Every finding on record at Grays Harbor Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) was reviewed and explained in a form and/or manner, understood by 2 of 3 sampled residents (Resident 74 & 75) reviewed for binding arbitration agreements. This failure placed residents at risk for lacking understanding of the legal document signed and a diminished quality of life.Findings included.Resident 74 was admitted to the facility on [DATE]. The admission Minimum Data Set, (MDS, assessment tool), dated 04/30/2026, showed Resident 74 was cognitively intact. Record review of Resident 74's electronic health record (EHR) showed Resident 74 signed a Patient and Facility Arbitration Agreement on 04/27/2026. In an interview on 05/07/2026 at 12:30 PM, Resident 74 said they did not recall signing an arbitration agreement or being informed about their right to rescind the agreement within 30 days of signing it.Resident 75 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 75 was cognitively intact. Record review of Resident 75's EHR showed Resident 75 signed a Patient and Facility Arbitration Agreement on 04/30/2026.In an interview on 05/07/2026 at 11:36 AM, Resident 75 said they signed an arbitration agreement but did not recall being informed about their right to rescind the agreement within 30 days of signing it.In an interview and record review on 05/06/2026 at 10:53 AM, Staff E, Business Office Manager, said they reviewed the Patient and Facility Arbitration Agreement with Resident 74 and Resident 75. When asked how Staff E ensured residents understood their right to rescind the arbitration within 30 days, Staff E stated, they can rescind it at any time. When asked if residents could rescind the arbitration agreement 30 days after signing it Staff E stated, yes they can.In an interview on 05/07/2026 at 1:04 PM, Staff A, Administrator, said the facility arbitration agreement was voluntary and after signing it, residents had 30 days to rescind the agreement. No Reference WAC

Based on interview and record review, the facility failed to ensure residents received information about the risk and benefits and failed to obtain informed consent prior to the administration of psychotropic medications for 1 of 5 sampled residents (Resident 52) reviewed for unnecessary medication use. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with psychotropic medications.Findings included . Resident 52 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 04/08/2026, indicated Resident 52 was severely cognitively impaired.Record review of Resident 52's physician orders, dated 04/08/2026, indicated to give Duloxetine (a prescription medication used to treat depression [a mood disorder]) one capsule by mouth one time a day for depression.Record review of Resident 52's Electronic Health Record (EHR) did not show consent for Duloxetine.During an interview on 05/07/2026 at 9:08 AM, Staff D, Resident Care Manager/Licensed Practical Nurse, said they covered the risk and benefits of psychotropic medications with residents and/or their representatives and then got consent. Staff D said he could not find a consent for Duloxetine.Reference WAC 388-97-0260 (2)(d)

Based on observation, interview and record review, the facility failed to ensure staff maintained proper infection control practices for storage of personal care equipment in 1 of 1 resident's room (room [ROOM NUMBER]) reviewed for infection control. This failure placed residents at risk for infection and a diminished quality of life. Findings included.In an observation on 05/04/2026 at 12:20 PM, a specimen hat (container used to collect urine or stool) was observed on the floor near the sink with no protective covering in room [ROOM NUMBER]. In an interview and observation on 05/04/2026 at 3:03 PM, when asked what the specimen hat on the floor near the sink in room [ROOM NUMBER] was used for, Staff H, Certified Nurse Assistant, said It was used for emptying the colostomy bag (a small, waterproof plastic pouch used to collect waste from the body) belonging to the resident in bed 107-3. In an interview and observation on 05/04/2026 at 3:55 PM, Staff I/Registered Nurse (RN), observed the specimen hat on the floor in room [ROOM NUMBER]. Staff I said it was the expectation that the specimen hat was cleaned and kept in a plastic bag off the floor after use. In a joint interview on 05/06/2026 at 9:03 AM, with Staff B, Director of Nursing/RN and Staff G, Infection Control/Staff Development/RN, Staff B said it was the expectation that staff cleaned the specimen hat and bag it after using it. Reference WAC 388-97- 1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure anticoagulant (blood thinner) medication related side effects were monitored for 1 of 4 sampled residents (Resident 61) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects from anticoagulant medication use and a diminished quality of life.Findings included. Resident 61 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 04/11/2026, documented Resident 61 was cognitively intact. In an interview on 05/04/2026 at 12:34 PM, Resident 61 said he had a blood clot in his right arm and thought he was on a blood thinner medication. Record review of Resident 61's Nursing Notes, dated 04/20/2026, documented, Results for Ultrasound [a test used to diagnose conditions in soft tissues in the body] as follows: (Occlusive [blockage], likely acute to subacute deep venous thrombosis [DVT, a blood clot in a deep vein causing pain, swelling, and redness] within the right brachial [arm] vein) MD [Medical Doctor] notified and ordered Eliquis [an anticoagulant medication]. Record review of Resident 61's physician orders, dated 04/20/2026, showed Resident 61 was prescribed Eliquis for DVT. Review of Resident 61's Medication Administration Records, dated April and May 2026, showed Resident 61 was receiving Eliquis two times a day for DVT. Review of Resident 61's Electronic Health Record did not show documentation of monitoring for anticoagulant medication side effects. In an interview on 05/06/2026 at 12:31 PM, Staff D, Resident Care Manager/Licensed Practical Nurse, said when residents were on anticoagulant medication, they would monitor for side effects of the medication, like bleeding and bruising, and it would be put on their care plan they were on anticoagulants. After looking at Resident 61's EHR, Staff D said when Resident 61 was started on anticoagulant medication, it should have been put on his orders to monitor for side effects of the medication every shift, and it was not. In an interview on 05/06/2026 at 12:43 PM, Staff B, Director of Nursing/Registered Nurse, said Resident 61 should have had anticoagulant medication side effect monitoring and a care plan addressing anticoagulant medication and a DVT. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to obtain a physician's order for oxygen use for 1 of 2 sampled residents (Resident 12) reviewed for respiratory care. This failure placed residents at risk for unmet care needs, and a diminished quality of life.Findings Included.Record review of the facility's policy, titled, Quality Of Care Respiratory Care/Tracheostomy Care & Suctioning, dated July 2018, documented . b. There will be a practitioner's order for oxygen therapy to include indication for use. The type of equipment to use, baseline SpO2 [a measurement of how much oxygen a person's blood is carrying] SpO2 levels to initiate and/or discontinue oxygen therapy. Resident 12 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 04/04/2026, showed Resident 12 was cognitively intact and was on oxygen therapy.In an observation on 05/04/2026 at 10:51 AM, Resident 12 was observed lying in bed with oxygen on via nasal cannula (a flexible tube with two prongs used to provide oxygen through the nose) via an oxygen concentrator, running at 2 liters per minute (lpm). Resident 12 said she used oxygen at 2 lpm intermittently for shortness of breath. Record review of Resident 12's care plan, dated 03/25/2026, documented a Focus, [Resident 12] has altered respiratory status/difficulty breathing r/t [related to] recent COVID [19] [a respiratory illness] and acute Hypoxic [low oxygen] respiratory failure with oxygen use, asthma. Oxygen per order.Record review of Resident 12's electronic health record did not show a physician's order related to use of oxygen.In an interview on 05/07/2026 at 10:17 AM, Staff B, Director of Nursing/Registered nurse, said it was her expectation that residents using oxygen had physician's orders in place prior to oxygen being administered.Reference WAC 388-97-1060 (1)(3)(vi)

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for 1 of 3 sampled resident (Resident 36) reviewed for skin conditions, and 1 of 4 sampled residents (Resident 61) reviewed for anticoagulant (blood thinning) unnecessary medications. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included. Resident 36 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 04/15/2026, documented Resident 36 was moderately cognitively impaired. In an interview on 05/04/2026 at 2:49 PM, Resident 36 said she had something going on with the bottom of her foot and she didn't know what it was. Record review of Resident 36's physician orders, dated 04/15/2026 and discontinued 04/27/2026, documented an order, apply betadine to left foot bottom of 2nd toe leave ota [open to air]. Record review of Resident 36's physician orders, dated 04/23/2026, documented an order, monitor abrasion to bottom of left foot 2nd [second] toe. Further review of the physician orders, dated 04/23/2026, documented an order, apply skin prep [a film-forming protective barrier wipe applied to skin to create a layer that protects the skin] to scab on bottom side of 2nd toe left foot BID [twice daily]. Review of Resident 36's Electronic Health Record (EHR), May 2026 Monitors, showed Resident 36 was receiving skin prep to scab on bottom of the second toe twice daily for skin care. In a joint observation on 05/07/2026 at 12:20 PM with Staff F, Licensed Practical Nurse (LPN), a scabbed area was observed on the bottom of Resident 36's left foot second toe. Record review of Resident 36's Comprehensive Care Plan, date initiated 04/11/2026, date revised 04/21/2026, did not show a Focus area or Goal for a skin at risk care plan and/or a scab to the bottom of the left foot second toe. In a joint interview on 05/07/2026 at 12:53 PM with Staff D, Resident Care Manager/LPN, and Staff B, Director of Nursing/Registered Nurse, Staff B said Resident 36 should have had a care plan developed for skin at risk and for the area on the bottom of the left second toe and there was not. Resident 61 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 61 was cognitively intact. In an interview on 05/04/2026 at 12:34 PM, Resident 61 said he had a blood clot in his right arm and thought he was on a blood thinner medication. Record review of Resident 61's Nursing Notes, dated 04/20/2026, documented, Results for Ultrasound [a test used to diagnose conditions in soft tissues in the body] as follows: (Occlusive [blockage], likely acute to subacute deep venous thrombosis [DVT, a blood clot in a deep vein causing pain, swelling, and redness] within the right brachial [arm] vein) MD [Medical Doctor] notified and ordered Eliquis [an anticoagulant medication]. Record review of Resident 61's physician orders, dated 04/20/2026, showed Resident 61 was prescribed Eliquis for DVT. Review of Resident 61's Medication Administration Records, dated April and May 2026, showed Resident 61 was receiving Eliquis two times a day for DVT. Review of Resident 61's EHR did not show a comprehensive care plan for a DVT and/or the use of anticoagulant medication. In an interview on 05/06/2026 at 12:31 PM, Staff D said when residents were on anticoagulant medication, it would be put on their care plan they were on anticoagulants. After looking at Resident 61's EHR, Staff D said there was not a care plan for Resident 61 addressing a DVT or anticoagulant medication use and there should have been. In an interview on 05/06/2026 at 12:43 PM, Staff B said Resident 61 should have had anticoagulant medication side effect monitoring and a care plan addressing anticoagulant medication and a DVT. Reference WAC 388-97-1020(1)(2)(a)

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 1 of 4 sampled residents (Resident 8) reviewed for dementia (a decline in mental ability including memory, language, and problem-solving) care. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included. Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 8 was moderately cognitively impaired, had Non-Alzheimer's Dementia (a type of dementia), and did not use a wander/elopement alarm (Wander Guard, a security system that uses a wearable tag and/or sensor designed to prevent people with cognitive impairments from leaving secure areas to ensure their safety, by triggering alerts to caregivers). Record review of Resident 8's physician orders, dated 02/06/2026, documented, Wander guard to left ankle check for placement and functioning every shift replace if needed every shift for wandering. Record review of Resident 8's elopement risk/wanderer care plan, date revised 04/09/2026, documented an Intervention/Task area, dated 06/28/2024, .wander guard placed on left ankle check for placement and functioning and change as needed. In an observation and interview on 05/06/2026 at 3:25 PM, Resident 8 was observed sitting in her wheelchair in her room with a Wander Guard alarm bracelet attached to her left ankle. When asked about the Wander Guard alarm on her left ankle, Resident 8 reached down and touched alarm stating, It stays on my ankle 24/7 [24 hours per day, seven days per week] to keep an eye on things. In an interview on 05/07/2026 at 9:17 AM, Staff B, Director of Nursing/Registered Nurse, said the Wander Guard alarm should have been captured on the MDS and it would need to be fixed. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to provide a written Bed-Hold notice to residents and/or residents' representative at the time of transfer to the hospital for 2 of 5 sampled residents (Residents 4 and 8) reviewed for hospitalization and/or discharge. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.Findings included. Record review of the facility policy, titled, ADMISSION, TRANSFER AND DISCHARGE Notice of Bed Hold Policy Before / Upon Transfer, date revised November 2018, documented, The facility will provide written information to the resident or resident representative specifying the duration of the state bed-hold policy, if any, during which time the resident is permitted to return and resume residence in the facility. 2. Two notifications will be provided. The first one well in advance of any transfer and the second one at the time of transfer. 3. The second notice will be provided to the resident and the representative at the time of transfer or within 24 hours if the transfer was an emergency. 4. In the event the facility is unable to reach the representative, the facility will document the attempts made. Resident 4 was admitted to the facility on [DATE]. The Admission/5-day Minimum Data Set (MDS), an assessment tool, dated 04/14/2026, indicated Resident 4 was alert and oriented. Record review of Resident 4's hospital transfer form, dated 04/30/2026, indicated Resident 4 was transferred to an acute hospital for shortness of breath (bronchitis, pneumonia). Record review of Resident 4's electronic health records (EHR) did not show documentation the bed hold was reviewed with Resident 4 or Resident 4's representative. During an interview on 05/07/2026 at 8:47 AM, Staff D, Resident Care Manager/Licensed Practical Nurse, said the bed hold would be offered prior to the transfer or the following day if it was not done because of an emergency. Staff D said he spoke with Resident 4 at the hospital the following day but did not think it was documented in the EHR. Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 8 was moderately cognitively impaired. Review of Resident 8's EHR showed Resident 8 was transferred to the hospital on [DATE]. Further review of Resident 8's EHR did not show documentation of a written bed-hold notice, nor contact was made to the resident and/or representative regarding bed-hold information. In an interview on 05/06/2026 at 3:25 PM, when asked about her transfer to the hospital on [DATE], Resident 8 said the facility did not mention if her bed would be held and did not talk to her about it, stating, I wasn't sure if I'd have my room or not. In an interview on 05/07/2026 at 9:04 AM, Staff F, Licensed Practical Nurse, said when a resident was transferred to the hospital, they would give the resident a copy of the bed hold policy and review it with them. In an interview on 05/07/2026 at 9:13 AM, Staff B, Director of Nursing/Registered Nurse, said Resident 8 was not given information regarding a bed-hold, or offered a bed-hold, and she should have been. Reference WAC 388-97-0120 (4)

Based on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 3 sampled residents (Resident 36) reviewed for pressure ulcer/injury (damage to the skin and underlying soft tissue caused by prolonged pressure, usually over a bony area), and for 1 of 4 sampled residents (Resident 8) reviewed for anticoagulant (blood thinner) unnecessary medications. This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included.Resident 36 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 04/15/2026, documented Resident 36 was moderately cognitively impaired and did not have a pressure ulcer/injury. Record review of Resident 36's physician orders, dated 04/12/2026 and discontinued 04/21/2026, showed an order for a sacral (the area of the triangular bone at the base of the spine) wound treatment daily and as needed. Record review of Resident 36's Comprehensive Care Plan documented a Focus area, dated 04/11/2026, [Resident 36] has a (specify stage) pressure ulcer of the sacrum. In an interview on 05/07/2026 at 12:17 PM, Staff F, Licensed Practical Nurse, said Resident 36 had a pressure area on her bottom when she was first admitted to the facility and it had been resolved. In an interview on 05/07/2026 at 12:58 PM, Staff B, Director of Nursing/Registered Nurse said Resident 36 did not have a pressure ulcer, stating, The care plan needs to be fixed. Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 8 was moderately cognitively impaired and was not taking anticoagulant medication. Review of Resident 8's Electronic Health Record showed Resident 8 was taking Apixaban (an anticoagulant medication) twice daily that was discontinued on 02/09/2026. Record review of Resident 8's anticoagulant care plan, dated 11/03/2023, documented a Focus area, [Resident 8] is on anticoagulant therapy. Further review of the anticoagulant care plan documented Intervention/Tasks areas, dated 11/03/2023, Administer ANTICOAGULANT medications as ordered by physician.Resident is on anticoagulant medication. In an interview on 05/07/2026 at 9:22 AM, Staff B said Resident 8's care plan should have been updated to reflect she wasn't taking anticoagulant medication any longer. Reference WAC 388-97-1020 (2)(a)

Based on observation, interview and record review, the facility failed to ensure nurse staffing information was posted and updated daily at the beginning of each shift for 32 of 32 days reviewed for nurse staff postings. These failures placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels.Findings included.In an observation on 05/04/2026 at 9:28 AM, the posted nurse staffing information located on the first floor (main floor) was dated 04/30/2026. In an observation on 05/06/2025 at 10:26 AM, the posted nurse staffing information located on the first floor was dated 05/05/2026. In an observation, interview and record review on 05/06/2026 at 12:30 PM, Staff C, Staffing Coordinator, observed the posted nurse staffing information located on the first floor and said it was a day behind. Staff C said she usually posted the previous day's nurse staffing information. Staff C said she did not update the staffing numbers and hours for each shift on the Daily Nursing Staff Information postings throughout the day when there were changes but would post the updated information the next day. Staff C said this process was done for staff postings reviewed from 04/04/2026 through 05/04/2026. When asked what the process was when a staff member called out, Staff C said if someone called out, the staff postings were updated the next day.In an interview on 05/07/2026 at 10:07 AM, Staff B, Director of Nursing/Registered Nurse, said it was the expectation that posted nursing staff information showed the current date and that changes to the staffing levels were adjusted every shift. Reference WAC 388-97-1620(2)(b)(i)

Based on interview and record review, the facility failed to implement care-planned interventions for 1 of 5 sampled residents (Resident 1) reviewed for care planning. This failure placed residents at risk of fall injuries, unmet care needs, and a diminished quality of life.Findings included. Record review of facility policy, titled, Quality of Life, dated November 2017, documented, The facility will develop a care plan and implement interventions to maintain, improve or prevent an avoidable decline in ADLs [activities of daily living] based on the resident's assessed needs, goals and preferences. Resident 1 admitted to the facility on [DATE]. The 5-day admission Minimum Data Set, an assessment tool, dated 02/28/2026, documented Resident 1 required assistance with ADLs and was moderately cognitively impaired. Record review of Resident 1's ADL care plan, initiated 02/27/2026, documented the intervention, Bathing/Showering: The resident is partial/moderate assistance of (1) staff to provide bath/shower and as necessary. The care plan did not document a preference for the resident to be showered by family members. Record review of Resident 1's progress note, dated 02/24/2026, documented, Wife will do laundry and reports that she will be here in the evenings to shower him on his shower days. In an interview on 03/17/2026 at 4:38 PM, Resident 1 said while he was in the facility, the facility staff did not shower the resident. Resident 1 said his wife assisted him while he was admitted to the facility. In an interview on 03/24/2026 at 12:31 PM, Staff D, Licensed Practical Nurse, said the wife of Resident 1 insisted on showering the resident and did not want facility staff involved. In an interview on 03/24/2026 at 12:38 PM, Staff E, Residential Care Manager/Registered Nurse, said Resident 1's wife was insistent on showering the resident. Staff E said she could not say that an orientation to the shower room for Resident 1's wife had been completed because it was not documented anywhere. Staff E said there was a fall risk with resident's family showering the resident in the facility. In an interview on 03/24/2026 at 2:05 PM, Staff A, Administrator, said she heard about the wife of Resident 1 showering the resident after the fact, and the showers provided by the wife of the resident was not something the facility sanctioned. Staff A said there was an assessment to verify safety with showering, but that was not completed for Resident 1. Reference WAC 388-97 -1020(1)(2)(a)(b).

Based on interview and record review, the facility failed to provide Occupational Therapy (OT) services for 1 of 5 sampled residents (Resident 1) reviewed for therapy services. This failure placed residents at risk of delayed healing, a decrease in Activity of Daily Living (ADL) participation, and a diminished quality of life.Findings included.Resident 1 admitted to the facility on [DATE]. The 5-day admission Minimum Data Set, an assessment tool, dated 02/28/2026, documented the resident required assistance with ADLs and was moderately cognitively impaired. Record review of Resident 1's fall risk care plan, initiated 02/24/2026, documented the intervention, Refer to OT PRN [as needed] per orders. Record review of Resident 1's physician orders, dated 02/24/2026, documented, Occupational therapy evaluation and treatment as indicated. In an interview on 03/17/2026 at 4:38 PM, Resident 1 said that he did not recall working with therapy staff while admitted to the facility. In an interview on 03/24/2026 at 11:40 AM, Staff C, Director of Rehabilitation Services, said Resident 1 was ordered occupational therapy two times per week. Staff C said the resident was seen for an evaluation for OT services on 02/25/2026. Staff C said after the evaluation, no other OT services were given. Staff C said the facility did not currently have a full-time occupational therapist, and the facility had been utilizing a part-time weekend therapist and PRN COTA (as needed certified occupational therapy assistants). In an interview on 03/24/2026 at 1:25 PM, Staff B, Director of Nursing Services/Registered Nurse, said the facility had reached out to the therapy area manager to assist with OT staffing. Staff B said for two times a week OT the facility had enough staff, barring illness or unforeseen circumstances. Staff B said the facility had been advertising for several therapy positions. Reference WAC 388-97-1280(1)(a)(b)(4).

Based on observation, interview, and record review, the facility failed to ensure resident oxygen administration orders were completed per physician order for 1 of 4 sampled residents (Resident 1) reviewed for oxygen administration. This failure placed residents at risk of low oxygen levels and a diminished quality of life.Findings included. Resident 1 admitted to the facility on [DATE]. The 5-day admission Minimum Data Set, an assessment tool, documented the resident was on oxygen therapy and was severely cognitively impaired. Record review of Resident 1's oxygen care plan, initiated 07/14/2025, documented, Administer oxygen @ 2L/min [at two liters per minute] via nasal cannula; Continuous for dyspnea [trouble breathing]. Record review of a physician order, dated 07/11/2025, documented, Administer oxygen @ 2L/min via nasal cannula; Continuous for dyspnea. In an observation on 09/03/2025 at 9:30 AM, Resident 1 was observed in her room, in bed, under covers, eyes closed. Resident presented confused and asked where she was. An oxygen concentrator was near the resident bed, turned off, with the nasal cannula wrapped on top of the machine. Near the bed was the resident's wheelchair, and on the back of the wheelchair was an oxygen tank that was empty. In an interview on 09/03/2025 at 9:34 AM, Staff C, Licensed Practical Nurse, said she thought Resident 1's oxygen orders had been changed, but reviewed the orders and said Resident 1 had orders for continuous oxygen therapy. In an observation on 09/03/2025 at 9:37 AM, Staff B, Director of Nursing/Registered Nurse, observed Resident 1 in her room and confirmed the resident was not on oxygen while in the room, and the oxygen tank on the back of the wheelchair was empty. In an interview on 09/03/2025 at 9:46 AM, Staff B said Resident 1's orders state continuous oxygen therapy, and the order had not been changed since the resident admitted to the facility on [DATE]. Staff B said with orders for continuous oxygen orders she would expect Resident 1 to have oxygen applied at all times. Reference WAC 388-97-1060 (3)(j)(vi).

Based on interview and record review, the facility failed to ensure timely completion of physician-ordered Urinalysis (UA) labs for 1 of 4 sampled residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for delayed care, unmet care needs, and a diminished quality of life. Findings included. Resident 1 admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set, an assessment tool, dated 07/14/2025, documented the resident was mildly cognitively impaired. Record review of Resident 1's physician's order, dated 07/18/2025, documented, UA with C&S [culture and sensitivity] if indicated. No directions specified for order. Record review of Resident 1's skilled nursing note, dated 07/18/2025, documented, Pt [patient] shorter with staff than normal and resting more than normal awaiting for UA sample from pt for lab. Record review of Resident 1's nursing note, dated 07/21/2025, documented, UA drawn and took to lab. Awaiting results. In an interview on 08/07/2025 at 10:24 AM, Staff C, Residential Care Manager/Registered Nurse, said UA's should be collected on the same shift they were ordered on, usually within the first couple of hours. Staff C said she would obtain an order for a straight catheter or send the resident to the hospital if it took too long to obtain the UA. Staff C said a three day collection time for a UA would not be considered timely. Staff C said if the doctor ordered a UA it should have been obtained that day, if not the next day. In an interview on 08/07/2025 at 10:46 AM, Staff D, Residential Care Manager/Licensed Practical Nurse, said staff should try to obtain a UA lab every shift. Staff D said once the order was entered into the resident's electronic medical record, the order would alert the nurse to complete the order. Staff D said he could not answer whether or not the three day collection time for the UA would be considered timely. Staff D said he would have to refer to the Director of Nursing on if there was a policy related to timely completion of UA labs. In an interview on 08/07/2025 at 12:13 PM, Staff B, Director of Nursing/Registered Nurse, said UA labs should be collected within 24 hours. Staff B said she investigated the issue and found a nurse had entered the order from the provider; however, the order was not scheduled, and without the scheduling details, the order would not flag the nurse to complete the lab. Staff B said Resident 1's UA would not be considered a timely completion of the lab. Reference WAC 388-97 -1620 (2)(b)(i).

Based on observation, interview, and record review, the facility failed to obtain a consent and physician's order for 1 of 2 sampled residents (54) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . Review of the facility's policy entitled, Quality of Care Bed Rails, dated 02/2018, documented .The resident and/or representative will be informed of the risks and benefits of bed rails and informed consent will be obtained prior to installation of bed rails . Resident 54 was admitted to the facility on [DATE]. The Medicare-5 day Minimum Data Set assessment, dated 03/07/2025, documented Resident 54 was moderately cognitively impaired. Review of Resident 54's ADL (activities of daily living) self-care performance deficit care plan, dated 02/11/2025, documented, Assist Rail for bed mobility . Date Initiated: 03/04/2025. A Skilled Nursing Note, dated 03/05/2025, documented, Devices/Equip [equipment] . bed rails. On 03/16/2025 at 10:41 AM, Resident 54 was observed lying in bed with quarter bed rails on the left and right side of the bed. On 03/17/2025 at 1:10 PM, Resident 54 was observed lying in bed with quarter bed rails on the left and right side of the bed. On 03/18/2025 at 2:46 PM, Resident 54 was observed lying in bed with quarter bed rails on the left and right side of the bed. Review of Resident 54's Electronic Health Record showed no resident and/or representative consent, or physician's order related to bed rails. On 03/19/2025 at 10:20 AM, Staff D, Unit Manager and Licensed Practical Nurse, said for residents using bed rails, they would have a consent, assessment, physician orders, and care plan. Staff D said he saw on 03/18/2025, Resident 54 did not have consent and physician orders for bed rails, and she should have. At 10:41 AM, Staff B, Director of Nursing and Registered Nurse, said it was her expectation consent and physician orders are obtained prior to bed rails installed for residents. Staff B said they did not follow their process for Resident 54. Reference WAC 388-97-0620 (4)(a)(b)

Based on observations, interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 2 of 7 sampled residents (18 & 42) reviewed for bowel management, and failed to ensure that physicians orders for consultations were arranged for 1 of 3 (55), residents reviewed for physician orders for urology and vascular consults. These failures placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . <Bowel Managment> Per Facility Bowel Management Policy, entitled Bowel Protocol and Bowel Tracking, undated : 2. Residents assessed as having inadequate bowel function manifested by absence of regular bowel movement in excess of three days will be assessed by the nurse. This assessment will include the following: a. Resident/staff interview. 3. The following bowel protocol will be implemented as established by physician's orders: a. Administration of stool softeners b. Administration of laxatives/bowel stimulants and c. Administration of enema. 1) Resident 18 was admitted to the facility on [DATE]. The Admission Minimum Data Set Assessment (MDS), dated [DATE], documented the resident was moderately cognitively impaired. The Bowel and Bladder Elimination task sheet showed Resident 18 had a Bowel Movement (BM) on 03/04/2025 at 8:29 PM, and did not show another BM until 03/08/2025 at 5:19 AM, over 81 hours since her last documented BM. Review of Resident 14's March 2025 Medication Administration Report (MAR) showed the bowel protocol was not initiated between the dates of 03/04/2025 and 3/08/2025. 2) Resident 42 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was alert and oriented. The Bowel and Bladder Elimination task sheet showed Resident 42 had a BM on 02/19/2025 at 8:51 PM, and did not show another BM until 02/25/2025 at 5:38 AM, over 128 hours since her last documented BM. Review of Resident 58's October 2024 MAR showed the bowel protocol was not initiated between the dates of 02/19/2025 and 10/25/2025. On 03/19/2024 at 10:23 AM, Staff D, Unit Manager and a Licensed Practical Nurse (LPN), said after three days of no BM, facility initiates the bowel protocol, and residents are to be administered either Miralax (a laxative) or Senna (a laxative). Staff D was unable to provide documentation of BM protocol being initiated for both Residents 18 or 42. Staff D said he would expect to find documentation in the HER. At 1:43 PM, Staff B, Director of Nursing Services (DON) and Registered Nurse (RN), said she expects the bowel protocol to be initiated and documented per facility policy. Staff B was unable to provide further documentation of BM intervention being initiated for residents 18 and 42. 51254 <Urology Consult> Resident 55 was admitted to the facility on [DATE] with an indwelling foley catheter (tube placed in the bladder to drain urine). The 5 day MDS assessment, dated 02/11/2025, indicated Resident 55 was alert and oriented. The facility urinary catheterization policy, dated 04/2021, listed the indications for indwelling urinary catheterization to include: a. Acute urinary retention or bladder outlet obstruction; b. Accurate measurement of urinary output; c. Assist in healing of open sacral or perineal wounds in incontinent residents; d. Need for prolonged immobilization; e. Improve comfort during end of life care. The transfer orders from the hospital, dated 02/07/2025, indicated to remove foley catheter. A progress note, dated 02/10/2025, stated Resident was started on a Trial void (Urinate) and the Foley was removed today around noon, by 8pm, resident had not voided, 16F (French) 10cc (Cubic Centimeters) balloon was inserted without obstruction, over 300cc return. A progress note, dated 02/11/2025, at 6:48 AM, documented a urology consult was ordered to obtain an appropriate diagnosis for the retention of urine. <Vascular consult> A progress note, dated 02/11/2025 at 3:52 PM, stated Wound team initial evaluation of DTI (deep tissue injury) of right great toe. A progress note, dated 02/14/2025 at 1:32 PM, stated During weekly skin checks LN (Licensed Nurse) noticed blisters on bilateral heels. An ARNP (Advanced Registered Nurse Practitioner) progress note, dated 02/18/2025 at 5:48 AM, documented, [Resident 55] has a full thickness wound to left lateral lower leg. Bilateral doppler ultrasound ordered. The doppler report, dated 02/23/2025 at 5:12 AM, concluded moderate stenosis (the narrowing of a blood vessel) in the arterial system of the lower extremities- occlusion bilateral ata (anterior tibial artery) and dpa (distal popliteal artery). A progress note, dated 02/24/2025 at 9:59 AM, documented ARNP was made aware of the doppler results and ordered a vascular consult. On 03/19/2025 at 9:07 AM, Staff G, Unit Manager and LPN said the nursing staff would generally send the paperwork to the specialist indicating the need for the referral. Staff G said no one was really assigned to follow up after the referral packet was sent. Staff G said there was no real process for who does this. Staff G said there was no system to track what appointments were made. Staff G was unable to determine if Resident 55 had a urology and vascular appointments scheduled. At 10:22 AM, Staff F said the unit managers set up or got the referral started and social services might fax it over to provider to assist the unit managers. Staff F said she was not sure how the nurses track whether a referral for a specialist was arranged. Staff F said social services was only responsible to set up transportation to the appointments once they are made. At 11:18 AM, Staff B, said at times she would ask social services to help facilitate appointments. Staff B said the staff should document each time they made contact to arrange appointments with an outside provider. Staff B was unable to provide supporting documentation that Resident 55 was set up to be evaluated by a urologist or a vascular surgeon. Reference WAC 388-97-1060 (1),(3)(c)

Based on interview and record review, the facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASRR) and ensure a referral for a Level II evaluation was completed for 1 of 5 sampled residents (34) reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. Findings included . Resident 34 was admitted to the facility on [DATE] with diagnoses to include depression, and anxiety. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 34 was moderately cognitively impaired. The Level I PASRR, dated 05/24/2024, did not reflect Resident 34's diagnoses of depression, and anxiety. The Physician's Progress Note, dated 08/16/2024, documented Resident 134 was prescribed Duloxetine for her depressive symptoms, to include verbalized negative statements, and sadness. A second Level I PASRR, dated 02/24/2025, was completed by Staff F, Social Services Director, and sent off for a Level II referral. This was over eight months since admission. On 03/19/2025, at 9:56 AM, Staff F, Social Services Director, said if there is a 30 day exemption from a doctor, I note it, and few days prior to the 30 days, if resident still here, I sent off for level II. Staff F said this step was missed with resident 34. Staff F stated, This should have been sent off last year. It was not. At 1:41 PM, Staff B, Director of Nursing Services and Registered Nurse said she was aware of the missed PASRR. Staff B said it was her expectation that PASRR were processed per facility policy. Reference: WAC 388-97-1915 (1)(2) (a-c)

Based on observation, interview and record review, the facility failed to ensure bed rails were securely fastened to the bed and without gaps between the mattress and bed rail, for 1 of 1 sampled resident (28) reviewed for accident hazards. This failure placed residents at risk for injury and/or entrapment. Findings included . Review of the facility's policy entitled, Quality of Care Bed Rails, dated 02/2018, documented .Bed rails will be compatible with the bed frame and mattress in use by the resident .Bed rails that are in use will be checked routinely to verify condition and installation security. Resident 28 was admitted to the facility on [DATE]. The annual Minimum Data Set assessment, dated 01/08/2025, documented Resident 28 was moderately cognitively impaired. On 03/16/2025 at 2:52 PM, Resident 28's bed was observed with 1/2 length bed rails on the upper right and left side of the bed. The bed rails on the right and left side were observed to be loose. The rail on the right was leaning outward about 3 inches and had about five to six inches of movement back and forth, and about five inches of space between the mattress and the rail. A box of tissues was observed to have fallen in between the rail and mattress. The rail on the left had about 3 inches of movement back and forth. On 03/17/2025, at 8:47 AM, Resident 28's bed rails were observed to be loose. At 1:10 PM, Resident 28 said she used the bed rail on the right to help her get in and out of bed, and to move around in bed. Resident 28 said the rail was pretty loose and it made it harder to use and move around in bed when it was loose. Resident 28 reached over to the right bed rail and wiggled it back and forth and side to side about five to six inches. Resident 28 said it had been loose like that a long time, stating, It slides like this, i don't want it to slide, but i want to get up. At 1:17 PM, Staff H, Licensed Practical Nurse, said maintenance installs bed rails and checks them. Staff H said if there were any problems with bed rails like proper placement or safety, they would request maintenance to fix them through TELS (electronic work order system). Staff H said she did not have any issues with bed rails right now. At 1:41 PM, Staff I, Maintenance Director, said the TELS system prompted them to check bed rails two times per year, every six months. Staff I said if there was a problem with a bed rail such as it did not work or it was loose, the staff would notify them through TELS. At 1:49 PM, Staff I went to Resident 28's room to look at the bed rail. Resident 28 was observed sitting in her wheelchair beside the bed, reached over and moved her bed rail back and forth, stating, What bothers me is this, this thing swings back and forth. Staff I moved the right-side bed rail back and forth, stating, Thats not right, those need to be tightened, oh ya, those need to be tightened. At 1:51 PM, Staff B, Director of Nursing and Registered Nurse, said staff should report it in TELS if a bed rail was loose. Staff B said she expected bed rails were maintained so they were not loose and properly fitted to the bed. Reference WAC 388-97-2100 (1)

Based on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 5 of 12 sampled residents (18, 161, 54, 19 & 55) reviewed for ADs. This failure place residents at risk for not having their healthcare preferences honored and a diminished quality of life. Findings included . The facility's policy entitled, Resident Rights Advanced Directives, dated 11/2017, documented, 3. Upon admission, if the resident has not formulated an advance directive, the facility will determine if the resident wishes to formulate an advance directive. As indicated, the facility will inform the resident of his or her right to establish advance directives and provide assistance to the resident in the development of advance directives in accordance with state law. The resident can accept or decline the help. Documentation in the medical record will reflect the discussion of advance directives occurred, and that assistance has been offered to the resident, and the resident's acceptance or declination of assistance. 1) Resident 18 was admitted to the facility on [DATE]. The Admission 5-Day Minimum Data Set (MDS) assessment, dated 03/03/2025, showed Resident 18 was moderately cognitively impaired. The Interdisciplinary Team Conference (IDT), dated 02/28/2025, documented, Yes, indicating Resident 18 had AD in place. Resident 18's Electronic Health Record (EHR) showed no additional AD documentation was uploaded, reviewed, or re-addressed since admission. 2) Resident 161 was admitted to the facility on [DATE]. The Admission 5-Day MDS, dated [DATE], showed Resident 161 was alert and oriented. The IDT Conference, dated 03/12/2025, documented, Yes, indicating Resident 161 had State Specific Advance Health Care Directive in place. Resident 161's EHR showed no additional AD documentation was uploaded or addressed since admission. On 03/19/2025 at 10:31 AM, Staff F, Social Services Director, said ADs were addressed in the initial admission care conference. Staff F said several residents' ADs had been completed. When asked about Resident 161's AD, Staff F stated, We don't have it. Just the POLST [Physician Orders for Life-Sustaining Treatment]. At 1:37 PM, Staff B, Director of Nursing Services and Registered Nurse (RN), said ADs should be reviewed, addressed and documented in the EHR per facility policy. Staff B was unable to provide additional AD documentation for Resident 161, and stated, We are aware several are missing. POLSTs were completed and uploaded instead. 47518 3) Resident 54 was admitted to the facility on [DATE]. The Medicare-5 day MDS assessment, dated 03/07/2025, documented Resident 54 was moderately cognitively impaired. The IDT Care Plan Conference, dated 02/11/2025, did not document yes or no, if Resident 54 had an AD in place. Review of Resident 54's care plan, dated 03/02/2025, documented a Focus area, I do not have a Living Will or other Advance Directive on file . I will receive information related to my right to have an Advance Directive. The IDT Care Plan Conference, dated 03/07/2025, documented, Yes, indicating Resident 54 had an AD in place. Resident 54's EHR did not show documentation that information or assistance was provided related to the development of an AD. The EHR did not show a record of an AD or documentation requesting a copy of AD. On 03/18/2025 at 8:47 AM, Staff B said Social Services (SS) completed the AD with residents. Staff B said SS thought the POLST was good enough for the AD. Staff B said SS was not doing an AD for residents, only a POLST. Staff B said they did not have an AD for Resident 54. 50416 4) Resident 19 was admitted to the facility on [DATE]. The Admission 5-Day MDS assessment, dated 02/09/2025, documented Resident 19 was moderately cognitively impaired. Review of Resident 19's care plan, dated 02/28/2025, documented an interventions, Facility will place my Advance Directive in my medical record. Resident 19's EHR did not show a copy of an AD. The IDT Care Plan Conference, dated 03/04/2025, documented, Yes, indicating Resident 19 had an AD that was reviewed, verified and a copy was in the medical record. On 03/19/25 at 1:12 PM, Staff A, Administrator, said it was her understanding the POLST form was an AD and communicated this information to social services who used the POLST form as an AD. Staff A said consequently, the facility did not accurately assess if Resident 19 had an advanced directive. 51254 5) Resident 55 was admitted to the facility on [DATE]. The 5-day MDS assessment, dated 02/11/2025, indicated Resident 55 was alert and oriented. At 10:25 AM, Staff F said she was given misinformation and was using the POLST form as an AD. Staff F said the facility was now making corrections to this process to obtain/offer an AD on admission. Staff F was unable to provide documentation showing Resident 55 was offered assistance with an AD. Reference WAC 388-97-0280 (3)(c)(i)

Based on interview and record review, the facility failed to ensure residents were informed in writing of their potential liability for payment related to Medicare services ending for 1 of 3 sampled residents (34) reviewed for Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). This failure placed the residents at risk of not having adequate information to make care and financial decisions during their continued stay. Findings included . Resident 34 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility. The Quarterly Minimum Data Set assessment, dated 02/26/2025, documented Resident 34 was moderately cognitively impaired. Review of Resident 34's records revealed a Notice of Medicare Non-Coverage (NOMNC), was issued and signed on 01/31/2025, which informed the resident and the representative that skilled nursing services would end on 02/02/2025. The notice informed the resident Medicare would probably no longer cover skilled services, and the resident may have to pay for any services received after 02/02/2025. Further review of the record revealed the SNF/ABN was not issued to the resident or representative as required. This form would have explained the amount the resident would be liable to pay, if they remained in the facility for long-term care. On 03/19/2025 at 9:20 AM, Staff F, Social Services Dircector, said Resident 34 should have received the SNF ABN before the last covered day. Reference WAC 388-97-0300 (1)(e)(5)(6)

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 sampled residents (1) reviewed for medication errors. This failure caused harm to Resident 1 when medications were not administered as ordered and the resident suffered a significant change in level of consciousness requiring the administration of Narcan (a medication used for known or suspected signs and symptoms of narcotic overdose) and hospitalization . This failure placed residents at risk for medication overdose, medical complications, and a diminished quality of life. Findings included . According to the Davis Nursing Drug Guide (www.drugguide.com), undated, extended-released medications are not to be crushed or chewed before swallowing as doing so caused dangerously rapid absorption of large doses that were intended to be released slowly over many hours. Resident 1 was admitted to the facility on [DATE] with diagnoses including pain, cellulitis (skin infection), heart failure, pneumonia and dementia. The admission Minimum Data Set, an assessment tool, dated 04/22/2023, showed the resident had severe cognitive deficits, able to make some needs known, and required assistance with activities of daily living. Review of the April 2023 Physician Orders showed Resident 1's daily morning medications (given between 8:00 AM and 9:00 AM) included one 30 milligram (mg) tablet of morphine sulfate (narcotic) for pain and one 25 mg tablet of metoprolol succinate (for blood pressure). Both medications were extended release tablets. Extended release medications were slowly released into the body over a period of time, usually 12 to 14 hours. Review of the April 2023 Medication Administration Record (MAR) showed Resident 1 was administered the extended release morphine and metoprolol (along with other routine scheduled medications) on 04/23/2023 at 8:00 AM by Staff B, Registered Nurse (RN). Review of the nurse alert progress notes, dated 04/23/2023 at 12:14 PM by Staff C, Licensed Practical Nurse (LPN), showed Resident 1 was discovered in his room, lethargic and non-responsive. Staff C contacted Staff B regarding the morning medication pass and was informed the medications for Resident 1 were crushed prior to administration by Staff B. Review of the facility investigation, dated 04/28/2023 by Staff D, RN, showed staff notified the physician and received orders for administration of Narcan. Resident 1 responded slightly to the injected medication, was transported to the hospital, and was admitted for further evaluation and treatment. On 05/03/2023 at 12:30 PM, Staff A, Director of Nursing Services and RN, said nurses were aware never to crush extended release tablets and in doing so had caused the changed condition in Resident 1. Staff A said ongoing education and monitoring were planned by managers and pharmacy services. Reference WAC 388-97-1060 (3)(k)(iii)

Based on observation, interview and record review, the facility failed to implement an effective COVID-19 screening process for staff and visitors entering the facility. This failure placed residents, staff and visitors at risk for contracting the COVID-19 virus, serious injury and potential for death. This failure resulted in an Immediate Jeopardy on 10/15/2020 at 7:00 PM, when staff came into the facility without having their screening forms reviewed, and a State Agency Staff came into the building to the administrative offices without being screened during a COVID-19 outbreak. The immediacy of the Immediate Jeopardy was lifted on 10/23/2020 when the facility was observed with a screening process that monitored and reviewed the screening forms for all staff and visitors prior to entering the facility. Findings included . The Emergency & Disaster Preparedness Pandemic [MEDICAL CONDITION] Event policy, dated 08/2020, documented employees will be evaluated daily for symptoms identified by the CDC. The Process for Screening Visitors During the COVID-19 Pandemic policy, dated 03/2020, documented, Visitors are screened upon entry into the facility, using the questions on the Visitor Log . A nurse or authorized administrative personnel can review the visitor's screen and determine if the visitor can enter the facility . Persons who are deemed authorized to approve visitor entry will receive education on COVID-19 symptoms and on the importance of accurately screening potential visitors . Any provider, consultant or vendor visiting the facility is subject to these same requirements. The Process for Screening Employees During the COVID-19 Pandemic policy, dated 05/2020, did not include guidance for how the screening process should be done. COVID-19 Screening tools (facility COVID-19 screening form) for Staff F, Nursing Assistant (NA), dated 10/03/2020 and 10/04/2020, showed no documentation Staff F's screening forms were reviewed. A lab test, dated 10/05/2020, documented Staff F was positive for COVID-19. Staffing schedules showed Staff F worked at the facility on 10/03/2020 and 10/04/2020. Review of COVID-19 Screening tools, dated 10/03/2020 through 10/10/2020, showed six undated COVID-19 screening tools for Staff G, Licensed Practical Nurse. Five of the six undated forms showed no documentation the screening forms were reviewed. A lab test, dated 10/12/2020, documented Staff G tested positive for COVID-19. Staffing schedules showed Staff G worked at the facility on 10/07/2020, 10/08/2020, 10/09/2020 and 10/10/2020. A COVID Screening tool, dated 10/03/2020, showed Staff I, Nursing Assistant (NA), marked Yes to having a headache and muscle or body aches. The screening tool showed no documentation the screening form was reviewed. Staffing schedule, dated 10/03/2020, showed Staff I worked from 6:00 AM to 6:00 PM. COVID Screening tools, dated 10/03/2020 and 10/05/2020, showed Staff E, Dietary Manager Trainee, marked Yes for all of the following questions: Have you had a recent test for COVID-19; Have you worked in any other facility in the last 14 days; and, Did any facility/location you visited have recognized COVID cases? The screening tools showed no documentation the screening forms were reviewed. A COVID Screening tool, dated 10/05/2020, showed Staff H, NA, did not document Staff H performed hand hygiene, documented a temperature of 76.6 Fahrenheit, marked Yes to working in another facility the last 14 days and did not answer COVID symptom screening questions for cough, fever/chills, new loss of taste or smell, congestion/runny nose, nausea/vomiting and fatigue. The screening tool showed no documentation the screening form was reviewed. Staffing schedule for 10/05/2020 showed Staff I worked from 2:00 PM to 6:00 PM. A COVID Screening tool, dated 10/05/2020, showed Staff J, unknown position, marked Yes to having cough, congestion or runny nose, nausea or vomiting, sore throat and recently being tested for COVID. On 10/06/2020, Staff J documented Yes to having a cough and nausea or vomiting. On 10/07/2020, Staff J documented Yes to having nausea or vomiting, fatigue and recently being tested for COVID. The screening tools showed no documentation the screening forms were reviewed. COVID Screening tools, dated 10/05/2020 and 10/06/2020, showed Staff C, Receptionist, did not document she had performed hand hygiene and did not answer symptom screening questions for cough, fever/chills, new loss of taste or smell, congestion/runny nose, nausea/vomiting and fatigue. The screening tools showed no documentation the screening forms were reviewed. A COVID Screening tool, dated 10/06/2020, showed Staff I, NA, answered Yes to having muscle or body aches. An undated Screening tool showed Staff I documented Yes to having congestion or runny nose, fatigue and muscle or body aches. The Screening tools showed no documentation the screening forms were reviewed. Staffing schedule, dated 10/06/2020, showed Staff D worked from 6:00 AM to 6:00 PM. COVID Screening tools, dated 10/06/2020 and 10/07/2020, showed Staff D, Staffing Coordinator, did not document she performed hand hygiene and marked Yes to having shortness of breath or difficulty breathing, headache, diarrhea, sore throat, muscle or body aches, exposure to any person infected with COVID, working in another facility with recognized COVID cases the past 14 days and working with a COVID confirmed resident/patient. The screening tools showed no documentation the screening forms were reviewed. Staffing schedule, dated 10/06/2020, showed Staff D worked from 6:00 AM to 6:00 PM assisting on floor as aid. Review of the COVID-10 Screening Tools, dated 10/03/2020, 10/04/2020, 10/05/2020, 10/06/2020 and 10/07/2020, showed there was no documentation the screening process was completed and/or reviewed by the facility for 159 of the 163 COVID-19 screening forms reviewed. On 10/14/2020 at 11:39 AM, Staff C answered the facility entrance doorbell. Staff C did not assist and ensure completion of screening process by the State Agency Staff (SAS) upon entering the facility. Staff C brought Staff A, Administrator, to the SAS and Staff A escorted SAS to her office. When asked why the SAS was not screened prior to entrance into the facility, Staff A said she expected all staff and visitors to complete the COVID-19 screening upon entrance to the facility, at the main entrance, and at the COVID unit entrance. Staff A indicated the process was not completed allowing the SAS to enter with screening. At 11:49 AM, Staff C said when anyone entered the facility she requested hand hygiene (alcohol based hand rub) be used; the screening form to be completed by individual entering; and if abnormal answers on screening form, she would get the nurse, Staff A or Staff B, Director of Nursing Services, to review the Screening form. At 1:12 PM, Staff A said the screening forms were reviewed by Staff A, Staff B, a floor nurse or the facility receptionist, Staff C. If there were concerns with the answers, the Screening form would be given to Staff A for further review and a determination as to whether the staff required testing and/or was able to begin their shift. Staff A said the COVID screening stations were not staffed full time. Staff A said COVID screening forms were reviewed by Staff A twice daily, at shift change, every day Staff A was in the facility. Staff A said the receptionist and Staff B also reviewed the screening forms. Staff A said a rapid COVID test would be done if the staff's screening form documentation showed signs or symptoms of COVID and the employee would be seen by Staff B for further evaluation. On 10/15/2020 at 4:05 PM, Staff A was asked to review a COVID screening form for an illegibly named employee, dated 10/04/2020. The form showed the employee had marked Yes to having shortness of breath, headache, diarrhea, sore throat, muscle or body aches, being exposed to any person infected with COVID-19, recently tested for COVID-19, working in another facility with recognized COVID in the last 14 days, and working with COVID confirmed resident/patient. When asked if the form showed documentation it had been reviewed, Staff A stated, I understand what you are talking about. Staff A said there was no documentation showing the screening form was reviewed. On 10/16/2020 at 11:52 AM, when asked what education was received for reviewing COVID screening forms prior to 10/15/2020, Staff C stated, Initially, they just said check temperature and hand hygiene. Staff C said she was recently trained to ensure staff perform hand hygiene; ask staff and document the answers to all of the screening questions on the screening form; have staff provide name, phone number and sign and date the form; and if any Yes answers or a temperature greater than 100 degrees Fahrenheit, she was to find a nurse, Staff A or Staff B. At 12:45 PM, when asked if education on reviewing COVID screening forms had been provided since the start of COVID-19, Staff K, NA, stated, Yes. Today. At 1:52 PM, when asked about education provided to staff who completed and reviewed COVID-19 screening forms, Staff A said she educated nurses and the nurses educated the Nursing Assistants (NA). Staff A stated, We need to do a better job. On 10/19/2020 at 3:23 PM, Staff D, Staffing Coordinator, said prior to 10/15/2020, facility education on the staff screening process included completing the screening tool, taking temperature, performing hand hygiene and wearing a mask. Staff D said when she completed the Screening forms on 10/06/2020 and 10/07/2020, the forms were in a notebook by the facility front entrance and no designated staff was present to assist with completing and reviewing the Screening forms. On 10/23/2020 at 12:48 PM, Staff B said all screening forms should be screened and reviewed by a designated staff and reviewed by a nurse if Yes answers were present, prior to the start of their shift. On 10/28/2020 at 10:02 AM, Staff A said all staff and visitors should answer every question on the COVID Screening form honestly. All Yes answers were to be reviewed by the nurse on duty, Staff A or Staff B. At 3:52 PM, Staff E, Dietary Manager in Training, said before the screening training was provided on 10/15/2020, it was hit and miss if another staff was at the screening station. Staff E said at the training she learned any Yes answer on the screening form meant a rapid COVID test was to be done. Staff E said she was not tested at the time of completing the screening form on 10/03/2020 or 10/05/2020. Staff E said she was tested during an all-staff COVID testing after her shift started on 10/05/2020. On 10/29/2020 at 3:08 PM, Staff B said on all-staff COVID screening days a majority of staff are tested prior to starting their shift and some are tested after they start their shift. Reference WAC 388-97-1320 (1)(a)(2)(a)

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 1 of 8 sampled residents (#1) reviewed for resident rights. This failure placed residents at risk for emotional distress, anxiety and a diminished quality of life. This caused harm to Resident #1 when she felt harassed and intimidated by staff when she smoked cigarettes. Findings included . The Facility Policy, dated 03/2019, documented the facility will be smoke free within the building. The smoke free area will be outward from the building designated by State and Local Laws. Residents, visitors, contractors, and staff are not permitted to smoke on the property at any time. The Hospital History and Physical, dated 10/18/19, documented Resident #1 smoked daily. The Facility's Nursing Admission/Readmission Evaluation, dated 10/22/19, documented Resident #1 smoked one pack of cigarettes a day for a long time. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 10/29/19, documented Resident #1 had no cognitive impairment; required limited assistance with personal hygiene and walking; extensive assistance with mobility, transferring from surfaces, and dressing; and currently used tobacco. Progress notes, dated 10/23/19, document Resident #1 told Staff C, Social Services, she was feeling to urge to smoke and thought she had on a nicotine patch. The care plan, dated 10/24/19, documented Resident #1 will not be able to return to the Family Member's (FM) home and would require long-term living arrangement in the community due to alcohol and verbal abuse. Progress notes, dated 11/05/19, documented Resident #1 wanted to leave the facility and have a beer and a smoke. The resident was reminded she agreed not to smoke or drink in the facility. Progress notes, dated 11/11/19, document Resident #1 was observed outside smoking cigarettes. Resident #1 was reminded this was a non-smoking facility. It was explained to Resident #1 if she was off property or with her family she could smoke. Progress notes, dated 11/12/19, documented Resident #1 was found smoking twice and explained this was a non-smoking facility. Resident #1 said she did not care and refused to turn in her cigarettes. an order for [REDACTED].>Progress notes, dated 11/13/19, documented the smoking policy was reviewed with Resident #1. The Facility's policy, Physical Environment Smoke Free Facility, was signed by Staff C and Resident #1 on 11/13/19. The care plan, initiated 11/13/19, documented Resident #1 had a history of [REDACTED]. Staff would educate the resident on her right to smoke off the facility grounds, provide a nicotine patch, and discuss the risk and benefits of smoking. Progress notes, dated 11/15/19, documented Resident #1 was observed smoking next to the building that morning. Staff addressed ongoing smoking, disregard for safety of others, and the smoking policy. Resident #1 willingly gave up her cigarettes and was told they would return them when she discharged . Resident #1's FM was contacted and informed the facility intended on issuing a notice of discharge related to the safety of other individuals. Progress notes, dated 11/16/19, documented Resident #1 was observed smoking outside. Progress notes, dated 11/18/19, documented Resident #1 continued to smoke outside on facility grounds. Resident #1's FM reported the FM's home was not a safe discharge option for the resident and reported the concerns to the local community state case manager. The Interdisciplinary Team (IDT) was aware and working on discharge options. Progress notes, dated 11/21/19, documented staff had intervened with Resident #1's smoking three times that week on the facility property. Resident #1 stated she knew she was not supposed to smoke, but she did not care. The resident and FM indicated they were aware of the smoking policy. Progress notes, dated 11/21/19, documented Resident #1 had been observed on the side of the road smoking. Staff attempted to have Resident #1 sign a risk and benefit statement which the resident declined to sign without the FM. Resident #1's FM reported concerns about Resident #1 feeling harassed, threatened, singled out, and forced to follow the rules when she was off the property. The resident was placed on alert for psychosocial harm. The Facility's Risk vs. Benefit, dated 11/22/19, documented Resident #1 was independent with decision making and continued smoking with unsafe terrain when ambulating outside per PT (Physical Therapy), and was at risk for fall, fracture, head injury, or death. The interventions included allowing Resident #1 to make her own decisions to provide a sense of control and educate resident/family on possible outcomes of not complying with care. Progress notes, dated 11/25/19, documented Resident #1 continued to smoke. An order was received to discontinue the nicotine patch. On 11/27/19 at 2:55 PM, a staff member was observed smoking outside by the parking lot. The staff member was visible from inside the facility. The Facility's Nursing Smoking Screen, dated 12/06/19, documented Resident #1 smoked ten plus times a day, throughout the day. The screen documented the resident had no cognitive loss, visual deficits, dexterity problem, issues demonstrating safe smoking practices or additional risks that prohibited smoking. On 12/09/19 at 10:35 AM, Resident #1 said she smoked cigarettes regularly for many years. The resident said after she was admitted to the facility, she began smoking outside the building. Resident #1 said she did not realize it was an issue because she saw other residents and staff smoking outside the building. The resident said staff began to approach her to tell she was breaking the rules and could not be smoking. Resident #1 said she was told she could go off the property to smoke, which she then began to do. Resident #1 said staff approached her even when she was off the property. Resident #1 said, one time, she could see staff smoking and they came over to her and told her she could not smoke. Resident #1 said felt the staff were demanding and purposely intimidating to her when discussing her smoking. Resident #1 said she was always alone when they approached her and felt they were waiting for her to screw up. Resident #1 said it took a lot to intimidate her, but they succeeded in making her feel harassed and intimidated. Resident #1 stated, If they treated me like that, how do they treat the older ones who are ill, and she was tired of being apprehensive with her activity. Resident #1 was hesitant to say which staff made her feel intimidated, and adding she was scared she could be kicked out of the facility at any time. Resident #1 said Staff A, Administrator, was the staff member who contributed to her feelings of intimidation. On 12/16/19 at 2:21 PM, Resident #1 FM said Resident #1 was her own decision maker, had a long standing history of substance abuse, and had smoked cigarettes for many years. The FM said after Resident #1 was admitted to the facility, Resident #1 saw other residents and staff outside smoking. Resident #1 began to call her and asked the FM to bring her cigarettes many times a day. The FM said she spoke with the nurses on a few occasions and requested a nicotine patch. The nursing staff consistently told her since Resident #1 had not smoked for a while, the doctor would not prescribe the patch. The FM said no other smoke cessation or interventions were offered. The FM said she ended up bringing Resident #1's cigarettes after personally witnessing staff and residents smoking outside the building. The FM said Staff A contacted her on 11/11/19 and said they found Resident #1 smoking outside and asked the FM if she provided Resident #1 with smoking material. The FM said she told Staff A she did bring Resident #1 smoking materials. The FM said Staff A explained it was a non-smoking facility and that smoking was a dischargeable offense. The FM said she apologized for bringing in smoking material and discussed with Staff A how they would obtain the resident's cigarettes. The FM asked if the staff could search Resident #1's person and room for smoking materials. The FM said Staff A said yes. The FM said when she and Staff A met with Resident #1, the resident became upset when the FM asked for the resident's cigarettes and told Resident #1, Don't make them search you or your room, and Staff A nodded. The FM said Resident #1 handed over her cigarettes, and Staff A said the resident could have a cigarette with her FM present prior to turning over her cigarettes. The FM said as Resident #1 went towards the door with her cigarettes, Staff A stopped Resident #1 and told Resident #1 that it was not part of the deal to take her whole pack of cigarettes. Staff A told the resident she could have one cigarette and to give Staff A the pack of cigarettes, which the resident did. The FM said on 11/15/19, Staff A and Staff C contacted Resident #1's FM and told the FM Resident #1 continued to smoke outside and they would be discharging Resident #1 to the FM's house today. The FM said Resident #1's care plan reflected Resident #1 was not to come to her home upon discharge. Resident #1's FM said she explained her concerns to Staff A and Staff B, but was told they were sorry but that was just the way it was. After learning the facility is not allowed to discharge without proper notice, the FM said she made attempts to contact Staff A, but Staff A never returned her calls. The FM said when she went to the facility, Resident #1 had been made aware of the conversation related to her discharge. The FM said on 11/21/19, Resident #1 called the FM and reported Staff D, Admissions Coordinator, had approached the resident while she was off property and told Resident #1 to give Staff D her cigarettes. The FM came to the facility shortly after and observed Staff D smoking near the front of the building. The FM said when she asked Staff D about the incident, Staff D said she was told to go deal with Resident #1 by Staff [NAME] The FM said on 11/22/19, the FM told Staff A she had concerns about how Resident #1 was being treated. The FM said Staff A stated, If it's so bad here, why aren't you moving her out of here? The FM said she voiced concerns about staff smoking when residents could not smoke, and Staff A told her it was different for staff. The FM said she told Staff A she disagreed, and Staff A responded by telling the FM she enabled Resident #1 but would not let her live with her. The FM said she felt Resident #1 sustained ongoing bullying, harassment, and intimidation. The FM said Resident #1 had experienced weight loss and a nervous stomach as a result of her fear of harassment and intimidation. On 12/26/19 at 11:05 PM, Staff C said Resident #1 was found smoking outside on multiple occasions. Staff C said Staff A and Staff D had spoken with Resident #1 about smoking and the smoking policy on multiple occasions. Staff C said the resident continued to smoke. Staff C said Staff A, with Staff C present, called Resident #1's FM and [MEDICATION NAME] said they caught Resident #1 smoking again and the facility would be giving Resident #1 a notice of discharge. Staff C said Staff A did not provide details of what the discharge meant or when the discharge would occur. Staff C said no physical discharge notice was ever given or completed. At 11:35 AM, Staff D said she reviewed the smoking policy with Resident #1 prior to admission. Staff D said she did observe Resident #1 outside smoking in an area she thought was unsafe, by the road, so she approached Resident #1. Staff D said Staff A and Staff C had most of the discussions with Resident #1 and the FM related to smoking and the risk and benefits of continued smoking. At 12:20 PM, Staff E, Registered Nurse, said when a resident who smoked was admitted to the facility, the hospital usually ordered nicotine patches. Staff [NAME] said when a resident had been at the hospital for a few days, they would usually be done with craving cigarettes by the time they were admitted to the facility. Staff [NAME] said she was not aware Resident #1 smoked when she was admitted . After reviewing the admission assessment, Staff [NAME] said it was identified Resident #1 smoked a pack a day upon admission. Staff [NAME] said Resident #1 did not have an order for [REDACTED].#1 was told she could smoke off the property. At 12:40 PM, Staff A said the first time she was aware of Resident #1's smoking was on 11/11/19. Staff A said they made attempts to remind the resident it was a non-smoking facility and she was not allowed to smoke. Staff A said they never provided a discharge notice to the resident and that decision comes from corporate. Staff A said Staff C noted this discussion about discharge in the progress notes but that was wrong and she was never a part of that conversation. Staff A said when she spoke with the Resident #1's FM, she felt like she was going to be targeted, and the FM was irritated and yelling at her. Staff A said she tried to explain they were just trying to follow their policy. Staff A said she had little interaction with Resident #1 and her FM. Reference WAC 388-97-0180 (1-4)

Based on interview and record review, the facility failed to prevent the development of an avoidable pressure ulcer not present on admission to the facility for 1 of 8 sampled residents (#1) reviewed for pressure ulcers. This failure placed residents at risk for skin impairments, a change in health status, pain and a decreased quality of life. This caused harm to Resident #1. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS), an assessment tool, dated 01/17/19, documented Resident #1 had moderate cognitive impairment, required extensive to extensive assistance with activities of daily living, was at risk for pressure ulcer (PUs), and currently had an unstageable PU. Progress notes, dated 01/18/19, documented Resident #1 had a peripheral vascular access device (PVAD - catheter inserted into veins, may be called an IV or PIV) placed in her left posterior hand and secured with a dressing to prevent the resident from pulling at her PVAD. There was no orders place for monitoring PVAD site or flushing the PVAD during the timeframe of the PVAD placement. Progress notes, dated 01/21/19, documented Resident #1's PVAD was removed and an unstageable pressure ulcer, measuring 1.0 x 1.0 centimeters, was identified by the facility. The cause of the pressure ulcer was identified as pressure from the hub of the PVAD and a dressing holding the PVAD in place. The care plan, dated 01/25/19, documented Resident #1 was at risk for pressure ulcer with a history of skin breakdown on bony prominences. On 03/06/19 at 3:00 PM, Staff A, Director of Nursing Services, said the chart lacked any sign of regular monitoring the Resident #1's PVAD site or flushing of the PVAD. Staff A said this should have been done each shift. Staff A said the hospital wrapped the PVAD good on 01/18/19, and guessed the facility was not checking the site because it appeared Resident #1 had the same dressing on from the hospital. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to provide monitoring and care to prevent the development of a pressure ulcer for 1 of 5 sampled residents (#14) reviewed for skin issues. This failure placed residents at risk for inadequate skin care and skin breakdown. This caused harm to Resident #14 when an unmonitored and untreated pressure ulcer resulted in a [MEDICAL CONDITION]. Findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 8/23/17, documented Resident #14 was alert and oriented, and was independent in transfers and personal hygiene. On 12/7/17 at 1:00 p.m., when asked about any sores or wounds on her right leg when admitted to the facility, Resident #14 said, Before? Oh, no. It used to be pink, good color, no swelling. Resident #14 said one day she noted a spot of drainage on her sock. When asked if she told any of the nurses about it, she said, No, I was taking care of it. It was getting better. Then when I saw the drainage was getting worse I didn't know what to do so I stayed in the lobby until the nurse looked at it. On 12/7/17 at 1:30 p.m., when asked about the status of Resident #14's skin, Licensed Nurse (LN) A stated, She didn't have any sores on that (right) leg. I didn't do her skin checks but as far as I know she didn't have any concerns. When asked about treatments ordered for Resident #14, LN A stated, No. The other BKA (amputation) had been long healed. To my knowledge, nothing was wrong with her skin. LN A stated weekly skin checks are usually done on the days residents are showered. LN A stated Resident #14 is a very private person and doesn't like to take showers. LN A stated Resident #14 was independent with transfers and toileting, and the aides would provide assistance with set-up and Resident #14 did not want anyone in the room with her when she showered. LN A stated Resident #14 was pleasant and appropriate, and does her own blood sugars. We never had any reason to think anything was wrong. She had good communication with us except for the skin issue that occurred. LN A stated there had been an odor in Resident #14's room for a few weeks prior to discovery of the wound. LN A stated they had done a deep-clean of the room and resident's laundry., and management had provided an ionizer. LN A stated the smell would dissipate and then would come back again. LN A stated she was the one who found the wound on 11/23/17 when she was alerted by another staff member who noted a spot of drainage on the resident's foot, and a trail on the floor behind the resident in her wheelchair. LN A indicated she was asked to look at the resident's foot. When asked to describe the wound, LN A said, It was ugly. LN A indicated she wrote the dimensions in the chart, and it was an open wound with a foul odor. LN A said she notified nursing management, and the physician, wrapped the foot in gauze, and transported the resident to the hospital. LN A stated, I'm just so upset that happened. We didn't know. On 12/7/17 at 6:15 p.m., the Director of Nursing Services (DNS) said there was a strong odor in Resident #14's room that was part of my investigation. The DNS said when they cleaned the room, the odor got better. A nursing note, dated 11/14/17 at 1:32 p.m., documented, Resident room continues with increased foul odor, resident also with noted odor, declined offer of bath or clothing changes, no improvement of odor after housekeeping in to clean room. A nursing note, dated 11/23/17 at 12:39 p.m., LN A documented, (Resident #14) was noted by staff to have discolored area to plantar area sock of left foot. (Resident) was asked by this writer to look at her foot and a 5 cm x 7 cm necrotic (blackened dead tissue) ulcer was visualized by this writer. (Resident's) ulcer has necrotic slough and foul odor. This writer placed a clean Q-tip and noted a tunnel about 4.5 cm long that feels to end against bone. (Resident) states that it started as a small open area that resolved. (Resident) states, It must have opened back up. (Resident) states that she has [MEDICAL CONDITION] and could feel the wound with her finger. (Resident's) foot was wrapped with Kerlix and (Hospital) ER was called, given report concerning (resident's) wound. Message was left for DNS and Administrator was notified by phone. (Resident) was sent to (Hospital) ER for evaluation and treatment. Review of Resident #14's record documented readmission to the facility on [DATE] after a [MEDICAL CONDITION] on the limb where the wound was discovered four days prior. Reference WAC 399-97-1060(3)(b)

Based on interview and record review, the facility failed to ensure the safety of 1 of 4 sample residents (#19) reviewed for supervision to prevent accidents. This failure to transfer the resident with one staff member resulted in a fall from the lift, a neck fracture and other injuries. This caused harm to Resident #19. Findings include: Resident #19 was admitted to the facility in 2012 and had [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 6/8/17, documented the resident required extensive assistance of 2 staff members with most daily living tasks and bed mobility, and was totally dependent on staff for transfers to and from bed with the help of two people and a mechanical (Hoyer) lift. On 9/7/17 review of nursing notes and facility investigation documents noted Resident #19 incurred a fall on 9/3/17 at approximately 8:30 p.m. A statement by Nursing Assistant (NA) G included in the facility's investigation, documented, I took (Resident #19) to his room to get ready for bed. (NA E) said she will be right there. I hooked (Resident #19) up to the Hoyer and waited and waited but she didn't show up. I raised him in the air, he fell out of the sling on his head. I called for help. (Licensed Nurse (LN) G) and (another NA) came. I know I should have waited longer for (NA E). On 9/7/17 at 2:50 p.m., LN G stated she was the nurse on duty the evening of 9/3/17. LN G said she heard calls for help from Resident #19's room. When LN G entered the room, she stated she saw Resident #19 lying on the floor under the Hoyer sling, with his head on the large metal beam at the base of the Hoyer lift. LN G stated the sling was still attached to the lift by three corners, and one of the four corners was dangling. At 3:18 p.m., NA E said NA G had asked her for help with (Resident #19) on 9/3/17 and they agreed to meet in Resident #19's room as soon as NA E was done assisting another resident. NA E said after she had finished assisting that resident, her roommate also needed assistance to the bathroom. NA E said, I'm not going to leave her. I know she will self-transfer and will fall. While assisting the residents, NA E stated she heard yelling, and was told by a resident's family member that NA G had run out into the hall, yelling that she had dropped Resident #19. NA E said when she went into Resident #19's room, and saw Resident #19 on the floor under the Hoyer lift. LN G was on the floor next to him, and NA G was standing in the room, freaking out. NA E stated NA G said, I know, I know, I should have waited. When asked how NAs are trained to transfer residents using a mechanical lift like the Hoyer, NA E stated, with two people. NA E stated, I'm so upset she didn't wait for me. This all happened because of stupidity. The resident's medical chart noted Resident #19 complained of neck pain after the incident. Emergency services were contacted to transport the resident to the hospital for evaluation. Review of hospital emergency department records, dated 9/3/17 at 9:33 p.m., documented Resident #19 had injuries to his head, neck and left shoulder after he fell approximately 3 feet from a Hoyer lift and sustained a blow to his head. The resident's complaints of headache, back pain and tenderness over a hematoma (bump containing clotted blood within the tissue) on the right side of the back of his head was noted on his arrival. Resident #19 was admitted to the hospital for further evaluation. A hospital discharge summary, dated 9/6/17 at 12:53 p.m., documented Resident #19 had a Type 3 dens (vertebra) fracture, a Clay Shoveler's fracture (fracture on a different part of the vertebra), and a hematoma to the back of his head. The hospital documentation noted, after evaluation, Resident #19 was not found to be a surgical candidate. When Resident #19 returned to the facility on [DATE], orders for his care included strict bedrest and wearing a cervical (neck) collar for 6 weeks to allow the fractures to heal. The facility investigation into the incident documented NA G assisted Resident #19 to transfer via a Hoyer lift without a second staff member per facility guidelines, and did not completely secure the Hoyer sling with 3 of 4 hooks placed prior to using the lift. The facility documented NA G had asked for another NA to help her with the transfer, however NA G did not wait for the other NA to complete her current task, and transferred the resident independently. The facility noted, during the Hoyer lift transfer, the resident slid out of the lift sling and landed to the floor. Failure to ensure two staff members worked with this resident resulted injuries to the resident and placed residents who require the assistance of two or more staff at risk of accidents. This caused harm to Resident #19. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide restorative services for 1 of 1 residents (#31) reviewed for treatment/services to improve/maintain activities of daily living (ADL's). Failure to provide restorative services related to walking and transferring caused a decreased quality of life when the resident experienced a decline in the ability to walk and transfer. This caused harm to Resident #31. Findings include: Resident #31 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool, dated 8/15/17, showed Resident #31 was cognitively intact, required set-up assistance from staff for wheelchair locomotion and required extensive physical assistance with transfers from 2-plus people. The resident had not walked, had been in his wheelchair once or twice and had no qualifying restorative therapy during the 7 day lookback period for the MDS assessment. The resident's MDS, dated [DATE], showed during the 7 day lookback period the resident was independent and required no staff assistance with wheelchair locomotion and had no qualifying restorative therapy during the 7 day lookback period for this assessment. The resident's ADL care plan (CP), revised on 1/5/17, identified the resident had a self-care performance deficit and required assistance with transfers with a goal of the resident will maintain current level of assist of one to transfer through the target day of 9/4/17. The resident's limited physical mobility care plan, revised on 1/5/17, documented the resident Ambulates with four wheel walker with assist of one to two staff and Encourage to ambulate. The CP's goals included the resident would improve current level of function in functional ADL tasks (toileting, bed mobility, transfers) and would be assist of one for transfers, assist of one to two with ambulation using FWW, by a target date of 9/4/17. The CP interventions showed Nursing Rehab/Restorative staff were to provide restorative programs to the resident including active range of motion, a Transfer Program and a Walking Program. Each intervention was to occur 6 times each week. Nursing Assistant (NA) documentation in ADL tasks, between 8/17/17 and 9/15/17, indicated the resident was not out of bed for 23 of those 30 days. Between 2/2/17 and 9/18/17 there were 192 opportunities for restorative to provide planned restorative services to the resident. Restorative program documentation indicated services were not provided and offered to the resident for 161 of the 192 opportunities. Multiple observations on, but not limited to, 9/11/17 at 11:54 a.m. and 3:15 p.m.; 9/12/17 at 8:36 a.m., 1:02 p.m. and 4:11 p.m.; and 9/13/17 at 8:29 a.m., 9:26 a.m., 10:21 a.m., 11:23 a.m., 2:02 p.m., and 2:15 p.m., showed the resident lying in bed. Restorative documentation showed no attempts to provide restorative services to the resident during these dates. Restorative was not observed working with the resident during the survey period. On 9/13/17 at 11:46 a.m., NA K said Resident #31 had not been out of bed for about 1 ½ weeks. On 9/15/17 at 10:54, NA H stated he had not ever observed the resident working with restorative therapy. NA H said the resident required only stand by assistance from staff for transfers several months ago and currently required 2 staff members to actively assist him with transfers. At 10:50 a.m., Licensed Nurse (LN) I indicated he had not observed the resident walking for a long time. At 10:55 a.m., LN H said the resident probably should be removed from restorative. At approximately 11:00 a.m., the Physical Therapy Manager (PTM) stated Resident #31 was walking with assistance and required stand by or limited staff assistance with transfers when he finished physical therapy in January 2017 or early February 2017 and began restorative therapy. Failure to complete care planned restorative interventions resulted in the resident having a severe decline in physical function. This caused harm to Resident #31. WAC 388-97-1060 (2)(b)

Based on observation, interview and record review, it was determined the facility failed to ensure the safety of 1 of 4 sampled Residents (#1) reviewed for supervision to prevent accidents. This failure resulted in harm when the resident was turned in bed by one staff member, fell from her bed, and sustained a head injury. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS), an assessment tool dated 2/8/17, documented Resident #1 had functional limitations in range of motion of both her upper and lower extremities and was bedbound (was not transferred between surfaces such as to or from a bed, chair, wheelchair, etc.). The most recent MDS assessment, as well as previous assessments dating back to 4/27/12, documented Resident #1 required extensive assistance of 2 persons for assistance with activities of daily living and bed mobility. On 2/17/17 review of nursing notes and facility investigation documents revealed Resident #1 incurred a fall on 2/4/17 after 10:35 a.m., when Licensed Nurse (LN) A entered Resident #1's room to perform a dressing change. LN A documented Resident #1 was positioned on the left side facing the window, the LN had sufficient access to the wound and did not reposition the resident. According to the facility investigation, after LN A removed the old dressing, she turned around to obtain supplies to clean the wound when Resident #1 began rolling out of bed. LN A's nursing notes documented that she saw the resident's upper body go off the bed and then the lower part of her body. The LN tried to get a hold of the resident to prevent her falling but was unable. The LN documented that she heard Resident #1's head hit the floor and noted blood on the floor from the resident's head wound. LN A documented she yelled for help, and when other staff responded, NAs stayed with Resident #1 while the LN called 911 and prepared paperwork for the resident to be transported to the hospital. Review of the procedure note at the hospital dated 2/4/17 at 12:39 p.m., documented Resident #1's head wound was 4 cm (1.5 inches) long and required 10 sutures (stitches) to close the edges. On 2/17/17 at 1:25 p.m., when asked how the resident got the scab on her forehead, Resident #1 stated the nurse let me fall. I told her I was falling but she dropped me. At 2:37 p.m., LN B changed Resident #1's pressure ulcer dressing on her coccyx (tailbone) area while NA A assisted the resident with positioning. During the dressing change, Resident #1 was tearful and cried out several times, and said I'm falling and Don't let me fall. While NA provided reassurances to Resident #1 she appeared to remain afraid of falling during the dressing change. At 3:29 p.m., Resident #1's care plan to prevent fall or injury was reviewed with LN B, who acknowledged that the care plan called for 2 people when performing cares. On 2/17/17 at 3:36 p.m., about Resident #1 the Administrator stated, Yeah, she fell here. Failure to ensure two staff members worked with this resident resulted in harm and placed all residents who required the assistance of two or more staff members at risk of accidents.

Based on interview and record review, it was determined the facility failed to obtain medications in a timely manner for 1 of 4 sampled Residents (#1) reviewed for timely care and services. The failure to obtain medications to treat a urinary tract infection [MEDICAL CONDITION] resulted in harm to Resident #1 when she [MEDICAL CONDITION] (total body infection) and placed all residents at risk of the same/similar deficient practice. Findings include: On 11/14/16, review of Resident #1's record indicated she was admitted to the facility on [DATE] with multiple health conditions that included dementia and insulin dependent diabetes. The Minimum Data Set (MDS), an assessment tool dated 8/5/16 documented Resident #1 was significantly cognitively impaired and required extensive assistance with activities of daily living. Review of Resident #1's record documented that on 11/1/16 the resident was becoming lethargic, with decreasing appetite and required prompts and assistance to eat and drink; the MDS documented that Resident #1 normally ate and drank with set-up and supervision. On 11/1/16, the physician was contacted and an order received to draw labwork and get a urine sample. A nurse's note dated 11/2/16 at 4:30 p.m. documented Resident #1 was transported to the local hospital due to abnormal lab values. Review of hospital emergency room (ER) documentation dated 11/2/16 at 7:54 p.m. indicated Resident #1 was obtunded (mentally dulled or with diminished awareness), urinary tract infection, severely uncontrolled diabetes and shock due to dehydration and acute kidney injury. The physician assessed Resident #1's infection as quite [MEDICAL CONDITION], requiring treatment with double antibiotics and admission to the intensive care unit (ICU). On 11/3/16 the hospital progress notes revealed Resident #1's condition was improving, and she was starting to eat. The resident was noted to have ESBL (type of superbug UTI and very resistant to many antibiotics). On 11/4/16, Resident #1 was discharged and returned to the facility just before shift change at 2:00 p.m. with orders to continue on oral antibiotics two times a day for 6 more days. A facility nurse's note dated 11/4/16 at 10:31 p.m. documented the new orders were put in the system and orders sent to the pharmacy. The following afternoon on 11/5/16 at 1:23 p.m., a nurse documented Resident #1's antibiotic was not given: None from hospital and none in Pixis (an automated medication dispenser), waiting for delivery. At 8:04 p.m., a nurse documented Resident #1's antibiotic was not given: Waiting for medication to be delivered. Two days after the antibiotic order on 11/6/16 at 2:47 a.m., a nurse documented Resident #1's . [MEDICATION NAME] (antibiotic) has not arrived from pharmacy. At 3:10 a.m. Licensed Nurse (LN) B documented a conversation with the consulting pharmacist where a local pharmacy would be called in the morning to have the medication sent right over. At 3:10 a.m., LN B's note documented Resident #1's physician was notified the resident had missed two doses of [MEDICATION NAME] (antibiotic). In a late entry for 6:00 a.m. (written 11/6/16 at 4:32 p.m.) LN C documented the pharmacy was to deliver the antibiotic by 9:00 a.m. At 11:00 a.m., the LN documented no local pharmacies had the medication in stock, the pharmacy needed to look into some notes and would call the LN back. The LN agreed. At 6:14 a.m., nursing documented RN assessed Resident, we got 180 cc (3/4 cup) of water this shift. At 1:21 p.m. LN C documented Resident #1 continued to be lethargic, mostly nonverbal, had sunken in eyes and decreased skin turgor (an assessment of decreased hydration). At 1:54 p.m., the nurse documented Resident #1 received a small portion of five crushed medications, but spit most of it out. The nurse's note 1:54 p.m. continued that the Resident #1's antibiotic was not given because have not received yet, waiting for call back from MD. According to a nurse's note dated 11/6/16 at 3:05 p.m., LN C spoke with the on-call physician responsible for Resident #1's care, and requested an antibiotic in tablet form and IV fluids. The on-call physician ordered Resident #1 be transported to the hospital ER for evaluation. Review of hospital documentation dated 11/6/16 showed on arrival Resident #1 was unresponsive and severely dehydrated with severely high sodium and blood sugar levels, had [MEDICAL CONDITION] with UTI, and a new acute kidney injury. The hospital documentation noted Resident #1's skin was pale and dry and her mucous membranes were dry, indicators of dehydration. The physician also noted the resident had not received her antibiotics for the UTI since being discharged from the hospital on [DATE]. Resident #1 was treated at the hospital for five days with antibiotics, fluids and other medications to correct the electrolyte abnormalities and received a blood transfusion. On 11/11/16, shortly before 2:00 p.m., Resident #1 was discharged from the hospital back to the facility with a central line (a large diameter IV which delivers potent IV medications into the large vein above the heart), for administration of IV antibiotics to treat the resident's severe UTI. On 11/14/16 at 1:45 p.m., Resident #1's Medication Administration Record [REDACTED]. When asked how many doses of the antibiotic [MEDICATION NAME] were administered to Resident #1, LN A stated that from Friday until the resident was sent out on Sunday, she had missed 3 doses. The LN stated that at that point the on-call physician was contacted with orders to send the resident to the hospital. When asked why the [MEDICATION NAME] was not given, LN A stated the pharmacy said it wasn't available so they didn't send it. The LN stated at one point a nurse was told it was on the way. The LN stated that before Resident #1 returned to the facility on [DATE], after the second hospitalization , facility staff contacted the pharmacy to make sure the ordered antibiotic was in stock and available. Review of the facility's investigation documented education was provided to nursing staff on 11/7/16 indicated when receiving new medication orders, to obtain an estimated delivery time from the pharmacy. If the drug is not available by the first ordered dose, staff are expected to contact the pharmacy for an estimated time of delivery and immediately inform the physician. The resident incurred harm when the facility failed to recognize and act on Resident #1's deteriorating health status when it failed to aggressively pursue acquisition of ordered, necessary antibiotics or to request a substitute medication to treat Resident #1's severe and resistant infection. This failure resulted in deterioration of the resident's health status such that she required an additional five days in hospital, placement of a central line and continuation of IV antibiotics after discharge.

Based on observation, interview and record review, it was determined the facility failed to monitor and intervene for weight loss and ensure implementation of dietician recommendations for 3 of 4 residents (#88, 118 and 11) reviewed for nutrition. This resulted in actual harm to Resident #88, when he experienced severe weight loss over a 4 month period. These failures placed residents at risk for experiencing unintended weight loss, delayed healing and/or decline in condition. Findings include: <Resident #88> Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS, dated [DATE], documented the resident required extensive two person assistance with bed mobility, toileting and transfers. The diet order, on admit, was for enhanced meals (extra calories added to meals through foods such as butter, cream, and gravy), mechanical soft texture and regular consistency liquids. No other diet specific orders were listed. The care plan for alteration in nutrition documented, on [DATE], the resident was to eat in the dining room and required assistance with set up and encouragement to eat. The resident's admission weight on [DATE] was 148.9 pounds (lbs.). Weights were documented taken once monthly in January and February 2016. The [DATE] weight, dated [DATE], was documented at 156.0 lbs. The [DATE] weight, dated [DATE], was documented at 137.4 lbs., an 18.6 lbs. and 11.9% weight loss from March. Another weight was not documented until [DATE] with additional weight loss recorded. On [DATE], the weekly wound log documented a 3 centimeter (cm) long x 3 cm wide and 0 cm deep, stage 2 pressure ulcer to the coccyx, identified on [DATE]. On [DATE], the weekly wound log documented the depth of the wound had increased to 0.2 cm. Additional nutritional interventions to support wound healing were not implemented until [DATE], which was 37 days after the initial weight loss of 18 pounds was identified on [DATE]. On [DATE], the resident's documented weight was 128.9 lbs., a 27 pound or 17.3% weight loss from [DATE]. A nutrition progress note, dated [DATE], documented, Resident's weight continues to trend down [DATE] 126.7(pounds) .6 month weight is down from 148.9, or about 22.2(pounds) = to (about) 14.9%. This is not planned nor desirable . On [DATE] at 11:37 a.m., the spouse of Resident #88 stated Resident #88 had poor food intake and required encouragement to eat which she provided each evening while visiting. On [DATE] at 4:30 p.m., the spouse of Resident #88 was observed waiting for the resident to awake and be readied for the dinner meal. She stated I have to help him eat more so I come every evening. On [DATE] at 4:20 p.m., the Registered Dietician (RD) stated the resident had been on enhanced meals since admission and had Med Pass 2.0, a nutritional supplement, added in June. She was unsure of other interventions that went into place after the identified weight loss. The RD said Interdisciplinary Team (IDT) meetings regarding nutrition and weight loss should be documented in IDT progress notes. There was no documentation found during chart review to show other interventions had been addressed. At 4:48 p.m., the RD stated other than the enhanced meals and a dental exam, she did not believe any other interventions were put into place following the identification of weight loss in April. The resident developed a wound shortly after and then Juven was started to support wound healing. The RD stated the goal for the resident's weight was to not go down but to sustain or go up. No progress notes regarding weight loss were documented for the month of April following the identified weight loss. On [DATE] at 11:31 a.m., the Corporate Nurse Consultant (CNC) stated normally after an identified weight loss the resident should be re-weighed. If weight loss is determined, the resident should be put on weekly weights. The RD would be notified and the IDT would meet to make a plan. On [DATE], Licensed Nurse (LN) D stated a large weight loss could be a discrepancy so staff should re-weigh to verify actual weight loss. LN D stated she looked at the mouth of Resident #88 when he showed a decreased interest in eating. The resident wore dentures and he would not open his mouth. The LN asked for a speech consultation and it was determined the resident was much happier with no dentures at all. About the same time, [MEDICATION NAME] (an antidepressant with appetite stimulation properties) was increased. LN D stated, The resident had a total turn around since those two interventions went into place. The [DATE] physician orders [REDACTED]. On [DATE], a speech therapy recommendation for discontinued use of the upper and lower dentures for eating , to promote increased food intake and efficiency, was documented in the physician orders. On [DATE] at 12:08 p.m., the CNC stated IDT notes regarding the weight loss should be documented. The staff should have re-weighed the resident and it looked like that didn't happen. The resident should have then been put on weekly weights and the RD and doctor should have been notified. <Resident #118> Resident #118 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The Residents Minimum Data Set, an assessment tool dated [DATE], indicated the resident needed set-up and supervision or cuing during meals. Resident #118's Nutritional Care Plan, dated [DATE], documented a goal that resident will maintain adequate nutritional status as evidenced by maintaining weight. Resident #118's recorded facility weights showed a significant decline in weight since her admission to the facility as follows: [DATE] 314 pounds [DATE] 278.4 pounds [DATE] 265.2 pounds From [DATE] to [DATE] the resident lost 35.6 pounds, which was 11.3% of her body weight. From [DATE] to [DATE] the resident lost 48.8 pounds, which was 15.5% of her body weight. Review of Resident #118's Medication Administration Record [REDACTED]. The resident's Nutritional Evaluation, dated [DATE] and conducted by the RD, documented the resident's goals were to improve labs, improve skin issues, weight to trend down, and increase strength. The RD documented nutritional recommendations which included adding vitamin D, adding Juven (a protein supplement)and add double protein sources at meals. Review of Resident's #118's June and July Physician orders [REDACTED]. On [DATE] at 4:03 p.m., the RD agreed the recommended nutritional interventions had not been implemented for Resident #118. The RD stated, I go straight to (the physician) with important things like this and she will tell me yes or no. The RD stated she was not sure if she spoke with the physician about Resident #118 and was unable to identify any documentation which indicated the physician was aware of the nutritional recommendations. At 4:21 p.m., the CNC indicated that after the RD does their review, they write a summary sheet which is placed in the unit manager's box. The unit manager then reviews and follows up with the physician to identify whether or not to carry out the interventions. The CNC stated, starting this week, we have changed that process. By the resident's discharge on [DATE], the facility failed to act upon the RD's recommendations to support the nutritional needs of Resident #118. <Resident #11> A record review of the MDS history indicated Resident #11 was admitted to the facility on [DATE] and had multiple discharges to the hospital and re-admissions to the facility. The most recent discharge was on [DATE] and the resident was readmitted to facility [DATE]. A record review of weight summary indicated Resident #11 had a significant weight loss of 21 pounds (16.9%) over a 180 day period from [DATE] through [DATE]. An additional weight on [DATE] was 118 pounds which was down 5 pounds from the previous week. In interview on [DATE] at 4:36 p.m., Resident #11 reported not liking to eat but that s/he liked the health shakes. In interview on [DATE] at 9:25 a.m., LN A reported Resident #11 was barely eating when s/he came back from hospital on [DATE]. LN A went on to state that Med Pass (a shake to supplement calories and protein) and enhanced diet (fortified with calories and protein) were started [DATE] for the resident which was almost 4 weeks after Resident #11 had readmitted . A review for weight loss intervention revealed in [DATE] Resident #11 was receiving Med Pass and Health Shakes for weight loss. [DATE] Resident #11 was receiving Med Pass and Health shakes prior to transfer to hospital when they were discontinued [DATE]. These did not resume when Resident #11 readmitted [DATE]. A physician order [REDACTED]. IDT progress note dated [DATE] at 2:56 p.m. noted significant weight loss over 180 days. Note goes on to state diet changed to Enhanced and Med Pass added. Record review of skin and weight meeting minutes, dated [DATE], listed this week's recommendations for Resident #11 diet enhanced and Med Pass was to start [DATE]. Fax to physician. Facility form titled Skin & Weight Meeting stated the team will ensure there is an appropriate intervention in place. Interventions may include supplement or diet change.

Based on observation, interview and record review, it was determined the facility failed to identify and/or prevent and treat pressure ulcers for 5 of 5 resident's (#88, 35, 61, 91 &117) reviewed for pressure ulcers. This failure caused harm to Resident #88 when s/he developed a new and painful pressure area. This failure caused harm to Resident #35 when s/he developed an unstageable pressure ulcer. These failures placed all residents at risk for acquiring pressure ulcers and/or experiencing treatment delays. Findings include: <Resident #88> Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), an assessment tool dated [DATE], documented the resident required extensive two person assistance with bed mobility, toileting and transfers. The care plan for impaired skin integrity, dated [DATE], included the staff were to assist the resident with repositioning, to keep skin clean and dry, a low air loss mattress was to be used, the resident will be up in his wheelchair three times daily to maintain skin integrity as he allows and to follow treatment per physician orders. On [DATE], the weekly wound log documented a 3 centimeter (cm) long x 3 cm wide and 0 cm deep, stage 2 pressure ulcer to the coccyx, identified on [DATE]. The log entry documented the wound developed in house and was painful to the resident. A fax to the physician, dated [DATE], documented the resident had an open area on the coccyx measuring 3 cm x 3 cm. The wound was dark in color and was painful to the touch. The resident also had a second area on the right buttock which looked like a skin sheer and measured 2 cm x 2 cm. The fax stated the resident had been up in his wheelchair for longer periods of time working with physical therapy (PT). PT will evaluate the chair for a better suited set-up for his needs. On [DATE], the weekly wound log documented the depth of the wound had increased to 0.2 cm and was a stage 3 pressure ulcer which caused pain to the resident. The [DATE] wound documentation indicated the wound had improved and was causing episodic pain to the resident. The [DATE] wound log was created but no information was documented on the form. On [DATE] the wound log documented the wound was nearly resolved with no open area. The [DATE] Treatment Administration Record (TAR) documented the wound treatment and prevention orders were not regularly completed as ordered for a variety of reasons to include resident refusals. On [DATE], the wound log documented a stage 2 wound on the gluteal fold that measured 0.7 cm x 0.2 cm x 0.1 cm. with episodic pain to the resident. On [DATE] at 11:37 a.m., the spouse of Resident #88 stated the resident's wheelchair had been giving him sores and he needed to be put back into bed right after meals. The resident was to get a new chair but she was still waiting to hear back on when he would get it. It had been a several month process. On [DATE] at 11:32 a.m., Licensed Nurse (LN) D stated when a wound is identified the nurse should make a log in the 24-hour report and document it in the progress notes. The Director of nursing and physician would be notified. The LN indicated she may make suggestions to the doctor since she could see the wound and get the okay to put them into place. LN D stated the resident had been having issues with his wheelchair and it may have been the cause of the skin issues. The resident just in the last couple of days got a whole new wheelchair because that may have been the cause of the problem. <Resident #35> Resident #35 was admitted to the facility in 2009 with multiple medical [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], documented the resident was at risk for pressure ulcers and required extensive assistance for all activities of daily living (ADLs). On [DATE], a Braden Scale (which predicts pressure ulcer risk), indicated the resident was at high risk for developing pressure ulcers. A Weekly Wound Log, dated [DATE], documented, shearing (pulling forces which move skin in an opposite direction of supporting tissues) area to right buttock. Review of Resident #35's progress notes showed documentation of ongoing redness to the resident's buttocks from [DATE] through [DATE]. A progress note dated [DATE], documented, on alert for small open area to right buttocks, appears to be a couple layers of skin are gone. On [DATE], a progress note documented the area to Resident #35's buttocks measured 3.8 centimeters (cm) wide by 1.8 cm long and 0.1 cm deep. The note documented the area had a small amount yellow adherent slough (dead tissue). Resident #35's Potential for Impaired Skin care plan, initiated [DATE] and reviewed [DATE], documented a goal that the resident would not have any skin breakdown through the next review period. The care plan did not identify the resident's persistent redness to her buttocks or the eventual skin breakdown to her buttocks. No new interventions related to the resident's skin were identified since the last review date of [DATE]. Review of Resident #35's TAR showed no interventions in place to treat the buttocks wound from [DATE] to [DATE]. On [DATE] an order to monitor skin to coccyx every shift was instituted. A treatment (other than monitoring) for the resident's buttocks skin impairment did not start until [DATE] when a dressing was placed after the area progressed from persistent redness to open with slough on the wound bed. On [DATE] at 11:46 a.m., observation of Resident #35's wound was conducted with LN D. The area to the right coccyx area was open and the wound bed was obscured by slough. The wound had a scant amount of drainage and the dressing had been changed that morning. At 1:45 p.m., the Corporate Nurse Consultant (CNC) indicated she was aware of the resident having an open area related to shearing (pulling forces on the skin) but was unaware of any persistent redness to the resident's buttocks prior to the open area developing. The facility failed to aggressively intervene when a resident at high risk for developing pressure ulcers had documented persistent redness to her coccyx. This caused Resident #35 harm when the facility failed to treat the persistent redness and the area developed into an unstageable open area to her buttocks. <Resident#61> Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], documented the resident had a history of [REDACTED]. The nursing home admit orders, dated [DATE], sent from the hospital ordered an air overlay mattress, frequent turns and bridging every ,[DATE] hours, to float heels off of pillows and an air cushion in the residents wheelchair. Wound care orders for two-stage 2 pressure ulcers on the spine of [MEDICATION NAME] (a non-adhering wound dressing) and [MEDICATION NAME] Gentle (a foam wound dressing) were ordered. The orders also included a note indicating, May be a good idea to cover spine (with) foam even after heals. Only the air overlay mattress portion of the listed orders was highlighted. The admission nursing assessment, dated [DATE], documented, .pressure sores to spine on admit . No other nursing wound documentation was located in the resident record or provided by the facility. A progress note, dated [DATE], stated the resident was, .2 extensive assist with transfers skin is fragile air mattress on bed . On [DATE], a progress note documented, .noted (stage) 2 pressure ulcer as documented from hospital to spine one measures 2x2 .other area measures 1x1 . No other progress notes documented the status of the pressure ulcers on the resident's spine. A physician order, dated to start two weeks after admission on [DATE], ordered a wound dressing to the mid spine to be changed every day. Cleanse with normal saline apply [MEDICATION NAME] cover with foam dressing - may change as needed when soiled or dislodged. The resident expired on [DATE]. On [DATE] at 3:19 p.m., the Corporate Nurse Consultant stated the physician orders [REDACTED]. She did not know why only two of the wound orders were highlighted and implemented. The wound care should have started the day of admit. <Resident #91> Resident #91 admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool dated [DATE], documented the resident required extensive assistance for his Activities of Daily Living (ADLs) and was at risk for developing pressure ulcers. Progress notes, dated [DATE], documented Resident #91's heels were intact and firm, indicating no skin impairment to the heels upon admission. Resident #91's Potential for Skin Impairment Care Plan, dated [DATE], did not list any goals and only listed one intervention which was a providing a pressure-reducing wheelchair cushion. Review of the resident's progress notes from admission to [DATE] do not document floating the residents heels or providing any additional protection to the resident's heels to prevent skin breakdown. On [DATE], a progress note documented the resident had developed fluid filled blisters to each heel. A progress note dated [DATE] documented the left heel pressure ulcer was much worse than (the) right, left heel has dry intact eschar (thick, leathery, dead tissue). On [DATE] at 10:27 a.m., when asked what interventions were in place to prevent skin impairments such as heel blisters, the Corporate Nurse Consultant (CNC) stated, I don't know what interventions were in place before the wounds developed. At 10:56 a.m., the CNC stated I cannot confirm or deny what interventions were in place (regarding the heel blisters). The facility failed to have preventative measure in place to prevent skin impairment in a resident who was identified as having a high risk of developing pressure ulcers. <Resident #117> Resident #117 admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #117's MDS dated [DATE], documented he required limited assistance with his ADLs and was at risk to develop a pressure ulcer. Resident #117's admission nursing note, dated [DATE] at 20:41 p.m., documented, gluteal left area pink, blanchable, no open area but appears fragile skin. A progress note dated [DATE] at 4:26 p.m., documented, MASD (Moisture associated skin [MEDICAL CONDITION]) to peri rectal area from loose stools. Progress notes throughout the resident's stay document ongoing loose stools related to the medication treatment for [REDACTED]. The resident's care plan, dated [DATE], identified the MASD and documented a goal of, resident's skin will heal by review date. On [DATE] a Weekly Wound Log documented the resident had developed two stage II pressure ulcers. The log described the wounds as small openings below and on the coccyx which measured 0.3 centimeters (cm) by 0.2 cm and 1 cm X 0.3 cm. Review of Resident #118's June Treatment Administration Record (TAR) did not show any treatment or monitoring in place to the resident's buttocks to prevent the area from worsening after it was identified as fragile upon admission and subsequently developed MASD and two pressure ulcers. The June TAR did not document any treatment or monitoring to the resident's coccyx after the stage 2 pressure ulcers were identified.

Based on interview and record review, it was determined the facility failed to assess for change in condition, perform blood tests as ordered, recognize unresponsiveness and seek immediate help for 1 of 1 former Residents (#1) reviewed for necessary care and services. This failure resulted in a delay in recognition, assessment and timely treatment of [REDACTED]. This failure delayed needed care/treatment that resulted in harm to Resident #1 and placed all residents at risk of the same/similar deficient practice. Findings include: Former Resident #1 was admitted to the facility on [DATE] with multiple medical conditions including deep blood clots to both legs. She was to receive surgical wound care following debridement (removal of dead tissue) of a right thigh wound. The resident was alert, oriented and able to communicate her needs. Once her wound healed, she was to return home. <Significant Change in Condition> On 5/19/16 at 10:00 a.m., during interview with a family member who visited Resident #1 daily, it was learned the resident had a change in condition several days prior to discharge to the hospital on [DATE]. According to the family member, the resident had been nauseated, vomiting the last week with reduced oral intake .she would normally eat anything you put in front of her .she had personality changes, more confused, unable to sign her name as she normally did, forgetting to chew her food and could not color in books as precisely as she had been doing. The resident's mental status and physical function had noticeably deteriorated and the facility had been informed of the resident's changes in condition yet no assessment or documentation about the resident's change in function and mental status was in the record. On 5/17/16 review of the Nursing Note (NN) dated 3/10/16 indicated the Resident's appetite decreased past three days from 50% to less than 25% . A late entry NN dated 3/14/16 (three days after the resident passed away on 3/11/16) by Licensed Nurse (LN) A (no times) indicated the resident had been nauseated and vomited yet there was no documentation to indicate this problem existed or other changes in condition had occurred other than received call from the wound clinic not to send her (Resident) if she is still vomiting . On 5/4/16 at 10:00 a.m., during interview with the wound clinic staff member, it was learned the resident could not be moved from the transport van to the wound clinic office on 3/11/16 because she was not alert enough to consent to treatment nor could she stand to transfer as she had done on previous weeks. When asked if this was normal behavior for the resident, staff said, No, not at all. She (Resident) is usually very jovial, talkative and was a pleasure to visit with during her treatments .but she was unresponsive this time .maybe over-sedated . On 5/17/16 at 3:30 p.m. during interview with LN A, she said the Nursing Assistant (NA) had reported to her that the resident had vomited the morning of 3/11/16, had not eaten breakfast, was drowsy and that she gave 2 narcotic ([MEDICATION NAME]) pain pills to the resident prior to leaving the facility for the wound clinic. She said she had not seen the emesis as the aides had cleaned up the resident before she got in the room and she had not reported the resident's condition to the physician and had not assessed or documented the resident's changes in condition so the resident could receive timely evaluation and treatment. In addition, no documentation regarding the resident's change in condition prior to leaving or upon returning from the wound clinic to the facility on [DATE] at 11:30 a.m. was found. A NN for 11:52 a.m., indicated Licensed Nurse (LN) B: received a report to help in room .walked into room, resident non-responsive to verbal/physical stimuli, did not move or grimace to deep painful touch; not responding to loud verbal stimuli; family in agreement to send to hospital; call placed to doctor's office and received order to send to the hospital . The hospital emergency room (ER) physician's note indicated the resident arrived on 3/11/16 at 12:15 p.m. The ER physician's assessment indicated the resident had extensive [MEDICAL CONDITION] (bleeding in the brain). The resident was admitted to the Intensive Care Unit (ICU) and passed away on 3/11/16 from extensive bleeding in the brain. On 5/17/16 at 3:45 p.m., the Director of Nursing Services (DNS) said she had reviewed the resident's record, spoke to staff and acknowledged the Resident's changes in condition had not been assessed, reported and documented. <physician's orders [REDACTED]. The record indicated the physician prescribed a daily blood thinner medication ([MEDICATION NAME]) to prevent further blood clots; obtain a PT/INR blood test before weekly transport to the wound clinic and to monitor for signs and symptoms of bleeding. On 5/17/16 at 3:30 p.m., during interview with LN A, she stated she was not aware of the physician's 1/15/2016 order (in the physician orders [REDACTED]. The PT ([MEDICATION NAME]) measures the time it takes for the liquid portion (plasma) of blood to clot. The normal PT reference range is between 11 and 13.5 seconds. The INR (Internationalized Ratio) measures how fast the blood clots. A therapeutic INR level is between 2-3. On 5/4/16 at 10:00 a.m., during interview with the wound clinic staff member, she said no paperwork/PT/INR was faxed as ordered prior to the wound treatment nor was any paperwork sent with the resident for the 3/11/16 visit. The previous INR level on the 3/4/16 wound clinic visit was 2.9 and was considered to be in the therapeutic range of 2-3 for the resident. The ER physician's note indicated the resident arrived on 3/11/16 at 12:15 p.m. The ER physician's assessment indicated the resident had unequal pupils, was non-responsive, snoring respirations, in critical condition, had a CH (Critically High) INR level (10.27) and a Pro-time of 78 with extensive [MEDICAL CONDITION] (bleeding in the brain). The resident incurred harm when the facility failed to: 1) Recognize, assess, ensure treatment when changes in the resident's mental and physical function were reported and/or observed. 2) Consult with the physician regarding the resident's nausea, vomiting and change in function. 3) Identify the resident's need for medical evaluation related to changes in function such as decreased appetite, change in daily routine, nausea/vomiting and decline in normal mental and physical functioning 4) Accurately and consistently document the Resident's changes in condition in the medical record. Refer to F 514

Based on observation, interview and record review, it was determined the facility failed to ensure 1 of 3 sampled Residents (#2) was supervised to prevent repeated falls and injury. This failure resulted in harm to Resident #2 when she suffered a head injury and needed 11 sutures to close the wound; fell again with head and facial trauma resulting in sutures to her lip/right hand and missing front tooth and when she was transferred to a new room without a functioning call light. This failure created the potential for repeated harm to this resident and placed to all residents in the facility at risk from the same/similar deficient practice. Findings include: Resident #2 was admitted to the facility from the hospital on [DATE] with multiple medical conditions including recent surgery to a pressure injury on her coccyx and right elbow; urinary tract infection (UTI); Parkinson's; dementia; incontinence and history of falls with recent pubic and sacral fractures. The resident required extensive assistance for transfers, toileting and mobility and was assessed as high risk for repeated falls due to decreased cognition, poor safety awareness and decline in physical ability. She could make her needs known. On 5/4/16 at 2:15 p.m., during observation and interview, Resident #2 had bruising to the left side of her face. Staff members said the resident had incurred some falls. Review of the Fall Risk assessment dated [DATE] indicated: A score of 10 or more was a High Risk for falls and MUST BE care planned. The resident's Fall score on this date was 17. The care plan indicated a low bed, personal alarms on bed and chair, and monitor bed positioning frequently. On 5/4/16, review of the records for 3/1/16 at 4:00 a.m., indicated the resident had an unwitnessed fall from bed and was found with her head resting on the bedside table in a pool of blood. The resident was assessed in the emergency room (ER) to have a large, 8 centimeter (cm) laceration to the left side of her head that required 11 sutures to close. After the fall on 3/1/16, the care plan was updated to include frequent visual checks and non-skid socks at all times. According to the record, on 4/22/16 at 4:00 a.m., the resident was found with discoloration to her left upper extremity measuring 10 cm x 7 cm. No determination was made about how the injury occurred. Documentation continued on 4/22/16 at 7:30 p.m., the resident was found on the floor, face down bleeding from her head and face. A staff member documented she saw the resident at 7:05 p.m .She (Resident) was trying to get up. I told her I would get her up in a little bit . which prolonged assistance to a resident who already had incurred harm from previous falls. T he resident was transferred a hospital with Facial Trauma/Head Injury. She returned with sutures to her lip/right hand; missing front tooth and swelling/bruising to her face. The care plan was not updated/revised since 3/1/16 to ensure supervision/safety measures were in place to prevent repeated falls and serious injuries. On 5/4/16 at 2:35 p.m., staff members were observed to move the Resident to a new room. The Resident was observed in bed with the call light hanging on the wall. When asked about the resident's need for a call light to summon help when needed, Licensed Nurse (LN) C attached the call bell to the resident's pillow. When asked if the call bell accommodated the Resident's ability to use it, the LN found there was no button in the call bell cover and would have been non-functioning if the resident used it. Failure to ensure the resident was supervised for safety; that care plans were updated/revised and that a functioning call bell was provided to the resident created the potential for repeated falls and injuries to the resident.

Based on observation, interview and record review, the facility failed to provide necessary supervision to ensure resident care was provided in accordance with the plan of care for 1 of 5 residents (#1) reviewed. Failure to adequately supervise Resident #1 who was known to be unsafe to consume hot beverages, had a known spill and staff did not thoroughly assess the resident immediately for potential hot liquid burns which resulted in harm to Resident #1 when he sustained second degree burns. Findings include: Resident #1 was re-admission on 1/22/13 with [DIAGNOSES REDACTED]. On 10/02/13 between 1:00 p.m. and 1:50 p.m., another resident reported to LN A (Licensed Nurse) that Resident #1 threw a coffee cup while sitting in his wheelchair at the front entrance. The nurse picked up the cup and mopped up the coffee that spilled on the floor. The cup matched the facility's coffee cups. On 10/02/13 between 1:00 p.m. and 1:50 p.m., LN A in a statement indicated she did not see any coffee on the resident at this time. Later at 1:50 p.m., an NA (Nursing Assistant) was placing the resident in bed and she noted that Resident #1's sweater was damp and smelled of coffee. Shortly after that, it was discovered that Resident #1 had a reddened area with an irregular shape measuring approximately 27 X 5 cm along the lower abdomen with a blistered area of 2 X 3 cm on left lower abdomen. On 10/15/13 at 11:00 a.m., Resident #1 was observed to have a dark pinkish red area approximately 27 X 5 cm with an irregular shape, along lower abdomen with a 2 X 3 cm open area with small amount of dark brownish scab around periphery of open area. Open area was covered with white cream and an unsecured abdominal pad. During staff interviews on 10/15/13 between the times of 11:00 a.m. to 12:20 p.m., all staff including: Administrator, Director of Nursing, ADON (Assistant to Director of Nursing), LN A and NA A were unable to identify where Resident #1 obtained the hot cup of coffee that burned his abdomen on 10/02/13. Resident #1's record indicated a "Smoking and Hot Beverage Safety Evaluation" was completed and dated 1/22/13. Resident #1 was an "8" which indicated that "Resident is unable to consume hot beverages safely independently. Resident requires supervision...while consuming hot beverages." During random observations at the front desk where the incident occurred, on 10/15/13 between the times of 11:00 a.m. to 12:20 p.m., staff members at were not actively supervision residents who were sitting in their wheelchairs at front entrance area. In addition, nurses behind the front receptionist area were occupied reviewing and writing in charts. As a result, the residents sitting at the front entrance area, where Resident #1 was sitting when he threw the coffee cup that resulted in second degree burns with blisters, could not be visualized at all times by facility staff. On 10/15/13 at 11:45 a.m., ADON confirmed that the tool utilized to communicate revision of care after an unusual occurrence was the care plan that can be found in a resident's chart. The revised care plan dated 10/02/13, which included nursing [DIAGNOSES REDACTED]. Staff was unable to access and view the revised care plan that included the following interventions: "1. Smoking/ Hot Beverage Assessment which directed staff regarding care to be provided, and 2. Notify MD PRN, and 3. Therapies as ordered." Although the burn incident occurred thirteen days prior and Resident #1 was identified at risk for injury from hot beverages, the revised care plan to direct staff to supervise the resident, was not in the resident's chart where it could be utilized by staff members to direct resident care. .

Based on observation, interview and record review, it was determined the facility failed to conduct ongoing assessments to evaluate resident clinical condition, define and implement interventions consistently, recognize standards of practice, monitor and evaluate the impact of interventions and/or revise interventions appropriately to provide timely necessary treatment and services to ensure that a resident without a pressure ulcer did not develop one, and to promote healing when a pressure ulcer did develop in 1 of 3 residents (Resident #161) reviewed for pressure ulcers. This failure resulted in the development of a painful, ongoing Stage 2 pressure ulcer causing harm to the resident. Findings include: Resident #161 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was generally alert, oriented and able to make his needs known but nursing notes documented he had periods of confusion. Nursing notes consistently indicated the resident was pleasant, cooperative with care and treatment, and required maximum 2 person assistance with bed mobility and use of a Hoyer mechanical lifting device for all transfers. On 09/06/13, when asked for a copy of the facility policy on pressure ulcers, the Director of Nursing Services (DNS) provided a document entitled Pressure Sore (ulcer) Monitoring Guidelines. The written policy stated the facility goal was to maintain skin integrity, promote healing and prevent new ulcers from developing. The policy instructed staff regarding measures to take when a pressure ulcer was identified, including: 1) gather accurate, consistent data, 2) notify the physician of pressure ulcers and transcribe treatments onto the Treatment Administration Record (TAR), 3) ensure that pressure ulcer identification, goals and interventions are addressed on the resident's care plan, 4) implement the recommended Braden Assessment Decision Tree (BADT) measures for maintaining and/or improving skin integrity within 24 hours and complete interventions within 72 hours, and 5) document resident understanding and participation with interventions such as repositioning for pressure relief. According to the facility Pressure Sore Staging Protocol, a Stage 1 pressure ulcer was a "Non-blanchable [DIAGNOSES REDACTED] (redness) of intact skin; the heralding lesion of skin ulceration." A Stage 2 ulcer was a "Partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough." An Unstageable (or non-stageable) ulcer had "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black)." Document review revealed the facility failed to follow its pressure ulcer policy for maintaining and/or improving skin integrity for Resident #161 as follows: Documentation related to the pressure ulcer on Resident #161's coccyx was not accurate and consistent. The nursing admission note written on 080/5/13 at 10:48 p.m. reported that Resident #161 was admitted at 3:20 p.m. and that the resident had a "reddened coccyx." The Weekly Pressure Sore Record (WPSR) documented that on 08/11/13 Resident #161 had a Stage 1 pressure ulcer on his coccyx measuring 1 x 2 centimeters (cm) without apparent pain and indicated that the pressure ulcer developed when the resident was in the hospital. On 08/21/13, the WPSR indicated Resident #161 had a Stage 2 ulcer on his coccyx measuring 3 x 4 cm. On 08/30/13, the ulcer was non-stageable, measuring 1.7 x 1 cm, and was causing the resident episodic pain. Despite identification of the pressure ulcer in the admission note and on the WPSR, the admission Minimum Data Set (MDS), an assessment tool, dated 08/12/13, one day after a Stage 2 pressure ulcer was identified and documented, reported that Resident #161 was at risk of developing pressure ulcers but stated he did not currently have any pressure ulcers at Stage 1 or higher. The MDS assessment reflected Resident #161's Braden Scale assessments, a tool for predicting pressure ulcer risk. On 08/05/13 and 08/11/13, Resident #161's Braden score was 12, indicating he had a moderate risk of developing a pressure ulcer. There was no indication in the Braden Scale assessments that a pressure ulcer had already developed. In an e-mail to the surveyor on 9/11/13, the Administrator stated the facility did not receive any documented skin assessments from the hospital when Resident #161 was admitted on [DATE], thus the status of the resident's skin integrity when he left the hospital was unknown. Resident #161's physician was not timely notified of the pressure ulcer, causing a delay in treatment. The reddened coccyx was first documented on 8/5/13. The physician was notified of the pressure ulcer 25 days later, on 8/30/13, after the ulcer had progressed to "open, non-stageable." The physician's Nursing Home Note, dated 8/20/13, indicated she was not aware of the pressure ulcer. The facsimile sent to the physician, dated 8/30/13, stated the resident had an "open area, non-stageable pressure ulcer to coccyx area, approximately 1.7 x 1 cm x 0.1 cm depth with white slough/ 20% pink." physician's orders [REDACTED]. Change twice daily and as needed." These treatments were transcribed onto the TAR on 8/30/13 and implemented that evening. Resident #161's care plan, dated 08/05/13, identified a potential for impaired skin integrity but was not revised to identify the pressure ulcer on the resident's coccyx, nor was the care plan revised to include the interventions ordered on [DATE]. Some BADT interventions for maintaining and/or improving skin integrity were incorporated into Resident #161's care plan within 24 hours of the admission skin assessment on 08/05/13, but not all interventions were completed within 72 hours (as directed by facility policy). The facility failed to implement Resident #161's care plan as follows: A) The care plan, dated 08/05/13, called for "pressure reducing devices to bed and wheelchair." Document review indicated a pressure reducing device was not placed on Resident #161's wheelchair until 8/18/13, and a pressure reducing device was not placed on his bed until 08/21/13, 10 days after the pressure ulcer was identified. The nursing note dated 08/18/13 at 11:55 a.m., stated "I placed a ROHO (pressure reducing) mattress in (Resident #161's) wheelchair and faxed the MD about getting an air mattress. Waiting for a reply." The earliest documentation indicating a pressure reducing device was placed on Resident #161's bed was a nursing note dated 08/21/13 at 11:51, stating "(Resident #161) has a ROHO cushion in his chair and an air mattress in place." (The physician wrote an order for [REDACTED]. B) The care plan, dated 8/5/13, instructed staff to "encourage and assist resident to turn and reposition every 1 to 2 hours." Multiple observations on different dates and times throughout the 5 day survey noted Resident #161 lying in bed. He was also observed sitting in his wheelchair. Each time the surveyor observed the resident in bed, he was lying on his back with no evidence of pillows or foam wedges placed to position the resident off of his coccyx. The resident's bed had a ROHO Sofflex 2 (a non-powered manually adjustable overlay air mattress) placed on top of a standard mattress. There was a ROHO pad on the seat of his wheelchair. The resident was noted on multiple occasions to grimace as he lay on his back in bed or while sitting in his wheelchair. On 09/04/13 at 13:11 p.m., Resident #161 was observed grimacing as he shifted his weight in his wheelchair. The resident told the surveyor his tailbone hurt but he did not like to take medication. On 9/6/13, at 10:15 a.m., review of Resident #161's TAR revealed no documentation of turning and repositioning. At 10:25 a.m., at the nursing station, the surveyor informed LN B she wanted to discuss Resident #161's pressure ulcer and would like to see documentation that the resident was being repositioned according to his care plan. LN B showed the surveyor random occasional nursing notes indicating the resident was on a turn schedule. LN B got up to leave and said she would be right back. When LN B returned at 10:30 a.m., she told the surveyor that LN C just informed her that whenever staff members repositioned Resident #161 off of his coccyx, he repositioned himself back onto his coccyx. At 11:32 a.m., during an interview, the DNS reported that earlier in the day she observed Resident #161 lying on his back and asked LN C about it. The DNS stated LN C informed her that staff were positioning the resident off of his coccyx but he would not stay in that position. The DNS stated she had been unaware this was occurring and said, "It is my expectation that staff will document when they reposition a resident who is on a turn schedule and, if the resident declines to be repositioned off the affected area or repositions himself back onto the area, there will be documentation of that." The DNS was unable to locate documentation that Resident #161 was not compliant with repositioning, nor could she locate a care plan addressing the resident's noncompliance. The DNS was unable to locate documentation to verify any attempts by staff to ascertain or address the resident's reason for noncompliance or any attempts by staff to educate Resident #161 about the rationale for repositioning. At 1:47 p.m., observation of the pressure ulcer on Resident #161's coccyx noted the appearance of the wound to be consistent with LN B's documentation on the WPSR, dated 09/06/13: Stage 2 with the wound bed measuring 1.5 x 1 cm x 0.1 cm deep. Surrounding skin white, measuring 2 x 1.5 cm. No foul odor or evidence of infection noted. The facility's failure to accurately and consistently assess and document the pressure ulcer, timely notify the physician, timely initiate interventions or review and revise the care plan as needed, resulted in the development of a painful, ongoing Stage 2 pressure ulcer on Resident #161's coccyx. .

Based on record review and interview the facility failed to provide adequate supervision to prevent the elopement and subsequent fall for 1 of 5 (#4) residents reviewed. This failure placed residents at risk for harm and caused actual harm to Resident #4 when he eloped from the facility and fell fracturing facial bones and requiring hospitalization . Findings include: All interviews took place 5/3/2012. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was assessed as being able to ambulate independently with the assistance of a walker. He was assessed as being alert but confused. He was also noted to have poor safety awareness and was considered a fall risk. Nursing notes stated on 4/5/12 "Resident threatened to 'walk out of here' but was convinced to stay another night." On 4/15/12 nursing notes stated, "Resident attempted to leave facility twice today. He walked out the front door; both CNA (certified nursing assistant) and RN (registered nurse) were present. Resident was convinced to come wait inside so his nephew could be contacted." On 4/19/12 nursing notes stated, "This evening he (Resident #4) took the elevator alone down to unit 3, he was returned to unit 1 by the 3rd unit RN." On 4/21/12 nursing notes stated, "Resident requesting to leave multiple times .....Resident last seen in room at 1945 hours (7:45p.m.) another resident's family member came into facility stating that there was a man on the side of the road bleeding at 2000 (8:00p.m.) ...." Resident was assessed, 911 was called and he was taken to the hospital for evaluation and treatment for [REDACTED]. Review of Resident #4's medical record indicated even though resident had had multiple attempts to leave the facility, had poor safety awareness, was considered a fall risk and was confused there had been no assessment of his potential for elopement. There was no care plan in place or any interventions in place to prevent Resident #4 from leaving the facility unnoticed by staff. "