress continued to be set on 'static'. On [DATE] at 1:00 p.m., Staff Member MM, a LN, stated she checked mattresses by pushing down on them and making sure the control lights were on. She stated it would be good to have an inservice which they used to do a long time ago, but not recently. She did not know where the controls should be and did not have any directions of which she was aware. Further, the [DATE] initial wound assessment identified on admission there was a right buttock pressure ulcer at body site #31 (on a graphed body diagram). The [DATE] weekly wound evaluation documented a left buttock pressure ulcer stage 2 at body site #32. Further wound assessment forms contained a left buttock pressure ulcer at a #32 body site and the coccyx at a #23 body site, thus displaying three separate sites of possibly the same pressure ulcer. The coccyx ulcer was identified on [DATE] as a healing stage 3 ulcer. However, there was no assessment and wound evaluation when the ulcer worsened to a stage 3 on [DATE], as identified in the care plan. Also, the wound evaluation documented 'slough' was present (which would determine the pressure ulcer was 'unstageable' and no longer a stage 3). Additionally, the [DATE] Registered Dietitian's (RD) admission assessment classified the resident with a Body Mass Index (BMI) of 69.7 (morbidly obese). The skin impairment reviewed by the RD was a pressure ulcer left buttock stage 2. The RD's summary and recommendations revealed the resident's nutrition was at risk. The plan was for the RD to follow up as needed. However, when the pressure ulcer advanced to a stage 3 and was identified on the coccyx rather than the left buttock, there was no nutrition re-assessment by the RD until [DATE] (22 days after identification of the worsening ulcer on [DATE]). 3) Resident #35. admitted on [DATE] with mutiple [MEDICAL CONDITION] and post-surgical fractured left femur. Transfer records from hospital revealed no pressure ulcers except for a wound and incision sites on the left thigh. The [DATE] pressure ulcer risk assessment (Braden Scale) identified him as a low risk to develop pressure ulcers. Nursing progress notes revealed on [DATE] at 9:45 p.m., the resident was noted with a swollen left foot and leg with tight and shiny skin. The left foot has 3 unopened blisters. The next documentation in the progress notes regarding the three blisters was on [DATE] at 8:43 p.m. The blisters were noted on the top of the resident's left foot after he was sitting up in his wheelchair all of shift. He removed his socks and found the areas. The physician was notified of the blisters and the swelling; the resident was sent to the hospital emergency room . (The physician was contacted approximately 24 hours after the initial assessment of the three blisters.) There was no cause of the blisters determined by the facility. Monitoring and treatment for [REDACTED]. On [DATE] at approximately 10:00 a.m., the DNS stated there was no investigation into the cause of the left foot blisters as they were not pressure ulcers. On [DATE] at 8:22 a.m., Staff Member N, a Licensed Nurse and Unit Manager, stated the resident did wear shoes when up in the wheelchair and with rehabilitation therapy. Although she had not assessed the blisters on [DATE], she would suppose that it was the resident's shoes causing pressure that resulted in the blisters. She stated she stages blisters caused by pressure as a stage 2 to start. The staff asked him not to put his socks on after the blisters were found, but he did and the blisters opened. Staff cut tops of socks to prevent friction after the blisters occurred. She reviewed the resident's record and stated there was no wound/pressure ulcer assessment completed. When he was discharged on [DATE], the wounds were still healing. Staff Member N stated she did observe the pressure ulcers on the foot but she did not assess the cause of the ulcer. On [DATE] at approximately 9:00 a.m., Staff Member P, a LN and treatment nurse, stated that the resident did wear shoes which could cause the blisters to form on the top of his left foot. Facility staff failed to identify the potential of friction and pressure on the top of the resident's foot due to increased swelling and his shoes pressing against the skin. The facility did not develop interventions to prevent pressure, and, thus, blisters. The care plan was not revised. 4) Resident #72. admitted to the facility [DATE] with [DIAGNOSES REDACTED]. A review of the [DATE] Resident Assessment revealed the resident was alert and oriented, required extensive assistance of two nursing staff with transfers, dressing and was non-weight bearing left leg/foot. Also the resident was assessed as dependent with positioning and turning in bed and at risk for development of skin issues. Additionally, the physician examined the resident on [DATE] and documented that the resident had no foot/heel ulcers on the skin assessment. Review of an incident investigation report dated [DATE], revealed the resident had a left heel blister-Stage 2 pressure ulcer that was purple in color and measured 3 x 3 cm in size (1-,[DATE] inch x 1-,[DATE] inch). An order to apply [MEDICATION NAME] to the left heel blister was ordered on [DATE] along with floating the resident's heels and eventually applied foam boots to protect and elevate the residents' heels. A skin assessment on [DATE] revealed the left heel blister measured 3 cm x 6 cm (1 X 2 inches), and had increased in size. The [DATE], [DATE], [DATE] skin assessment tool (the Braden scale) which measures resident's risk for skin breakdown was incorrectly filled out and measured the resident at low risk for skin breakdown, even though the resident had an actual skin breakdown which classifies a resident as high risk. On [DATE] at approximately 10:00 a.m., the resident's family members said that the resident was pushing up in bed with his left foot and was trying to reposition himself and that's why he got the blister on his left heel. On [DATE] at approximately 10:15 a.m., Staff Member W, a NA, said the resident required extensive assistance of two staff members to transfer and with positioning and daily care. The resident would slide down in his bed and push up on his left heel in the bed. The NA said the resident was hard of hearing but did participate with cares and that he now had the foam boots the help avoid his heels from rubbing on the bed. The resident was observed in his wheel chair on [DATE] from 7:40 a.m. through 1:10 p.m. not being re-positioned and foam boots were on the residents feet. Additionally, on [DATE], the resident was up in the wheel chair from 8:00 a.m. to 1:45 p.m. without being repositioned. On [DATE] at 9:50 a.m., Staff Member FF, a NA, said that the resident's boots were taken off in the morning while dressing the resident and at bath time. If there were any concerns about the resident's skin the nurse was notified. Also, during an interview, Staff Member FF stated the resident will sit-up for hours in the wheel chair and will refuse to lay down or change position. The facility failed to ensure that the resident, admitted without a pressure ulcer, did not develop a pressure ulcer. By failing to accurately evaluate the resident's clinical condition and pressure ulcer risk factors (Braden Scale). They also did not develop measures to prevent pressure ulcer development, until actual skin issues occurred and did not identify the cause of the pressure ulcer. 5) Resident #264. admitted [DATE] with [DIAGNOSES REDACTED]. The resident assessment(s) dated [DATE] and [DATE] revealed that the resident was alert and oriented and needed extensive assistance with two nursing staff for transfers, bed positioning and toileting. The resident was admitted with a skin tear on the upper right calf and had a dressing on it. There were no pressure ulcers on admission. On [DATE] at approximately 9:00 a.m., the resident said her right heel had been painful and tender. The staff was told about the pain and the pain had been there for at least 2 weeks. During the interview with the resident on [DATE] at 9:00 a.m., the resident's heels were on the bed without any support or elevation. The resident said that the staff were not consistent about having her heels on pillows. On [DATE] at approximately 11:00 a.m., Staff Member L, the Physical Therapist, said that the resident's shoes were old and rubbing against her right heel. She noticed last week that the resident complained of pain and Staff Member N, a Registered Nurse (RN), assessed the foot and thought the shoes were too tight and tried the anti-skid socks. Because of the pain, the resident did not participate as much when using the parallel bars to stand in therapy. On [DATE] at approximately 11:15 a.m., Staff Member Y, a NA, said that on [DATE] after giving the resident a shower. there was a small area of redness on the resident's right heel and the resident had complained of pain on the inner part of her right ankle. Staff Member Y notified Staff Member I, a Licensed Nurse (LN), about the resident's pain and redness at the right heel. According to the Physical Therapy Encounter Notes, dated [DATE], nursing was informed of a sharp pain at the resident right ankle with swelling; On [DATE] the resident had deferred ankle pump exercises due to increased pain and on [DATE] the resident reported being tired with pain on right ankle and lower leg. On [DATE] at approximately 9:30 a.m., Staff Member I, a LN, viewed the resident's right heel The LN said it was a callous. On [DATE] at approximately 2:30 p.m., Staff Member A, the DNS said with [MEDICAL CONDITION] of the right ankle and the resident's shoes rubbing the back of the right heel, it caused an unstageable pressure ulcer. The facility failed to thoroughly assess the resident's skin risk and did not thoroughly assess the resident's right heel pain and risk of development of an avoidable pressure ulcer. 6) Resident #138. admitted to the facility on [DATE] after a hip repair with [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] revealed the resident had [MEDICAL CONDITION], severe cognitive impairment and required extensive assistance of two staff to reposition in the bed. The resident had no pressure ulcers on admit; however he was assessed to be at risk to develop pressure ulcers. The assessment also did not identify pressure ulcer preventative measures such as pressure reduction devices on the bed or wheelchair and/or have a turning/repositioning program. Per review of a [DATE] facility incident report, a left heel stage 2 (intact non-fluid filled blister) pressure ulcer was discovered. The initial wound assessment of the same date identified the wound as a facility acquired pressure ulcer measuring 4.5 centimeters (cm) by 3.0 cm with a depth of 0.25 cm. (approximately 2 inches by 1 ¼ inches). On [DATE] the following interventions were started: 1) an air mattress for wound healing/prevention was placed on the resident's bed (according to an enabler evaluation/consent form in the resident's record); 2) a treatment to the heel wound was ordered and began; 3) a [DATE] order to float heels while in bed every shift was first documented on in the treatment record by nurses; and 4) an order read Res(ident) to wear pressure relieving boots EXCEPT when up for Physical Therapy- each shift to check placement of heel pad/boot FYI: Boots are on order- to wear egg crate heel pad until boots are in every shift for blister on heel. Eight days after the initiation of the above interventions, on [DATE] a right heel intact flat blister (stage 2 pressure ulcer) that measured 4.0 cm by 3 cm and 0.25 cm deep (approximately 1 ¾ inches by 1 ¼ inches) was reported in the resident's progress notes. On an incident report with the same date, the wound was identified as facility acquired and concluded the right heel blister is likely caused from pressure against surfaces. Further review of the [DATE] treatment record revealed the order to float heels and ensure place

Based on observation, interview and record review, the facility failed to administer operations and use resources to ensure resident safety, health, and well-being related to A) Prevention and management of pressure sores, B) Provision of sufficient staff to maintain needed care and services. C) Quality of care in medication management, [MEDICAL TREATMENT] and diet texture, and D) Provision of restorative services to maintain or improve range of motion. These failures resulted in substandard care and actual harm for Resident #'s 12, 35, 72, 111, 138, 252 and 264. Findings include: A) Pressure Sores. For 6 of 6 residents (#'s 12, 35, 72, 111, 138, and 264) reviewed for pressure sores, the facility failed to take necessary steps to identify residents at risk of developing pressure sores, take steps to prevent the formation of the pressure sores and/or provide effective treatment for [REDACTED]. This resulted in harm for Resident #'s 12, 35, 72, 111, 138 and 264. Refer to F314. B) Sufficient Staffing. The facility failed to ensure sufficient qualified staff was available to provide care and services in accordance with accepted professional standards of practice for pressure ulcer care and treatment, medication management, services to maintain/improve range of motion and daily care activities. Refer to F353. C) Quality of Care. a) Medication Management. For 1 of 3 residents (#252) reviewed for management of anti-coagulant medication, the facility failed to monitor for the appropriate amount of medication. This resulted in harm for Resident #252, who was hospitalized for [REDACTED]. b) [MEDICAL TREATMENT] Care. For 1 of 1 resident (#216) reviewed for [MEDICAL TREATMENT] care and treatment, the facility failed to consistently assess the resident's condition and communicate this information to the [MEDICAL TREATMENT] center. c) Assessment of Diet Texture. For 1 of 1 resident (#52) reviewed for broken dentures, the facility failed to assess her ability to eat regular textured food after her denture broke, resulting in the resident being unable to take an adequate amount of nourishment for 4 to 5 days. Refer to F309. D) Provision of Restorative Services. For 3 of 3 residents (#'s 25, 51 and 111) reviewed for range of motion, the facility failed to provide services to maintain or improve the resident's range of motion. Refer to F318. The failure of management staff in the facility to recognize the need for, and to provide the necessary oversight and monitoring of resident care as stated in the above care areas, caused harm to multiple residents and also placed the remaining facility poplulation for recieving less than adequate care.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to ensure, A) 1 of 3 residents (#252) reviewed for [MEDICATION NAME] (blood thinning) medication use received adequate monitoring to ensure safe use of the medication, B) [MEDICAL TREATMENT] treatment and care was coordinated between the [MEDICAL TREATMENT] company and the facility for 1 of 1 residents (#216), and C) an assessment and diet texture change for 1 of 1 resident (#52) reviewed with broken dentures. Failure to closely monitor the resident on [MEDICATION NAME] caused harm to Resident #252, and failure to coordinate [MEDICAL TREATMENT] care and follow up timely on dental issues placed resident #s 216 and 252 at risk for unmet care needs. Findings include: A) MEDICATION Resident #252. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 06/26/15 Resident Assessment the resident was cognitively impaired, required extensive assistance of two nursing staff for most activities of daily living for transfers, turning and repositioning in bed, toileting, dressing and oral care. A physician's orders [REDACTED]. The last INR level was done at the hospital before the resident admitted to the facility. According to the progress notes dated 07/01/15 at 5:10 p.m. the resident tested positive for blood in her stool. Staff Member LL, a Registered Nurse (RN), notified the physician. The physician gave an order to hold the [MEDICATION NAME] and ordered blood tests to include an INR test due to the resident's bleeding in the stool. On 07/02/15 the results of the blood work were significant for bleeding in the GI (Gastro-Intestinal tract), which required emergent care and hospitalization . On 08/13/15 at approximately 1:30 p.m., Staff Member E, a Licensed Nurse (LN), said she admitted the resident and thought that the [MEDICATION NAME] order said to give the medication for one month and then check the INR. In reviewing the physicians order it documented [MEDICATION NAME] was to be given for one month with an INR goal was 1.8-2.2. Staff Member E said she made a mistake. On 08/14/15 at 9:44 a.m., the Pharmacist Consultant said the nursing staff who admitted the resident would need to call and identify/clarify how often the physician would want the INR checked or drawn. He further noted the INR would determine if the dose of [MEDICATION NAME] was theraputic or if the resident was at risk for bleeding. If the INR was too high, the physician would have to change the dosage of the [MEDICATION NAME]. On 08/14/15 at 10:30 a.m, the facility Medical Director, stated the resident's [MEDICATION NAME] was to be managed by the orthopedic surgeon. The nurses should have notified the physician/surgeon for the frequency of INR laboratory tests. The Medical Director said she was in a panic when she got a phone call that the resident had blood in her stool. She had ordered the blood work. After the laboratory work came back with indicators of bleeding, she ordered and emergent transport to the hospital. The facility failed to notify and clarify the frequency of the INR labwork for the [MEDICATION NAME] with the orthopedic surgeon. As a result, the resident suffered bleeding from GI tract which required emergent hospitalization and blood transfusion. According to the hospital the 07/01/15 INR was 17 (extremely high level) which resulted in a significant condition which required emergent action. B) [MEDICAL TREATMENT] TREATMENT Resident #216. admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the latest comprehensive assessment dated [DATE] revealed the resident was alert and oriented, and required extensive assistance from staff for locomotion off the unit. He used a wheel chair and a walker. Review of the contract between the [MEDICAL TREATMENT] company (Center) and the facility dated 06/19/11 revealed in Section 3, Facility shall ensure that all appropriate medical. information accompany all Designated Residents at the time of transfer to Center. In Section 6, Facility will provide for the interchange of information useful or necessary for the care of the Designated Resident. In an interview on 08/13/15 at 3:55 p.m., Resident #216 stated he was doing well with [MEDICAL TREATMENT] now. He stated the communication between the [MEDICAL TREATMENT] center and the facility was bad at first, but has improved. He said his current routine was to go to [MEDICAL TREATMENT] on Monday, Wednesday and Friday in the early morning, around 6:15 a.m. He stated he was usually done before noon. In an interview on 08/18/15 at 10:36 a.m., Staff Member Q, a Licensed Nurse (LN), stated there wasn't any documented instructions about Resident #216's [MEDICAL TREATMENT] care. She stated she called the [MEDICAL TREATMENT] center if she had questions. She stated she was not usually here when he leaves for [MEDICAL TREATMENT], but was here when he returns. She said she usually takes his vitals when he was back in the building. She stated the [MEDICAL TREATMENT] center does not usually send any communication back about how the resident tolerated his treatment, and she only knows what the resident tells her. She stated she does not think any written report of the resident's condition was sent with him to [MEDICAL TREATMENT]. In an interview on 08/18/15 at 11:19 a.m., Staff Member J, the Assistant Director of Nursing, stated the [MEDICAL TREATMENT] center seldom communicated back to the facility about the resident's condition, so the facility would have to call and request the information. She stated she had educated nursing that they need to request that information from the [MEDICAL TREATMENT] center. On 08/19/15 at 5:45 a.m., Staff Member BB, a Nursing Assistant (NA), stated her responsibility was to help Resident #216 get ready to go to [MEDICAL TREATMENT]. She said she assisted him to dress and made certain he had his early breakfast. She stated she took vitals sometime after he got up, most of the time. On 08/19/15 at 6:00 a.m., Staff Member CC, a LN, stated she usually was the nurse who helped Resident #216 get ready to go to [MEDICAL TREATMENT]. She stated she took the vitals needed to administer his morning medications before he left for [MEDICAL TREATMENT]. She stated she had been told that [MEDICAL TREATMENT] did not want the information, so in the past, she did not send any information about the resident's condition, including vital signs, an assessment of his shunt site and an assessment of any pain the resident had experienced. She stated she had been instructed, starting today, to send the information about the resident's condition to [MEDICAL TREATMENT]. Review of Resident #216's medical record revealed for the 18 [MEDICAL TREATMENT] treatments from 07/06/15 through 08/14/15, vital signs were documented as follows: Pulse was recorded 12 times before and after [MEDICAL TREATMENT], temperature was recorded once before [MEDICAL TREATMENT], blood pressure was recorded before and after [MEDICAL TREATMENT] 11 times, and weight was recorded 15 times before [MEDICAL TREATMENT] and once after [MEDICAL TREATMENT]. During the same time period there were 3 progress notes with assessment of resident condition before or after [MEDICAL TREATMENT]. On 08/19/15 at 6:20 a.m., Resident #216 was observed in his wheelchair near the exit door of the lobby. He had a blue bag in a chair next to him. A folded paper was on top of the open bag. The resident stated he was waiting to go to [MEDICAL TREATMENT] and he was supposed to give the paper to the nurse at the [MEDICAL TREATMENT] center. He stated it was the first time he had ever been given a paper to deliver to [MEDICAL TREATMENT]. Review of the document the resident was to take to [MEDICAL TREATMENT] revealed a brief assessment, including the resident's weight, vital signs, the condition of his shunt site and a pain assessment. The document was signed by Staff Member CC. Failure to consistently assess the resident's condition, to communicate that information to the [MEDICAL TREATMENT] center and to obtain information about the [MEDICAL TREATMENT] treatment upon return to the facility resulted in both the facility and the [MEDICAL TREATMENT] center having incomplete information about the resident's condition. This placed the resident at risk of inappropriate or ineffective treatment. C) EATING ABILITY AND FOOD TEXTURE Resident #52. admitted with [DIAGNOSES REDACTED]. The annual comprehensive assessment dated [DATE] revealed no issues with the resident's dentures. The resident's diet was ordered as regular texture foods. On 08/10/15 at approximately 4:00 p.m., the resident was in her wheelchair outside of the dining room with a cup of coffee in her hands. She stated her lower dentures were broken but she still had the top denture. She thought the lower one was getting fixed so she could eat better. She stated that at times she can't chew some foods. She opened her mouth to show she had upper dentures but only her gums were visible on the lower jaw. On 08/11/15 at noon, the resident was finished with lunch. She had left the uncut spaghetti noodles with meat sauce, mixed vegetables (fresh green beans and carrots), and lettuce salad uneaten. The garlic bread crust was left but she had eaten the soft middle portion and she had eaten the ice cream cup. The resident stated she had trouble chewing most of the meal but that was okay. She again stated she was missing her lower dentures. On 08/12/15 at 08:30 a.m., the resident was finished with breakfast. She had eaten the rice crispies with milk, but the uncut, whole piece of french toast (solid fried egg batter crust with a bread crust on the outside) and an uncut sausage link were untouched. When asked, she said she could not chew the sausage and was not sure if she could eat the french toast either. On 08/12/15 at 12:35 p.m., the resident was in the dining room eating a noon meal of steamed broccoli, chicken, a green salad, wild rice, and apple crisp. She stated she had not been able to eat the chicken. She said she had trouble chewing the broccoli, so only ate a small amount of it, and could not eat the rice because my denture had a tooth missing and I don't have it now. Makes it hard to chew some foods. When asked about the apple crisp, she said it was not easy to chew and then agreed that she would like ice cream instead. On 08/12/15 at 1:00 p.m., the facility's Registered Dietitian (RD) stated if she was made aware of chewing problems caused by something like denture issues, then she could down-grade the texture of a diet for a resident. However, unless the licensed nurses reported an issue to her, she would not have been made aware of the resident's chewing problem. She further stated the licensed nurses could also down-grade a diet to mechanical soft if there was a need. When brought to the RD's attention by the surveyor regarding Resident #52's lack of a lower denture, she stated she she was not aware of the broken denture and she would write a diet order for the mechanical soft diet which would provide ground meat, too. On 8/13/15 at 12:30 p.m., the resident was in the dining room. She had eaten half of her fish and potato salad. She had eaten her pudding type dessert. The diet slip on the table had been changed to mechanical soft until lower dentures were replaced. The resident said she was not sure she was still able to chew very well; again stating she did not have her lower denture. Documentation in the progress notes revealed an entry on 08/09/15 that the resident's dentures had fallen on Friday night (08/07/15) sometime and were broken in half. Social Services was notified by nursing staff. An 08/12/15 entry by the RD noted the resident was on a temporary mechanical soft diet due to no bottom dentures, which were broken, Will receive ground meats and softer vegetables. An 08/17/15 entry by the Social Service Director noted the dentures had not yet been repaired. Five days after the resident's lower denture was broken, the diet texture was changed in an attempt to accommodate the resident's lack of chewing. Until brought to the attention of the Registered Dietician by the surveyor, the resident's inability to chew was not assessed by nursing, the Registered Dietitian and/or appropriate facility staff.

Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents (#1) with falls received adequate supervision and use of an assistance device to prevent an accident. A nursing assistant (NA) performed a one person manual transfer from bed to wheelchair instead of completing a two person sit-to-stand (mechanical lift) transfer as directed by Resident #1's plan of care. During the first transfer, the NA assisted the resident to the floor. There were two other inappropriate (manual) transfers that morning prior to discovery of the resident's right leg fracture. The resident was transferred to the hospital for further care. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. She had returned from the hospital on [DATE] after receiving treatment for [REDACTED]. The resident's plan of care documented a 3/26/14 change in her transfer status. She was to be transferred via the sit-to-stand lift. When interviewed on 7/22/14 at approximately 11:40 a.m., Administrative Licensed Nurse (LN) A stated it was a facility standard to have two staff assist for all sit-to-stand transfers. According to a 7/11/14 nursing entry, at 8:00 a.m. Staff Member B, a LN, was asked to go to Resident #1's room. When the LN arrived the resident was sitting in her wheelchair. She was told by a NA that when transferring the resident from bed to her wheelchair her legs buckled and she had an assisted fall to the floor. The resident stated her right knee hurt. Based on her facial expression and body language, her pain level was approximately 3 out of 10 (10 being the highest). There was blood on the front of the resident's sock on her right foot. First aid was performed for the skin tear. The resident was taken to breakfast. After breakfast she was transferred to her bed. At approximately 11:00 a.m. the resident complained her knee really hurt. Tylenol was administered. At approximately noon a portable x-ray was completed. The resident's physician examined the resident at approximately 12:30 p.m. Review of the 7/11/14 x-ray findings revealed a "long and mildly angulated fracture of distal femur (right upper leg bone on the end closer to the knee)" and a suspicious finding of an undisplaced left hip fracture. A follow-up nursing entry on 7/11/14 noted the resident was transferred to the hospital via ambulance at 1:15 p.m. The 7/11/14 facility investigation identified Staff Member C, the assigned NA caregiver, on 7/11/14 had performed a one person transfer from bed to wheelchair instead of using a two person sit-to-stand transfer as per her care plan. (The resident was assisted to the floor during the transfer.) Staff Member C then asked another NA, Staff Member D, to assist in transfering the resident from the floor to the wheelchair prior to having her assessed by a LN. The LN was summoned after the resident was back in the wheelchair. She treated the resident's skin tear and assessed her pain level. The resident was taken to the dining room when she didn't present with "evidence of excruciating or acute pain." Staff Members C & D performed a two person transfer, not following the care plan directive. When interviewed on 7/22/14 at approximately 10:15 a.m., Administrative Staff LN A stated after interviewing the involved staff members it was discovered that Staff Member C did not review the fact sheet (for the NAs) to accurately determine Resident #1's transfer status. Instead, Staff Member C asked Staff Member D about the resident's transfer directive. Staff Member D misinformed Staff Member C, stating Resident #1 was a one person transfer (instead of a two person sit-to-stand transfer). Staff Member C performed the one person transfer. After assisting the resident to the floor, Staff Member C made several attempts to get the resident up into the wheelchair by herself but was unable. Instead of summoning the LN directly after the fall per facility standard, Staff Member C sought the assistance of Staff Member D to place the resident into her wheelchair via another inappropriate transfer (a two person manual transfer). The LN was summoned only after the second inappropriate transfer. The resident was taken to breakfast and returned to bed. (A third inappropriate manual transfer was then performed). On 7/22/14 at approximately 12:25 p.m. Staff Member B, the LN on the unit on 7/11/14, stated on the day Resident #1 fell she was summoned to the room by one of the NAs. She was only told the resident had a controlled fall. She was not told how the resident had gotten to the wheelchair or any details about the transfer(s). The LN stated she was unaware of the resident's transfer status at that time but was told later by another LN. Staff Member B assessed the resident initially and provided first aid. The resident went to breakfast. Some time between 10:30 a.m. and 11:00 a.m. the resident was complaining of pain and she provided Tylenol but it was not helpful. Staff Member B had contacted the Director of Nursing after the fall and the Director of Nursing had called for an x-ray. Staff Member B later provided stronger pain medication for the resident prior to her being sent to the hospital. Review of hospital medical records revealed the resident was admitted to the hospital on [DATE] for evaluation and treatment of [REDACTED].

Based on record review and interview, the facility failed to provide: A) necessary wound care and B) adequate pain management for 1 of 3 sampled residents (#5) with wounds. Resident #5 experienced harm as a result of her wound deterioration and unrelieved pain. Findings include: A) Wound Management: Resident #5: Review of the medical record revealed she had multiple [DIAGNOSES REDACTED]. On 1/18/12 the resident's plan of care noted she had [MEDICAL CONDITION] (accumulation of fluid in her tissue) and was at risk for skin breakdown. According to nursing entries, on 2/05/12 the resident experienced shortness of breath and was sent to the hospital. Resident #5 returned to the facility on [DATE]. The 2/10/12 hospital transfer sheet identified there was a skin problem on the resident's right leg below the knee on the outer aspect. The facility 2/10/12 Resident Admission Profile documented the resident had a "hematoma, opened up" (a site with blood accumulated under the skin) on the right shin area. There was no measurement or assessment related to the size of the wound site identified at that time. There were no interventions noted on the plan of care to address the open skin site. Review of the February 2012 Treatment Record (TAR) did not reveal a treatment or dressing was provided. There was no documentation of physician notification or further mention of the wound site. The February 2012 TAR had an entry on 2/21/12 (11 days after admission) documenting a "dressing change to right lower leg macerated area check Q (every) day (change) Q 3-5 days". Despite the directive to change the dressing and the change noting the area was macerated (made soft by contact with a liquid), there was no specific dressing identified. Staff initialed the dressing checks and changes without a specific dressing being noted. No measurements of the size or condition of the wound site were documented. A nursing entry, dated 2/27/12, documented the resident had a lesion on the right mid calf. The site was "weepy" with a small amount of serous drainage and the area was warm and red. A culture was obtained and reportedly sent on 2/27/12. Review of the 3/02/12 lab results revealed the culture and sensitivity report was faxed to the facility on [DATE] and noted two organisms including a staph infection. Despite results from the culture on 3/02/12, the results were not faxed to the physician until 3/05/12 (3 days later). An antibiotic order was obtained from the physician on 3/06/12 (8 days after the culture was sent in and 4 days after the test results had returned to the facility). A specific dressing was started on 3/02/12. The dressing was to be changed every other day. The March 2012 MAR failed to note dressing changes between 3/05/12 and 3/09/12. There was no assessment of the wound size or condition. A 3/11/12 nursing entry documented a dressing change and the resident was complaining of tenderness, "redness and heat continues". On 3/12/12 the resident was transferred to the hospital for "lowered consciousness" and [MEDICAL CONDITION]. Resident #5 was readmitted on [DATE] and was sent back to the hospital on the same day due to "severe difficult (sic) breathing". A 3/19/12 wound care assessment in the hospital noted the resident's right lower leg had "ulcers scattered over an area of 13 centimeters (cm) by 11 cm (more than 5 inches by 4 1/3 inches). A medicated treatment was ordered. The resident returned to the facility and the wound was identified as a venous stasis ulcer. When interviewed on 4/11/12 at approximately 2:10 p.m., Staff Member A, a Licensed Nurse (LN), stated that on 2/10/12 the area on the resident's right lower leg looked like a blood filled hematoma that had opened. The LN was unable to locate physician notification of the condition of the resident's wound site in conjunction with the 2/10/12 admission. No initial treatment was identified for the open area and no order was found for a specific treatment order for the 2/21/12 dressing change. No wound assessments were located pertaining to the hematoma wound site on the right lower leg and the plan of care did not identify the actual wound site with interventions and a goal. An investigative interview was conducted with the resident's Power of Attorney (POA). The POA recalled the area on the resident's leg had started as an intact blackened area, like a bruise, at the facility and she had showed it to a facility LN. The resident went to the hospital shortly thereafter and the area worsened. Hospital staff placed a dressing over the area on the right leg below the knee. When the resident returned to the facility (on 2/10/12) the area was bandaged. The POA stated the facility did not change the dressing for approximately 1 1/2 weeks. The POA discussed the wound site/dressing issue with a couple LNs. One evening a LN checked and there was no directives for a dressing change but the LN changed the dressing. The POA recalled the area was the size of a 50 cent piece at that time. Later, the facility plan was to change the dressings every 3 days but the dressings would be "wet and discolored. One weekend the resident's pants were wet with the weeping." The resident developed a staph infection in the wound. Eventually, the wound went all the way to the back of her leg. It was painful and her legs were swelling. Staff could have done a better job with elevating her legs." B) Medications: Resident #5 was readmitted to the facility on [DATE] with hospice services. Original hospital (hospice) orders included [MEDICATION NAME] (a narcotic pain medication) 10 milligrams (mg) by mouth every 4 hours as needed for pain and [MEDICATION NAME] (an anti-anxiety medication) 1 mg orally every 4 hours as needed for anxiety. Updated hospice orders were sent on 3/23/12 (faxed at 1:35 p.m.) as the resident was having jerking behaviors: [MEDICATION NAME] 10 mg every 2 hours as needed and [MEDICATION NAME] 1-2 mg every two hours as needed. Additionally, [MEDICATION NAME] drops were available every 4 hours as needed for excess secretions. Review of the March 2012 MAR indicated [REDACTED]. The resident received two doses [MEDICATION NAME] and [MEDICATION NAME] during the evening shift of 3/23/12. No doses were provided after approximately 8:00 p.m. The resident received the 3/24/12 morning doses of [MEDICATION NAME] and [MEDICATION NAME] at 6:30 a.m. A 3/24/12 morning nursing assessment noted the family was requesting the resident receive additional doses of [MEDICATION NAME] and [MEDICATION NAME] and the resident was noted to be "grimacing" and had jerky movements. Staff Member B, a LN, contacted Hospice and the resident's 3/23/12 orders were faxed, the orders that allowed for the resident to receive [MEDICATION NAME] and [MEDICATION NAME] every two hours as needed. The resident received the [MEDICATION NAME] and [MEDICATION NAME] at 10:30 a.m. on 3/24/12 (4 hours after the previous dose). An investigative interview was conducted with the resident's Power of Attorney (POA). The POA recalled that during the night shift of 3/23/12 into 3/24/12 the resident did not receive any pain medication and appeared to be resting. The next morning at about 6:00 a.m. the resident began [MEDICAL CONDITION] behaviors and was experiencing distress. (The resident received a 6:30 a.m. dose.) When the resident needed the next dose (two hours later), the LN stated they didn't have the hospice orders to allow her to give the medications every two hours and she had to call hospice. This resulted in a delay in the resident receiving her pain and anxiety medications and the resident had convulsion-like behaviors/distress as she waited. When interviewed on 4/16/12 at approximately 11:30 a.m., Staff Member C, a day shift Nursing Assistant, (on 3/24/12) stated the family turned on the call light every two hours to request medication for the resident to calm her shaking, she was "shaking a lot". Staff Member C conveyed the medication request to Staff Member B but Staff Member B was giving medications to other residents. The family members continued to put on the call light to check on/request the medications for Resident #5. On 4/16/12 at approximately 11:50 a.m., Staff Member B, a LN, was interviewed. The LN stated on 3/24/12 she gave the resident medication, [MEDICATION NAME] and [MEDICATION NAME], at about 6:30 a.m. and the resident had [MEDICAL CONDITION] behavior. The family requested the next dose two hours later stating Hospice had provided the orders on 3/23/12 but the LN was unable to locate the orders. The orders had not been transcribed onto the March 2012 MARs. The LN contacted Hospice and obtained the orders. However, this resulted in a delay in the resident receiving her (pain and anti-anxiety) medications. Review of the March 2012 MAR indicated [REDACTED]. A Hospice Nursing entry, dated 3/24/12, documented that the family was complaining of "poor care for their family" (member). On 4/16/12 at approximately 10:45 a.m. the Hospice LN who visited the resident on 3/24/12 was interviewed. The Hospice LN stated when she arrived mid morning the resident looked uncomfortable and was struggling to breathe. When the resident was moved she "tightened or groaned". The Hospice LN spoke with the LN (Staff member B) and the caregiver (Staff Member C). She also noted there was no charting about the every two hour pain medication (on the March 2012 MAR). The Hospice LN calculated the amount of pain medication used and decided to order a pain patch to address the resident's pain. The Hospice LN also spoke to the family members about their care/comfort concerns.