Every finding on record at Hallmark Manor

Based on observation, interview and record review, the facility failed to conduct a full assessment, monitor, notify the provider and take timely action for a latent injury and a significant change in pain experience for 1 of 3 residents (Resident 1) reviewed for quality of care. Resident 1 who reported a popping noise after receiving care from staff and acute pain, experienced harm with increasing pain when there was a delay in transfer to the hospital for evaluation where they were diagnosed with a right ankle fracture. Findings included .<Facility Policy>Review of the facility's revised 11/11/2025 Pain Assessment and Management policy showed, based upon a comprehensive assessment of a resident, the facility would ensure residents received the treatment and care in accordance with professional standards of practice related to pain management. The policy showed residents would be assessed for pain indicators with any changes of condition and would address and treat the underlying causes and collaborate with the attending physician/provider to manage the pain.<Resident 1>According to the 05/12/2026 Quarterly Minimum Data Set (MDS-an assessment tool), Resident 1 had a history of a stroke (sudden brain attack that blocks blood to the brain), memory impairment, partial paralysis, and muscle weakness. The MDS showed Resident 1 was dependent on staff for all mobility transfers and activities of daily living (ADL).Review of the revised 03/20/2024 At risk for alteration in comfort/pain care plan (CP) showed staff would observe, report, and evaluate changes in Resident 1's usual routine and notify the provider if a current complaint was a significant change from Resident 1's previous experience of pain.Review of a 05/23/2026 progress note showed at 10:30 AM Staff C (Registered Nurse-RN) documented they were on duty in the morning and was told by Resident 1's family member they could not take Resident 1 out for a leave of absence, due to Resident 1 reporting increased pain in their leg and they wanted to stay at the facility. Staff C noted Resident 1 told them they had pain in their right knee area and assessed Resident 1's right knee of having no swelling. There was no further documentation to show an additional assessment was made to help identify an underlying cause of Resident 1's increased pain or to determine if there was injury. There was no documentation to show an assessment of other parts of the body was made and no notes indicating the provider was made aware of the increased pain.Review of a 05/24/2026 progress note showed at 8:00PM on 05/23/2026 Staff D (Licensed Practical Nurse), assessed Resident 1 as having severe pain and assessed right ankle to be swollen, red, warm to touch and sent Resident 1 out to the hospital for an evaluation.Review of a 05/25/2025 hospital imaging result showed Resident 1 had a fracture of their right ankle. In an observation and interview, on 05/28/20256 at 4:00 PM, Resident 1 stated they had a broken ankle after care staff took care of them and they remembered hearing a pop noise and told the staff. Resident 1 reported it was the worst pain, and they experienced it for several hours until they went to the hospital to get treated.In an interview with Resident 1's family member, on 06/01/2026 at 5:02 PM, Resident 1's family member stated they told Staff C (RN) that Resident 1 had increased pain in their leg and Resident 1 stated an injury occurred to their leg while care was being provided. The family member stated Staff C came to Resident 1's room after some time and did not assess Resident 1's full leg. Resident 1's family reported at 8:00 PM that evening, they received a call that Resident 1 was being sent out due to increased pain and the right ankle being swollen and red. Resident 1's family member stated Resident 1 was harmed at the facility and should not have waited all day in pain to receive proper care.In an interview, on 06/03/2026 at 4:50 PM, Staff C stated they were told by Resident 1's family Resident 1 was not wanting to leave the facility because of pain. Staff C stated they went to assess Resident 1 and asked the resident where their pain was and Resident 1 stated they had pain in their leg. Staff C stated they only looked at right knee and did not assess the full leg because Resident 1 was seated in a wheelchair and they had a history of chronic pain. Staff C stated it was important to ask residents with pain, where their pain was located, to assess for injuries and harm and to notify the provider. Staff C stated they did not do this for Resident 1 because they thought this was Resident 1's baseline of chronic pain. In an interview, on 05/28/2026 at 5:50 PM, Staff B (Director of Nursing) stated Staff C should have assessed Resident 1's full leg and may have discovered the fracture of Resident 1's ankle sooner and assessed for harm. Staff B stated Staff C should have notified the provider once they heard about the increased pain but did not and stated Resident 1 should have received treatment sooner.In an interview, on 5/28/2026 at 5:50 PM, Staff A (Administrator) stated the facility investigated the event regarding Resident 1 and was unable to determine the cause of the fracture. Staff A stated the nurse should have assessed for further injury but did not. REFERENCE: WAC 388-97-1060 (1),(2)(b),(3)(g)

<Resident 35> Review of a 10/22/2024 nursing progress note showed Resident 35 was transferred to the hospital for complaints of abdominal pain, chest pain, and shortness of breath. Review of Resident 35's records on 05/13/2025 showed no documentation staff provided Resident 35 or their representative with a written transfer notice. There was no progress note or copy of the written transfer notice available in Resident 35's record. In an interview on 05/13/2025 at 11:12 AM, Staff B and Staff F reviewed Resident 35's record and stated staff did not document the written transfer notice was provided as required. Staff B stated it was their expectation staff provided the notice within at the time of the resident being transferred, and in emergencies, the notice should be provided within 24 hours, and a copy was expected to be in the resident's record. Based on record review and interview, the facility failed to provide the bed hold policy upon transfers to the hospital for 2 of 7 residents (Residents 3 & 64), call report on resident's status to the receiving hospital for 3 of 7 residents (Resident 3, 64, & 80), provide a written transfer notification for 4 of 7 residents (Residents 3, 64, 80, & 35) , notify the Office of the State Long Term Care Ombudsman (LTCO) for 1 of 7 residents (Resident 94) reviewed for hospitalizations, and notify the medical provider for 1 supplemental resident (Resident 93) who discharged from the facility. Failure to offer bed holds placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Failure to call report to the receiving hospital placed residents at risk of a break in communication and continuity of care. Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights. Failure to notify the provider of resident's discharge placed resident's at risk for a break in continuity of care. <Resident 3> According to a 02/02/2025 Discharge Return Anticipated Minimum Data Set (MDS - an assessment tool) Resident 3 transferred to an acute care hospital on [DATE] with their return to facility anticipated. Record review of Resident 3's health records showed a bed hold was not offered to the resident or their representative for the 02/02/2025 transfer to hospital. Resident 3's records showed no written transfer notification was provided to the resident or their representative for the 02/02/2025 transfer to the hospital. Record review showed staff did not document they called the resident's medical report to the hospital upon transfer on 02/02/2025. In an interview on 05/06/2025 at 6:22 PM Resident 3's representative stated they were notified of the 02/02/2025 hospital transfer after the resident was in the hospital for a day. Resident 3's representative stated they were still unsure of the reason as to why Resident 3 was transferred to the hospital and did not receive a written notification of transfer from the facility. In an interview on 05/12/2025 at 12:13 PM Staff B (Director of Nursing) and Staff F (Regional Director of Clinical Services) reviewed Resident 3's health records and stated a written transfer notification was not provided to the resident or their representative for the hospital transfer on 02/02/2025. Staff F stated report was not called to the receiving hospital for Resident 3's transfer to the hospital on [DATE]. Staff F stated they expected staff to call report to the receiving facility upon resident transfer out and document the name of who the staff reported off to. Staff B stated they expected staff to provide a written transfer notification to the residents or representative to ensure they understood their rights regarding the transfer out. In an interview on 05/12/2025 at 1:27 PM Staff B stated they reviewed Resident 3's paper chart and records sent to the facility's medical records department. Staff B stated staff did not document they provided a written transfer notification provided to the resident or their representative. In an interview on 05/12/2025 at 2:31 PM Staff E (Business Office Manager) stated a bed hold was not provided to Resident 3 or their representative for the hospital transfer on 02/02/2025. <Resident 64> According to a 07/03/2024 Discharge Return Anticipated MDS Resident 64 was transferred to an acute care hospital on [DATE]. Resident 64's records also showed Discharge Return Anticipated MDS's for 07/27/2024, 08/10/2024, 09/11/2024, and 09/25/2024 transfers to an acute care hospital. Record review of Resident 64's health records showed a less than 24-hour transfer to an acute care hospital on [DATE]. Record review showed staff did not document they called the resident's medical report to the receiving hospital on [DATE], 07/27/2024, 09/11/2024, 09/25/2024, or 10/18/2024. In an interview on 05/12/2025 at 9:57 AM Staff G (Social Service Assistant) stated the LTCO was not notified for Resident 64's transfer to the hospital on [DATE]. In an interview on 05/12/2025 at 12:13 PM Staff B and Staff F reviewed Resident 64's records and stated staff did not document that report was called to the receiving hospital for the 07/03/2024, 07/27/2024, 09/11/2024, 09/25/2024, or the 10/18/2024 transfers to the hospital. Staff B and Staff F reviewed Resident 64's records and stated a written transfer notification was not provided to the resident for the 07/03/2024, 07/27/2024, 08/10/2024, 09/11/2024, 09/25/2024, or 10/18/2024 transfers. Staff B stated it was important to call a report to the receiving hospital when staff transferred a resident to an acute care hospital to ensure good communication for the resident's continuity of care and provide a written transfer notification to ensure the resident understood their rights to an appeal and how to do that. Staff B stated when staff obtained verbal consent for cares/treatments from a resident or resident representative, they expected staff to have another staff member witness the verbal consent. In an interview on 05/12/2025 at 2:31 PM Staff E showed bed hold forms for 07/03/2024, 07/27/2024, 08/10/2024, 09/11/2024, and 09/25/2024 with verbal consent from resident declining the bed holds. The bed hold forms showed Staff E's signature without a witness staff signature for the bed hold declinations. <Resident 80> According to the 01/25/2025 and 02/22/2025 Discharge Return Anticipated MDS Resident 80 was transferred to an acute care hospital on both of those dates. Record review showed staff did not document they called Resident 80's medical report to the hospital upon transfer on 01/25/2025. In an interview on 05/12/2025 at 12:13 PM Staff B and Staff F reviewed Resident 80's health records and stated a report was not called to the receiving hospital for the 01/25/2025 transfer out. Staff B and Staff F stated written transfer notification was not provided to Resident 80 or their representative for the 01/25/2025 or 02/22/2025 transfers to the hospital. In an interview on 05/12/2025 at 1:28 PM Staff B stated they reviewed Resident 80's paper chart and there was nothing supporting written transfer notifications for either of the hospital transfer on 01/25/2025 and 02/22/2025. <Resident 94> According to a 02/05/2025 Discharge Return Not Anticipated MDS Resident 94 discharged home. In an interview on 05/12/2025 at 9:57 AM Staff G stated the LTCO was not notified for Resident 94's transfer home on [DATE]. In an interview on 05/13/2025 at 9:49 AM Staff C (Social Service Director) stated they expected LTCO notification for all transfers out of facility. Staff C stated the LTCO should be notified of Resident 64's transfer to the acute care hospital on [DATE].<Resident 93> Review of Resident 93's medical record showed a progress note dated 02/11/2025 that Resident 93 was discharged home. Review of medical records did not show staff documented that Resident 93's medical provider was notified of the discharge. In an observation and interview on 05/13/2025 at 11:35 AM Staff B stated staff were to receive an order from the doctor when a resident was being discharged . Staff B reviewed Resident 93's medical record and stated they could not locate the discharge orders from the provider or that a notification to the provider was made regarding Resident 93's discharge. Staff B stated it was very important to receive the necessary orders from the provider before a resident discharged for safety and for the provider to be made aware of the discharge. REFERENCE: WAC 388-97-0120(2)(a-d)(3)(a)(4), -0140(1)(a)(b)(c)(i-iii). .

<North Unit> Observations on 05/06/2025 at 10:35 AM showed the north hall shower room door propped open without staff in the shower room. Chemical cleaning agents, razors, and scissors were observed in the north shower room unlocked cabinets. In an interview on 05/06/2025 at 10:36 AM Staff Q (CNA) stated the chemicals, razors and scissors should be stored behind locked cabinets. Observation on 05/07/2025 at 10:35 AM showed the north soiled utility room door unlocked and accessible to residents. The north soiled utility room had 2 bottles of chemical cleaning agents and a mini fridge with a lab specimen in it. In an interview on 05/07/2025 at 10:36 AM Staff V (Licensed Practical Nurse) stated the north soiled utility room should always remain locked. Staff V stated it was important to keep the soiled utility room locked for resident safety. <Storage Rooms> <Soiled Laundry Room> An observation and interview on 05/08/2025 at 9:02 AM, the door to the soiled laundry room was unlocked and no staff were present. Multiple containers of laundry sanitizer, softener and detergent were observed inside unlocked cabinets and on the counter. Chemical cleaning agents were observed on the counter. Staff AA (Laundry Assistant) stated locks for the cabinets were not available. Staff AA stated they unlocked the door at the beginning of their shift, and it remained unlocked until the end of their shift. <Central Supply Room> An observation on 05/09/2025 at 12:28 PM, the door to the central supply room was propped open and no staff were present. Eye drops, nail clippers, disposable razors, glucose testing and wound care supplies, anti-bacteria ointment, and bottles of rubbing alcohol, hydrogen peroxide and iodine were observed on the shelves and within reach. In an interview on 05/12/2025 at 1:01 PM, Staff I (Resident Care Manager) stated all rooms and cabinets containing chemicals and hazardous items should remain locked to ensure residents' safety. REFERENCE: WAC 388-97-1060(3)(g). .Based on observation, record review, and interview, the facility failed to ensure sharps and chemicals were stored safely for 2 units (South and North Units) and 2 storage rooms (Soiled Laundry Room & Central Supply Room) reviewed. This failure to ensure sharps and chemicals were secured placed residents at risk for exposure to sharps and chemicals, and other negative health outcomes. Findings included . <Policy> According to a facility policy titled, Storage of Chemicals, revised 06/17/2024, the facility would appropriately store chemical's to ensure residents environment remained free from accident hazards. The policy showed chemicals would be stored out of reach of residents. According to a facility policy titled, Safer Sharps and Safe Injection Practices Policy, revised 06/03/2024, the facility would ensure sharps devices were never left unattended within residents reach. <South Unit> Observations on 05/06/2025 at 9:47 AM, 05/08/2025 at 9:21 AM, and 05/09/25 at 12:25 PM, the door to the shower room on the south 600 hallway was propped open and no staff were present. Anti-dandruff shampoo, conditioner, body wash, shaving cream, disposable razors and toenail clippers were on the ledge of the shower wall within reach from the door. The overhead cabinets were unlocked. When the cabinets were opened, bottles of shampoo, conditioner, ointments, barrier cream, cleansers, and disposable razors were observed on the shelves and within reach. Observation on 05/06/2025 at 10:08 AM showed the south 700 hall shower room door unlocked. Inside the shower room was an open bottle of a virus killing cleanser. The bottle was on a low, half wall and not locked out of reach. In an interview on 05/08/25 at 10:56 AM, Staff T (Certified Nursing Assistant - CNA) stated they left the south unit 600 Hall shower room open because the lock was broken.

Based on record review and interview, the facility failed to provide required liability notices for 1 of 3 residents (Resident 247) reviewed for liability notices. Failure of the facility to issue a Notification of Medicare Non-Coverage (NOMNC) before coverage for Medicare services ended for Resident 247 and discharged from the facility, placed the resident at risk for not fully understanding their Medicare benefits. Findings included . <Resident 247> Record review revealed Resident 247 admitted to the facility on [DATE] and was discharged to an adult family home on [DATE]. Resident 247's record showed no indication the facility provided a NOMNC letter to the resident. A 01/28/2025 social services note showed the discharge plan was for the resident to discharge to an adult family home when they completed their course of antibiotic medication. A 01/29/2025 social services progress note showed Resident 247 was scheduled to discharge back to an adult family home, transportation was arranged to pick up the resident on 01/30/2025, and discharge papers were prepared. In an interview on 05/07/2025 at 11:03 AM Staff C (Social Service Director) stated they did not provide a NOMNC letter to Resident 247. Staff C confirmed the discharge was a planned discharge. REFERENCE: WAC 388-97-0300(1)(e),(5),(6). .

Based on observation, interview, and record review the facility failed to ensure a safe, clean, and homelike environment was provided to the residents. Failure to ensure resident rooms were personalized for 1 (South Wing) of 2 wings reviewed and maintain resident weight scales clean and free from rust for shower rooms on 2 (North and South Wing) of 2 wings reviewed, left residents at risk for a less than homelike environment. Findings included . <Facility Policy> According to the facility's Resident Belongings and Home Like Environment policy, revised 06/12/2024, the facility would provide a safe, clean, comfortable, and homelike environment. The policy showed it was the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. <South Wing> Observation on 05/06/2025 at 10:17 AM showed room [ROOM NUMBER] occupied one resident in the bed nearest the window. The walls were blank and did not have any décor or personal items for the resident. Observation on 05/06/2025 at 10:28 AM showed room [ROOM NUMBER] occupied one resident in the bed nearest the window. The walls were blank and the room did not contain any décor or personal items for the resident. The room smelled strongly of urine and a bedside commode was noted on the right side of the bed, containing urine in it. Observation on 05/13/2025 at 10:05 AM showed room [ROOM NUMBER] occupied two residents. The room was dark and the walls were blank. There was no décor or personal items in the room for the residents. In an observation and interview on 05/13/2025 at 12:42 PM, Staff A (Administrator) confirmed the walls were blank in the resident rooms. Staff A stated they were aware of the problem and were working with the company to try and obtain items that would add a personal touch. Staff agreed that the resident rooms could be improved and more homelike. <North Wing> Observation on 05/12/2025 at 8:44 AM of the shower room in the 300 hall had a weight scale with a ramp. The scale ramp had rust around the poles and along the bottom edges along the ramp. <North Wing - room [ROOM NUMBER]> In an observation and interview on 05/12/2025 at 9:21 AM, Resident 85 rolled themselves out of their room and were looking for staff members. Resident 85 stated the light bulb was out in the hallway leading into their room. The light switch was in the on position and there was no light in the hallway in the resident's room. The hallway contained two resident closets and the resident's bathroom door. Resident 85 stated the light was out for the last two days and they told staff about it, but no one fixed it. Resident 85 stated it was very dark, and they did not like it when it's dark, especially at night time. In an interview on 05/12/2025 at 9:27 AM, Resident 85 told Staff Q (Certified Nursing Assistant) their light was not working in their hallway. Staff Q observed light was not working. Staff Q stated when they become aware of a maintenance issue, they told the maintenance staff directly, or put the concern into the facility's maintenance system. Staff Q stated they did not know the light bulb was out, but it should be changed because it was not safe for the residents' lights to be out. Observation on 05/13/2025 at 8:37 AM showed the hallway light into room [ROOM NUMBER] was off, the light switch was in the on position indicating the light was not working. In an interview on 05/13/2025 at 9:58 AM, Staff B (Director of Nursing) stated staff should have notified the maintenance department when the light bulb was out. The maintenance team should be notified in person or by phone to fix the light as this was important for residents' safety and to prevent falls. REFERENCE: WAC 388-97-0880. <South Wing - 600 Hall> An observation on 05/06/2025 at 9:47 AM showed the roll-on weight scale in the shower room on 600 hall had rust on the ramp and the top edges of the three safety rails. Rust dust was on the floor surrounding the scale. In an interview on 05/12/2025 at 1:01 PM, Staff I (Resident Care Manager) stated residents could come into contact with the rust and the scale should be repaired or replaced.

Based on record review and interview, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed within 14 days from the date of determination for 1 of 1 resident (Resident 92) reviewed for death. Failure to identify the need for a SCSA when Resident 92 had a decline in condition and started on Hospice/Palliative care services placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . According to the Resident Assessment Instrument Manual (RAI - a document directing staff when assessments of resident status is required) a .SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains in the nursing home. <Resident 92> Review of Resident 92's 03/03/2025 Minimum Data Set (MDS - and assessment tool) showed a 03/03/2025 Death in Facility MDS. Resident 92's records did not show a SCSA was completed. Review of Resident 92's health records showed a 01/26/2025 Social Services significant change progress note stating the resident was on comfort care measures for increased confusion and was bedridden due to fatigue (weakness and/or loss of energy). Resident 92's records showed a 02/04/2025 progress note reporting the residents' blood pressure was dropping below parameters and the Nurse Practitioner instructed staff to discontinue Resident 92's blood pressure medications at that time. Resident 92's records showed a 02/10/2025 progress note reporting a new pressure ulcer to sacrum. Resident 92's records showed a 02/12/2025 progress note reporting resident refusing all foods and fluids due to difficulty in swallowing and was experiencing increased pain. The 02/12/2025 progress note showed the resident representative requested comfort measures for Resident 92's goal for care. Resident 92's records showed a 02/23/2025 physician order for Hospice service for comfort care was implemented. In an interview on 05/13/2025 at 10:46 AM Staff B (Director of Nursing) reviewed Resident 92's health records and stated the progress notes showed the resident started refusing food and fluids on 02/12/2025 and the nurse practitioner ordered palliative/comfort care services per the representative's request. Staff B stated they would expect staff to complete a SCSA per the RAI manual guidelines when a resident enrolls in terminally ill services. In an interview on 05/13/2025 at 11:32 AM Staff D (MDS Nurse) reviewed Resident 92's health records and stated they had a change in mobility, food and fluid intake, level of assistance required, increased pain, and obtained a physician order for Hospice for Comfort care. Staff D stated a SCSA should be completed when two or more changes in activities of daily living occurred and without progress after a 14-day observation period per the RAI Manual. Staff D stated Resident 92 should have a SCSA completed prior to their death but did not. REFERENCE: WAC 388-97-1000(3)(b). .

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status for 1 of 3 residents (Resident 94) reviewed for closed records and 1 of 7 residents (Resident 1) reviewed for falls. This failure placed residents at risk for unidentified and/or unmet needs, and a diminished quality of life. Findings included <Facility Policy> According to the facility's Resident Assessment Instrument and Care Plan Development policy revised 09/05/2024, the facility would follow procedures described in the Resident Assessment Instrument (instructions/guidelines) when completing MDS assessments. <Resident 1> According to the 03/06/2025 Quarterly MDS, Resident 1 had intact cognition, normal thinking and memory. The MDS showed Resident 1 had functional impairment to one arm and one leg, required partial/moderate assistance from staff for transfers in and out of their bed and wheelchair, and for sitting to standing position. The MDS showed Resident 1 did not have a fall during the assessment period. Observation and interview on 05/06/2025 at 9:33 AM showed Resident 1 lying in bed, their bed was in a low position. Resident 1 stated they fell a lot. Review of a 02/22/2025 nursing progress note showed staff documented Resident 1 was seen lying on the floor in their room by a staff member. The progress note showed the resident was trying to get clothes from their closet without staff assistance and fell onto the floor. In an interview on 05/13/2025 at 9:55 AM, Staff D (MDS Coordinator) reviewed the 03/06/2025 Quarterly MDS and confirmed the MDS should have captured Resident 1's 02/22/2025 fall, but the MDS was inaccurate. <Resident 94> According to a 02/05/2025 Modification of Discharge Return Not Anticipated MDS, Resident 94 discharged to an acute care hospital on [DATE]. Review of Resident 94's health records showed a 02/05/2025 progress note that the resident discharged home per doctor orders. In an interview on 05/12/2025 at 11:45 AM Staff L (MDS Coordinator) stated Resident 94 discharged home and the MDS should be coded as discharge home/community but it was coded in error as discharged to hospital. REFERENCE: WAC 388-97-1000 (1)(b). .

Based on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (a process to determine what mental health services residents required after a Level 1 PASRR determined mental health services were necessary) were obtained for 5 (Residents 35, 80, 3, 5, & 71) of 9 residents whose PASRRs were reviewed. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Policy> According to a facility policy titled, Pre-admission Screening and Resident Review, revised 09/26/2024, a resident with a Serious Mental Illness (SMI) would indicate a positive level 1. The policy stated a positive level 1 screen necessitated an in depth evaluation of the resident by the state designated authority, known as a PASRR level 2, which would be conducted prior to admission to the facility or the referral would be made for the level 2 at time of new identified SMI's. <Resident 35> According to the 03/13/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 35 had diagnoses of a brain disorder that caused a gradual decline in thinking abilities, memory, and behavior, and anxiety and depression. The MDS showed Resident 35 had rejection of care one to three days during the assessment look back period. Review of Resident 35's 11/29/2024 PASRR Level 1 showed the resident was being reassessed for mental health conditions due to a recent change in condition. This PASRR showed Resident 35 had a SMI of mood, anxiety, and psychotic disorders. The PASRR showed Resident 35 was being referred for a PASRR Level 2 evaluation. Review of Resident 35's documents, assessments, Care Plan (CP), and progress notes on 05/13/2025 showed no indication a PASRR Level 2 determination was obtained. There were no progress notes showing the facility followed up to obtain the Level 2 determination, five months after the referral was sent. In an interview on 05/13/2025 at 10:28 AM, Staff C (Social Services Director) stated the facility sent the referral for the PASRR Level 2 evaluation but the facility did not have a process for following up on PASRRs that were referred for Level 2 evaluations to ensure they were obtained. <Resident 80> According to a 07/13/2024 admission MDS Resident 80 admitted to the facility on [DATE]. The MDS showed Resident 80 had diagnoses of, but not limited to, depression. Record review of Resident 80's health records showed a 07/08/2024 diagnosis of anxiety disorder. Resident 80's records showed a PASRR 1 with SMI documented as depression and anxiety disorder. Resident 80's PASRR 1 showed no level 2 evaluation indicated. <Resident 3> According to a 06/13/2024 Annual MDS, Resident 3 had diagnoses of, but not limited to, anxiety disorder, depression, and psychotic disorder. Record review of Resident 3's health records showed a 06/26/2024 updated PASRR 1 with SMI documented as Schizophrenic disorder (mental disorder affecting the way a person thinks, feels, and behaves), psychotic disorder, depression, and anxiety disorder. Resident 3's PASRR 1 showed no level 2 evaluation referral was made. <Resident 5> According to a 01/09/2025 Annual MDS, Resident 5 had diagnoses of, but not limited to, depression, anxiety disorder, and post traumatic stress disorder. Record review of Resident 5's health records showed a 03/08/2024 updated PASRR 1 with SMI documented as depression and anxiety disorder. Resident 5's PASRR 1 showed no level 2 evaluation indicated. In an interview on 05/12/2025 at 9:57 AM, Staff G (Social Service Assistant) stated Resident's 80, 3, & 5 had SMI so they should have been referred for a level 2 PASRR. Staff G stated a level 2 evaluation was important to ensure the residents were receiving appropriate mental health care services. In an interview on 05/13/2025 at 9:49 AM, Staff C stated they expected a PASRR 2 referral to be made when a resident had SMI's per regulation. Staff C stated it was important to ensure the residents were receiving the best mental health care services. <Resident 71 > According to the 02/26/2025 Quarterly MDS, Resident 71 admitted to the facility on [DATE] and had diagnoses of anxiety and depression. According to the revised 08/08/2023 PASRR Level 1 screening, Resident 71 required an updated PASRR Level 1 because of a new diagnosis of depression. The PASRR Level 1 showed no level 2 was indicated. Review of the 10/13/2023 Behavior Problem CP showed Resident 71 had a behavior problem of seeking pain medication, feelings of emptiness, and worrying. Review of a physician ordered dated 03/19/2024 showed Resident 71 had diagnoses of depressive disorder and anxiety. Record review did not show a change of condition PASRR Level 1 was completed and did not show a PASRR level 2 referral was made after the 03/19/2024 diagnoses. Review of the 05/24/2024 CP showed Resident 71 had the potential to be verbally aggressive related to ineffective coping skills and poor impulse control. Observation on 05/07/2025 at 9:33 AM showed Resident 71 lying in bed, watching Television, (TV) and stated they were watching TV but did not really like anything that was on TV. Resident 71 stated they had pain all the time in their joints and was verbally upset at the facility for taking away their arthritis cream. In an interview on 05/13/2025 at 11:45 AM Staff C stated for changes of condition an updated PASRR Level 1 screening was important to keep track of residents' condition and to inform the facility of physical and mental changes. REFERENCE: WAC 388-97-1915(4). .

Based on record review and interview the facility failed to ensure development of a Palliative care plan for 1 of 3 residents (Resident 92) reviewed for closed records. Failure to develop a Palliative care plan placed residents at risk of unmet care needs and decreased quality of life. Findings included . <Policy> According to a facility policy titled, Comprehensive Care Plans and Conferences, revised 09/05/2024, the facility would ensure timeliness of each resident's person-centered care plan, and that each resident/representative would be involved in development of their care plan. <Resident 92> According to a 03/03/2025 Death in facility Minimum Data Set (MDS - an assessment tool) Resident 92 passed away in the facility on 03/03/2025. Review of Resident 92's health records showed a 02/13/2025 physician progress note stating the resident representative agreed to Palliative care services. Resident 92's health records showed no Palliative care plan. In an interview on 05/13/2025 at 10:46 AM Staff B (Director of Nursing) reviewed Resident 92's health records and stated they did not have a Palliative care plan but should have. Staff B stated it was important to develop Palliative care plans to ensure staff were aware of interventions to keep the residents as comfortable as possible for the end of life. Reference: WAC 388-97-1020(1), (2)(a)(b). .

Based on interview and record review, the facility failed to facilitate quarterly care conferences for 3 of 3 residents (Resident 1, 50, & 64) reviewed for care conferences, and failed to ensure Care Plans (CP) were revised as required for 2 (Resident 71 and 88) of 2 residents reviewed for care planning. These failures placed residents at risk for unmet care needs, unnecessary care, frustration, and other negative health outcomes. Findings included . <Facility Policy> According to a facility policy titled, Comprehensive Care Plans and Conferences, revised 09/05/2024, the facility would ensure the timeliness of each resident's person-centered, comprehensive CP, and ensure the comprehensive CP was reviewed and revised by the interdisciplinary team composed of individuals who have knowledge of the resident and their needs, and each resident and/or resident representative was involved in developing the CP and making decisions about their care. The policy showed the interdisciplinary team consisted of, at a minimum, the resident's physician, a registered nurse, a nurse aide, a member of the dietary department, the resident, and the resident representative, if applicable. The policy showed care conferences would be offered/conducted within seven days of admission, quarterly, and as needed. <Care Conferences> <Resident 1> According to the 03/06/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 admitted to the facility on [DATE]. The MDS showed Resident 1 had diagnoses including inability to control blood sugar levels, anxiety, and depression. In an interview on 05/06/2025 at 9:39 AM, Resident 1 stated they were not sure about when they last had a care conference with staff. Review of Resident 1's progress notes showed an 11/26/2024 social services note stating the resident declined to have a quarterly care conference. There were no other progress notes or follow up documentation regarding scheduling further care conferences or that the next quarterly care conference was offered. These progress notes showed the last care conference documented was on 11/09/2023, over two and a half years ago. <Resident 50> According to the 03/12/2025 Quarterly MDS, Resident 50 admitted to the facility on [DATE]. The MDS showed Resident 50 was in a persistent, vegetative state and had diagnoses including a seizure disorder, anxiety, and depression. Review of Resident 50's record showed a 12/12/2024 social services progress note that a voicemail was left with the resident's representative to schedule a quarterly care conference. There were no other progress notes or follow up documentation regarding scheduling further quarterly care conferences. In an interview on 05/13/2025 at 10:19 AM, Staff C (Social Services Director) stated care conferences for long-term care residents should be held quarterly. Staff C stated care conferences were documented in progress notes in the resident's record. Staff C confirmed Resident 1 and Resident 50 were not offered/provided care conferences quarterly. Staff C stated their process for providing quarterly care conferences was a work in progress.<Resident 64> According to a 03/28/2025 Quarterly MDS, Resident 64 readmitted to the facility on [DATE]. The MDS showed Resident 64 had no memory impairment. In an interview on 05/07/2025 at 8:41 AM, Resident 64 stated the facility did not offer or conduct a care conference with them since their admission to the facility. Review of Resident 64's records showed no documentation a care conference was performed. In an interview on 05/12/2025 at 9:57 AM, Staff G (Social Service Assistant) reviewed Resident 64's health records and stated there was a social service progress note on 02/05/2025 stating Resident 64 declined a quarterly care conference. Staff G stated Resident 64's records showed no other care conferences were offered or conducted. Staff G stated they were expected to offer care conferences within 72 hours of admission, quarterly, and as requested/needed. In an interview on 05/13/2025 at 9:49 AM Staff C stated they expected care conferences be conducted within the first week of admission if possible, quarterly, if they could get to them, but at least annually, and as needed. Staff C stated social services, nurse manager, business office manager, dietary, and therapy would attend new admission care conferences and skilled resident care conferences, and social services and nurse manager would attend long term care resident care conferences. When asked if dietary or activities would attend long term care resident care conferences, Staff C stated they used to but stopped showing up to resident's care conferences. <Resident 71> According to an 02/26/2025 Quarterly MDS, Resident 71 had respiratory failure. According to revised 02/27/2024 oxygen CP, Resident 71 was to have oxygen supplementation, as needed, if their oxygen saturation rate (measure of oxygen carried by the blood) was below 92%. Review of May 2025 Medication Administration Record (MAR) did not show oxygen supplementation was provided. In an interview on 05/13/2025 at 9:58 AM Staff F (Regional Director of Clinical Services) stated Resident 71's CP should have been revised to remove oxygen saturation monitoring after supplemental oxygen was discontinued, but was not. Staff F stated this could cause confusion and the CP should be revised. REFERENCE: WAC 388-97-1020(4)(e),(5)(b). <Care Plan Revision> <Resident 88> According to the 04/22/2025 MDS, Resident 88 had multiple medically complex diagnoses including risk for malnutrition (lack of nutrients to maintain health), heart failure, and dysphagia (difficulty speaking). Review of physician admission note dated 04/10/2025 at 3:21 PM showed the provider was aware Resident 88 had delirium during the recent hospital admission and was refusing care. Review of a 04/10/2025 physician order directed staff to obtain Resident 88's weight for the first 3 days following admission, once per week for 4 weeks and then once per month. An order dated 05/09/2025 showed staff were to reweigh Resident 88 on the same day. Review of progress note dated 05/08/2025 at 11:48 AM showed provider noted Resident 88's weight was to be monitored for the management of medications related to heart failure. Review of Resident 88's weight summary report on 05/12/2025, showed weigh entries of 211 pounds on 04/10/2025 at 2:48 PM and 96 pounds on 05/02/2025 at 1:03 PM. Review of Resident 88's April and May 2025 Medication Administration Records (MARs) showed staff attempted to obtain Resident 88's weight on 04/11/2025, 04/12/2025 and 04/13/2025, treatment was refused and no weights were recorded. An entry on 04/17/2025 showed Resident refused treatment and 211 pounds was documented. Entries on 04/24/2025 and 05/01/2025 showed Resident 88 was weighed and 211 pounds was documented. An entry on 05/08/2025 showed Resident 88 was weighed and weight was documented as N/A. An entry on 05/09/2025 at 5:01 PM showed no weight recorded and coded as drug refused. Review of a nursing progress note dated 04/11/2025 at 1:32 PM and 04/13/2025 at 5:49 PM showed Resident refused to be weighed. Review of CP, last revised on 04/29/2025, showed Resident 88 was resistive to care; brief, linen changes, meal refusals, medication refusals and showers with a goal that they would cooperate with care through the next review date. The CP goal and interventions for resistance to care were initiated on 04/11/2025 and remained unchanged. Review of Resident 88's record on 05/12/2025, showed no documentation of specific interventions performed by staff to obtain the resident's weight. In an interview on 05/12/2025 at 1:01 PM, Staff I (Resident Care Manager - RCM) stated they were aware of Resident 88's refusals to be weighed, expected staff to accept refusals of care as the resident's right, and to follow the current CP interventions. In an interview on 05/13/2025 at 12:36 PM, Staff F (Regional Director of Clinical Services) reviewed Resident 88's CP and stated obtaining weights should have been included in Resident 88's list of care refusals. Staff F stated they expected staff to revise the CP to include specific interventions to assist staff in obtaining Resident 88's weight.

Based on observation, interview, and record review the facility failed to ensure: physician orders were obtained for bed rails and blood sugar parameters, clarify physician orders, and medications were administered within ordered parameters for 3 (Residents 80, 88, & 1) of 20 sample residents. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . <Blood Sugar Parameters> <Resident 80> According to a 07/13/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 80 had a diagnosis of, but not limited to, Diabetes (unstable blood sugar levels). Review of Resident 80's records showed a physician order for a blood sugar lowering injectable medication. Resident 80's records did not include physician orders for parameters of when to notify the physician of dangerously out of range blood sugar levels. In an interview on 05/12/2025 at 12:13 PM, Staff B (Director of Nursing) stated Resident 80 should have physician instructions to notify when their blood sugar was less than 60 but did not. Staff B stated this was important to ensure the resident's blood sugar did not drop below 60 and end up in the hospital <Obtaining Physician Orders> <Resident 80> Observation and record review on 05/06/2025 at 9:24 AM showed bilateral bed rails to Resident 80's bed. Review of Resident 80's records showed no physician order for the bilateral bed rails. In an interview on 05/12/2025 at 12:13 PM, Staff B stated Resident 80 should have a physician order for the bilateral bed rails but did not. Staff B stated it was important to obtain physician orders for all cares/treatments for a resident. <Administering Medications Outside of Parameters> <Resident 88> According to the 04/22/2025 admission MDS, Resident 88 had multiple medically complex diagnoses including high Blood Pressure (BP - pressure against blood vessel walls when the heart pumps). Review of a 04/10/2025 physician order directed staff to administer a medication to reduce BP twice daily with instructions to hold the medication if Systolic BP (SBP - a measure of the pressure inside your arteries when the heart squeezes) was less than 110 mmHg (millimeters of mercury). Review of Resident 88's April and May 2025 Medication Administration Records (MARs) showed staff did not follow instructions and administered the medication on 04/18/2025 and 05/06/2025 at bedtime, and 05/04/2025 and 05/09/2025 in the morning when their SBP was less than 110 mmHg. In an interview on 05/12/2025 at 1:01 PM, Staff I (Resident Care Manager) reviewed Resident 88's record and confirmed staff failed to hold the medication per the physician's orders. Staff I stated it was their expectation staff follow physician orders and hold medications, as instructed. <Clarifying Physician Orders> <Resident 1> Review of Resident 1's physician orders tab showed a 04/29/2025 order directing staff to administer a diuretic (medication that removed excess fluid from the body) to the resident once daily. The order included instructions to staff to check Resident 1's BP prior to administering the medication. Review of Resident 1's April 2025 and May 2025 MARs showed the instructions to check the resident's BP did not transfer to the MAR, therefore staff were not checking the resident's BP prior to administering the medication. In an interview on 05/13/2025 at 10:55 AM, Staff B and Staff F (Regional Director of Clinical Services) reviewed Resident 1's order for the diuretic and the MAR. Staff B and Staff F stated the order required clarification from the physician. Refer to F700 - Bedrails. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). .

<Resident 61> According to the 02/22/2025 Quarterly MDS, Resident 61 was moderately impaired with their thinking/processing abilities and required cues and supervision for daily decision making. Resident 61 had impairment to both legs and required the use of a wheelchair for mobility. Resident 61 was totally dependent on staff for transfers to and from their bed to wheelchair. Observation on 05/06/2025 at 10:32 AM showed Resident 61 sitting in their wheelchair in their room, the resident was asleep. Observations on 05/07/2025 at 9:03 AM showed Resident 61 asleep, sitting in their wheelchair in their room. The room was dark, the television and radio were off. In an interview on 05/07/2025 at 10:40 AM, Resident 61's representative stated the facility would assist Resident 61 out of bed in the morning before breakfast and then leave the resident in their wheelchair until around 3:00 PM. Resident 61's representative stated the resident usually ate dinner in bed because they were too tired to get up in the wheelchair again. Resident 61's representative stated I wish [staff] would put Resident 61 back in bed after breakfast. Observation on 05/08/2025 at 8:55 AM showed Resident 61 sitting in their wheelchair in a group activity in the day room. Resident 61 was asleep. Observations on 05/08/2025 at 10:06 AM and at 12:23 PM, showed Resident 61 was back in their room in their wheelchair. Observation on 05/12/2025 at 9:48 AM showed Resident 61 at an activity, asleep in their wheelchair. Observations on 05/12/2025 at 11:36 AM and 1:22 PM showed Resident 61 sitting in their wheelchair. In an interview on 05/12/2025 at 1:41 PM, Staff P stated Resident 61 did not lie down after breakfast and that staff kept the resident in the wheelchair. In an interview on 05/13/2025 at 11:21 AM, Staff B stated they expected staff to provide assistance to residents to lie down, especially if the resident was asleep in their wheelchair. REFERENCE: WAC 388-97-1060(2)(c). <Resident 46> According to the 01/06/2025 admission MDS, Resident 46 could make their needs known, understood others, and was dependent on staff for bathing, lower body dressing, and putting on footwear. According to the 01/02/2025 ADL self-care performance deficit CP, Resident 46 had deficits related to impaired balance. Staff were to encourage Resident 46 to participate in ADLs and document any refusals. The CP showed Resident 46 was dependent on staff for bathing, hygiene/oral care, and two staff were needed for dressing. Review of Resident 46's care staff task list from 05/01/2025 through 05/13/2025 showed staff documented ADL care daily for all day and evening shifts except evenings of 05/11/2025, 05/12/2025, and 05/13/2025. There was no documentation showing Resident 46 refused showers, dressing, or personal hygiene, on day or evening shifts. In an interview on 05/06/2025 at 10:22 AM, Resident 46 stated staff did not clip their nails and the resident had to bite them to keep them short. Resident 46 stated the staff did not offer to clip their toenails, and stated they had diabetes (inability of the body to regulate blood sugar levels), and their feet, hands, and skin should be observed by staff. Resident 46 stated the staff did not give them a washcloth in the morning and one of the nurses told Resident 46 it was not their job to provide nail care. Resident 46 stated they did not think the nurses wanted to provide nail care to them. In an interview on 05/06/2025 at 1:37 PM, Resident 46 stated their feet became swollen and they needed diabetic socks. Resident 46 stated they told staff they would like to be shaved but staff stated they could not shave the resident because of their diabetes. Resident 46 stated the care staff did not routinely offer them a washcloth to wash their hands or their face. Observation on 05/12/2025 at 8:37 AM showed Staff H (Registered Nurse) assess Resident 46's bilateral feet and legs. Resident 46 had long toenails extending a half inch past the nail bed. Some nails were cracked and had jagged edges. Dry, flaky, and dark black skin was observed in several spots around both feet. Resident 46's left leg was more swollen in comparison to their right leg. Resident 46 was observed to tell the nurse the care staff did not remove the resident's socks in three weeks. In an interview on 05/12/2025 at 8:42 AM, Staff H stated Resident 46 often refused care including showers and nail care, and Resident 46 was not on the list to see the podiatrist due to refusals. Staff H stated staff should document refusals of care and the nurses were responsible for informing the social services team when a resident needed to be added to the podiatrist list. In an interview on 05/12/2025 at 9:03 AM, Staff G (Social Service Assistant) stated the facility had a podiatrist that came to the facility every 6 to 8 weeks. Staff G stated the social services team placed residents on the list for the podiatrist and they added diabetic residents to the podiatrist list routinely as diabetic residents were susceptible to skin and wound issues. Staff G stated Resident 46 was not on the podiatrist list for routine diabetic foot care. In an interview on 5/13/2025 at 9:43 AM Staff B (Director of Nursing) stated care staff should have alerted the nurses right away for any issues they observed. Staff B stated for diabetic foot care, the nurses should make a referral to the podiatrist and routinely check diabetic residents' skin. Staff B stated the staff should have alerted the nurse for all refusals of care and then the unit manager and social services team would be aware. Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 (Residents 46, 61 & 62) of 7 residents who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's [ADLs] policy, revised 09/10/2024, residents would receive assistance with ADLs as needed. Any change in the ability to perform ADLs would be reported to the nurse. For bed and wheelchair mobility, staff would assist residents with bed/wheelchair repositioning as necessary to prevent skin breakdown. For fingernail care, staff would ensure fingernails were clean and trimmed to avoid injury and infection. <Resident 62> According to the 04/28/2025 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 62 had a significant change in their health status, resulting in their transition to hospice care (a comfort-focused approach). Resident 62's functional abilities for eating were changed from setup assistance to supervision assistance. Review of a revised 05/07/2025 Care Plan (CP), showed Resident 62 required supervision by one staff member when eating. Observations on 05/08/2025 at 12:40 PM, 05/09/2025 at 7:46 AM, 05/09/2025 at 12:52 PM, 05/10/2025 at 1:02 PM, and 05/12/2025 at 8:29 AM, showed Resident 62 with a meal tray on their bedside table and no staff supervision provided between delivery time and removal of the tray. In an observation on 05/09/2025 7:58 AM, Resident 62 was heard coughing from the hallway while feeding themselves. Staff I (Resident Care Manager) entered Resident 62's room and exited room at 8:01 AM. No eating supervision was provided. In an interview on 05/07/2025 at 12:39 PM, Resident 62 stated they lost weight since they were admitted to the facility. In an interview on 05/12/2025 at 08:32 AM, Staff P (Certified Nursing Assistant - CNA) was assigned to care for Resident 62 and stated they were setup assistance only for meals. In an interview on 05/12/2025 at 1:01 PM, Staff I reviewed Resident 62's most recent MDS and stated the resident was assessed to require staff assistance with eating. Staff I reviewed Resident 62's CP and stated a staff member should sit with them during each meal to provide support.

<Resident 80> According to a 07/13/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 80 admitted to the facility on [DATE] and had no memory impairment. The MDS showed Resident 80 had a diagnosis of, but not limited to, high cholesterol. Review of resident 80's health records showed 03/04/2025 physician orders for a cholesterol lowering medication and a medication for high uric acid (a waste product that can cause painful inflammation in the body when not excreted) levels in the body. Resident 80's health records showed no lab results for blood cholesterol or uric acid level. Resident 80's health records did not show a diagnosis related to high uric acid levels. In an interview on 05/12/2025 at 12:13 PM Staff B (Director of Nursing) reviewed Resident 80's health records and stated they did not have a cholesterol or uric acid level monitored but should. Staff B reviewed Resident 80's most recent hospitalization and stated they did not see the labs were not obtained at the hospital either. Staff B stated it was important to obtain these levels prior to prescribing these medications so they were not administering the medications unnecessarily. Staff B stated they expected staff to ensure they received copies of blood work for these medications to ensure the medications were not prescribed in error. <Change In Condition> <Resident 46> According to an 01/06/2025 admission MDS, Resident 46 had clear speech, was understood and able to understand others. The MDS showed Resident 46 had an active diagnoses of heart failure with pulmonary edema, morbid obesity, diabetes and was at risk for skin pressure injuries. Review of an 01/02/2025 ADL self-care performance deficit Care Plan (CP), showed Resident 46 was totally dependent on two staff for mobility, dressing and personal hygiene. Staff were to observe and report any changes in Resident 46's condition and decline in functional abilities. In an interview on 05/06/2025 at 1:37 PM Resident 46 stated they were diabetic and no one at the facility checked their feet or legs to see if they had swelling. In an interview on 05/12/2025 at 8:27 AM Resident 46 stated the staff probably could not see their legs were swollen because the staff did not take their socks off while providing care to check their legs. Observation on 05/12/2025 at 8:37 AM Staff H (Registered Nurse) assessed Resident 46's legs. Resident 46 had blue socks that were pulled up towards the middle part of their leg. Staff H removed the socks and stated Resident 46 had edema to their left leg in comparison to their right leg. Resident 46 told Staff H, the staff did not take their socks off for three weeks and no one had looked at their legs when providing care. Staff H stated no one had reported to them that Resident 46 had edema in their legs. In an interview on 05/13/2025 at 9:43 AM Staff B (Director of Nursing) stated they expected staff to provide care as stated in the CP and to observe and report any findings or changes in condition to the nurse and the nurse would assess the resident right away. Staff B stated staff were expected to routinely monitor residents with diabetes for the condition of their skin. <Resident 44> According to an 02/27/2025 quarterly MDS Assessment, Resident 44 had diagnoses of end stage renal disease, history of a stroke, partial body weakness, communication deficit and was dependent on dialysis treatments. Review of the 03/18/2024 Dialysis CP, showed staff were to report any signs and symptoms of infection of the dialysis access site for redness, swelling, warmth or drainage. Staff were to observe and report peripheral edema and not to take a blood pressure in the right arm due to interference with the dialysis access site. Observation and interview on 05/13/2025 at 8:32 AM showed Resident 44's right hand was red in color and was swollen. Resident 44 stated they had pain and wanted to put their arm up. In an interview on 05/13/2025 at 8:35 AM Staff H (Registered Nurse) observed Resident 44's right hand was swollen, warm to the touch and was red in appearance. Staff H stated no one told them that Resident 44's hand was swollen and red. In an interview on 05/13/2025 at 9:35 AM, Staff W (CNA) stated they did not notice anything wrong with Resident 44's right hand while providing morning personal hygiene care. Staff W stated Resident 44 had a shower today and the shower aid did not report to them an issue with the resident's hand. In an interview on 05/13/2025 09:40 AM, Staff Q (CNA-Shower Aid) stated they gave Resident 44 a shower today but did not notice swelling to Resident 44's right hand and noticed Resident 44 had a pillow underneath their right arm, but did not know why and did not report this to the nurse. In an interview on 05/13/2025 at 9:43 AM, Staff B (Director of Nursing) stated staff were to observe for changes of condition when providing care, especially when issues caused discomfort or pain, or were considered unusual. <Pain Management> <Resident 65> According to an 03/12/2025 Quarterly MDS assessment, Resident 65 had a history of falling and had a history of fracture to their vertebrae. Review of the revised 12/24/2024 Vertebrae Fracture CP showed staff were to provide pain medications as ordered. Review of the May 2025 Medication Administration Record (MAR) showed an order dated 05/08/2025 for Resident 65 to receive their pain medication according to their pain rating, on a pain scale level of 1 out of 10 (1 meaning no pain and 10 meaning the highest pain). Resident 65 should receive one tablet of pain medication when the resident's pain level was 1 to 4 on the pain scale and should receive two tablets of pain medication when their pain level was 5 to 10 on the pain scale. According to the May 2025 MAR, staff documented Resident 65 received one tablet of pain medication instead of two tablets as ordered on the following dates: on 05/08/2025 pain level was a 5; on 05/9/2025 pain level was a 6; on 05/10/2025 pain level was a 6; on 05/12/2025 pain level was a 7 and on 05/13/2025 pain level was a 6. <Pain Patch> Review of May 2025 Medication Administration Record showed a 05/08/2025 physician's order for a pain patch and to apply it every 72 hours for chronic pain disorder and then remove the patch. The MAR showed on 05/08/2025 the staff did not give Resident 65 their pain medication because the medication was not filled by the pharmacy. Review of progress notes showed staff received the pain patch on 05/09/2025, one day after the missed dose on 5/8/2025 but did not give Resident 65 their pain patch until their next scheduled application date on 5/11/2025, three days after the order was received. In interviews on 05/08/2025 at 11:36 AM and on 05/12/2025 at 11:36 AM Resident 65 stated they did not have any pain. In an interview on 05/13/2025 at 11:40 AM Staff B stated they expected the nurses should follow physician orders as indicated as this was important for improved pain management for residents using pain medications based on the pain scale. Staff B stated staff should have restarted the pain patch when they received it on 05/9/2025 instead of waiting until 05/11/2025, but did not. REFERENCE: WAC 388-97-1060 (1). Based on observation, interview, and record review, the facility failed to ensure adequate laboratory testing for 2 (Resident 80 & 88) of 5 residents reviewed for unnecessary medications, failed to report changes of condition for 2 (Residents 44 & 46) of 2 sampled residents, and failed to administer pain medications for 1 (Resident 65) of 1 sampled residents. These failures to ensure adequate testing to prevent unnecessary medication use, identify changes of condition, and administer pain medications placed residents at risk for the administration of unnecessary medications, discomfort from skin impairments and untreated pain, and other negative health outcomes. Findings included . <Laboratory Testing> <Resident 88> According to the 04/22/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 88 had multiple medically complex diagnoses including hypothyroidism (HT - thyroid gland does not make enough thyroid hormones). Review of a 04/10/2025 physician order directed staff to administer a medication to increase Resident 88's thyroid hormone level. Review of Resident 88's April and May 2025 Medication Administration Records (MARs) showed staff administered the medication to Resident 88 each day, beginning on 04/11/2025. Review of Resident 88's record on 05/12/2025, showed no documentation of a Thyroid Stimulating Hormone (TSH -test to measure thyroid function) blood test having been drawn. In an interview on 05/12/2025 at 1:01 PM, Staff I (Resident Care Manager) reviewed Resident 88's record and stated the facility failed to draw a TSH blood test. Staff I stated it was possible the hospital had drawn the test prior to Resident 88's admission. No further documentation was provided.

<Resident 3> Continuous observation on 05/08/2025 at 12:11 PM showed staff bring Resident 3 their lunch tray to their room. Staff elevated Resident 3's head of bed to a sitting position, placed their lunch tray on the over the bed table in front of them, and then exited the room. The lunch tray had ground pork in gravy, potatoes, and green beans. Observation showed Resident 3 did not feed themselves. At 1:04 PM Staff BB (CNA) entered Resident 3's room to remove the lunch tray and Resident 3 stated they could not feed themselves. Staff BB asked Resident 3 if they wanted assistance and Resident 3 stated yes but the food was probably cold now. Staff BB stated it was still warm and asked if Resident 3 wanted a bite of green beans, the resident replied yes. Staff BB assisted Resident 3 with a bite of green beans and the resident stated yuck, it's cold. Staff BB asked how about some meat and assisted Resident 3 with a bite of ground pork. Resident 3 stated yuck, it's cold. Staff BB stated they did not think they had a microwave to warm the food up and asked Resident 3 if they wanted some pudding. At 1:12 PM, two other staff entered the room and stated they were there to assist with changing Resident 3's brief. One of the staff, Staff R (CNA), asked for the resident's tray and proceeded to remove it from the room. Staff BB or Staff R did not offer a meal replacement to Resident 3. Resident 3's lunch tray had one bite of ground pork, one bite of green beans, and 75% of the pudding missing, less than 10 % of the total meal consumed. Review of Resident 3's health records showed no documentation of a meal replacement offered for the less than 10 % lunch consumed on 05/08/2025. In an interview on 05/12/2025 at 12:13 PM, Staff B stated they expected staff to offer and document in the resident health records a meal replacement when less than 50 % of the meal was consumed. Staff B stated this was important for residents' health and nutritional status. Based on observation, interview, and record review the facility failed to provide nutritional care, weight monitoring, and storage of food provided by outside sources for 3 (Resident 46, 62, and 88) of 8 residents reviewed. The failure to offer meal replacements when residents consumed less than 50% of their meals, collect timely and accurate weights as ordered and per facility policy, and proper storage of foods brought to residents by outside sources, placed residents at risk for nutrition-related complications, unplanned weight fluctuations, inaccurate assessments and delayed interventions of nutritional status, fluid overload, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 09/10/2024, Hydration and Nutrition Policy, each resident would receive enough food to maintain acceptable parameters of nutritional status and were to be offered a therapeutic diet when there was a nutritional problem. Each resident would be offered three meals per day and if a meal or food was refused, the resident would be offered a substitute of a similar nutritive value. The facility would document intake percentages, and the physician would be notified of any concerns. <Meal Replacements> <Resident 46> According to the 03/24/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 46 had diagnoses including morbid obesity, heart failure, high fat in the blood, and malnutrition (lack of nutrients to maintain health). Review of the 01/02/2025 Diabetic Care Plan (CP) showed staff were to provide a diabetic diet and Resident 46 was lactose (milk sugar) intolerant. Review of physician's orders dated 02/04/2025 showed Resident 46 was not to be provided milk or milk products. In an interview on 05/06/2025 at 1:27 PM, Resident 46 stated they were diabetic and lactose intolerant, and they told staff all the time they could not eat high fats or sugar, but staff do not listen. In an interview on 05/09/2025 at 8:32 AM, Resident 46 stated for breakfast they received three slices of bacon and one slice of toast cut in half, and stated they did not want to eat that. Observation on 05/09/2025 at 8:44 AM Staff R (Certified Nursing Assistant - CNA) stated they would offer Resident 46 snacks when they refused their meal. Staff R stated they would provide residents with crackers and cookies if they refused their meal. Interview on 05/09/2025 at 8:51 AM showed Staff R brought Resident 46 two fruit flavored grain bars, honey graham cookies, two nut candy bars, and one carton of milk. Resident 46 stated to Staff R they were lactose intolerant and could not drink milk. Staff R stated they knew Resident 46 was lactose intolerant but knew Resident 46 would refuse it. Observation on 05/09/2025 at 12:51 PM Resident 46 stated they did not want any of the lunch food and stated they would be eating the bag of chips on their nightstand. In an observation and interview on 05/12/2025 at 8:28 AM, Resident 46 stated they did not want the breakfast that was served as it was always the same thing. Resident 46 stated the facility bought them an outside vendor sandwich yesterday on 5/11/2025 and they would eat that today instead of the meals provided. Resident 46 pointed to an undated, wrapped sandwich on their nightstand. Resident 46 stated they did not think the ham sandwich would be old if they ate it today. In an interview on 05/12/2025 at 9:07 AM, Staff G (Social Services Assistant) stated Resident 46 often refused their meals but was not sure about supplements provided if Resident 46 refused to eat. Staff G stated the facility did buy Resident 46 the sandwich yesterday and the facility had a resident refrigerator that could store residents' food, but the sandwich was not stored. In an interview on 05/13/2025 at 10:39 AM, Staff N (Registered Dietician) stated if Resident 46 refused their meal, staff should offer snacks, sandwiches, or meal alternatives and never offer Resident 46 milk. In an interview on 05/13/2025 at 9:43 AM, Staff B (Director of Nursing) stated staff should offer meal alternatives for Resident 46 if they refused their meal and all outside food brought in should be stored in the nurse's refrigerator. <Resident 88> In an observation and interview on 05/08/2025 at 1:23 PM, Staff JJ (CNA) entered Resident 88's room and removed their meal tray. Staff JJ stated they would document 5% of the meal was consumed and offer Resident 88 ice water. The lid was removed and one bite of food was eaten from the plate. No meal replacement was offered. In an observation and interview on 05/09/2025 at 7:55 AM, Staff II (CNA) entered Resident 88's room, removed their meal tray and stated they would document 25% of the meal was consumed. The lid was removed and 25% of food had been eaten. No meal replacement was offered. In an observation and interview on 05/09/2025 at 1:21 PM, Resident 88 was observed in bed with their eyes closed. Their meal tray was on the bedside table with lid covering plate. Staff II entered the room, removed the meal tray and stated they would document 0% of the meal was consumed. The lid was removed and the food was untouched. No meal replacement was offered. In an interview on 05/12/2025 at 1:01 PM, Staff I (Resident Care Manager) stated staff should offer meal replacements to all residents who consume less than 50% of their original meal. Staff I stated they expected staff to verbally report to the nurse what meal replacement was offered and the percentage consumed.<Resident 88> <Weight Monitoring> According to the 04/22/2025 admission MDS, Resident 88 had diagnoses including risk for malnutrition, heart failure, and dysphagia (difficulty swallowing). Review of a 04/10/2025 physician order directed staff to obtain Resident 88's weight for the first 3 days following admission, once per week for 4 weeks, and then once per month. A 05/09/2025 order directed staff to reweigh Resident 88 on the same day. Review of Resident 88's weight summary report on 05/12/2025, showed weight entries of 211 pounds on 04/10/2025 at 2:48 PM and 96 pounds on 05/02/2025 at 1:03 PM. Review of Resident 88's April and May 2025 Medication Administration Records showed staff attempted to obtain Resident 88's weight on 04/11/2025, 04/12/2025 and 04/13/2025, treatment was refused and no weights were recorded. An entry on 04/17/2025 showed Resident refused treatment and 211 pounds was documented. Entries on 04/24/2025 and 05/01/2025 showed Resident 88 was weighed and 211 pounds was documented. An entry on 05/08/2025 showed Resident 88 was weighed and weight was documented as [not applicable]. An entry on 05/09/2025 at 5:01 PM showed no weight recorded and coded as refused. Review of a nursing progress note dated 04/11/2025 at 1:32 PM and 04/13/2025 at 5:49 PM showed Resident 88 refused to be weighed. In an interview on 05/12/2025 at 1:01 PM, Staff I reviewed the weight entry on 05/02/2025 at 1:03 PM of 96 pounds and stated the facility failed to accurately document Resident 88's weight on that date. Staff I stated the facility failed to follow the physician order to obtain weights. Staff I stated expected staff to attempt alternative methods to weighing residents who frequently refuse care. REFERENCE: WAC 388-97-1060(3)(h). .

Based on observation, record review, and interview, the facility failed to ensure ongoing monitoring of bed rail use for 3 of 6 residents (Residents 5, 64, & 80) reviewed for accident hazards. This failure placed residents at risk for injury, entrapment, and other negative health outcomes. Findings included . <Policy> According to a facility policy titled, Bed Rails - Safe and Effective Use of Bed Rails, revised 09/06/2024, the facility would ensure, at a minimum, evaluation for bed rail use would be completed quarterly and with a change of condition. <Resident 5> According to a 01/09/2025 admission Minimum Data Set (MDS - an assessment tool) bed rails were not used on Resident 5's bed. Observation on 05/06/2025 at 1:06 PM showed bilateral bed rails on Resident 5's bed. Review of Resident 5's records showed a 06/17/2024 physician order for bed rails to be applied to their bed. Resident 5's health records did not show ongoing bed rail use monitoring was completed. <Resident 64> According to a 03/28/2025 Quarterly MDS bed rails were not used on Resident 64's bed. Observation on 05/07/2025 at 9:04 AM showed bilateral bed rails on Resident 64's bed. Review of Resident 64's records showed a 02/14/2025 physician order for bilateral bed rails to their bed. Resident 64's health records did not show ongoing bed rail use monitoring was completed. <Resident 80> According to a 07/13/2024 admission MDS bed rails were not used on Resident 80's bed. Observation on 05/06/2025 at 9:24 AM showed bilateral bed rails on Resident 80's bed. Review of Resident 80's records showed a 07/22/2024 care plan for bilateral bed rails on their bed. Resident 80's health records did not show ongoing bed rail use monitoring was completed. In an interview on 05/12/2025 at 12:13 PM Staff B (Director of Nursing) reviewed Residents 5, 64, and 80's health records and stated quarterly bed rail use evaluations were not done as expected. Staff B stated it was important to monitor ongoing use of bed rails to ensure they were still appropriate and safe for the residents. Refer to F658 - Services Provided Meet Professional Standards. Reference: WAC 388-97-1060(3)(g). .

Based on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to the resident records and that the recommendations were reviewed and acted upon for 2 (Resident 35 & 1) of 5 residents who were reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes, risk for adverse side effects, and receiving medications without required pharmacist oversight. Findings included . <Facility Policy> According to the facility's Pharmacy Services and Medication Regimen Review policy, revised 09/16/2024, the facility would maintain the resident's highest practicable level of physical, mental, and psychosocial well-being while preventing or minimizing adverse side effects of medications by ensuring oversight by a licensed pharmacist. <Resident 35> According to the 03/13/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 35 received several medications including antipsychotic (medication that affects brain function), antidepressant, anticoagulant, antiplatelet, medications to help control blood sugar levels, and antiseizure medications. Review of a MRR binder provided by the facility showed Resident 35 had a 01/08/2025 through 01/10/2025 MRR recommendation form. This form showed the reviewing pharmacist recommended staff obtain routine blood work for Resident 35 related to cancer treatment medication Resident 35 was receiving. The MRR was blank and not acknowledged by staff. The MRR was not included in Resident 35's record. Review of Resident 35's progress notes and orders on 05/13/2025 showed staff did not complete the pharmacist's recommendations or discuss the recommendations with the physician, for more than five months after the recommendation was received. Review of the MRR binder showed a 02/01/2025 through 02/06/2025 MRR that was not included in Resident 35's record. Review of Resident 35's records showed the only MRR reports included in their record were August 2024, September 2024, and December 2024. There were no other MRR reports in the resident's record. In an interview on 05/13/2025 at 11:05 AM, Staff B (Director of Nursing) and Staff F (Regional Director of Clinical Services) confirmed the January 2025 MRR was not followed up on or implemented for Resident 35. Staff B stated the MRR form should be provided to the physician for review, orders completed, and included in the resident's record, but it was not. <Resident 1> Review of Resident 1's 03/06/2025 Quarterly MDS showed the resident received several medications including antianxiety, antidepressant, water pills, and antiplatelet (blood thinning) medications. Review of the facility's MRR binder showed a 01/08/20025 through 01/10/2025 MRR recommendation form for Resident 1. The form gave recommendations to staff to consider reducing one of their medications related to blood test results. The form was blank and no response from staff was documented. A second MRR for dated 01/08/2025 through 01/20/2025 gave a recommendation to staff to consider decreasing a second medication related to blood test results. This form was also blank and no response from staff was documented. Review of Resident 1's progress notes showed the pharmacy recommendations were not addressed until 03/16/2025 and 03/20/2025, over two months after the pharmacist gave the recommendations. Review of Resident 1's records showed the only MRR reports included in their record were April 2025 and September 2024. There were no other MRR reports in the resident's record. In an interview on 05/13/2025 at 11:01 AM, Staff B confirmed the 01/08/2025 MRR was not included in Resident 1's record. Staff B stated it was their expectation MRRs were addressed within one month of receiving the recommendation. REFERENCE: WAC 388-97-1300(1)(c)(iii), (4)(c). .

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 6 sampled residents (Resident 26) reviewed for unnecessary medications. Failure to evaluate the need for continued use of an antibiotic medication placed residents at risk for use of unnecessary medications and at risk for adverse side effects. Findings included . <Facility Policy> According to the facility's 11/28/2022 Antibiotic Stewardship guidelines, antibiotic stewardship would be accomplished by improved antibiotic prescribing, administration and management practices to reduce inappropriate use, to ensure that residents received the right antibiotic for the right indication, dose and duration. According to the 03/06/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 26 admitted to the facility on [DATE] with a history of urinary tract infections and a skin infection of the lower leg. Review of the 01/10/2025 Pain care plan,showed Resident 26 had pain in their lower leg related to a recurring bacterial skin infection. Review of a 03/15/2025 physician order directed staff to administer an antibiotic to Resident 26 twice daily to treat their chronic skin infection to their lower leg. The order directed staff to follow up with the provider regarding the infection. Review of a 04/02/2025 pharmacy medication review dated showed the pharmacist noted the antibiotic 500 mg medication was missing a stop date or duration time of use and noted this increased the risk of resistance and adverse events that Resident 26 could experience. Recommendations were provided to the facility's interim director of nursing and facility physician to document the intended duration of therapy or stop date. The pharmacy medication review showed the physician noted Resident 26 had a history of recurring lower leg skin infection and the resident was on a maintenance or suppressive therapy dosage. There was no notation on the form to show a stop date or duration was provided by the facility. Review of the March 2025, April 2025 and May 2025 Medication Administration Records (MAR) showed Resident 26 started the antibiotic medication on 03/15/2025 and received the medication daily every 12 hours through 05/13/2025. Review of Resident 26's progress notes did not show a provider was notified of the need for a stop date or to clarify the duration of the antibiotic usage. In an interview on 05/12/2025 at 12:35 PM, Staff J (Infection Preventionist-IP) stated they were only aware Resident 26 was on an antibiotic for another condition and that medication was discontinued on 3/14/2025. In an interview on 05/13/2025 at 9:23 AM Staff J stated they did not follow up on Resident 26's antibiotic for the skin infection and was not aware Resident 26 was receiving this medication. Staff J stated the antibiotic usage should be documented on the care plan but was not. Staff J stated both the nursing staff and the IP should have followed up with the provider as stated on the physician's order, but did not. REFERENCE: WAC 388-97-1060(3)(k)(i). .

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 4 medication carts (Medication Cart 300/400) and 2 of 4 halls (600 & 300 Hall) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life. Findings included <Medication Cart 300/400> Observation on 05/06/2025 at 9:56 AM showed three opened inhaler medications without the open date on the inhalers. In an interview on 05/06/2025 at 10:15 Staff V (Licensed Practical Nurse) stated all inhalers should have an open date on them, but they didn't. Staff V stated the inhalers are only good for 30 days after the open date and would need to be disposed of after 30 days.<300 Hall> Observation and interview on 05/07/2025 at 11:08 AM showed an opened bottle of vitamins with ten remaining tablets next to the sink in room [ROOM NUMBER]. Staff GG (RN) stated they did not see them there before, but residents should not have medications at the bedside. In an interview on 05/07/2025 at 11:10 AM Staff HH (Resident Care Manager) stated the resident in room [ROOM NUMBER] often ordered from an online delivery store. Staff HH stated they spoke with the resident in room [ROOM NUMBER] and educated them about medications at bedside requiring a physician order. Staff HH stated the resident denied knowledge of the medications, so they removed the bottle from the room. Staff HH stated medications at bedside should include a resident assessment, physician order, and be stored behind a locked cabinet. Staff HH stated inhalers should be dated when they are opened and discarded in 30 days. Staff HH stated all medications should be stored behind locked doors for resident safety. REFERENCE: WAC 388-97-1300(2), -2340. <600 Hall> Observation on 05/06/2025 at 9:47 AM showed the door to the shower room on the 600 hall was propped open, no staff were present. The overhead cabinet was unlocked and contained an unsecured prescription medication, labeled with a resident's name, on the shelf within reach. In an interview and observation on 05/06/2025 at 2:10 PM, the shower room door on the 600 Hall was propped open. Staff S (Registered Nurse - RN) stated the prescription medication should be secured in the medication cart. Staff S removed the medication from the cabinet and carried it out of the shower room.

Based on observation, interview, and record review the facility failed to serve foods that were appetizing in appearance and palatable. Observations of meal trays and interviews with 5 (Residents 61, 46, 71, 145, & 29) sample residents and 4 supplemental (Residents 69, 45, 83, & 70) residents identified concerns about the taste and overall palatability of the meals served, and being offered alternate meals by the facility. Facility failure to ensure meals were palatable, appetizing in appearance, and alternate meals were offered by staff placed residents at risk for less than adequate nutritional intake and dissatisfaction with daily meals. Findings included . <Facility Policy> Review of the facility's Hydration and Nutrition policy revised 09/10/2024, showed if a resident refused a meal or particular food, staff would offer a substitute of similar nutritive value. <South Hall Day Room> Observation of breakfast on 05/09/2025 at 8:18 AM showed several residents in the South Hall day room eating breakfast. Resident 69 and Resident 45 were eating together at a table. Both breakfast trays contained eggs that were a pistachio green color. The residents were not eating the eggs. Observation on 05/09/2025 at 8:22 AM showed Resident 61 receiving assistance with eating their breakfast by Staff X (Certified Nursing Assistant - CNA). When asked what the green item on the breakfast tray was, Staff X furrowed their eyebrows and stated they are scrambled eggs. Staff X stated the residents were served green eggs before. <400 Hall Trays> In an interview on 05/09/2025 at 8:41 AM, Resident 83 and Resident 70 were in their joint room. The residents no longer had their breakfast trays in front of them. Resident 83 and Resident 70 were asked how breakfast was that day. Resident 83 stated Green eggs today! They were nasty! Resident 70 expressed dissatisfaction with breakfast stating the eggs were green and mushy. Resident 83 and Resident 70 stated they were not offered alternate breakfast meals. Both residents stated staff never offered them an alternate meal when they do not like what was served. <Resident 46> In an interview on 05/06/2025 at 10:22 AM, Resident 46 stated, they did not get enough food from the facility and they asked their family to bring in outside food. In an observation and interview on 05/09/2025 at 8:32 AM, Resident 46 had three slices of bacon and one slice of bread cut in half. Resident 46 stated the bread was stale and did not look good so they did not want their breakfast that day. <Resident 71 > In an interview on 05/09/2025 at 8:16 AM, Resident 71 was observed eating breakfast in their room. Observation showed the breakfast tray had pale green colored, scrambled eggs that were mushy in appearance. Resident 71 stated they were only going to eat 1 piece of bacon and their hot cereal, and would not eat the eggs. Resident 46 stated, .look at these eggs would you want to eat them? Resident 46 stated they would like other food options but that was all they were provided. <Resident 145> In an observation and interview on 05/09/2025 at 8:17 AM, Resident 145 was in bed eating breakfast. Staff U (CNA) held a fork and placed eggs in Resident 145's mouth. Resident 145 stated yuck. The eggs were pale green. Staff U stated the eggs were green and Resident 145 did not like them. <Resident 29> In an observation and interview on 05/09/2025 at 8:37 AM, Resident 29 was in their room and their breakfast tray was on the bedside table. Resident 29 stated they had eaten everything except the scrambled eggs. Resident 29 stated the eggs did not taste right. Resident 29 stated they liked eggs, but not the facility's eggs. In an interview on 05/09/2025 at 11:02 AM, Staff Y (Cook) stated they had problems with the eggs that morning. Staff Y stated the facility did not get their regular shipment of eggs and were sent a substitute of egg whites from the facility's supplier. Staff Y stated they cooked the eggs as usual and placed them on the steam table. Staff Y stated they turned green after being on the steam table, but served the eggs anyway. Staff Y said nobody likes green eggs. In an interview on 05/12/2025 at 1:10 PM, Staff Z (Dietary Director) stated the facility had problems with supply and the steam table turned the eggs green. Staff Z stated it was their process to send out an announcement to the residents letting them know when there were food related problems. Staff Z stated all residents should be offered alternative meals and resident room should have a list of alternate meals available. REFERENCE: WAC 388-97-1100(1)(2). .

Based on observation, interview, and record review the facility failed to ensure staff followed infection control practices to help prevent the transmission of communicable diseases. The facility failed to ensure staff performed Hand Hygiene (HH) when providing personal care for 1 (Resident 50) and failed to follow an Enhanced Barrier Precaution (EBP) sign for 1 (Resident 50) who required EBP. These failures placed residents at risk for the development of contagious, communicable diseases, and an unclean environment. Findings included . <Facility Policy> Review of the facility's Hand Hygiene policy, revised 06/03/2025, showed staff would perform HH (even if gloves were used) before and after resident contact and after contact with body fluids. Review of the facility's Transmission-based Precautions and Isolation Procedures policy, revised 09/24/2024, showed EBPs were an infection control intervention designed to reduce transmission of multidrug-resistant organisms and utilized gown and glove use during high contact resident care activities. <Resident 50> Review of Resident 50's tube feeding (a method of delivering nutrition directly into the stomach through a surgically placed tube) care plan, revised 10/16/2023, showed the resident required nutrition via a feeding tube related to a swallowing disorder. The care plan included an intervention directing care staff to use EBP. Observation on 05/07/2025 at 9:45 AM showed Staff O (Certified Nursing Assistant) providing personal care to Resident 50. Staff O wiped Resident 50 with incontinence wipes and removed their soiled brief. Staff O removed their soiled gloves, did not perform HH, left the resident's room to obtain a new box of gloves, returned to the resident's room, did not perform HH, and put on a clean pair of gloves. In an observation on 05/12/2025 at 11:41 AM, Staff S (Registered Nurse) was preparing to administer feeding and medications to Resident 50 through their feeding tube. Staff S opened the feeding tube and removed residual feeding from Resident 50's feeding tube. Staff S did not follow the EBP sign and put on a gown prior to working with Resident 50's feeding tube. In an interview on 05/12/2025 at 2:03 PM, Staff S confirmed they forgot to put a gown on prior to assisting Resident 50 with their feeding tube and stated they should have gowned up. Staff S stated anytime staff worked with Resident 50's feeding tube, staff were supposed to gown up. In an interview on 05/13/2025 at 11:23 AM, Staff B (Director of Nursing) stated it was their expectation staff performed HH before and after providing care to a resident. Staff B stated they expect staff to follow EBP signs and gown up when directed. REFERENCE: WAC 388-97-1320 (1)(a),(c). .

Based on interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer/pressure injury (PU/PI) for 1 of 4 sampled residents (Resident 1). Resident 1 experienced harm when they developed an unstageable (a pressure injury that is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) wound to their right foot requiring hospital treatment and amputation. Findings included . <Resident 1> Review of the 02/21/2024 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 1 had no pressure ulcers, was dependent on staff to put on/take off footwear, required substantial/maximal assistance with bed mobility, and was assessed as at risk of developing PU/PIs. Review of the Braden Scale (an assessment for predicting pressure sore risk) dated 05/06/2024 showed Resident 1 was assessed at a severe risk of developing pressure sores. According to the assessment, Resident 1 was confined to bed, had very limited ability to change and control body position, and required maximum assistance in moving. Review of the at risk for break in skin integrity Care Plan dated 12/29/2023 showed Resident 1 was admitted with a hard cast to their right lower extremity (RLE) due to a surgically repaired ankle fracture. Interventions included directions to staff to check skin integrity around the hard cast on RLE every shift (added 03/07/2024), and the hard cast was padded around the edges to prevent friction against the skin (added 03/09/2024). Review of the May 2024 Treatment Administration Record (TAR) showed an 02/28/2024 order to check circulation, movement, and sensation on right leg every shift and report abnormalities to Medical Doctor/Nurse Practitioner. The order was discontinued on 05/14/2024. Review of the Orthopedic Aftercare notes dated 04/22/2024 showed the cast was removed, the resident's RLE Range of Motion (ROM) was assessed as supple and pain free. The documented plan included Resident 1 may transition gradually to WBAT (Weight Bearing as Tolerated). Recommend use of a lace-up brace, especially during Physical Therapy (PT). Specific instructions included okay for WBAT to right lower extremity, in a lace up ankle brace (if resident tolerated). Continue working with PT to gain strength to the extremity. No orders were written. Review of the Physical Therapy Evaluation dated 04/24/2024 showed the brace prevented testing of Resident 1's ROM. Right ankle in lace up ankle brace; no instructions provided for ROM in the orders. The resident was assessed as not appropriate for skilled therapy services and recommended Restorative Nursing Program (RNP) to maintain ROM in BLE (Bilateral Lower Extremities) if resident tolerated it. Review of the Restorative Nursing Communication Tool dated 04/24/2024 showed directives for LE Passive ROM with instructions to not perform ROM on the right ankle as the right ankle was immobilized in lace up ankle brace. Review of the Wound Observation Tool (WOT) dated 05/14/2024 showed that Resident 1 was noted with a facility acquired Deep Tissue Injury (DTI) and open area to their right lateral (side) foot and 5th toe. The wound measurements were 3.0 centimeter (cm) long, 5.0 cm wide and 0.6 cm deep. The wound on the right lateral foot and right 5th toe were clustered as one because of the proximity to each other. The toe presented with a DTI, the lateral foot wound had parts of it open with surrounding DTI. The wounds were attributed to the result of pressure from Resident 1's preference of lying on the right side. The physician was notified and treatment orders obtained. Review of a 05/20/2024 facility Investigation Report of the right lateral foot wound showed the Resident wears an immobilizer to the RLE related to fracture repair and revision. Review of Nursing Assistant Witness Statements showed that after the cast was removed, Resident 1 always had a bandage/ace wrap/wraps on their leg when the nursing assistants provided care. According to the provider, the wounds were unavoidable related to the immobilzer in place and comorbidities present. Review of Wound Healing provider notes showed on 05/21/2024 the resident's right lateral foot wound was evaluated. The Right Lateral Foot was assessed with a full thickness wound, measuring 5 cm by 13 cm by 0.5 cms, with exposed bone. There was moderate wound drainage and the area surrounding the wound was acutely inflamed. Initial assessment showed concerns for gangrene (death of body tissue due to lack of blood supply), bone was present at the wound base. Review of a 05/21/2024 Nursing Skin/Wound Note showed the wound was bigger in size, malodorous (smelling very unpleasant), with necrosis (death of body tissues due to injury) and bone exposure. Resident 1 was transferred to a local emergency room (ER). Review of Hospital Inpatient records dated 05/21/2024 showed Resident 1 had a cast in place which was removed on 04/22/2024 and was recommended a soft brace to be placed during therapy. Apparently the brace was in place for two weeks and once the brace was removed the resident was noted to have an ulcer on right foot lateral aspect. During evaluation in the ER, Resident 1's right food showed deep necrotic ulcer with exposed fifth metatarsal (long bones of the foot, located between the heal/ankle and toes) head with warm erythematous (abnormal redness) surrounding foot. The resident was started on antibiotics and admitted to the hospital. During an interview on 05/29/2024 at 10:00 AM, Resident 1's representative stated that after the 04/22/2024 Orthopedic Aftercare appointment they gave the facility the after visit summary and told them the splint was to be worn during therapy. Resident 1's representative stated if the facility staff had taken the boot off, they would have seen the wound earlier. Resident 1 was sent to the ER with clearly exposed bone, admitted to the hospital and scheduled for an above the knee amputation on 05/30/2024. During an interview on 06/12/2024 at 1:26 PM, Staff C, Restorative Nursing Assistant, stated they did ROM on Resident 1's UEs, and Left LE, but did not do ROM on the affected (Right) LE. Staff C stated Resident 1 always had the right leg wrapped. During an interview on 06/12/2024 at 2:02 PM, Staff D, Licensed Practical Nurse, stated they checked the circulation in the resident's toes. Staff D stated the splint was on all day and they did not take it off when they worked. During an interview on 06/12/2024 at 12:34 PM, Staff B, Director of Nursing, stated the facility staff should have clarified with the orthopedic provider when the splint was to be worn and if ROM exercises to the RLE should be performed. Staff B acknowledged the care plan was not revised after the cast was removed to include removal of the brace for skin checks. REFERENCE: WAC 388-97-1060(3)(b)

Based on observation, interview, and record review the facility failed to initiate Basic Life Support, which included rapid defibrillation and early CPR (Cardio-Pulmonary Resuscitation), when Resident 1 experienced a change in condition that required an immediate staff response to address a medical emergency. This failure increased the likelihood of unsuccessful CPR and resulted in Resident 1's death. An Immediate Jeopardy was called on [DATE] and removed on [DATE] when staff were trained, mock drills conducted, and staff records were updated with documentation of current staff CPR cards. Findings included . Review of [DATE] facility policy titled Cardiopulmonary Resuscitation (CPR) Guidelines, showed if a resident experienced a cardiac or respiratory arrest and did not show obvious signs of irreversible death (e.g. Rigor mortis, dependent lividity, decapitation, transection, or decomposition), the facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives or verbal wishes and any related physician order, such code status. Staff were instructed to a have a coworker retrieve an AED (Automatic External Defibrillator, a portable device that automatically diagnoses and treats life threatening cardiac arrhythmia's). If the staff were to be alone, the staff should retrieve the AED and other emergency equipment and return to the resident and begin emergency treatment until emergency medical services arrived. Resident 1 According to the [DATE] Admission Minimum Data Set (an assessment tool, MDS), Resident 1 admitted to the facility on [DATE], with a life expectancy of 6 months or more. Resident 1 had medically complex conditions including [CONDITION(S)] (CAD), Heart Failure (CHF), Hypertension ([CONDITION(S)]), and Diabetes Mellitus (DM). A review of Resident 1's Discharge Care Plan (CP) dated [DATE], showed Resident 1 intended to discharge to their home in the community. On [DATE], the Department received an intake dated [DATE] that showed the facility staff reported Resident 1 as unresponsive and without a pulse (heart rate) or respirations(breathing). The medical records showed Resident 1 had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:50 PM, Staff D, Licensed Practical Nurse (LPN), said they were told Resident 1 expired and there was a 10 to 14 minute delay in initiating CPR. Staff D, stated that on [DATE] at 6:06 AM, Staff C Registered Nurse (RN) reported Resident 1 expired. A review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing progress notes dated [DATE] at 06:40 AM showed Staff C, documented at around 6:00 AM, this nurse considered Resident 1 to be un-responsive. On [DATE] at 2:00 PM Staff E, Licensed Practical Nurse (LPN), stated they arrived to work at 6:00 AM. According to Staff E, Staff C reported Resident 1 expired. Staff E stated that they informed Staff C that Resident 1 was a full code (staff should perform rescue breathing and chest compressions and use an AED) and facility staff had to call Code Blue, (the facility emergency system.) Staff E stated that they went to Resident 1's room where they found Resident 1 warm to the touch and without a pulse. Staff E stated they initiated CPR and performed CPR on Resident 1 until the paramedics arrived at the facility and took over. Staff E stated that the paramedics identified Resident 1 with a thready pulse and after performing CPR pronounced the resident deceased at 6:40 AM. On [DATE] at 2:30 PM, in an interview Staff C, stated that, they went into Resident 1's room at 4:00 AM to administer routine medication and there was no change in the resident's condition. According to Staff C, when they returned at 6:00 AM there was a problem with the resident. The resident was not responding and Staff C stated, He wasn't good. When Staff C was asked what was meant by not good, Staff C repeated, (Resident 1) wasn't good. Staff C was asked a second time to describe Resident 1's condition, Staff C replied, He no good. On [DATE] at 8:25 AM, Staff F, LPN, stated that they arrived on the nursing unit on [DATE] at 6:05 AM. Staff F, stated that Staff C was overheard saying Resident 1 died . Staff F stated that, Staff E went into room [ROOM NUMBER] (Resident 1's room) and they (Staff F) went to the nurse's station to verify Resident 1's code status (Full code-CPR) and called Code Blue. Staff F stated that they were unsure what time the paramedics arrived but the resident was pronounced deceased by the paramedics at 6:40 AM on [DATE]. On [DATE] at 9:22 AM, Staff B, Director of Nursing stated that on [DATE] at 6:06 AM, Staff C called Staff B and said, 506 [Resident 1] is dead. Staff B stated that they asked Staff C for the name of the resident in room [ROOM NUMBER] and the code status. Staff C replied, I must call the doctor, and hung up the phone, before providing any additional information to Staff B. Staff B stated that after placing a call to the facility to instruct other nurses to initiate CPR and call the paramedics, Staff B arrived at the facility and was told that the paramedics were unable to resuscitate Resident 1. Staff B stated, I am not going to lie, It's unclear if Staff C activated the emergency call system or if [Resident 1] was assessed [for a change in condition]. Staff B stated that although Staff C documented they called a Code Blue and initiated CPR, it appears CPR wasn't initiated until 6:06 AM when Staff E arrived in the Resident's room and initiated CPR. During a tour of the facility on [DATE] at 5:20 PM, on the North and the South side of the facility, a white box was observed hanging on the wall in the Nurse's Station with red lettering, AED. On [DATE] at 5:25 PM, Staff G, RN stated that the white box was the facility's AED and was to be used when staff called a Code Blue, when a resident had respiratory or cardiac arrest. Staff G stated that the AED machine would direct you to either perform CPR or to shock the patient. On [DATE] at 5:25 PM, Staff H RN, stated that to use the AED they would place pads on the resident and instruct staff to stand clear and shock the resident. In a subsequent interview on [DATE] at 5:30 PM, Staff F was asked if the facility used the AED when providing care for Resident 1. Staff F said, No, We did not use the AED. It does not take the paramedics that long to get here and they were already in route to the facility. An audit of the staff records of current CPR status showed four Licensed Nurses and 14 Nursing Assistants had expired CPR certifications. Refer to WAC: [DATE](1)(2), [DATE](1)

Based on interview and record review the facility failed to provide adequate supervision, confirm planned fall interventions were implemented, functional, and effective to prevent falls for one (Resident 1) of four residents reviewed for accidents. These failures of the facility resulted in harm to Resident 1 and placed the other residents at risk for injury. Findings included . The Annual Minimum Data Set (MDS - an assessment tool), dated 12/16/2021, showed Resident 1 had medically complex conditions and Alzheimer's dementia, was cognitively intact (BIMS score of 13), with no behaviors. According to this MDS the resident was independent, with set up only for transfers, walking in room, toileting, was steady moving on and off the toilet, and used a walker. The resident was assessed as always continent of bowel and bladder and not on a urinary toileting program. The resident had one non injury fall and one injury fall since the prior MDS dated [DATE]. The resident was on anti-anxiety, antidepressant, and diuretic medications all seven days of the seven day assessment period. The question of a drug regimen review was not addressed and medication follow up showed it was not assessed/no information. Review of the Fall Risk Care Plan (CP) initiated 10/06/2020 showed the resident had an unwitnessed fall on 02/02/2022, 02/28/2022, 03/18/2022, and 03/25/2022 and a second unwitnessed fall when Resident 1 hit the back of their head on 03/25/2022. The listed goal was that Resident 1 would not sustain serious injury requiring hospitalization . 02/02/2022 at 12:45 AM Review of a facility fall investigation showed the resident had an unwitnessed fall on 02/02/2022 at 12:45 AM. According to the investigation the nurse was summoned to the resident's room where the resident was standing near the foot of the bed. The resident stated that they fell , but were not able to state how or why they fell . The resident complained of pain to the back of their head, at a level 7 out of 10. According to the Fall Scene Investigation Report fall interventions prior to this fall and implemented immediately after this fall to help prevent another fall were both Bed in low position. Review of the Fall Interventions summary showed the facility planned interventions of, Medication review for interactions, PRN (as needed) use reduction, change of times of medications, water pills given in AM, Encourage Resident to request assistance with transfers, getting out of bed, ambulating and toileting, and Low bed position. A Risk Management form dated 02/03/2022 listed recommendations/actions taken as, Staff instructed to monitor behaviors, monitor for falls. A Risk Management form dated 02/07/2022 listed recommendations/actions taken as, Pharmacist to review medications. Staff will assist with ambulation and transfers. During an interview on 03/29/2022 at 10:42 AM, Staff B (Director of Nursing), stated that the interventions identified were different. Staff B referred to Resident 1's CP and stated, It was not updated. The intervention of the low bed was not on the care plan. The 01/21/2021 CP showed that Resident 1 is independent with toileting. When asked if the resident needed assistance, Staff B stated, yes, but the resident did not adhere to that plan. Staff B was not able to provide the Pharmacy review that was planned. 02/28/2022 at 2:30 AM Review of a facility fall investigation showed the resident had an unwitnessed fall on 02/28/2022 at 2:30 AM. According to the investigation the resident stated that they dropped the water pitcher, and slipped on the water on the floor when they tried to sit in their chair. The resident did not ask for assistance. According to the Fall Scene Investigation Report the resident ambulated and transferred independently and was toileted at 2:15 AM. The intervention implemented immediately after the fall to help prevent another fall was to anticipate resident needs. Review of the witness statement written by the caregiver showed they were tending to Resident 1's roommate when they saw Resident 1 got up to use the bathroom. When the caregiver left the room, Resident 1 was still in the bathroom. The notes section of the fall report, dated 03/03/2022 showed that Resident 1 was a one person assist with transfers and the resident will transfer (them) self from bed to wheelchair, but staff encourages her to call for assistance for safety. Staff will continue to redirect her and monitor for activity during the night and assist her as needed. Review of the Fall Risk CP showed an intervention was added 02/28/2022 to, Anticipate residents needs. Review of an Evaluation for Bowel and Bladder Training dated 03/15/2022, showed Resident 1 was aware of toileting needs and used the bathroom independently, had occasional incontinence episodes, used adult incontinent products, and was assessed as a good candidate for individual training. Review of progress notes dated 03/15/2022 showed Resident 1 participated in a cognitive assessment, with a decline noted (BIMS 9 - Moderately Impaired Cognition). 03/18/2022 at 4:20 AM Review of a facility fall investigation showed the resident had an unwitnessed fall on 03/18/2022 at 4:20 AM. The nurse was walking down the hallway and heard a loud noise from the resident's room. Upon entering Resident 1 was observed lying in the entryway of the bathroom. The resident stated that they fell and needed to use the bathroom. The resident was noted with a lump to the back of the head. During an interview on 03/29/2022 at 9:55 AM, Staff B stated that Resident 1 could ambulate technically, and gets up without assistance, and walks to the bathroom. Staff B stated that Resident 1 had balance issues. According to the witness statements, Resident 1 was last seen in bed at 2:00 AM, 2 hours and 20 minutes prior the fall. During an interview on 03/29/2022 at 10:42 AM, Staff B stated that the night shift staff should round frequently. When asked about residents who are known to not use the call light and fall frequently, Staff B stated yes, Resident 1 should be monitored frequently. Review of the Summary of Investigation dated 03/22/2022 showed Resident 1 ambulated to the bathroom unassisted and was found on the floor with no injuries. The recommendations/action taken was Staff were to monitor the Resident during the night, and assist with toileting needs. Review of the Fall Risk Care Plan showed the 03/18/2022 intervention of Every 2 hour toileting schedule implemented for safety. During an interview on 03/29/2022 at 11:46 AM, Staff C (Unit Manager) stated that NAs care directives were posted inside residents' closets. Observation inside Resident 1's closet on 03/29/2022 at 11:57 AM, showed a Bedside Kardex dated 03/22/2022 with conflicting information. Under the section of Toileting was written, Assist with toileting as needed, Independent with toileting, Resident 1 is independent with toileting. Under the section of Mobility was written, Ambulation: (Resident 1) uses walker for walking in the room and independent. Under the section Transferring was written, Independent assist with transfers. Under the section Safety was Every 2 hours toileting schedule implemented for safety. Review of a Care Management note dated 03/21/2022 showed that the resident required limited assistance with cares, and used a walker and/or wheelchair for mobility. The Resident's cognition was noted to have declined, will continue to monitor but is not noted to be significant at this time as the resident is able to make needs and wants known appropriately. 03/25/2022 at 7:20 PM Review of a facility fall investigation showed the resident had an unwitnessed fall on 03/25/2022 at 7:20 PM. Review of a witness statement showed around 7:20 PM the Nursing Assistant (NA) was responding to a call light Resident 1's roommate had turned on. When the NA entered the room, Resident 1's roommate pointed to the bathroom door, which the NA opened to find Resident 1 on the bathroom floor. Review of 03/25/2022 8:41 PM Event Note showed that the NA reported to the nurse that Resident 1 was lying on the bathroom floor, the resident's nose was bleeding noted, and there was feces all over the body. The Resident went to bathroom by herself, lost her balance and fell on the bathroom floor. Review of the 03/25/2022 incident report showed Resident 1, directs her care and at times makes the wrong decisions. She had just been educated a few hours earlier to call for assistance whenever she needs to use the bathroom but she chose to go to the bathroom again unassisted. Review of the Fall Risk CP showed on 03/25/2022 the intervention was added, Educated to call for assistance whenever she wants to use the bathroom. During an interview on 03/29/2022 at 11:46 AM, Staff C, Unit Manager, stated that they needed to do teaching to call for assistance because it seemed like Resident 1 was getting weaker. When asked why Staff C believed teaching would be effective, Staff C stated that Resident 1's BIMS score was 13 (cognitively intact). (However, the 03/15/2022 BIMS score was 9). According to the investigation report the resident stated they tried to go to the bathroom. The investigation did not identify what time the resident was last toileted. The investigation failed to note the toileting schedule as a fall intervention, nor identify if the intervention was implemented as planned. 03/25/2022 at 10:30 PM Review of a facility fall investigation showed the resident had an unwitnessed fall on 03/25/2022 at 10:30 PM. Review of a Witness Report showed Resident 1 was last seen at 7:30 PM in the bathroom. The NA documented, Resident's bed is close to the bathroom and most of the time she does not use her walker. During an interview on 03/29/2022 at 10:42 AM, when asked if staff failed to implement the toileting program as planned, Staff B stated, Or if they did they didn't document having done so. Review of a witness statement showed a NA heard a scream from Resident 1's room, ran to see what was wrong and found Resident 1 on the bathroom floor screaming, with a bleeding nose, and vomiting. The incident report dated 03/25/2022 stated that Resident 1 was not responding well, exhibited weak verbal speaking. Stated they hit their head. The Resident went to bathroom by themselves, lost their balance, and fell on the bathroom floor, again. The resident suffered two falls in same shift, and was sent to emergency room for evaluation after consulting with the physician. Resident 1 was admitted to the hospital 03/25/2022, and had not yet returned to the facility. Review of hospital records showed the resident had a small subdural hematoma (a condition due to bleeding under the membrane covering the brain), acute appearing fractures of left 12 th rib, L1 and L2 transverse processes (located where muscles attach to the lower spine). During an interview on 03/29/2022 at 11:46 AM, Staff C, stated that Resident 1's bed was very close to the bathroom, that sometimes Resident 1 would walk into the bathroom without the walker. Staff C stated that after the fall on 03/18/2022 the resident was put on a toileting program and every two hour check. Review of the NA documentation showed that on day and evening shift of 03/25/2022, Resident 1 walked within their room and toileted with no supervision, set up, or physical assist from staff. On 03/29/2022 at 12:47 PM, Staff A (Executive Director) and Staff B were notified the facility failed to implement care planned interventions to prevent falls with substantial injury. Reference: WAC 388-97-1060(3)(g)

Based on record review and interview, the facility failed to recognize, comprehensively assess, evaluate treatment, and implement timely interventions for one of three residents (Resident #1), reviewed for critical laboratory results. The facility failed to monitor Resident #1's [MEDICAL CONDITION] and respiratory process to rule out complications related to [MEDICAL CONDITION] ([MEDICAL CONDITION]- a condition of blood clots forming deep inside the body) and respiratory infection. These failed practices resulted in serious harm in the form of delayed treatment and contributed to the development of [MEDICAL CONDITION] (blood infection) resulting in death. Findings included . Refer to: CFR 483.21(b)(2)(i)-(ii), F-657, Care Plan Revision CFR 483.50(A)(2)(I)(II), f-773, Lab Services Physician Order/Notify of Results CFR 483.20(f)(f)(5), F-842, Resident Records RESIDENT #1 Resident #1 admitted to the facility on [DATE]. According to the [DATE] Admission Minimum Data Set (MDS - an assessment tool), the resident was assessed as cognitively intact and had multiple medically complex diagnoses, [MEDICAL CONDITIONS], high blood pressure, low sodium, asthma, and required care related to a recent [MEDICAL CONDITION]. The resident discharged to the hospital on [DATE] for care needs related to a [MEDICAL CONDITION], and returned to the facility on [DATE]. According to the [DATE] 5 Day MDS the resident continued to have care needs related to [MEDICAL CONDITION], cancer, hypertension, asthma and low sodium levels. This MDS specified multiple acute embolism: unspecified deep veins of left distal low extremity, acute embolism and [MEDICAL CONDITION] of . the left iliac vein, left femoral vein, left popliteal vein and the left calf muscular vein. The resident was identified at this time with no infection. According to Physician notes dated [DATE] and [DATE] indicated the resident, is here currently to get stronger to be able to tolerate the chemo ratiation treatment. Occupational Therapy documents dated [DATE] listed patient goals of, I wanted to get stronger and walk more to go back home again. [MEDICAL CONDITION]/ RESPIRATORY STATUS According to Advanced Registered Nurse Practitioner (ARNP) Progress Notes dated [DATE], the resident was assessed with [REDACTED]. Upon readmission to the facility on [DATE] at 2:47 PM, the resident's BP was assessed as ,[DATE] and a pulse of 65. According to the Admission/Readmission collection tool dated [DATE] the resident was assessed with [REDACTED]. reason for admission was cardiovascular/coagulation and listed embolism and [MEDICAL CONDITION] of the left leg but had no assessment of the left leg as it related to [MEDICAL CONDITION] symptoms. The SND dated [DATE] showed a BP of ,[DATE] and a pulse of 110 with no assessment of the resident's LLE (Left Lower Extremity). An SND dated [DATE] showed a BP of ,[DATE] and a pulse of 94 with, Left leg still slightly swollen but gradually improving but there was no further objective measurable assessment of the leg (i.e. the extent of the swelling, presence and or extent of [MEDICAL CONDITION]). Physical Therapy (PT) notes dated [DATE] showed Pt displayed SOB (shortness of breath) at end of both trials (a period of working with the therapist) and requested to have inhaler at end of first trial. Nursing came in to provide pt with inhaler during rest break of first trial. Pt reported having increased pain today as compared to yesterday when therapist arrived. Notified Nursing and Nursing came in to provide pt pain medication during session. The therapist documented Patient verbalized pain and indicated the pain limited the patient's functional activities. The pain was assessed as Pain at rest = ,[DATE]; frequency = constant Location: LLE - from knee down and described the pain as aching. There was no documentation to support nursing staff assessed the resident's lung status (check prog notes) or assessed the resident for signs/symptoms of [MEDICAL CONDITION] to the LLE. The [DATE] SND showed a BP of ,[DATE] , a pulse of 140 and, Res left leg swollen and c/o pain noted. There was no objective assessment of the left leg. The [DATE] SND assessed the resident with a BP of ,[DATE] and a pulse of 138. Therapy notes dated [DATE] showed the resident had a missed session related to, Feeling sick and states she is going to get an IV for dehydration. According to Advanced Registered Nurse Practitioner (ARNP) notes dated [DATE], an acute LLE (left lower extremity) [MEDICAL CONDITION]-extensive .per hospital H/P (history and physical), management rsd (resident) may need vascular surgery consult .LLE still with pain and swelling, difficulty in walking .patient is on [MEDICATION NAME] (pain medication) (as needed) for LLE pain. denies effective. The ARNP at this time assessed the resident with [MEDICAL CONDITION] +3 LLE, RLE +1. In an interview on [DATE] at 3:05 PM, when asked if nursing staff should have provided an ongoing assessment of the resident's [MEDICAL CONDITION] status to determine if the symptoms were resolving or deterioration, Staff A replied, Yes. Staff A was asked to provide evidence staff objectively assessed the resident's lower extremities for [MEDICAL CONDITION] symptoms. No information was provided. The [DATE] ARNP note documented the resident's BP as ,[DATE] with a pulse of 119 and indicated, .due to (decreased) BP (blood pressure), will d/c (discontinue) ([MEDICATION NAME]) and change to [MEDICATION NAME]. At this time the ARNP lowered the resident's Metroprolol (a BP medication) from 25 mg to 12.5 mg twice a day. Review of the [DATE] Medication Administration Records (MARs) showed the resident continued to receive [MEDICATION NAME] for four additional days, four times on [DATE], three times on [DATE], twice on [DATE] and twice on [DATE]. Occupational Therapy (OT) notes dated [DATE] showed, Pt (patient) declined getting up for therapy, dressing, toileting, pt in too much pain. complained of pain in LE as 9-,[DATE] had a hard time with breathing, notified nursing of pt's complaints. Pt's 02 80% and pulse 37. Record review showed no indication nursing staff assessed the resident's respiratory status or provided interventions based on the OT's report. Physical Therapy (PT) notes dated [DATE] showed, Pt presents with dyspnea on approach and requesting inhaler and pain medication. RN notified and brought inhaler but unable to bring pain medication at this time. Pt agreeable to sitting (edge of bed) for better posture for breathing. The therapist documented the resident had Pain with movement = ,[DATE]; frequency =- constant; location bil (bilateral) LE, left calf; Pain description: ache. An ARNP note dated [DATE] documented, Also, nurse reports (increased pain) (with) [MEDICATION NAME] and again indicated, D/C [MEDICATION NAME] . and BP ( decreased) will try [MEDICATION NAME] 5 mg 2 tabs (every) four (hours) and hold if sedated or RR ( respiration rate less than 12). In an interview on [DATE] at 3:20 pm Staff A, Administrator, indicated that the ARNP did not leave her notes with facility staff and was unsure why the order wasn't implemented. Failure to discontinue the [MEDICATION NAME] and start the [MEDICATION NAME] as intended by the ARNP placed the resident at risk for continued low blood pressures and unrelieved pain. UNTREATED MEDICAL CONDITION According to [DATE] MARs, staff were directed to obtain a CBC (Comprehensive Blood Count) and a BMP (Basic Metabolic Panel - bloods test) on [DATE]. According to the MAR, staff did not obtain the lab as directed on [DATE]. ARNP notes dated [DATE] identified the resident had [MEDICAL CONDITION], dehydration, SOB (Shortness of Breath) . with diminished respiratory status. There was no objective assessment of this diminished status. Nursing notes on [DATE] at 6:59 PM, Resident left leg swollen, complains of pain noted .her vital signs not stable. ARNP seen her. Stat CBC, CMP (Comprehensive Metabolic Panel) (blood test done this afternoon) and stat chest xray two view rule out PE (Pulmonary Emboli- blood clots in the lung). According to the MAR indicated [REDACTED]. Nursing staff failed to identify the [DATE] ARNP directives differed from the previous order and a CMP was not obtained as directed, nor were either test run as a stat. According to lab records, these blood tests were drawn on [DATE] at 2:56 PM and reflected a critically high WBC (White Blood Cell Count- indicative of infection) levels of 23.00 (normal range 4XXX,[DATE].50) High [DIAGNOSES REDACTED]s levels (indicative of infection/stress) of 21.2 (normal levels 1XXX,[DATE].9) and numerous other results that were out of normal range, including a low sodium level. Additionally, while the chest xray results were completed on [DATE]. There was a progress note dated [DATE] indicating the on call physician was notified of the chest xray. An entry dated [DATE] was made on the xray result which read, lung mets (metastasis) and [MEDICATION NAME] (an antibiotic) was written, then crossed out in error. Lab staff documented the facility was notified of the critically high result on [DATE] at 12:56 PM, 23 hours after the labs were drawn. Record review showed no indication facility staff acted on the knowledge of these abnormal labs, failed to notify the physician of critically high labs and failed to identify the ordered CMP wasn't drawn. Progress notes dated [DATE] at 5:48 PM noted the resident was, noted with borderline hypotensive blood pressure .lung sounds course with rales .complaint of shortness of breath x1 given pro-air inhaler with relief .medicated for left leg lapin, resident states the leg pain has gotten worse over days, she is concerned because she had a [MEDICAL CONDITION] on this extremity .vm (voice message) left for on-call MD with a request for call back. I will endorse to evening shift for follow-up. However, on [DATE] at 10:50 PM, nursing staff documented, lungs clear to auscultation .resp. even and unlabored on O2 at 2 LPM. Record review showed there was no further communication with the MD until 12 hours later when progress notes dated [DATE], at 5:44 AM, Resident noted to have 2 natural bowel movements noted with bloody stool. On call MD notified of resident's dx (diagnosis), recent history of LLE [MEDICAL CONDITION] with current complaints of pain to LLE and current findings. MD ordered for [MEDICATION NAME] (blood thinner) to remain on hold until bloody stools cease then resume as previously ordered. CBC ordered . According to the Physician Orders on [DATE] at 06:49 AM, a Stat (urgent or rushed, immediately) order for a CBC was placed. Record review continued to show facility staff failed to notify the on call MD or the resident's Primary Care Provider (PCP) of the critical and abnormal results from the labs drawn on [DATE]. According to Laboratory documents, the stat CBC was drawn on [DATE] at 10:19 AM. Per lab documents received [DATE], facility was notified of the STAT results on [DATE] at 12:51 PM. This lab still reflected elevated WBCs of 21.43 in addition to other abnormal lab results. Record review showed the ARNP did not note these labs until [DATE]. A separate skilled nursing note dated [DATE] at 2:57 PM showed, .LN drew blood for CBC, CMP and sent out stat, will follow-up Record review showed no Physician Order on [DATE] for a CBC and CMP, nor any indication additional labs were ordered or drawn on [DATE], after the 6:49 AM order for a CBC was placed. Progress notes dated [DATE] at 2:46 PM showed, Noted shortness of breath lung sounds coarse with rales on auscultation. Record review showed there were no further nursing assessments to determine the resident's lung status. Physical Therapy (PT) notes dated [DATE] showed, Pt presents with dyspnea (difficulty breathing) on approach and requesting inhaler and pain medication. RN notified and brought inhaler but unable to bring pain medication at this time. Pt agreeable to sitting (edge of bed) for better posture for breathing. However, the nursing Respiratory Symptoms Screening Tool dated [DATE] indicated the resident had no shortness of breath or respiratory symptoms. According to ARNP notes dated [DATE] Pt (patient) signed POLST (Physician order for [REDACTED]. Physician Orders showed the UA order was placed into the computer at 1:32 PM on [DATE]. There was no indication facility staff attempted to obtain the UA until 17 hours after the original order when a progress note on [DATE] at 7:09 AM showed, writer was attempting to obtain a UA for a sample ordered by the MD . According to [DATE] MARs, staff were directed to administer the antibiotic [MEDICATION NAME] at [DATE] for infection. Staff documented this was administered at 10:28 AM. Record review showed no indication of the origin of this order. In an interview on [DATE] at 3:50 PM, Staff A stated, the ARNP started the antibiotic for the elevated white count, not an identified infection. Staff A was asked, if the antibiotic was started for an elevated white blood cell count, wouldn't it be expected that it be started sooner, given the initial critical high WBC count drawn on [DATE], Staff A replied, yes. Progress notes dated [DATE] at 12:40 PM showed, found (resident) lethargic/vitals unstable 02 at 77% at 3L via N/C BP at ,[DATE], resp(irations) at 22 .she is in respiratory distress .911 called and paramedics took resident to St. Francis Hospital. Hospital records dated [DATE] showed that upon presentation to the hospital, the resident is found to be unresponsive, in respiratory distress, met criteria for [MEDICAL CONDITION] with fever, [MEDICAL CONDITION] tachypnea, leukocytosis, shock, acute kidney injury .Respiratory exam showed significantly decreased coarse breath sounds, worse on the right side with decreased air entry indicating possible aspiration pneumonia with [MEDICAL CONDITION] conservation. Lab results upon admission to the hospital included WBCs of 23.2, similar to the labs drawn by the facility on [DATE], with no treatment interventions. In an interview on [DATE] at 2:52 PM, Staff E, ARNP, indicated the resident's demonstrated low blood pressure and high pulse were indicative of a brewing infection which was why she ordered labs on [DATE]. When asked if an antibiotic should have been ordered based on the [DATE] critical lab results, Staff E stated, Yes. Hospital documents dated [DATE] indicated the resident had acute [MEDICAL CONDITION], suspected to be secondary to [MEDICAL CONDITIONS], dehydration. The resident was identified with Urinary Tract Infection- urinalysis showed negative [MEDICATION NAME], 2+ Le(ukocytes) 3+ bacteria, 92 WBCs. Hospital records showed the resident had [MEDICAL CONDITION]-suspected to be secondary to [MEDICAL CONDITION], shock. Hospital records showed the resident had, O2 sats noted to be in the 60s on room air, improved to 98% on 10L oxygen by oxygen mask. CT chest without contrast performed today shows increased bilateral lower lung dependent portions consolidation indicating chronic aspiration. A hospital Death Summary Report indicated the resident died on [DATE] at 1:35 AM due to severe sepesis. REFERENCE: WAC [DATE](1).

Based on interview and record review, the facility failed to provide adequate supervision of staff, and care and services for residents, that was necessary to avoid accidents and serious harm, for one of two residents (#1) reviewed for accidents. The facility failed to provide care and services according to standards of care for positioning when it was found that a care giver rolled Resident #1 out of bed and the resident landed on the floor, sustaining major head injuries, including a subdural hematoma (bleeding in the brain) which resulted in death. Findings included . Refer to CFR 483.483.21(b)(1), F-656, Develop/Implement Comprehensive Care Plan RESIDENT #1 Resident #1 admitted to the facility on [DATE]. The [DATE] Admission Minimum Data Set (MDS- an assessment tool) indicated the resident had [DIAGNOSES REDACTED]. The most recent [DATE] Significant change MDS showed the resident now had bilateral upper and lower extremity ROM (range of motion) limitations. According to the most recent [DATE] Significant Change MDS, the resident was assessed to require extensive two person assistance for bed mobility, dressing, and toileting and was totally dependant on two staff for transfers. According to the associated Urinary Incontinence Care Area Assessment, staff documented the resident requires total assistance with incontinence care. According to the most recent [DIAGNOSES REDACTED]. According to the [DATE] Bed Mobility Care Plan (CP), staff documented, The resident is totally dependent on (X) staff for repositioning and turning bed. The intervention was clarified on [DATE] to reflect, The resident is totally dependent on staff for repositioning and turning in bed every ,[DATE] hours but did not direct staff as to the number of staff required for this task. According to an investigative documented dated [DATE] at approximately 4:30 AM, Licensed Staff, was called to room by CNA (Certified Nursing Assistant), she explained that she was changing Resident, had lifted her on one side and the resident went all the way over, I found Resident on her back on the ground and bed was in high position . The resident was identified with a goose egg a little smaller than a golf-ball to the left occipital (base of the skull). The investigation also indicated the resident was noted with a Hematoma (localized bleeding into tissue) to Left occipital temple (the side of the head behind the eye between the forehead and the ear). According to this document, education was provided to staff about not turning resident away from you. According to a [DATE] statement by Staff C (Registered Nursing Assistant - the staff providing care at the time of the accident), the resident, tumbled off the bed hitting her head on the dresser on the right side of her bed while doing a bed change. Staff documented on the [DATE] accident investigation that the root cause of the fall was CNA changed Resident by herself, Resident is a two person assist-per her Care Plan. According to progress notes dated [DATE], at approximately 10:30 AM, the resident was identified with [MEDICAL CONDITION] and vomiting and was transferred to the hospital. Hospital documents showed the resident was identified with, Large .hemorrhage in the left frontal lobe measuring up to 5.6 cm with surrounding cerebral [MEDICAL CONDITION] (brain swelling) in addition to subdural hematomas (bleeding in the brain) in two other areas. Resident #1 subsequently died on [DATE]. In an interview on [DATE] at 2:10 PM, when asked if Resident #1 would have fallen if Staff C had turned the resident toward her rather than away from her, Staff B, Director of Staff Development, stated, I don't believe the resident would have fallen from the bed (if the resident was turned towards staff), she would have been able to block her fall . When asked if it was Staff C's failure to turn Resident #1 towards her caused the fall, Staff B stated, Correct. In an interview on [DATE] at 11:00 AM, Staff A, Administrator, confirmed that Resident #1 was totally dependent on staff for mobility and was not able to move on her own. REFERENCE: WAC [DATE](3)(g).

Based on observation, interview and record review, the facility failed to ensure safety measures were followed to prevent potential complications associated with nutrient delivery through tube feeding devices for two (#s 355 & 73) of five residents observed for maintaining the head of the bed at least 30 degrees during administration times, This failure placed residents at risk for aspiration (inhaling food contents into lungs) and development of lung infection and constituted an Immediate Jeopardy. Findings include Refer to CFR 483.40(a)(1)(2), F-741, Sufficient/Competent Staff-Behavioral Health Needs According to the facility [MEDICATION NAME]/Enteral Nutrition Therapy (Tube Feeding) policy revised 11/28/16, [MEDICATION NAME] fluids and nutrition must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan and the resident's goals . RESIDENT #355 Resident #355 was admitted on [DATE] with multiple medically complex [DIAGNOSES REDACTED]. September (YEAR) Medication Administration Records (MARs) directed Licensed Nurses (LNs) to Elevate head of the bed at least 30 degrees while tube feeding running and one hour after tube feeding completed, to prevent aspiration. Current Care Directives (undated), informed nursing assistants that Resident #355 was NPO (nothing by mouth), and that he Eats In Own Room, but did not indicate resident's nutrition was supplied via enteral administration or that the head of the bed (HOB) was required to be elevated at least 30 degrees during enteral nutrition administration to prevent aspiration. On 09/07/18 at 7:53 a.m., Resident #355 was observed to have enteral nutrition actively administered. The HOB was less than 30 degrees upon observation. Staff V (Registered Nurse) was notified of this observation and asked if head of the bed was at the required elevation. Staff V stated, No, it should be between 30 to 45 degrees, and that a magnetized protractor should be attached to the bed frame to allow staff to elevate the head of the bed to the correct degrees. Staff V then elevated the head of the bed to the directed degrees. In an interview on 09/13/18 at 11:30 a.m., Staff F (Resident Care Manager - RCM) indicated the Care Directives failed to include instructions to the nursing assistants about the presence of enteral nutrition and pertinent information for head of the bed elevation in order to prevent aspiration. Review of (MONTH) (YEAR) MAR indicated [REDACTED]. In an interview on 09/14/18 at 11:41 a.m., Staff D (Staff Development) stated all water and formula amounts should be documented in the MAR. RESIDENT #73 Resident #73 admitted to the facility on [DATE] with multiple clinically complex [DIAGNOSES REDACTED]. Due to these conditions, the resident was to receive 100% of nutrition via gastric tube. Record review revealed 04/24/18 Physicians Order's (PO) for Resident #73: to be NPO secondary to oral/pharyngeal dysphagia (swallowing disorder); and to elevate HOB at least 30 degrees while tube feeding running and one hour after tube feeding is completed. Observation on 09/07/18 revealed Resident #73 lying in bed with [MEDICATION NAME] 1.2 infusing via gastric tube. The HOB was elevated to approximately 20 degrees. On 09/10/18 the following observations were made: at 8:55 a.m. resident lying in bed with tube feeding infusing, HOB at approximately 10-15 degrees; 9:37 a.m. resident lying in bed with tube feeding infusing, HOB at approximately 10-15 degrees; and at 9:45 a.m. the resident was observed lying in bed, calling out (indiscernible) and coughing intermittently, the resident's HOB remained at 10-15 degrees. On 09/10/18 at 9:45 a.m. Staff D agreed to obtain a tool to measure the elevation of Resident #73's HOB. Upon returning to Resident #73's room, Staff K (Licensed Practical Nurse - LPN), was observed exiting the resident's room. Staff K acknowledged at that time she had repositioned the resident and elevated the HOB. Staff D proceeded to measure the elevation of the HOB (after it had ben elevated) and determined it was at 31 degrees. In an interview on 09/18/18 at 7:49 a.m., when asked why resident's actively receiving tube feeding should have their HOB elevated to at least 30 degrees Staff D stated, To decrease the risk of reflux and aspiration. When asked if having the HOB below 30 degrees would increase the risk of aspiration Staff D stated, yes. Facility staff's failure to ensure that residents actively receiving tube feeding had the head of their bed elevated to at least 30 degrees, consistent with professional standards of practice and POs, placed residents at immediate risk for aspiration and/or respiratory compromise. Additionally, record review revealed a 04/26/18 PO to provide [MEDICATION NAME] 1.2 at 80 cc/hr x 20 hours per day. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In an interview on 09/18/18 at 7:53 a.m. when was asked if Resident #73's tube feeding was put on hold when the resident received incontinent care Staff K responded yes. When asked if nursing documented the amount of tube feeding actually infused Staff K stated, no, we sign that it was turned on at 7:00 p.m. and off at 3:00 p.m. When asked how they account for the time the resident did not receive tube feeding during the 20 hour period e.g. on hold for skin check, peri care, etc. Staff K stated, good point. When asked if the facility should be documenting the amount of tube feeding actually infused Staff K stated, yes. REFERENCE: WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to identify, assess and monitor pressure ulcers and ensure residents received care consistent with professional standards of practice to prevent the development of and/or heal pressure ulcers for three (#s 75, 76 & 40) of five and three (#s 20, 9 & 73) supplemental residents reviewed for pressure ulcers. Facility failure to implement measures to prevent development of avoidable pressure ulcers caused harm to Resident #75, who developed a pressure ulcer with full thickness skin loss. Findings include: Refer to CFR: 483.25(c)(1)-(3), F-688, Increase/Decrease ROM/Mobility 483.25(K), F-697, Pain Management 483.50(a)(1)(i), F-770, Laboratory Services RESIDENT #75 According to the 08/08/18 Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool), the resident had severe cognitive impairment, exhibited behavioral symptoms directed towards others such as hitting, screaming, which occurred daily, which had no impact on resident care. The resident exhibited no rejection of care, required two person extensive assistance with bed mobility, transfers, dressing, toileting, had functional limited Range of Motion (ROM) on both upper extremities (UE) and lower extremities (LE) without therapy or restorative nursing services. The resident was assessed as at risk of pressure ulcers, and without pressure ulcers. According to the MDS Resident #75 did have a skin tear and staff applied ointments and non surgical dressings. The associated Pressure Ulcer Care Area Assessment (CAA) revealed a SCSA MDS was completed due to the resident's admission to hospice from progression of [MEDICAL CONDITION] and significant weight loss. According to the CAA, the resident was identified as, at risk for skin breakdown r/t (related to) weakness, impaired mobility, bowel and bladder incontinence, on antidepressant and antianxiety (medications), pain, foot drop and contractures. Braden scale of 12 indicating at risk for pressure ulcers. Res(ident) does not have any pressure ulcers at this time but skin tear to the left middle finger. Treatment in place. The documented plan included, Weekly skin checks are done by LN (Licensed Nurse) and treatment per order. The 08/23/18 Risk for Impaired Skin Integrity Care Plan (CP) identified Resident #75 at risk for impaired skin integrity r/t, Depression, Pain, Incontinence, Contractures, severe muscle deconditioning, Parkinson. On 07/18/18 the CP was revised to include Resident #75 has skin tear to the left middle finger. On 08/30/18 the CP was revised to include, Re-opened area to left middle finger. Listed goals included, Skin will remain intact daily through next review date, Skin tear to left middle finger will remain free from infection and show evidence of healing by next review date. Approaches included, Notify nurse immediately of any new areas of skin breakdown .noted during bathing or daily care, Tx (treatment) as ordered by MD (Medical Doctor), and LN to provide tx as ordered by MD. Record review revealed the 08/05/18 Weekly Skin Integrity Data Collection (WSIDC) noted the resident had a skin tear, left middle finger open area with treatment. The 08/12/18 WSIDC was scheduled but not performed. According to the 08/19/18 WSIDC the resident had a left middle finger open area with treatment. The 08/26/18 WSIDC was blank, although it was signed off on the (MONTH) (YEAR) Treatment Administration Record (TAR) as done. The Monthly Summary dated 08/26/18 indicated the resident's skin condition was good, and did not note the presence of open areas, pressure ulcers or skin tears. According to the summary the resident had contractures to hand without ROM, Splints, or handrolls. The 08/23/18 Activities of Daily Living (ADLs) CP listed approaches including,Insert Carrot orthotic on both hands up to level 6 x 1 hr (hour) 6 x 1 wk (week). Review of Physician order [REDACTED]. Review of the (MONTH) Restorative Administration Record (RAR) revealed the programs were last done in (MONTH) on 08/22/18. They were not scheduled on 08/24/18, 08/29, 08/30, and circled as not done on 08/23, 08/25, 08/26 and 08/27/18. An 08/26/18 progress note revealed, .Resident has contractures of both hands and feet. Resident usually have accumulation of molds due to excessive moisture in between fingers and resident will decline care when offered Resident declines care to toenails and fingernails. Is sometimes combative and using inappropriate language .all pressure areas intact with no tears, inflammation and lacerations was noted . An 08/30/18 progress note revealed, .resident noted to reopened area to left middle finger due to some contractures present on that arm and sometimes moistures and sweats resident is not compliance with nail care accepts sometimes when husband is around new treatment order received to clean site with normal saline apply skin prep to surrounding areas of the affected site, cover with xeroform, change dressing daily and PRN (as needed) as resident permits will continue to monitor. A PO dated 8/31/18 noted, re-opened area to left middle finger. Cleanse area with NS (normal saline). Apply skin prep to edges, cover site with [MEDICATION NAME] dressing daily and PRN. Record review revealed a 08/31/18 progress note revealed, .resident has new recommendation to start Bactrim DS PO (orally) BID (twice a day), [MEDICATION NAME] 2% cream three times daily and a wound culture due to open area left middle finger Hospice was notified and LN received a request for new recommendations to be faxed which was conducted. Will continue to provide care and monitor outcome. Review of the (MONTH) (YEAR) TAR revealed the lab for culture due to drainage from left middle finger was scheduled for 08/31/18, but not documented as done. Review of the labs revealed it was collected as scheduled, the final report dated 09/02/18 which listed culture results of many mixed organisms typical of skin source and identified a moderate number of white blood cells. moderate number of squamous [MEDICATION NAME] cells, many gram positive cocci, few gram negative rods culture results. A progress note dated 09/01/18 revealed, resident has open area to left middle finger. treatment in placed, resident refused to clean her fingers at first, but later in the day agreed to clean her hand and fingers, [MEDICATION NAME] 2% cream applied as ordered. On ABO (antibiotic) Bactrim BID, no side effects noted r/t use of ABO. took medications as ordered. Will continue to monitor. As of 09/06/18 at 12:41 p.m. there were no progress notes of documented monitoring since 09/01/18 at 5:11 p.m. The WSIDCs dated 09/02/18 and 09/09/18 indicated the resident had a left middle finger open area with treatment. On 09/05/18 at 1:28 p.m. Resident #75 was observed in bed with bilateral clenched hands without splints or carrot in place. In an interview at that time, when asked if she was able to feed herself, Resident #75 replied, No, I'm not and commented, with these hands? See? and held up her hands with bent fingers. When asked about pain, Resident #75 said Yes, in my hands. When asked, if she had any sores, open areas, or pressure ulcers, Resident #75 replied, Yes I do, see in there as she partially opened her left hand. An open area was observed on the resident's left thumb, without a dressing or protection. When asked what the staff did for the open area, Resident #75 said They take the crap off. The (MONTH) TAR listed a 09/13/18 PO for [MEDICATION NAME] cream, apply to left middle finger three times a day until resolved, which was scheduled for 9:00 a.m., 1:00 p.m. and 8:00 p.m. It was documented as done through 09/16/18. On 09/17/18 at 10:06 a.m., Staff R (Registered Nurse - RN) was informed the surveyor wanted to observe the dressing change to Resident #75's hand. Staff R said it was scheduled for 9:00 a.m. to 10:00 a.m., you go in, she may refuse, try again. At 10:14 a.m. Staff R was preparing supplies and said, To clean I usually get the swabs because it does not hurt her. Staff R retrieved a pink oral swab toothette and when questioned, commented the hospice nurse said if we do (the treatment) with this is (it is) gentle on her skin and she don't refuse. In the resident's room, Staff R was observed to to don gloves, clean the resident's inner hand with the toothette, to which resident #75 commented, Oh boy, that's tough. Staff R patted the hand dry with gauze. The resident's thumb was observed to apply pressure against her hand. When asked what size the wound was, Staff R replied It's big. Staff R measured the wound as 2 cm (centimeter) long by 2 cm deep. Staff R applied the [MEDICATION NAME] cream to the open area on the resident's left thumb with a gloved finger. Staff R commented, She's separating her thumb. She will usually press against it She was pressing it before so we were using swab to help her open it, but today she just opened it. On 09/17/18 at 10:29 a.m. Staff B (Director of Nursing) was requested to provide documentation of the weekly Pressure Ulcer (PU) rounds. Staff B reviewed the spread sheet with weekly measurements and found none for Resident #75, I don't have here. On 09/17/18 at 10:30 a.m. Staff D (Staff Development) said, The RCMs (Resident Care Managers) have weekly pressure ulcer status records in the resident record. Staff D looked in the RCM office, reviewed the PU records and said No, I don't see (any pressure ulcer records) for Resident #75. Staff D reviewed the resident's record and was unable to locate any information regarding a wound to the resident's left thumb, All notes refer to open area of left middle finger. While Staff D observed the resident's left hand, Resident #75 said, It's sensitive. When asked what the open area was, Staff D said It looks pressure related. When Staff D asked the resident, can we put something in it, Resident #75 replied, used to have carrots, they didn't come back. Staff D told the resident, I need to put something in your hand so this will heal. In an interview on 09/17/18 at 10:46 a.m. when asked why the RNP was discontinued, Staff H (RCM) replied, She's hospice. When asked why the carrot was not replaced with another form of protection for example gauze or washcloth, Staff H replied, with (Resident #75) it's hard. When asked if the nurses reported anything to him regarding the resident's hand, Staff H said, the contractures. We already talked to Therapy but was unable to recall when, sometime back, I can't remember. When asked if he had been notified of the wound, Staff H said No. In an interview on 09/17/18 at 11:05 a.m. when asked why the carrot had been originally ordered, Staff L (Director of Rehab) said, to keep (hand) from closing because of the skin. When asked if to his knowledge the resident was still receiving the RNP, Staff L said I think so. When asked if he had been told otherwise, Staff L said I think they approached me. I just said keep trying. On 09/17/18 at 10:39 a.m., Staff D requested Staff H to obtain measurements of the thumb wound. Staff H measured the wound as 2.5 cm x 2 cm and classified it as a Stage III pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue are often present). Staff D informed Staff H they needed to complete an incident report, a pressure ulcer tracking form and obtain treatment orders. RESIDENT #9 Resident #9 admitted to the facility on [DATE], and according to the 06/07/18 SCSA MDS required extensive assistance with ADLs, was at risk for pressure ulcer development, had severe cognitive impairment and received hospice services. Observations revealed Resident #9 lying in bed supine with head of bed elevated to approximately 10 degrees, and heels flat on mattress on: 09/05/18 at 12:23 p.m.; 09/06/18 at 10:57 a.m.; and 09/06/18 at 12:23 p.m. Record review revealed Hospice notes on: 08/14/18 that identified, Unstageable PUs to the right and left posterior heels.; a 08/23/18 note that stated, .Has unstageable PUs to bilateral heels, dry eschar noted .floated heels with pillows during visit .; and a 08/28/18 note that stated, .Has unstageable PUs to bilateral heels, dry eschar noted .floated heels with pillows during visit .RCM aware of above skin issues . Review of the (MONTH) (YEAR) TAR revealed staff failed to perform the, Head to Toe Skin Assessment by LN (Licensed Nurse) on 08/18/18 as scheduled, and the 08/25/18 skin assessment was signed off but the associated WSIDC form, which directed staff to identify new and old skin conditions, was not completed. Review of the (MONTH) (YEAR) TAR revealed Resident #9 had head to toe skin checks performed on 09/01/18 and 09/08/18. Review of the WSIDC for 09/01/18 revealed staff documented, Discoloration/gangrene toes with tx (treatment). There was no identification of the bilateral heel pressure ulcers. The WSIDC for 09/08/18 was blank. Review of the medical record revealed no documentation by facility staff about the unstageable PUs to Resident #9's bilateral heels, for over three weeks, despite being identified by the hospice nurse on 08/14/18. There was no indication that facility staff had identified the areas, were measuring, monitoring or treating the ulcers. In an interview on 09/07/18 at 12:40 p.m. Staff G (RCM) was asked if she was aware of Resident #9 having any PUs to which she responded, Nope . When asked if there were any PUs on his heels Staff G stated, Not that I know of. On 09/07/18 at 12:56 p.m., Staff G and Staff B were present to perform a skin check for Resident #9. The skin check revealed a 1.6 cm by 0.8 cm area of dry black eschar to the left heel and 1 cm by 0.7 cm area of dry black eschar to the right heel. In an interview on 09/07/18 at 1:43 p.m. Staff B stated she would have expected the bilateral heel pressure ulcers to have been identified on the weekly skin checks. When asked if there was any indication staff had identified, assessed and monitored the areas Staff B stated, No. RESIDENT #76 Resident #76 was initially admitted to the facility on [DATE] and, after a six day stay at a local hospital, re-admitted on [DATE] with multiple medically complex diagnoses, including history of contractures and chronic pain. In an interview on 09/05/18 at 1:22 p.m., Resident #76 stated, Right now I wanna' get up but nobody comes to get me up. Resident #76 also reported he had open areas to his left hip, right foot, left leg and two or three sores and that some of them, they say are getting better. In another interview with Resident #76 on 09/11/18 at 07:43 a.m., he stated he was not refusing to turn on his back or to the side and, If I roll over on that (left) side it takes two aides then I roll right back over . I guess I'm top heavy. I go back to the right side naturally. SCSA MDSs dated 04/20/18 and 08/14/18, indicated Resident #76 required extensive assistance of two people for bed mobility and toileting, was frequently incontinent of urine and always incontinent of bowels, and was cognitively intact. An Initial Data Collection tool, completed on 12/30/17, identified Resident #76 was incontinent of bladder and had non-blanchable redness to right foot toes and dry flaky skin to lower legs. A Braden completed on 04/09/18, identified Resident #76's skin as constantly moist from very moist and went from chairfast to bedfast, which placed him at an increased risk for development of pressure ulcers. Pressure Ulcer Risk Assessment Tools (PURAT) completed on 12/30/17, 01/06/18 and 01/22/18 indicated Resident #76 had, No pressure related skin issues. The following PURATs indicated Resident #76 developed a deep tissue injury pressure ulcer to his left heel and hip (01/31/18), a deep tissue injury to his left lower back (02/01/18) and upper left sacrum ulcer (02/07/18), a deep tissue injury to the right hip and ankle, a deep tissue injury to his fourth and fifth right toes and an open area to his right inner foot (04/25/18), a mid-back abrasion (05/07/18), and a deep tissue injury to the sacrum (07/19/18). Pressure Ulcer Status Records identified a Stage III pressure ulcer to the right inner foot (date first observed: 06/26/18) and an unstageable right hip ulcer (date first observed: 07/19/19). An Assessing Unavoidable Pressure Ulcers/Quality Assurance Tool, signed by the physician on 04/15/18, deemed Resident #76's development of pressure ulcers as unavoidable as, all (identified, care planned and implemented) reasonable measures did not prevent the formation of pressure ulcers. Care Directives, printed on 09/07/18, which instructed nursing assistants to reposition Resident #76 every two hours indicated no toileting program. Additionally, it instructed the nursing assistants to place pillows, between Resident #76's legs and heel boots on feet. The At Risk for Impaired Skin Integrity and Pressure Ulcer CPs, dated 07/30/18, incorrectly identified the resident as, independent with bed mobility. This CP directed staff to provide a low air loss mattress (with no indication of setting to maintain adequate surface support), assist as needed to reposition/shift weight to relieve pressure and turning and repositioning program frequently (with no indicated frequency), avoid skin to skin contact (with no indication how), consult/make referral for occupational or physical therapy and wound nurse as needed, minimize pressure over bony prominences (with no indication how), position with pillows to maintain body alignment as needed, provide elbow/heel protectors. The Incontinence CP of the same date informed staff that Resident #76 was on a check and change program, which required two people to assist for toileting and incontinence care (with no indication how often to check on Resident #76). This CP indicated the resident used a bed pan and urinal (with no indication how often to offer). In an interview on 09/17/18 at 10:28 a.m., Staff T (MDS Coordinator) confirmed that between 04/20/18 and 09/17/18, staff failed to identify appropriate interventions based on the identified declines in mobility and incontinence, which increased Resident #76 risks for development of pressure ulcers. Review of TARs, between (MONTH) and (MONTH) (YEAR), revealed Resident #76 refused to be turned or repositioned 70% of the time. (MONTH) (YEAR) MARs directed LNs to check for proper functioning of the Low Air Loss mattress (LAL) but failed to identify which setting. Additionally, this MAR indicated [REDACTED]. In an interview on 09/17/18 at 8:56 a.m., Staff D stated the setting of the mattress should be included in the order and the LNs should indicate why Resident #76 refused to turn and reposition. Review of Nurses Notes between 03/01/18 through 09/05/18, revealed Resident #76 refused to be turned or repositioned (03/01, 03/18, 03/20, 04/04, 04/09, 04/19, 04/20, 04/21, 04/26, 04/29, 05/05, 05/06, 05/09, 05/14, 06/21, 06/28, 07/01, 07/06, 07/21, 08/11, and 08/15/18), allow dressing changes (03/18, 03/21, 04/21, 05/12, 05/15, 05/18, 06/07, 07/07), or allow pillow placement between legs (06/27, 08/15, 08/22). There was no evidence staff identified the reasons behind Resident #76 refusals, or implemented alternative interventions to prevent the formation of pressure ulcers. Nurse's note of 06/27/18 identified, Resident #76 refuses to have a pillow between his legs and favors the right side and hence leans on it which has led to skin breakdown. Another Nurse's Note on 08/01/18 revealed, The healing process for his wounds is stalled due to the fact that he is non-adherent with skin care and refuses (to allow) staff to turn and reposition him. Education continues to be provided by staff about the risks and benefits of refusing to be turned. Despite identification of stalled wound healing and multiple risk factors, the resident was not referred to a wound clinic until two weeks later when on 08/15/18 a progress note revealed, Patient has a low air loss mattress and supposed to be using pillows between his legs to prevent pressure between the legs and feet .The pressure on the left leg has caused the wound on the right inner foot to worsen and exposing the bones. MD (Medical Doctor) notified and referring to wound clinic. Turning and repositioning continues to be offered, sometimes he agrees and sometimes he refuses. In another Nurse's Note of 08/22/18, Right inner foot wound continues to be subjected to pressure due to the patient's refusal to have a pillow between the legs and this causing pressure on the right inner foot by the left leg. In an interview on 09/17/18 at 08:56 a.m., Staff D stated the wound clinic referral should have occurred at the time of the identified stalled wound and reason for refusals of wound care, repositioning and offloading identified with alternatives considered. Hourly observations on 09/07/18 (from 7:45 a.m. to 1:34 p.m.), 09/10/18 (between 8:20 a.m. to 11:04 a.m.), and 09/14/18 (between 7:49 a.m. to 11:31 a.m.), Resident #76 was observed lying on his right side, without heel boots, elbow protectors or pillows between knees and/or left leg directly resting on right inner foot (the site identified with bone exposure on 08/15/18). During direct observation of Resident #76 on 09/14/18 at 08:47 a.m., Staff F (RCM) verified Resident #76 had no pillows between his knees or heel protectors and that they should have been in place. In an interview on 09/18/18 at 08:02 a.m., Staff E (RCM) stated, .when the increase in wounds developed we referred him to Hospice. When presented with progress notes (03/11, 03/25, and 05/12/18) which identified Resident #76 was assessed with [REDACTED]. In addition, Staff E stated she could not recall if Resident #76 had been referred to therapy for re-evaluation of wheel chair positioning, alternatives to offloading bony prominences, and care giver technique to facilitate turning and repositioning, and that they should have been considered. Wound Care Center notes, dated 08/30/18, requested an X-ray to the right foot and placed Resident #76 on antibiotics. Follow-up visit notes, dated 09/13/18, revealed Resident #76 developed [MEDICAL CONDITIONS] (an infection resistant to antibiotics) of the right foot ulcer and was placed on two antibiotics with orders to, offload. RESIDENT #73 Resident #73 admitted to the facility on [DATE], and according to the 07/30/18 Quarterly MDS the resident required extensive two person assistance with bed mobility, transfers, toileting, was at risk for pressure ulcers and had severe cognitive impairment. Record review revealed a 08/06/18 Braden (standardized assessment predicting pressure ulcer risk) that determined Resident #73 was at High Risk for pressure ulcers. A 05/02/18 PO directed staff to implement a Air mattress, LN to check proper function every shift. Resident #73 was observed lying in bed on a LAL mattress, the pump to the LAL mattress was off and not functioning on: 09/05/18 at 10:10 a.m.; 09/06/18 at 8:41 a.m.; 09/07/18 at 8:53 a.m.; and 09/07/18 at 10:51 a.m. At this time Staff KK (Maintenance Director) was standing outside Resident #73's door and stated, I received a call for this room but the resident couldn't tell me what the problem was .I am waiting for someone to tell me what the issue is for this room. At 10:55 a.m. Staff KK clarified that someone told him the LAL mattress was not functioning. RESIDENT #20 Similar findings were noted for Resident #20, who admitted to the facility on [DATE]. According to the 06/07/18 Quarterly MDS the resident required extensive assistance with ADLs, had functional limitations in ROM to bilateral LEs, was at risk for pressure ulcers and was cognitively intact. According to a 03/31/18 CP, Resident has pressure ulcer(s) and at risk for skin breakdown and to develop more pressure ulcers .location coccyx stage 3-resolved 12/14/16 . staff were directed to implement LAL mattress to maintain skin integrity. A 09/06/18 Braden determined Resident #20 was, At risk for pressure ulcers. Record review revealed a 04/09/18 PO for, Low Air Loss mattress to maintain skin integrity. LN to check for proper functioning every shift. On 09/05/18 at 10:11 a.m., Resident #20 was observed lying supine in bed on a LAL mattress. Observation of the LAL mattress revealed that although the power button was in the on position, the LAL pump was not on or functioning. Resident #20 stated, It probably came unplugged .it comes unplugged when my bed is moved up and down. When asked how frequently this occurred, Resident #20 stated, I don't know but it happens .sometimes I know (the LAL mattress is not functioning) because I can't hear the pump or the (mattress) feels different .but this time I didn't notice. On 09/06/18 at 10:19 a.m., Resident #20 was observed lying in bed supine, the LAL mattress was in place and functioning, the setting were alternating with a comfort level of 3. Per Resident #20, It was off yesterday because it was unplugged from the wall. When asked if staff identified the mattress wasn't functioning, Resident #20 stated, No, I told them . On 09/18/18 at 9:46 a.m., Resident #20 was again observed lying in bed with the LAL mattress power button in the on position, but no power to the pump. Observation of the plug revealed it was only partially plugged in. At 9:48 a.m. Staff EE (Licensed Practical Nurse - LPN) observed the LAL mattress and stated, No, it is not on. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to ensure six (# 35, 95, 97, 23, 76 & 75) of nine sample residents, and three (#s 20, 101 & 11) supplemental residents reviewed for Mobility/Limited Range of Motion (ROM), received appropriate treatment and services to improve and/or maintain mobility, increase range of motion and/or prevent further decrease in range of motion. Failure of the facility to implement preventative measures to prevent decline in range of motion and skin impairment caused harm to Resident #76 who experienced a decline in ROM/developed a contracture and Resident #75 who developed a pressure ulcer with full thickness skin loss and placed other residents at risk for further decline in ROM and mobility. Findings include: Refer to CFR: 483.25(b)(1)(i)(ii), F-686, Treatment/Services to Prevent/Heal Pressure Ulcers According to the 11/2016 Restorative Nursing Policy, the facilities purpose is to Implement a restorative nursing system that meets the individual needs of each patient and assists each patient in reaching the highest practicable level of physical, mental, and psychosocial functioning. The policy references outdated regulations (F311) and states, Each patient must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care. and A patient with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion and A patient with limited ability receives appropriate services, equipment and assistance to maintain or improve mobility with maximum practicable independence unless reduction in mobility is demonstrably unavoidable. This policy further indicated, in (an) effort to promote the patient's optimum function a restorative program will be developed by proactively identifying, care planning and monitoring of a patient's assessments and indicators. RESIDENT #76 Resident #76 was admitted to the facility on [DATE]. Resident #76 required a hospital transfer on 12/25/17 and returned to the facility on [DATE] with medically complex diagnoses, including existing contractures to his lower extremities. The Quarterly Minimum Data Set (MDS - an assessment tool) of 08/14/18 identified the resident as cognitively intact. In an interview on 09/05/18 at 01:56 p.m., Resident #76 stated, They started range of motion just yesterday . I don't remember why it stopped, and that it has been, quite a while . six months easy, since he had any range of motion (ROM) program for his lower extremity (LE) contractures. A Rehabilitation Services Multidisciplinary Screening Tool (RSMST), completed on 03/29/17, indicated Resident #76 complained of increased pain to his lower extremities. On 05/22/17, a Restorative Nursing Program (RNP) was issued for bilateral knee splinting with PROM (passive range of motion). In an interview on 09/18/18 at 07:13 a.m., Staff GG (Restorative Aide - RA) stated, Before (Resident #76) went to the hospital, he was doing ROM and splinting well. He was wearing his splints. Then he went to the hospital, came back and I asked, Are we gonna' resume splinting? Staff GG recalled Staff L (Director of Rehab) went in there and Resident #76 would not even let Staff L touch his legs. It was (because of) pain to his knees. (Staff L) was gonna' refer (Resident #76) to someone because (Resident #76) wouldn't let us touch him because of the pain. The last time ROM and splinting was done was before he went to the hospital. Review of a RSMST, completed on 01/21/18, revealed a recommendation to a Rehabilitation Physician for management of severe contractures, increased tone and pain as Resident #76 was Tender to touch; can't perform ROM. Not receiving RA (restorative aide) for ROM and splinting to bilateral lower extremities at this time. Review of a (MONTH) (YEAR) Restorative Administration Record (RAR) revealed splinting and PROM to bilateral lower extremities were discontinued on 02/27/18. Restorative Assessments, completed by various Licensed Nurses, indicated Resident #76 continued to receive ROM and splinting to his LEs. Restorative Assessments dated 12/30/17, 1/22/18, and 04/18/18 indicated Resident #76 refused the splint; 05/17/1, and 08/14/18 indicated Resident #76 was unable to tolerate splinting. In a 09/18/18 interview at 09:02 a.m., when asked to explain how the resident's participation continued to be reviewed for six months despite a discontinued RNP, Staff E (Resident Care Manager - RCM) stated, I didn't get notification the program was discontinued when I spoke with the Restorative Aide. She said he is not participating. I said (to her) do whatever you can. When shown the RARs, Staff E, I did not review those when I completed the Restorative Assessments. Physical Medicine and Rehabilitation Clinic Progress visit notes, dated 03/12/18, described Resident #76 as being unable to move his legs at all . legs remain contracted and bent at the knees and hips, and that Resident #76 reported, his legs are constantly in pain, had no treatments for his pain, and would like to discuss treatment options. These notes described Resident #76, to be (in) significant distress, with significant atrophy of the major muscle groups . unable to tolerate the most gentle of touch in the bilateral lower extremities. Resident #76 was referred to a orthopedic clinic for consideration of tenodesis (suturing a tendon to a bone in order to restore or increase joint motion). The consulting physician concluded the procedure was one Resident #76 was definitely willing to go through as he is quite miserable at this time. A RSMST dated 04/20/18 indicated Resident #76, bilateral lower extremities are tight, painful and contracted. He has refused to wear his splints. He refuses range of motion program . has recently gone to hospice . refuses to have his BLE touched. Not appropriate for skilled therapy intervention at this time. A following RSMST, dated 08/21/18 indicated, Resident #76 agreed to resume PROM of bilateral lower extremities (BLE) that is severely contracted because he refused to do Restorative ROM and Splinting. He cannot have the leg splints on due to the severity of his flexion contractures. In a 09/17/18 interview at 10:08 a.m., Staff L stated Resident #76 refused to have his BLE touched due to pain. When asked if pain modalities were considered on or after the 01/21/18 screening, Staff L stated, I think we did that before. No, we didn't evaluate him for pain, it didn't work for him in the past. No, that pain is not new. We couldn't even touch him so how could we see him for pain modalities. It's nothing that we could have been done, that's why I was looking forward to Harborview assessing him for the tenodesis. I haven't heard anything from Harborview and the tenodesis. When asked if Resident #76 contractures worsened, Staff L stated, Definitely it got worse due to his refusals. Staff L was unable to provide documentation of alternatives explored or offered for addressing refusals of previous contracture management program after re-admission from the hospital through 08/21/18. In an interview with Staff HH (Unit Secretary) on 09/17/18 at 01:48 p.m., she verified the facility had not established the appointment ordered on [DATE] for the for tenodesis consideration. On 08/24/18, a RNP for gentle PROM to Resident #76's BLEs was issued. Staff GG stated in an interview on 09/18/18 at 7:13 a.m., (Therapy) re-assessed him last month in August, and they wrote a program for us to continue. I could range him a little more when he was splinted but not now. RESIDENT #75 On 09/05/18 at 1:28 p.m. Resident #75 was observed in bed with bilateral clenched hands without splints or a carrot (orthotic used to position the fingers away from the palm to protect the skin from excessive moisture, pressure, and the risk of nail puncture). On 09/06/18 at 8:11 a.m. Resident #75 was observed asleep in bed, both hands visible, with no adaptive or protective equipment in place. Similar findings were observed on 09/10/18 at 12:36 p.m. According to the 08/08/18 Significant Change in Status Assessment (SCSA) MDS, the resident had severe cognitive impairment, exhibited behavioral symptoms directed towards others such as hitting, screaming, which occurred daily, and had no impact on resident care. The resident exhibited no rejection of care, required two person extensive assistance with bed mobility, transfers, dressing, toileting, had functional limited Range of Motion (ROM) on both upper extremities (UE) and LEs without therapy or restorative nursing services. The resident was assessed as at risk of pressure ulcers, without pressure ulcers, did have a skin tear and staff applied ointments and non surgical dressings other than to feet. The 08/23/18 Activities of Daily Living (ADLs) Care Plan (CP) listed a 11/30/18 goal of Prevent contracture of hands through next review date. Approaches listed included, Insert Carrot orthotic on both hands up to level 6 x 1 hr 6 x 1 wk, and Refer to therapy for screen and evaluation, treatment as indicated. Review of the (MONTH) (YEAR) RAR revealed four RNPs; one ordered 09/26/18 To maintain PROM to BUEs (bilateral) and avoid pain and worsening tightness/contracture 6 times per week PROM to BUEs to all planes able 2 sets of 10 reps, another ordered 11/18/16 PROM towards all planes BLE. Fixed range of 0-20 degrees, three times weekly 2 sets of 10 reps as tolerated, another ordered 05/18/18 Cleanse both hands while performing gentle ROM 6 x week as tolerated, and another ordered 05/18/18 Insert Carrot Orthotic on both hands up to level 6 x 1 hour 6 x week as tolerated. Staff documented provision of PROM to BUEs on 06/01, 06/02, 06/09, 06/16, and 06/22/18. Staff documented provision of cleaning both hands and application of the carrot on 06/22/18. Staff documented the resident refused 19 times, and the program was withheld twice. In an interview on 09/17/18 at 9:30 a.m. Staff U (RA) said program withheld is usually if they are short, so they try to get as many people done if they can. Review of the resident record, including MDS data revealed the resident was transferred to the hospital 07/11/18 and readmitted [DATE]. Review of current Physician order [REDACTED]. Further review of POs revealed an order dated 09/06/18 to d/c RA program - res refuses and is on Hospice. In an interview on 09/17/18 at 9:30 a.m. Staff U (RA on call) said Resident #75's RNP was discontinued on 09/06/18. When asked why, Staff U said She went to the hospital and then hospice. When asked for clarification, Staff U said The RCM d/cd (discontinued) her. In an interview on 09/17/18 at 10:46 a.m. when asked why the RNP was discontinued, Staff H (RCM) replied, She's hospice. When asked what services hospice provided, Staff H said They said she's refusing. See their notes, it's all refusals. When asked if they tried something else, Staff H said I usually get the orders from therapy. Staff H indicated he had not referred the resident back to therapy, When they are hospice they won't pick them up. When asked if the nurses reported anything to him regarding the resident's hand, Staff H said, the contractures. We already talked to Therapy but was unable to recall when, sometime back, I can't remember. In an interview on 09/17/18 at 11:05 a.m. Staff L said the resident had been receiving skilled services and he was able to get a carrot in there and d/c her to restorative. When asked if the restorative staff had reported back, Staff L replied I know before she went on hospice she was refusing. I said keep trying. Staff L recalled Resident #75 refused care from him, maybe once, she has to know you. When asked why the carrot had been ordered, Staff L said, to keep (hand) from closing because of the skin. When asked if to his knowledge the resident was still receiving the RNP, Staff L said I think so. When asked if he had been told otherwise, Staff L said I think they approached me. I just said keep trying. Review of (MONTH) (YEAR) RAR listed the same four RNPs as in (MONTH) (YEAR). In (MONTH) the four RNPs were documented as done 07/21/18, 07/30/18, not scheduled 07/22/18, 07/29/18, circled as not provided on 07/18, 07/19, 07/20, 07/23, 07/24 and not offered 07/25-07/28, and discontinued 07/31/18. The only narrative during that time period was on 07/31/18, Rsd refused prog x 3. Yelling to get out of room. The 07/31/18 Restorative Assessment indicated the resident was bed bound, required extensive assistance of two with hoyer transfers, extensive assist with dressing, grooming, eating, bed mobility and required total dependence with splint/brace assistance. According to the assessment the resident had impaired ROM on both side of upper extremities and lower extremities, with contributing factors of pain, comprehension, and cognitive. Problems identified included ROM, Right, Left, UB (upper body), LB (lower body), Passive, Active. The Restorative P[NAME] (plan of care) was blank for the reps, sets, and frequency. The Restorative Assessment form had directions to be completed upon admission, referral, quarterly and upon significant change of residents being considered for or participating in a restorative program. In an interview on 09/17/18 at 10:46 a.m. Staff H indicated he completed the Quarterly review on 07/31/18, that was the last one. It's not due until three months, quarterly. Staff H was unable to provide and answer, or explanation for why he did not complete and assessment when he discontinued the program. The 07/18/18 Social Service Assessment indicated the resident was exhibiting behavioral symptoms, Yes. Refusal of cares with a documented approach of Staff to re-approach. The (MONTH) (YEAR) Behavior/Intervention Monthly Flow Record (BIMFR) did not list refusal of care as a Target Behavior (TB). Listed TBs did include uncooperative which was documented as exhibited on 07/28, 07/29 and 07/30/18. According to this BIMFR, the TB of Combative with cares was not exhibited in July. In an interview on 09/17/18 at 9:36 a.m. Staff U said I've worked with her a couple times. When asked what program she did, Staff U said clean the hand and apply Carrot splint. When asked how the resident tolerated the program, Staff U replied, it was hit or miss with her. She refused sometimes. She's only let me put in on a couple times. Once on she tolerated it, and then would take it off after the allotted two hours, I believe. Review of the (MONTH) (YEAR) RAR revealed the 07/18/18 RNPs of hand cleaning while performing gentle ROM and provision of the carrot were last done in (MONTH) on 08/22/18. They were not scheduled on 08/24/18, 08/29, 08/30, and circled as not done on 08/23, 08/25, 08/26 and 08/27/18. Review of (MONTH) (YEAR) RAR revealed the 07/18/18 RNPs of hand cleaning while performing gentle ROM and provision of the carrot were documented as withheld 09/02 and 09/04, refused on 09/03/18 and discontinued 09/06/18. The Monthly Summary dated 08/26/18 indicated the resident's skin condition was good, and did not note the presence of open areas, pressure ulcers or skin tears. According to the summary the resident had contractures to hand without ROM, Splints, or handrolls. In an interview on 09/05/18 at 1:28 p.m. when asked if she was able to feed herself, Resident #75 replied, No I'm not and commented, with these hands? see and held up her hands with bent fingers. When asked about pain, Resident #75 said yes, in my hands. When asked if the staff perform exercises to her hands, Resident #75 replied, No. When asked, Do you have any sores, open areas, or pressure ulcers, Resident #75 replied, yes I do, see in there as she partially opened her left hand. An open area was observed on the resident's left thumb, without a dressing or protection. When asked what the staff did for the open area, Resident #75 said They take the crap off. An 08/26/18 progress note revealed, .Resident has contractures of both hands and feet. Resident usually have accumulation of molds due to excessive moisture in between fingers and resident will decline care when offered Resident declines care to toenails and fingernails. Is sometimes combative and using inappropriate language .all pressure areas intact with no tears, inflammation and lacerations was noted . An 08/30/18 progress note revealed, .resident noted to reopened area to left middle finger due to some contractures present on that arm and sometimes moistures and sweats resident is not compliance with nail care accepts sometimes when husband is around new treatment order received to clean site with normal saline apply skin prep to surrounding areas of the affected site, cover with xeroform, change dressing daily and PRN (as needed) as resident permits will continue to monitor. A progress note dated 09/01/18 revealed, resident has open area to left middle finger. treatment in placed, resident refused to clean her fingers at first, but later in the day agreed to clean her hand and fingers, [MEDICATION NAME] 2% cream applied as ordered. On ABO (antibiotic) Bactrim BID (twice a day), no side effects noted r/t (related to) use of ABO. took medications as ordered. Will continue to monitor. As of 09/06/18 at 12:41 p.m. there were no progress notes of documented monitoring since 09/01/18 at 5:11 p.m. In an interview on 09/17/18 at 10:46 a.m. when asked if he had been notified of a wound, Staff H said no. When asked why the carrot was not replaced with another form of protection for example gauze or washcloth, Staff H replied, with (Resident #75) it's hard. On 09/17/18 at 10:30 a.m. Staff D (Staff Development) observed the resident's left hand, Resident #75 said It's sensitive. When asked what the open area was, Staff D said It looks pressure related. When Staff D asked the resident, can we put something in it? Resident #75 replied, used to have carrots, they didn't come back. Staff D told the resident, I need to put something in your hand so this will heal. RESIDENT #95 According to the 60 day MDS dated [DATE] the resident was assessed with [REDACTED]. According to the MDS the resident required two person extensive assist with bed mobility, transfer, dressing, toileting, dependent on staff to eat, was not ambulatory, used a wheelchair, had functional limitation in ROM, UE impairment on one side, received Occupational Therapy (OT) services from 06/22/18-8/16/18, Physical Therapy (PT) services from 6/22/18-8/15/18 and no RNP. The 07/06/18 ADL CP indicated the resident had self-care and mobility deficit related to left side weakness, left hand contracture, and dementia. Approaches included Refer to therapy for screen and evaluation, treatment as indicated. The 07/06/18 Falls CP listed an 08/16/18 approach for a RA program 7 x wk 1) splinting to RUE 2) PROM to RUE on all planes as tolerated with a goal To prevent further deformity and maintain joint flexibility. On 09/06/18 at 10:07 a.m. Resident #95 was observed seated in a Tilt in Space (TNS) wheelchair. The resident's right hand was clenched in a fist. Resident #95 was observed to partially open the hand upon request. When asked if he could open his right hand using his left hand, Resident #95 replied, If I need to. When asked if staff exercised his hands, Resident #95 replied, They will if you request it. I had a splint for my right hand to keep my fourth finger open instead of clenching up. When asked where the splint was, Resident #95 said I lost track of it. I could get another one, passing the word on to the therapist. According to Resident #95, the splint had been missing for three months. On 09/07/18 at 12:03 p.m. Resident #95 was observed seated in a TNS with his right arm strapped onto a padded arm rest. No splint was in place. No arm/hand splint was on 09/11/18, 09/17/18 at 9:49 a.m. and 10:07 a.m. On 09/12/18 at 10:05 a.m. Resident #95 was observed with a right arm splint in place. In an interview at that time, Staff AA (Certified Nursing Assistant - CNA) said the RA applied the splint, just a little while ago. The resident was observed with the right arm splint in place on 09/13/18 at 11:02 a.m. A 08/15/18 Nursing - Therapy Referral Form included a RNP of Bilateral Left AROME (Active Range of Motion Exercises) using 2 lbs (pound) - 3 lbs AW (ankle weights) x 10-15 reps on all functional planes or use of Nustep for 15 minutes 3-6 x week to increase bilateral LE strength for decreased assistance to transfer from bed to/from w/c (wheelchair) from staff. A 08/16/18 Nursing - Therapy Referral Form included a restorative program of PROM with R (right) UE all planes as tolerated. Splinting RUW 7 x wk 9 a.m. -5 p.m. to prevent further deformity and maintain joint flexibility. Review of the (MONTH) (YEAR) RAR revealed the 08/15/18 RNP was written as two separate programs. Staff documented provision of the Nustep on 8/24 and 8/28/18. Staff documented provision of BLE AROME on 08/26, 08/29, 08/30, and 08/31/18. There was no documented use of ankle weights. The 08/16/18 RNP for splinting was not added to the (MONTH) (YEAR) RAR and not offered or provided as ordered. Review of the (MONTH) (YEAR) RAR revealed the 08/16/18 RNP for splinting seven days a week was listed, but not offered 09/01, and withheld on 09/02, 09/09, and 09/16/18. On 09/03/18 the splint was not applied, Unable to locate splint. On 09/04/18 the resident was out of the facility. On 09/05/18 staff documented unable to apply splint (missing) will refer to therapy. On 09/06/18 a new RUE splint provided. A sticky note was on the RAR Splint is in Rsd bedside drawer. In addition, the RNP directed staff to apply the splint from 9:00 a.m. to 5:00 p.m. Staff documented application of splint for four hours 09/10, 09/11 and 09/12/18. On 09/10/18 staff documented, Rsd takes off splint himself requiring frequent checks and on 09/12/18 Had to reapply splint 3 times resident takes off. Staff documented application of the splint on 09/13/18, Rsd kept splint on for 2 hours ., 09/15/18, Rsd tolerated 2.5 hours of splint prior to removing himself. In an interview on 09/17/18 at 9:30 a.m. Staff U said she had performed Resident #95's RNP a couple times last week. Staff U said his splint he takes off himself, it gets misplaced so then I would go find a new one for him .down in therapy. He's gone through two. Review of the (MONTH) (YEAR) RAR also listed a 08/22/18 RNP for BLE AROM using 2-3# AW x 10 reps on all functional planes OR Nustep x 15 mins 3-6 X Week as tolerated to increase BLE strength for assist staff with transfers from bed to wheelchair and back. Staff documented provision of reps and mins performed on 09/05, 09/06, 09/07, 09/10, 09/11, 09/12 and 09/13/18. There was no documentation of the ankle weights, if a 2 or 3 lb weight was used, or if the resident had used the Nustep. In an interview on 09/17/18 at 9:30 a.m. Staff U indicated the Nustep was not used, or it would have been documented on the last line #. Staff U said if he can't tolerate 3lbs, I'll go down to 2 lbs if he can tolerate 2 lbs then I'll use (weights). Staff U said if she used ankle weights during the program it should be documented in the notes. Review of the notes revealed no documented ankle weights. RESIDENT #11 Resident #11 admitted to the facility 02/21/18. According to the 03/01/18 Admission MDS the resident required extensive assist of one to transfers, one person supervision to walk in room and both staff and resident believed the resident was capable of increased independence. According to the 06/01/18 Quarterly MDS the resident required set up and supervision with transfers and set up only to walk in room. The ADL Care Area Assessment (CAA) for the 03/01/18 MDS revealed the Resident is able to ambulate without device in his room and he is using wheelchair for long distance. Wife states he can use the bathroom by himself. His goal is to maintain his current mobility at this time .Resident is at risk to decline in physical function, falls and skin breakdown. Nursing staff to assist with ADLs and mobility needs as needed, .PT and OT eval and tx was d/cd r/t he is ambulatory and at baseline with transfers and self care. will proceed with care plan. The 02/21/18 ADL CP listed a 09/28/18 goal of Resident #11 wishes to maintain his ability to propel self in wheelchair and to ambulate as able in his room daily through next review date. Approaches included Eats in room with tray set up, and w/c and FWW (Front wheeled walker) for locomotion, added 08/31/18 Fall waking independently with PT only also Resident will walk without assist he still needs one person assist. Review of Physician order [REDACTED]. Pt is ambulating and at baseline with transfers & self care. Skilled therapy not needed at this time. A 02/22/18 SMST revealed, Pt ambulating with FWW with his wife with no signs of unsteadiness. I got him a wc per wife request as he fatigues. Able to get in/out of bed and transfer with supervision. Pt here for long term care . Is resident currently receiving restorative services? No - will write a program.Based on the screen the resident is not appropriate for skilled therapy intervention at this time. A 03/06/18 Nursing - Therapy Referral Form included RNP for UE and LE group exercise. Walk to dine (WTD) also 3 to 5 x/wk. An associated 03/06/18 PO was written for RA Program: group exercises BUE/BLE. Walk to dine 3-5 x/wk. Review of the (MONTH) (YEAR) RAR revealed the group exercise program was documented as offered 03/08, 03/09, 03/12 through 03/22/18. Restorative progress notes had documented refusals including on 03/08/18 Resident stated I am not doing group exs or walk to dine. I walk on my own, on 03/17/18 Rds refusing WTD. States he is eating in his room for breakfast/lunch so he will not need to walk anywhere, and 03/21/18 Rds refused WTD. Waiting for wife to come in. In an interview on 09/18/18 at 8:56 a.m. Staff H said Resident #11 eats, sometimes in his room, sometimes in the dining room. His wife is here with him every day. When asked if the nursing assistants offered walk to dine, Staff H said They tried. Staff H was unable to provide any documentation to support the resident was offered WTD as assessed to require. There was no documentation the resident was offered a RNP in (MONTH) (YEAR) after the 22nd, in (MONTH) (YEAR), or in (MONTH) (YEAR). On 09/07/18 at 12:36 p.m. Staff QQ (Medical Records Assistant) was requested to locate (MONTH) and (MONTH) (YEAR) RARs. On 09/07/18 at 12:47 p.m. Staff J (Medical Records Director) said Sorry I can't find them. Record review revealed a 05/01/18 progress note that Fall IDT meeting held. Patient has been refusing restorative on multiple occurrences. Restorative orders dcd. MD/RP aware. There was an associated 05/03/18 PO to D/C RA program for group exercises BUE & BLE and also for walk to dine 3-5 x /wk. Review of the resident's record revealed no admission Restorative Assessment. A Restorative assessment dated [DATE] indicated the resident was walking independent and w/c (manual), dressing independent, grooming independent, eating independently with set up, transfers independently, Res declined RA programs and was discharged . The quarterly Restorative assessment dated [DATE] indicated the Res is independent with ADLs and staff to assist PRN. In an interview on 09/18/18 at 8:56 a.m. Staff H said the restorative program was discontinued because he was refusing to walk to the dining room. When asked why the resident refused, Staff H replied, He walks around by himself sometimes. Staff H indicated he had notified rehab but not social services. In an interview on 09/18/18 at 10:03 a.m. Staff L said once I write the (RNP) I don't manage it anymore. If they notice something wrong they come to me and we go check it out, if not it's all fine. When asked if he had been notified the resident was not participating in the RNP, Staff L said No, not until this month. On on 09/07/18 at 12:09 p.m. Resident #11 was observed seated in a wheelchair, in his room with his wife at his side. In an interview at that time Resident #11's wife said Resident #11 had sustained, three falls his legs are weak, he's getting therapy now. When asked about the resident's refusal of restorative services, Resident #11's wife said she did not see him refuse, but he probably did. He will do If I'm here. Resident #11's wife said she was at the facility four to five hours a day and they need to exercise him to build up the muscles in his legs, that will take time, and I will be here everyday to be sure he does. In an interview on 09/18/18 at 10:03 a.m. Staff L said PT and OT were started on 09/06/18 as the resident did have a decline from his prior level, he wasn't walking as well. When asked the resident's participation, Staff L said we can only make him do it if his wife is here. The 09/06/18 PT evaluation noted the reason for referral was due to decline in static balance, dynamic balance, functional capacity/cardiopulmonary skills and functional mobility. Patient had fallen three times in past year. At the evaluation the resident required moderate assistance with transfers, minimum assistance with ambulation, on a flat surface, 40 feet with a two-wheeled walker. The 09/06/18 OT evaluation listed the reason for referral as Patient had fallen back to sitting transferring out of his wife's car. OT screened his transfer and he did require Moderate assist. He has gotten weaker from not participating in RA program. Then he had two more falls the next week going to the bathroom which necessitated he be seen for toilet transfers and strengthening. RESIDENT #35 Resident #35 was admitted to the facility on [DATE]. Record review revealed the resident was assessed to require, and was to be started on a RAP on 05/04/18, but was hosptalized on [DATE]. The resident was readmitted to the facility on [DATE], and according to the 05/21/18 Admission MDS the resident had [DIAGNOSES REDACTED]. The resident was assessed as able to walk in room with set up and supervision, walk in corridor with set up only, and utilized a walker for ambulation. Observations throughout the survey revealed the resident utilizing either a walker or a wheelchair for ambulation. Record review revealed the resident was not reassessed for the need for the RAP, which included group exercises, BUE/BLE exercise and a walk to dine program. The Quarterly MDS dated [DATE] reflected a decline in ambulation as the resident now required extensive one person assistance with walking in room and corridor. The resident was subsequently assessed to require PT services starting on 08/31/18. In an interview on the morning of 09/17/18, Staff D (Staff Development) was asked to provide any information to support why Resident #35 was not reassessed for the RAP she was originally assessed to require in (MONTH) (YEAR), after she was readmitted from the hospital. No information was provided. RESIDENT #101 Resident #101 admitted to the facility on [DATE] and according to the 12/28/17 Admission MDS the resident usually understands and was usually understood in conversation, identified as having the preferred language of Spanish and need(s) or want(s) an interpreter to communicate with a doctor or health care staff. Observations on each day of the survey revealed an elderly female r

Based on observation, interview and record review, the facility failed to recognize, assess and treat three (#s 76, 101 & 83) residents who experienced significant pain. Failure to timely identify and implement effective interventions to reduce pain, including administration of pain medication and/or non-medication interventions, prior to care and services that were identified to cause pain, resulted in Resident #101 experiencing trendable, recurrent episodes of untreated pain and caused Resident #76 at risk for untreated pain with dressing changes, which constituted harm. In addition, failure of the facility to monitor pain and effectiveness of interventions placed Resident #83 at risk of untreated pain. Findings include: Refer to CFR: 483.24(a)(1)(b)(1)-(5)(i)-(iii), F-676, Activities of Daily Living FACILITY POLICY According to the facility policy on Pain Management dated 11-2016, the facility was to promote patient well-being by reducing their pain. The policy indicated, Based on comprehensive assessment (of) the patient, the facility must ensure that pain management provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility must ensure that the patient obtains optimal improvement or does not deteriorate within the limits of a patient's right to refuse treatment, and within the recognized pathology and the normal aging process. This policy indicated the facility, Recognizes when the patient is experiencing pain and identifies circumstances when pain can be anticipated. Evaluates the existing pain and the causes(s), and Manages or prevents pain . This policy indicated the facility will assess patients for the following types of pain: Somatic: Pain of the musculoskeletal System, Visceral: Pain of the body's, Neuropathic :Pain initiated or caused by a primary lesion or dysfunction in the nervous system. RESIDENT #76 Resident #76 was admitted to the facility on [DATE] with medically complex diagnoses, including existing contractures to his lower extremities and chronic pain. The Quarterly Minimum Data Set (MDS - an assessment tool) of 08/14/18 identified the resident as cognitively intact. In an interview on 09/17/18 at 02:23 p.m., Resident #76 shared he was given [MEDICATION NAME] for pain management and, when he was unable to take [MEDICATION NAME], he drink(s) (beer) to manage the pain and, when he does not have beer then, They don't give me anything. Pain Assessments completed between 02/15/18 and 08/14/18 identified chronic pain secondary to contractures to bilateral lower extremities, currently on around the clock pain medications, and pain during turning and positioning in the lower extremities. Pain Care Plans (CPs) dated 04/18/18 and 07/20/18, directed staff to educate Resident #76 to request pain medication early, before pain is out of control, Make a referral to Resident #76's physician to consider pre-medication for pain prior to treatments to optimize participation, and to Turn and reposition for comfort as needed. Review (MONTH) through (MONTH) 20, 18 Medication Administration Records (MARs) directed Licensed Nurses (LNs) to offer non-pharmacological pain intervention prior to administering pain medications, and to apply Aspercreme with 4% [MEDICATION NAME] Maximum Strength to bilateral knees 4 times a day as needed for soreness. Physical Medicine and Rehabilitation Clinic Progress notes dated 03/12/18 revealed Resident #76 reported that, his legs are constantly in pain, had no treatments for his pain, and would like to discuss treatment options. These notes also identified Resident #76, to be (in) significant distress, and .unable to tolerate the most gentle of touch in the bilateral lower extremities. Resident #76 was referred to a hospital orthopedics clinic for consideration of tenodesis (suturing a tendon to a bone in order to restore or increase joint motion). The consulting physician concluded the procedure was one Resident #76 was definitely willing to go through as he is quite miserable at this time. Review of Treatment Administration Records (TARs), between (MONTH) and (MONTH) (YEAR), revealed Resident #76 refused to turn or reposition 70% of the time. (MONTH) through (MONTH) (YEAR) MARs revealed no information regarding what non-pharmacological interventions were used prior to administering pain medications or their effectiveness. Review of progress notes and MARs between (MONTH) through (MONTH) (YEAR) revealed Resident #76 was identified as having pain during wound dressing changes with no evidence LNs provided pre-medication to Resident #76 prior to the procedure (03/11, 03/25, 05/12). Also, LNs administered Aspercreme without re-assessing its effectiveness (05/7, 05/15, 05/26). Additionally, nursing staff also documented Resident #76 experienced breakthrough pain without physician notification for added pain relief measures (3/15, 07/10, 08/06). Furthermore, Resident #76 reported he had too much pain to turn off back (3/27) and refused dressing changes due to pain (04/21) and there was no evidence nursing staff offered or provided pain relief measures. Finally, nursing staff assessed and documented Resident #76 reported experiencing pain levels ranging from 6 to 9 on a ten-point scale, with 7-10 as excruciating intensity, with no evidence of pain relief measures (04/14-15, 04/21-22, 05/01, 05/11-14, 05/16-21, 05/24-25, 05/27-31, 07/05, 07/11, 08/7, 08/09, 09/13). In an interview on 09/17/18 at 10:08 a.m., Staff L (Director of Rehab), stated that Resident #76's pain was not re-evaluated by Therapy between (MONTH) and (MONTH) (YEAR). He said, I think we did that before. It didn't work for him in the past. That pain is not new. It's nothing we could have been done, that's why I was looking forward to Harborview assessing him for the tenodesis. I haven't heard anything from Harborview and the tenodesis. Staff L was unable to provide any records indicating re-evaluation of Resident #76's pain, inclusive of pain management, between (MONTH) and (MONTH) (YEAR). In an interview on 09/17/18 at 08:02 a.m., Staff E (Resident Care Manager - RCM) stated that between the tenodesis procedure occurred and current, Resident #76's pain management was his scheduled/routine pain medication. When asked if other options should have been considered upon review of unmet care issues related to pain management, Staff E stated other options should have been considered for pain management but were not. After review of the above progress notes and MARS/TARs on 09/17/18 at 08:42 a.m., Staff D (Staff Development Nurse/Licensed Practical Nurse - LPN), indicated the physician should have been called for consideration of an as needed pain medication for breakthrough pain and notified of continued refusals of an ineffective intervention of turn and reposition for pain management. Staff D also said Resident #76 should have been pre-medicated prior to wound dressing changes or stopped the procedure and re-assess. RESIDENT #101 Resident #101 admitted to the facility on [DATE] and according to the 12/28/17 Admission MDS the resident usually understands and was usually understood in conversation, identified as having the preferred language of Spanish and need(s) or want(s) an interpreter to communicate with a doctor or health care staff. The 03/26/18 and 06/26/18 Quarterly MDSs similarly reflected the resident's preferred language of Spanish and indicated the resident reported no pain. Record review revealed the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The 08/26/18 five day MDS indicated the resident had no scheduled pain medication regimen, no as needed (PRN) pain medication, no non medication interventions for pain, experienced no pain and had significantly impaired cognition. An attempted interview with the resident on the morning of 09/05/18 revealed the resident was able to answer simple questions in English, but was unable to elaborate when asked how long she had been in the facility or what brought her there. In an interview on 09/05/18 at 1:05 p.m., Resident #101's family member indicated the resident currently experienced pain stating, Yes, she has pain on the left shoulder and her head (gesturing to left side of her head) because of the Shingles. He (the nurse) said he was going to proceed to talk to the Dr. about a pain pill and sleeping pill because she wasn't sleeping well. In an interview on 09/07/18 at 9:13 a.m., Staff P (Certified nursing Assistant -CNA who is Spanish speaking) stated the resident, speaks our language (Spanish) and the resident communicated, better in our language. Progress notes dated 08/09/18 indicated This LN (Licensed Nurse) was notified this morning that rsd (resident) had a red rash around the neck, chin and earlobes. When assessed rsd has water looking blisters throughout the red rash. Rsd was also wheezing. According to (MONTH) (YEAR) MARs, the resident was identified with hives on 08/09/18 which was treated with Beady. The resident was treated with multiple medications for identified breathing difficulties on 08/09/18. Progress notes on 08/10/18 indicated the resident denies discomfort but there was no indication facility staff utilized translation services for the resident. The resident demonstrated left facial [MEDICAL CONDITION]/[MEDICAL CONDITION] which was treated with an antibiotic on 08/10/18. Progress notes on 08/11/18 indicated the resident was, on alert for [MEDICAL CONDITION] on face. But there was no indication facility staff considered the resident might be experiencing pain or discomfort related to this rash. According to the (MONTH) MAR, the resident had a fever on 08/12/18 which was treated one time with Tylenol for temperature 100 degrees. A 08/12/18 progress note indicated, Ice pack applied to neck 15 min for comfort but also indicated Res say no pain or itching but there was no formalized assessment of the resident's the identified discomfort (which required the ice pack). This same progress note indicated the facial [MEDICAL CONDITION], could be Shingles. In an interview on 09/12/18, Staff C (Corporate Nurse) indicated the facility utilized Lippincott as a nursing reference. According to Lippincott Manual of Nursing Practice (10 th Edition, 2014), Shingles is an [MEDICAL CONDITION] condition in which reactivation of the chickenpox virus produces a vesicular eruption (fluid filled blisters) along the distribution of the nerves from one or more dorsal root ganglia (a series of nerves). Management of this condition included: pain management (including aspirin, [MEDICATION NAME], non-steroidal anti-inflammatorily, opioid) and treatment with anticonvulsant agents for post herpetic neuralgia (nerve pain). Nursing [DIAGNOSES REDACTED]. While the resident was started on [MEDICATION NAME] ([MEDICAL CONDITION]) on 08/13/18 and [MEDICATION NAME] (corticosteroid) on 08/14/18 for inflammation associated with the Shingles, there was no consideration of, or treatment for [REDACTED]. Progress notes on 08/13/18 reflected, Patient is alert and oriented but communicates best in Spanish. She is denying pain at this time, however, the left cheek and jaw areas are swollen with brownish scattered papules (blisters). There was no indication facility staff utilized interpretive services to determine the resident's pain was accurately assessed or considered the swelling might be uncomfortable. The resident was subsequently sent to the hospital for evaluation of facial excessive inflammation and swelling on 08/14/18. According to hospital notes dated 08/14/18, Per (Emergency Department) limited (due to) dementia and language barrier .When asked if she is having pain, she points to the left side of her face. Rash with [MEDICAL CONDITION] on left side only, on face, neck and ears .Attempt to use interpreter phone, but (patient) stating, yes, I am here, I told you it hurts. The resident remained in the hospital and was discharged back to the facility on [DATE]. Admission notes indicated the resident was Spanish speaking and speaks few English words. While staff documented the resident, Denies any pain or discomfort and a pain assessment completed on 08/20/18 indicated the resident had no current pain identified the resident had a language barrier, there was no indication staff utilized interpretive services or the resident understood queries about pain in English. Record review revealed referrals to Physical Therapy (PT) and Occupational Therapy (OT) upon admission to the facility. A TO (Telephone Order) dated 08/22/18 indicated, (Discontinue) PT & OT eval(uation) and treat order. Pt refused twice to be evaluated. In an interview on 09/10/18 at 10:20 a.m., when asked why therapy wasn't implemented, Staff L stated, She (Resident #101) refused (therapy). When asked why the resident refused, Staff L replied, Probably because of pain, probably- her head /neck was red. When asked if the resident was assessed as to why she refused, Staff L stated, I wrote the TO. It was pointed out that the TO didn't say why therapy was refused, just that it was refused. When asked what was it that led him to believe the refusal was related to pain, Staff L replied, The Shingles was still fresh. Staff L indicated no Spanish interpreter was used during these interactions stating, She didn't say anything she just said, I don't want to get up . When asked what was done, as he believed the resident refused because of pain, Staff L stated, We (therapy) didn't do anything about it we can't do anything about Shingles, that is a medical condition . In an interview on 09/10/18 at 10:35 a.m. Staff A (Administrator), Staff C (Corporate Nurse), and Staff D (Staff Development) were interviewed and indicated Staff L, should have referred to nursing regarding the probable pain issue. Facility progress notes on 08/21/18 indicated the resident was speaking Spanish but had, no c/o pain or discomfort. Nursing staff documented on 08/22/18, Spanish speaking and denied pain or any discomfort and Res no verbally c/o pain or discomfort. Progress notes on 08/25/18 indicated, Rsd did not get out of bed, appetite was poor at lunch, stated she did not have an appetite .lying in bed, does not want blinds opened nor TV turned on. Stated she needed to sleep. There was no assessment or consideration of the resident's ability to express pain in a manner the facility could understand and no attempted use of interpretive services. Progress notes on 08/27/18 reflected the resident remained on isolation related to Shingles complications and that the resident ate poorly, claims no appetite. Took (as needed Tylenol) this am for headache with desired result. Staff indicated the neck and jaw resolving nicely, ear and behind ear remains affected. Rsd desired to lie in bed without tv. Observations on 09/10/18 on 8:51 a.m. revealed Resident #101 lying in bed and was noted with an open area/scratch on the left neck. With the use of an interpreter at this time, the resident complained of Mal (bad) pain to the left neck which extended to the back of the head. Upon reporting this to Staff K (LPN), Staff K stated she had asked the resident previously if she wanted, medicina but the resident declined. In a subsequent interview with the resident (using an interpreter), at 9:05 a.m., the resident indicated her pain was, mucho and conveyed that she would take pain medication if the nurse thought she should have it. Observation on 09/10/18 at 12:53 p.m. revealed the resident lying in bed, gesturing to her head/neck area saying Pica (itchy) repetitively. When this was reported, shortly thereafter, to Staff K, Staff K stated the resident, kept saying Pica, I thought it was throbbing . It was not until 09/10/18 that staff obtained an as needed order of [MEDICATION NAME] 600 mg (every) six hours as needed for pain x 48 hours. An as needed narcotic [MEDICATION NAME] was prescribe on 09/11/18 and [MEDICATION NAME] was prescribed on 09/13/18 for post herpetic [MEDICAL CONDITION] (nerve pain associated with Shingles). Observation on 09/13/18 at 9:24 a.m. revealed the resident lying flat in bed curled up on her right side. The resident's pillow was not utilized. In an interview (via interpreter) at that time, Resident #101 stated My head hurts, my neck hurts no one comes just my aide (Staff DD - CNA) .I hurt all over. The resident stated she had,mucho delore. When asked if she needed medication for the pain, the resident replied in Spanish, If they say they think I need it but also stating, My head feels like it is quebrado (shattering). The resident elaborated at this time that she wanted people who knew how to speak Spanish to care for her, not people who are atrasado (slow, backwards). The resident's pain was reported to Licensed Nursing staff who administered [MEDICATION NAME] at 9:35 a.m. In an interview on 09/13/18 at 9:58 a.m. Staff P stated that, yes, Resident #101 had complained of pain earlier in the morning, but indicated that the resident thought if she got up, it would be better. Rather than report the pain to the nurse, Staff P went to get therapy staff to get her up. Observation at this time revealed two therapy staff attempt to get the resident up, which she declined. When asked, in Spanish, why she declined to get up, the resident stated it was because she had fuerta (strong) pain. In an interview on 09/17/18 at 8:27 a.m., Staff E stated the primary symptoms of Shingles were, vesicles and pain. Staff E indicated the pain associated with Shingles was nerve pain that would typically be treated with [MEDICATION NAME]. According to the Pain Assessment completed on 09/10/18, the resident was at risk for pain, experienced pain in the past but did not have current pain and had language barrier. A pain assessment on 09/14/18, conducted with the aide of an interpreter, identified the resident was, currently in pain and reported, brain pain. The MAR indicated [REDACTED]. A pain flow sheet was not implemented until 09/10/18, after survey staff conveyed to facility staff the resident's reports of pain. According to the current MAR, staff were directed to perform Pain assessment: document 1-10 using numeric, faces or FLACC scales. Offer interventions PRN. In an interview on 09/17/18 at 10:21 a.m., when asked what the MAR meant when assessing FLACC scale Staff E said; isn't that for infants; I think that's used for children, we aren't using that. Staff E confirmed no pain assessment form was implemented until 09/10/18, stating, we should have had one (prior to 09/10/18) and indicated staff should have utilized one of the multiple Spanish speaking staff to perform the assessment. Additionally, even after the pain flow sheet was implemented on 09/10/18, staff failed to complete one or more of the following: type, current intensity, precipitating/aggravating factors, non med intervention, intensity of pain after intervention or side effects. In an interview (via an interpreter) on 09/18/18 at 08:25 a.m., Resident #101 stated she felt better than the other days but she felt mal (bad) because of the painful scabs on her head. When referencing the pain she experienced the previous week, the resident stated, Oh, it was horrible. The facility failed to recognize when Resident #101 was experiencing pain and failed to identify a clear circumstance when pain could be reasonably anticipated (Shingles). Once pain was identified, facility staff failed to evaluate the existing pain and the cause(s), and manage or prevent pain, consistent with current professional standards of practice, until almost three weeks after the resident was readmitted to the facility. RESIDENT #83 According to the 08/07/18 Quarterly MDS Resident #83 had pain at least five days during the assessment period, and was treated with an as needed medication during that time. During an interview on 09/05/18 at 11:04 a.m., Resident #83 stated her pain varied on a scale of 0-10, around an 8 or a 10. According to Resident #83, sometimes I'm in so much pain until I'm in tears and it usually happened when one nurse in particular was working on her unit. Resident #83 said, it take her an usually long time to bring pain medications. I feel like she doing it on purpose. According to Resident #83, her medications were delivered late or delayed, usually between 10:00 p.m., and 6:00 a.m. When asked if she had ever asked the staff why there seemed to be a delay in the administration or her pan medications, Resident #83 replied, Yes, because she doesn't like me. A review of the (MONTH) (YEAR) PRN (as needed) MAR indicated [REDACTED]. However, on 08/06, 08/11, 08/19, 08/20, and 08/30/18 during night shift, staff failed to consistently document the resident's pain level. Also, review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In an interview on 09/13/18 at 10:30 a.m. Staff H (RCM) was asked if the staff ever attempted non-drug interventions related to the resident's complaints of pain/discomfort. Staff H replied, Yes, it looks as though staff attempted to reposition the resident but that's never effective, she will continue to complain of pain or discomfort. Staff H was asked when repositioning the resident isn't effective what other non-drug intervention were the staff instructed to attempt for this resident. Staff H replied, this woman is very manipulative with her care and pain medications tried really hard to make her more comfortable, but nothing works. It's hard because she can be very manipulative. REFERENCE: WAC 388-97-1060(1).

Based on interview and record review the facility failed to identify one of seven residents (Resident #1) reviewed for neglect as being neglected when experiencing symptoms of possible heatstroke and failed to report this potential neglect to the State Hotline. This failure resulted in unidentified neglect when the resident experienced potentially deadly symptoms of heatstroke and subsequent hospitalization , and placed all other residents at risk for being neglected. Findings included: Refer to CFR 483.25 Care and Services/Highest Practicable, F-309 The facility's 02/07/2017 Reporting Alleged Abuse policy included, .2. All LCCA (Life Care) personnel are mandated to promptly report suspected resident abuse and/or neglect .12. Federal requirements mandate that facilities must ensure all allegations of abuse, neglect, exploitation or mistreatment are reported immediately to their state survey agency .must ensure that all violations .including injuries of unknown source .are reported immediately. Resident #1 was a [AGE] year old woman, who weighed 149 pounds and had [DIAGNOSES REDACTED]. Staff assessed Resident #1 to require set-up help of one staff for most activities of daily living. Additional clinical data described other [DIAGNOSES REDACTED]. Resident #1's clinical record included multiple data to support Resident #1 had dementia and other [DIAGNOSES REDACTED]. According to the facility's 06/25/2017 evidence of investigation, the facility was aware inclement weather was expected and attempted to hydrate residents but were unsuccessful in preventing dehydration and heatstroke/heat exhaustion for Resident #1 as described in 06/25-26/17 hospital and facility records. When asked if the facility notified the State Hotline of potential neglect, Staff B, the Administrator, replied No in an interview on 06/28/2017 at 2:30 p.m. Staff B was not able to provide documentation to support staff considered or realized Resident #1 was at higher risk of being compromised because of the heat or even experienced a heat related condition change until she became unresponsive on 06/25/2017, when Resident #1 experienced [MEDICAL CONDITION] and had a temperature recorded at 105.8 degrees Fahrenheit, more than thirty minutes after being removed from the source of the heat, the courtyard. In interviewed on 06/28/2017 at 2:38 p.m., Department/State staff said they did not receive any report from the facility about potential neglect as it related to Resident #1. The facility did not identify Resident #1's change in condition as being related to possible neglect and failed to notify the State of possible neglect. This failure prevented staff from accurately preparing other residents for the continued inclement weather conditions that remained in effect through 06/25/2017. Reference: WAC 388-97-0640 (2)(a)(b) Abuse Polices and Procedures

Based on observation, interview and record review the facility failed to ensure, for one of seven residents (Resident #1) reviewed for implementation of necessary and appropriate inclement weather preventative interventions, that Resident #1 was assessed for higher than normal risk for heatstroke and/or implemented interventions during a high temperature weather warning. This failure caused Resident #1 to suffer debilitating, life threatening heatstroke/heat exhaustion resulting in an emergency room visit and hospital admission. Findings included: Refer to CFR 483.13(b) & (c) F-226 Abuse Polices and Procedures Resident #1 was a [AGE] year old woman, who weighed 149 pounds and had [DIAGNOSES REDACTED]. Staff assessed Resident #1 to require set-up help of one staff for most activities of daily living. Additional clinical data described other [DIAGNOSES REDACTED]. Prior State assessment of Resident #1 in May of 2016 highlighted Resident #1's failure in a lesser care environment, .client has a history of getting lost outside residence and forgetting events of the day. Client is repetitive in conversation .Client is very interested UFO (unidentified flying objects). Client talks frequently about going in the space ships at night when she is sleeping .Client may not be changing (incontinent pads) due to leaking on the chair .Client will wear same clothing and needs reminders to change .Cue client to change clothes .Client has partial (dental plate) and seems confused about taking it out and rinsing daily .(informal care giver states) client's care is more than expected .Diagnoses; .Dementia, Stroke, [MEDICAL CONDITION], aortic valve disease (with symptoms of) dizziness/[MEDICAL CONDITIONS]/[MEDICAL CONDITIONS], physical/mental function fluctuates, shortness of breath/exertion, fatigue. January 2017 hospital notes indicated Resident #1 had a [DIAGNOSES REDACTED]. These notes included, .(Resident #1) has poor insight .she did not continue with any of the recommended treatments at the time of (the original discharge from the hospital) . Observed on 06/28/17 at 9:00 a.m., Resident #1 was wearing dark colored long-sleeved layered clothing. Resident #1 said of her 06/25/17 experience, .I sat outside where I can sit, (on) Sunday, too long .I woke up (in the hospital) with siderails all over .I was outside long enough to raise my temperature . Resident #1 was unable to describe how long or often she visited the courtyard on 06/24-25/17. June 18, 2017 Physician notes included a [DIAGNOSES REDACTED].#1 as, Slowly declining. Poor memory. The March 11, 2017 Physician's notes indicated Resident #1 experienced, Chronic weakness. The February 11, 2017 Physician's note included, .Mood is anxious with poor memory .oral intake is irregular but adequate .Weakness The January 14, 2017 Physician's note also included, .poor memory . The readmission Physician's note summarized the findings as, Resident had dizziness, episodes of syncopies (with) mild (shortness of breath) and weakness. According to the June 2017 physician's orders [REDACTED].#1 was receiving multiple medications including [MEDICATION NAME] CD 240 mg (milligrams) extended release once daily for her high blood pressure, and [MEDICATION NAME] XL 5 mg extended release twice daily for incontinence. Drug.com 2017 describes side effects of [MEDICATION NAME] during hot weather as exacerbating dizziness, or [MEDICAL CONDITION], and the [MEDICATION NAME] as decreasing perspiration and increasing the risk of heatstroke. Facility Staff recorded in the facility's 06/25/17 evidence of investigation, clinical records and hospital staff recorded in the 06/25-26/17 hospital records, Resident #1 was found unresponsive outside on the inner south courtyard sitting in the sun at 4:00p.m. on 06/25/17. emergency room staff recorded a rectal temperature of 105.8 Fahrenheit at approximately 4:35 p.m. the same day, more than thirty minutes after Resident #1 was removed from the heat source to an air conditioned building. emergency room staff included in their documentation, .(Resident #1) only slightly responsive, mumbling. Per EMT (emergency medical technicians) pt (patient) was seizing and unresponsive during transport pt beginning to ask questions, what happened .face, arms, torso, legs red. Pt very hot. The conversation between the hospital social worker and the hospital physician was documented on 06/26/17 at 9:25 a.m. and included, .patient is medically cleared .was seen for questionable heat stroke was rehydrated and doing well . A 06/26/17 3:22 p.m. facility progress note recorded Resident #1's readmission and included, Her [DIAGNOSES REDACTED].While at the ER (emergency room ) resident was suspected to have pneumonia .started treatment .then it was ruled out . Staff B, the Administrator, said in an interview on 06/28/17 at 8:35 a.m. and again at 9:40 a.m., she was aware of and concerned about the hot weather so educated staff to administer extra fluids and monitor residents throughout the building including the courtyards. Specific documentation supporting individual residents were assessed for heightened risk of heatstroke, and/or received additional fluids, and other hot weather considerations were implemented was requested but none was provided. Staff M, Activities Staff, interviewed on 06/28/17 at 10:00 a.m. said, I passed water and popsicles .I have an alarm on my phone that lets me know when I need to check residents about every thirty minutes. Asked specifically about Resident #1, Staff M replied that when she arrived to work about 9:40 a.m. on 06/25/17, Resident #1 was already at the South patio(courtyard). Staff M remembered providing four to five eight ounce glasses of water to Resident #1 but recalled Resident #1 refused fluids at one point. According to Staff M, (Resident #1) said she was fine. Staff M alluded to trying to get Resident #1 to return to the facility and change clothing, which she was unable to describe, but there was no documentation to support this and there was no evidence to suggest nursing staff were informed of any concerns about Resident #1 until Resident #1 was found unresponsive. Neither Staff B or Staff M were able to provide any records to support the timing or amount of fluids provided to any resident and were not able to say how often Resident #1 or any other resident was actually monitored whether inside the building or on the patio/courtyard. Staff J, the Certified Nursing Assistant who found Resident #1 unresponsive was interviewed on 06/28/2017 at 2:10 p.m. Staff J said of Resident #1, (she) didn't respond (when she was found outside) .(she was)wearing couple of jackets .no(hat) .she was in the sunlight. Staff J was not able to determine how long or how often Resident #1 was on the patio/courtyard but indicated she was very independent with ambulation and liked to spend time outside. Staff B, interviewed on 06/28/17 at 2:30 p.m. thought Resident #1 was wearing flannel pajamas at the time she was found outside in the courtyard. Resident #6, assessed to be able to make his own decisions according to the quarterly 04/19/17 MDS was interviewed on 06/29/17 at 7:30 a.m. Resident #6 who was present when Staff J found Resident #1 unresponsive, said She (Resident #1) goes out there all the time most of the time under the canopy but not this time. She was right in the sun. She was out of it. She was shaking when we got there .She was out there before we ever came .(other residents) don't have good judgement. Resident #5 would sit out there in the sun. He (Resident #5) was wearing flannel shirt and sweat pants the same thing he is wearing now. Resident #7 was assessed to be able to make her own decisions and with a [DIAGNOSES REDACTED]. Resident #7, interviewed on 06/29/2017 at 7:40 a.m. said, We (Resident #1) chatted quite a bit while seated outside in the courtyard. She (Resident #1) said she felt bad, weak, kind of tired and had a lot of pink to her skin .You know she had really dark clothing on that day .she'd had too much sun . Staff N, a Registered Nurse, interviewed on 06/28/17 at 10:15 a.m. said she was approached by a staff member to assist Resident #1 on 06/25/17. Staff N said Resident #1, .was non-responsive, (her whole body was) shaking whole body, (her skin was)skin hot, (staff) brought (Resident #1) inside because so hot. (I couldn't give) Water couldn't give because (the resident was) unresponsive (but I) put (water) on (her) face and hands. Oximetry (mechanism to determine blood oxygen level) no reading because of shaking . As part of the facility's evidence of investigation Staff O, the receptionist, inlcuded in her statement about the incident, .On Sunday 6-25-2017 at 2:09 pm, I went to clock out for lunch thru the (south) courtyard and saw (Resident #1) there sitting by the table in the sun .After lunch, I came back (through the courtyard at 2:40 pm) and there (Resident #1) was still reading and sitting outside in the sun .At 3:58 pm as I recorded Fire and Rescue got here and at 4:08 pm ambulance and medics got her for (Resident #1) . The facility's 02/09/09 Inclement Weather policy included restrictions for residents during inclement weather as, 1. Courtyards .are available for use for residents except during inclement weather conditions. Guidelines to consider: Temperature (less than) 32 egress or (greater than) 90 degrees, heat index (greater than 100 degrees .excessive humidity .severe weather watches or warnings 2. Residents should be dressed appropriately for weather conditions if outside. 3. Each facility should provide for periodic monitoring of residents in courtyard .4. Residents with moderate to severe cognitive impairment should be attended by staff or visitor when outside. Local news networks began broadcasting the potential for extremely high temperatures as early as 06/20/17 as recorded on multiple sources including local television and radio networks. One source included Federal Ways' 06/24/17 temperature as 89 degrees Fahrenheit and the temperature on 06/25/17 as 96 degrees Fahrenheit. According to another source, the average humidity in Federal Way was 69 percent, making the temperature on 06/24/17 feel as if it were 106 degrees and the temperature on 06/25/17 as if it were closer to 124 degrees Fahrenheit. Resident #1 had a [DIAGNOSES REDACTED]. While Resident #1 was free to choose to go outside the facility failed to implement their policy recommendations for inclement weather safety for residents by ensuring residents were wearing proper clothing or considering closing the courtyard for temperatures over 90 degrees Fahrenheit. The facility did not comprehensively assess factors such as the resident's age, how the resident's medications would affect the resident in hot weather or the actual and modified temperatures based on humidity, location in an enclosed courtyard with Resident #1 and other residents seated in chairs on heat retaining cement to determine the resident's ability to make a safe choices about being outside. Staff and residents said Resident #1 was sitting in the sun for an extended period of time. Despite honorable attempts to hydrate Resident #1 and other residents, those attempts were not successful in preventing Resident #1 from experiencing life-threatening heatstroke and noted dehydration with a temperature of at least 105.8. The facility also failed to accurately monitor the resident's location and fluid consumption and did not consider the potential [MEDICAL CONDITION] the skin from the sun or other inanimate objects that retained heat. Reference: WAC 388-97-1060 Care and Services/Highest Standards

Based on observation, interview, and record review, the facility failed to ensure a system that provided necessary care and treatment to prevent contractures for two (#136 & 100) of three sampled and one supplemental (#66) residents reviewed for contractures. This failure caused these residents to experience decreased mobility, limited range of motion, and pain, which constituted harm. Findings include: RESIDENT #136 Resident #136 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to the 03/28/17 Quarterly Minimum Data Set (MDS-an assessment tool) the resident required extensive two person assistance with dressing, bed mobility, transfers, toileting and no functional limitation in range of motion. The resident was assessed as cognitively intact. On 05/09/17 at 12:41 p.m. Resident #136 was observed lying in bed with her left hand across her abdomen. The second through fifth digits on the left hand were noted to be curled and the resident stated she was unable to straighten the fingers. When requested, the resident performed Passive Range of Motion (PROM-movement of a joint by an external force or person) to her left hand with her right. The resident was unable to fully range/extend the second through fifth digits of the left hand. Per the resident, I could when I got here, but I have been here about a year and a half. I think it started after I returned from the hospital when I was really sick. Record review revealed Resident #136 was hospitalized from [DATE] to 04/18/16. After readmission to the facility the resident was evaluated by Staff M, OT (Occupational Therapy) on 05/21/16. According to the evaluation, the reason for the referral was muscle weakness. The resident's upper extremity (UE) ROM was assessed with [REDACTED]. When interviewed on 05/17/17 at 9:41 a.m. Staff M (treating OT) and Staff C (Therapy Manager) acknowledged that Resident #136 did not have increased tone or contractures to the hands at that time, but did have some pain and swelling to the left hand. Resident #136 was discharged from OT services on 06/15/16 with a recommendation to resume the Restorative Program, Increase UE strength .bilateral UE exercises using red theraband (a long rubber band used for strengthening exercises) 3 set of 10 reps as tolerated with rest breaks 3 to 6 times per week. Review of the Restorative Administration Record revealed the UE strengthening program with a red theraband remained in place through December 2016. There was no range of motion program established for the resident's hand. In an interview on 05/17/17 at 9:03 a.m., Staff C confirmed no hand ROM was recommended at that time, only a UE exercises with theraband. In an interview on the morning of 05/17/17, Resident #136 stated staff never provided range of motion to her fingers or hands as part of her restorative program. In an interview on 05/16/17 at 10:12 a.m., when asked to describe Resident #136's UE ROM program, Staff D, RA (Restorative Aide) stated the RA's did not perform range of motion on the resident's hands, the resident just grasped the theraband and would do exercises with it. Staff F, RA who was present agreed and added, When (the resident) came back from the hospital her (Left) hand was swollen and painful so she did not want to use it (hand). According to Staff F nursing was aware of the issue. In an interview on 05/17/17 at 6:40 a.m., when asked to describe Resident #136's UE ROM program, Staff E, RA also stated that she just handed the theraband to the resident and cued the resident as needed. When asked if she ever performed ROM on the resident's hands Staff E stated, No. When asked if she noticed a contracture to the resident's left hand Staff E preceded to flex her fingers into a claw shape, and stated, I could see it (left hand) was like this. Staff E added but she never complained .and I didn't really notice because she grasped the theraband fine. Staff E was unable to provide a timeline on when she first noted the increased flexion to the resident's hand, but acknowledged she did not report it. In an interview on 05/17/17 at 8:46 a.m., when asked when he noticed a contracture or change in the resident's hand Staff F stated, I didn't notice (a contracture), but I noticed she guarded her (left) arm and would not use it, she avoided using the left hand to grab the rail, I asked why and she said it hurt. Staff F stated he reported it to the OT as the resident was receiving services at the time. Staff F indicated these issues were identified after she returned from the hospital. In an interview the morning of 05/16/17 when asked if nursing or the restorative aides had reported increased tone, decreased ROM, or hand pain, Staff C (Therapy Manager) stated, No, I went to (the resident's) room by chance and (the resident) showed them (hands) to me so I referred her (to OT). According to the 12/05/16 OT Evaluation, Resident #136 was placed on services for muscle weakness and an identified .contracture, left hand. Per this evaluation the resident resided at the facility and was mostly bedbound for several months. Assessment of the Left hand revealed: L(eft) hand PIP (Proximal Interphalangeal) joints, 2nd digit lacking 30 degrees extension, 3rd (digit) lacking 40 degrees extension, 4th (digit) lacking 50 degrees extension, 5th (digit) lacking 45 degrees extension, all of which are a hard end feel with no further PROM. In an interview on 05/17/17 at 9:17 a.m., Staff C clarified hard end feel, means unable to straighten. On 05/17/17 at 9:41 a.m., Staff M shared that Resident #136 had periods of illness and inactivity and previously had [MEDICAL CONDITION] and pain in the left hand. Staff M indicated yes the risk factors were identified before the development of the contracture. Resident #136 was identified by staff to have multiple risk factors for decreased range of motion, including bedbound status, inactive with impaired mobility, pain and swelling that caused the resident to guard and avoid/limit use of her left hand. Even after identification of the risk factors, the facility staff failed to assess, develop and implement preventative measures to ensure the resident did not experience a reduction in ROM. This failure resulted in formation of an avoidable contracture to the resident's left hand. RESIDENT #100 Resident #100 admitted to the facility on [DATE] with multiple medically complex diagnoses. According to the 07/14/16 and 10/07/16 Quarterly MDSs, the resident had limited ROM to one side of the Lower Extremities (LE) and received passive ROM restorative services. According to the 12/30/16 and 03/29/17 MDSs the resident had no limitations in functional ROM and no restorative services. A Restorative Nursing Referral completed by Physical Therapy staff, dated 05/19/16 indicated a restorative program was started for the resident to prevent joint contracture, tightness and stiffness due to immobility. The resident was subsequently placed on a Passive ROM protocol three times a week for both hip and knee ROM. Record review revealed the resident was assessed to require and historically receive a restorative program. An 11/17/16 telephone order revealed directed staff to discontinue this restorative program. In an interview on 05/17/17 Staff GG (Licensed Nurse) was asked to provide any assessment, rationale or justification why the restorative program, which the resident was assessed to require, was discontinued. No information was provided. According to Restorative Assessments dated 04/23/16, 08/26/16, and 03/03/17, the resident was identified with functional limitation in ROM for both lower extremities (in conflict with the 03/29/17 MDS). While pain was listed as a barrier/contributing factor for the 03/03/17 assessment and documentation did not support the resident had an active restorative program at that time, staff failed to attempt any interventions related to the identified pain as it related to the resident's ROM. Daily observations on 05/10, 5/11, 5/12, 5/15, 5/16 and 5/17/17, revealed the resident lying in bed. The resident was not observed to make significant changes in her position. In an interview on 05/17/17 at 8:43 a.m., Staff E (Restorative Aide) indicated that the resident was previously on a RA program but she refused and didn't participate. Staff E stated she was unable to remember to whom she reported this or who discontinued the resident's restorative program but it was a while back. In an interview on 05/17/17 at 9:31 a.m. Resident #100 indicated she did not currently receive a range of motion program. Observation at this time revealed Staff GG attempt to range the resident's lower extremities. Staff GG was unable to fully range the resident's knees or hips and the resident grimaced and called out in pain during the ranging process. The ROM assessment was discontinued due to the resident complaints of pain. A subsequent screen, assessment performed at the request of survey staff, on 05/17/17 revealed the following: Passive ROM exercises on BLE (Bilateral LE) observed with Restorative staff and showed same ROM. Noted of patient bilateral hip flexion limited to 80 degrees. Hip abduction limited to 30 degrees and knee range of motion 5 to 90 degrees .for knee flexion/extension .within functional limits but (complains of) pain. (Pain Scale) 5/10 (Left) greater than (right) due to tightness / stiffness but after several repetition pt claim it feels better. Pt agreeable to work with restorative for 3-6 x/week. Facility staff was asked to provide any information to support this was not a new limitation in ROM. Progress notes dated 05/17/17 indicated the resident again required a restorative program as evidenced by, Resident screened by therapy r/t stiffness to BLE. Therapy recommends RA program 3-6 times a week for PROM to BUE including fingers and BLE on all functional planes x 10 reps to decrease pain, stiffness and tightness . In an interview on 05/26/17 at 1:20 p.m., Staff C (Therapy Manager) stated Resident #100 had an evaluation on 04/17/16 that did not have objective measurements, but also did not identify a decline in ROM to the knees or hips. Staff C stated the evaluation on 07/28/17 evidenced an increase in tightness and limited ROM compared to the previous evaluation. Staff C stated the most recent screen from 05/17/17 was similar/the same from the last time (04/17/16) which showed a decreased ROM. While staff C indicated that contractures limited to 90 degrees he would neither confirm nor refute Resident #100 had contractures to the knees or hips but reiterated based on the most recent assessment the resident experienced a limitation in ROM. When asked if this limitation was a contracture Staff C replied, I have to determine the N field, if they can only do it (ROM) to 90 then sure .(it's a contracture). According to the 4/16 and 7/16 MDS's the facility previously identified the resident with limited functional ROM and determined the resident would benefit from restorative services. According to the 12/16 and 03/17 MDS's, the resident had no limited ROM and no restorative program to prevent a decline in ROM. Assessments conducted on 05/17/17 confirmed the resident experienced a decline in ROM. The facility failed to provide Resident #100, a resident with limited mobility, appropriate services and assistance to maintain or improve ROM. Discontinuation of a restorative program the resident was assessed to require, in the absence of either justification or attempts to implement interventions for identified barriers (pain) resulted in a decline in range of motion. RESIDENT #66 Resident #66 was admitted to the facility on [DATE] with multiple medically complex diagnoses. According to the 12/30/16 quarterly and 03/29/17 Annual MDSs, staff assessed Resident #66 as rarely/never understood, having functional limitation of ROM to bilateral lower extremities and no restorative program. According to a PT treatment plan dated 11/21/10, BLE joints are WFL (Within Functional Limitations), passively done and pain-free except for ankle . Staff documented the resident required treatment .to facilitate progress toward patient goals with LE ROM Exercises . According to this document the resident was subsequently transitioned to hospice care. Observations on 05/16/17 at 1:10 p.m. revealed the resident in the dining room in a tilt-n-space wheelchair which was reclined, with what appeared to be contracted knees as both legs extended straight out, unbending, with no leg support. In an interview on 05/16/17 at 2:06 p.m. Staff D (Restorative Aide) stated, She wasn't expected to live past two months .We tried sometimes to put on foot rests, but I haven't been able to get them on for .I don't know who long now. You never know with her. In an interview on 05/16/17 at 2:07 p.m. Staff E (Restorative Aide) stated, We tried (restorative) a long time ago . According to a CP with a target date of 06/29/17, the resident required extensive/total assistance with all ADLs and mobility. The listed goal was Resident will not have a decline to present ROM with no interventions which might prevent this outcome. In an interview on 05/25/17 at 1:40 p.m. Staff GG was asked how staff could prevent a decline in ROM when the resident did not receive any type of restorative or ROM services. Staff GG replied, That's a good question. In an interview on 05/26/17 at 1:53 p.m. Staff C said he just assessed Resident #66 stating I took a look at her knees and now identified Resident #66 with bilateral knee extension contractures, with the left knee that didn't bend at all and the right knee had a little give. Failure to provide necessary services caused this resident to develop a decline in range of motion as evidenced by contractures. Reference (WAC) 388-97-1060(3)(d)

Based on deficient practices identified throughout the annual and extended survey process, it was determined the facility's administration failed to ensure a system which assured residents, who were assessed with [REDACTED]. The facility failed to ensure adequate and competent staffing to ensure a system which prevented a decline in Range of Motion (Range of Motion). This failure resulted in substandard care in Quality of Care. Findings include: Refer to CFR 483.25(e)(1), F-317, No Reduction in ROM The facility failed to ensure a system that provided necessary care and treatment to prevent contractures for two (#136 & 100) of three sampled and one supplemental (#66) residents reviewed for contractures. This failure caused these residents to experience decreased mobility, limited range of motion, and pain, which constituted harm. In addition: F 157 - 483.10(b)(11) Notify of Change The administration failed to consult with a resident's physician concerning abnormal laboratory results which required a change in treatment. F281 - 483.20(k)(3)(i) - Services Provided Meet Professional Standards The administration failed to ensure facility staff provided care and services according to professional standards. F309 - 483.25 - Provide Care/services For Highest Well Being The administration failed to ensure facility staff provided care and services for five of 15 residents related to pain, skin monitoring and treatment, positioning and bowel care. F311 - 483.25(a)(2) - Treatment and Serviecs to Maintain/Improve The administration failed to ensure a system to provide treatment and services to maintain or improve resident's functional abilities for two of three sample and one supplemental resident reviewed for activities of daily living. F312 - 483.25(a)(3) - Dependent resident recieves Care Administration failed to ensure a system by which assistance with Activities of Daily Living (ADL's) related to bathing for two of three dependant residents reviewed for ADL's was provided. F314 - 483.25(c) - Pressure Sore Developement/Treatment The administration failed to ensure preventative measures for three of three residents reviewed for Pressure Ulcers and three supplemental residents. F315 - 483.25(d)(1)(2) - Restore Bladder Function The administration failed to accurately assess and identify a decline in urinary incontinence, ensure a plan for treatment and services to restore as much normal bladder function as possible for two of two residents reviewed for urinary incontinence. F318 - 483.25(e)(2) - Range of Motion Treatment and Services The administration failed to ensure one of three residents reviewed for Range of Motion (ROM) and eight supplemental residents identified by staff with decreased ROM received appropriate treatment and services to prevent development and/or further decrease in range of motion. F328 - 483.25(k)(6) - Special Needs-Intravenous Services The administration failed to ensure a system which provided appropriate treatment and care regarding Intravenous (IV) fluids and devices, including the use of peripheral IV lines and a Portacath (a specialized surgically implanted intravenous access device) for one of one residents reviewed and failed to provide podiatry services for four of five residents reviewed. F329 - 483.25(l)(1) - Unnecessary Drugs The administration failed to ensure a system by which three of five residents and two supplemental resident reviewed were free from unnecessary drugs. F332 - 483.25(m)(1) - Medication error rate 5% or greater The administratino failed to ensure a medication error rate of 5% or less. Three of three nurses failed to correctly administer 20 of 26 medications for five of six residents observed during medication pass which resulted in a medication error rate of 76 percent. F353 - 483.30 (a)(1) & (2) Sufficient Nurse Staffing The administration failed to have sufficient and competent nursing staff to provide and supervise care as evidenced by information provided by 16 of 24 Stage I resident interviews. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADL) including showers and personal hygiene, range of motion services and treatment, accurate and timely medication administration and call light response in accordance with established clinical standards, care plans, and preferences. F441 - 483.65(a) - Infection Control Program The administration failed to ensure an effective infection control program was implemented with monitoring to demonstrate ongoing analysis and trending of infectious organisms. F497 - 483.75(e)(8) - Nursing Assistant Inservice The administration failed to ensure performance reviews for all nursing assistants at least once every 12 months. The facility failed to ensure nurse aide competency training and education based on the outcome of these reviews for five of seven nurse aides reviewed which placed all residents at risk for needs not being met. F-498 - 483.75(f) - Nursing Assistant Proficiency The administration failed to ensure continuing education curriculum addressed special needs of residents related to dementia, cognitive impairment and abuse prevention and failed to ensure no less than 12 hours per year of training for seven of seven nurse aides reviewed. F514 - 483.75(l)(1) - Res Records-Complete/accurate/accessible The administration failed to ensure medical records were accurate and dated in order to provide correct information and assessment for residents. Reference (WAC) 388-97-75

Based on observation, interview, and record review, the facility failed to ensure five (#s 163, 69, 67, 66 & 79) of the 15 sample residents reviewed in Stage II, received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility failed to ensure provision of timely pain interventions for two (#163 & 69) of two residents reviewed for pain, resulting in the residents experiencing pain and anxiety, which constituted harm. The facility also failed to coordinate services for one (#163) of one resident reviewed for Hospice and for one (#67) of one resident reviewed for [MEDICAL TREATMENT]. The facility failed to ensure one (#66) of three residents reviewed was properly positioned, and one (#s 79) of three residents reviewed received services related to non pressure skin issues. Failure to identify and provide elements of care as required for these residents placed the residents at risk of unmet care needs. Findings include: Refer to CFR 483.15(a), F-241, Dignity CFR 483.20(k)(3)(i), F-281, Services Meet Standards PAIN RESIDENT #163 Resident #163 admitted to the facility on [DATE] with end of life care needs. According to the 03/16/17 Admission MDS (Minimum Data Set- an assessment tool), the resident was cognitively intact and utilized regularly scheduled and as needed pain medication. In an interview on 05/09/17 at 10:13 a.m., Resident #163, who was observed lying in bed on his back, indicated he did not get his pain medications timely. The resident stated, .the night crew . they will sometimes make me wait 2-4 hours to have a pain medication, I ask for pain meds and they don't bring it to me, I have the light on and they don't answer it. In an interview on 05/10/17 at 2:13 p.m., the Registered Nurse (RN) Patient Care Coordinator (PCC), Staff NN, for Resident #163, indicated the resident had expressed concerns about not receiving pain medication from nursing staff when it was requested. Staff NN stated, He has problems from night shift regarding getting his meds having to wait two to five hours .he calls me, I've put his number in my cell. He's brought it up to the DNS (Director of Nursing Services), we increased the pain medication so he doesn't have to ask as often. According to Hospice Nursing notes (obtained 05/15/17) dated 04/06/17, the resident, .suffered with pain most of the night, he complains of staff ignoring the call light when he has to urinate or defecate. Hospice nursing notes dated 04/26/17, Pt appears comfortable but stated having issues with nursing staff at facility, especially NOC (night) shift who refuses to give pt any PRN (as needed ) Pain meds .Instructed pt to call Hospice if nursing staff refuses to give PRN pain meds at NOC .PCC touched base with RCM (Resident Care Manager) who stated she will talk to the night shift nurse. On 05/04/17 hospice staff documented, (Resident) expressed frustration at night staff for not properly administering his pain meds . According to a statement in an investigation dated 05/10/17, Staff DD documented, He requested pain pill like an hour ago and the nurse didn't respond in time. He asked for pain pill again and (nurse) responded to him. Facility staff consistently failed to provide Resident #163 with timely pain medications and failed to provide any type of alternate intervention despite knowledge the resident's pain needs were not being met. RESIDENT #69 In an interview on 05/09/17 at 8:44 a.m., Resident # 69 expressed concerns regarding receiving pain medications and oxygen in a timely manner, stating, Getting people to give them to you when you want or need them is not easy most nurses are receptive, others will bawl you out for not coming down (to the nurses station). I can't because I need my oxygen . In an interview on 05/12/17 at 8:57 a.m., the resident lying in bed .pain medication : I don't like to ask for the pain medication too often (they don't give pain and anxiety at the same time) I wouldn't be anxious if I wasn't hurting so much. The resident elaborated, A lot of times I have to wait quite a while for pain medications .My opinion is they switch the people around so much, north to south, they don't really get to know us. When asked how long she had to wait for pain medication after it was requested the resident replied, Well over an hour, not quite two, there was one where I didn't get it. I get the feeling the aide either didn't tell the nurse or the nurse didn't think I needed it. HOSPICE RESIDENT #163 Resident #163 admitted to the facility on [DATE] with end of life care needs. Record review revealed the resident was enrolled in Hospice services on 03/16/17. However, the record did not contain information delineating services and/or frequency that would be provided by the facility versus those provided by hospice (bathing, Chaplin visits, massage therapists, Social Work visits). In an interview on 05/15/17 at 12:23 p.m., Staff B indicated the CP (Care Plan) should delineate who was to provide what care, as well as the planned frequency of that care. Record review revealed a log sheet which indicated the discipline and date of the Hospice worker visiting and an other column, but no working documents regarding the services provided by Hospice or how the resident responded to that care. In an interview on 05/12/17 at 12:38 p.m., Staff N (Resident Care Manager) was asked to provide the notes from the Hospice nursing visits. Staff N was unable to find any records which clearly identified the care Resident #163 was provided during visits. Staff N, at this time, reviewed the resident records and confirmed there was no CP by hospice in the record which delineated which staff provided what care. There were no CP goals or direction as to who would provide bathing or how often it would be provided. According to the Hospice & Palliative Care Log In Sheet, Hospice staff provided bathing on 02/21/17. On 03/31/17 Hospice staff wrote on the log sheet, Bath/resident refused, massage present. There was no documentation to support the resident was bathed again until 04/19/17. No subsequent bath was documented until 04/26/17 and then again on 05/10/17, a delay of 14 days. In an interview on 05/15/17 at 12:23 p.m., Staff X (Corporate Staff) indicated the facility should have the hospice CP and nursing progress notes available in the resident record. Facility failure to ensure a system by which Hospice and facility care were coordinated, placed the resident at risk for unmet care needs. [MEDICAL TREATMENT] RESIDENT #67 Resident #67 admitted to the facility on [DATE], and according to the 12/04/16 Admission MDS had multiple medically complex [DIAGNOSES REDACTED]. Review of Pre/Post [MEDICAL TREATMENT] Communication (PDS) forms for Resident #67 revealed these communication forms were incomplete. The PDS dated 04/06/17 didn't include the post [MEDICAL TREATMENT] condition of the access site. The 04/11/17 PDS did not contain any information regarding services received at the [MEDICAL TREATMENT] center, pre or post [MEDICAL TREATMENT] weight, condition of the access site, or any [MEDICAL TREATMENT] contact information. Similar incomplete [MEDICAL TREATMENT] communication forms were noted for 04/08/17, 04/17/17, 04/20/17, 04/22/17, 04/27/17, 04/29/17, 05/04/17 and 05/11/17. In an interview on 05/15/17 at 8:09 a.m., Staff GG confirmed the PDS forms located in the [MEDICAL TREATMENT] binder were incomplete. Staff GG indicated there were some days of PDS forms that were missing and components of the assessments were not complete. Record review revealed no consistent [MEDICAL TREATMENT] run sheets (documents produced by [MEDICAL TREATMENT] center detailing the lab results, treatments, infusion times and basic information regarding the treatment of [REDACTED]. In an interview on 05/12/17 at 8:09 a.m., Staff GG was asked about the labs associated with the [MEDICAL TREATMENT] run sheets. Staff GG stated, Usually the [MEDICAL TREATMENT] is suppose to fax us weekly reports .I would have the ward clerk get them, the RCM is responsible for follow up. When asked why the labs were important Staff GG stated, Usually that's where we get the labs, with [MEDICAL TREATMENT] patients, we have [MEDICAL TREATMENT] do whatever the required labs are, because of the diet, medications, they need to adjust the [MEDICAL TREATMENT] based on the labs, medications, diet, electrolytes etc . In an interview on 05/12/17 at 12:29 p.m., Staff N (Resident Care Manager) reviewed the [MEDICAL TREATMENT] records and confirmed some had no name, no pre/post [MEDICAL TREATMENT] weight, and/or no information as to what medication was provided. Staff N confirmed the forms were not completed and the [MEDICAL TREATMENT] center didn't send the forms that included the labs. Staff N stated it was difficult to get the information from the [MEDICAL TREATMENT] center. Failure to have a system by which the facility maintained active and effective communication with the [MEDICAL TREATMENT] center placed the resident at risk for delayed treatment of [REDACTED]. POSITIONING RESIDENT #66 Resident #66 admitted to the facility on [DATE]. According to the 03/29/17 Annual MDS, the resident was assessed with [REDACTED]. This MDS indicated the resident was rarely/never understood, had memory problems and was severely cognitively impaired and required extensive two person assistance for bed mobility, transfers, and toileting. Periodic daily observations on 05/10, 11, 12, and 15/17 revealed the resident was up in a reclined tilt-n-space w/c (wheelchair) that had no leg or foot rests. The resident's legs were noted to dangle unsupported. Observation on 05/16/17 at 1:10 p.m. revealed the resident in the dining room in her wc which was tilted back. Again, there were no leg rests or leg supports which left the resident's legs hanging unsupported. Observation by Staff GG on 05/16/17 at 1:29 p.m., confirmed there was no leg rests or support on the resident's wc. Staff GG stated at that time, There should be. In an interview on 05/16/17 at 1:29 p.m., Staff GG was asked to provide any information to support facility staff assessed the continued need for the leg/foot rests or the basis for their discontinuation. No information was provided. In an interview on 05/16/17 at 2:42 p.m., Staff C (Director of Therapy Services) stated all residents should have leg support as evidenced by leg/foot pedals unless contraindicated. He indicated that an assessment should be done to evidence the leg support was contraindicated prior to it's discontinuation. Staff C indicated that if a resident had contracted knees that were not supported by leg rests/foot pedal, there would be increased tension on the hips. Failure to attempt to ensure this resident received proper positioning and support put the resident at risk for pain, skin breakdown, and hip contractures. NON PRESSURE SKIN RESIDENT #79 Resident #79 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 03/21/17 Quarterly MDS the resident required extensive assistance with activities of daily living and was at risk for skin impairment. A 06/21/17 Potential for skin breakdown and for developing pressure ulcer . CP directs staff to perform a: weekly skin assessment; reposition per facility protocol and as needed; float heels; notify nurse immediately of any new areas of skin breakdown, redness, blisters or discoloration noted during bathing or daily care. Review of the Treatment Administration Record (TAR) revealed a skin check had been performed on 05/16/17. According to the associated Weekly Skin Integrity Data Collection Tool the residents skin was intact. On 05/16/17 at 11:08 a.m. (after the facility had completed a skin check and documented intact) Staff I performed a skin check with surveyor present which revealed a 0.3 cm (centimeter) by 0.4 cm dry black scab to the medial aspect of the resident's left great toe and a 0.3 cm by 0.3 cm dark brown scab to the medial aspect of the left knee. When asked if the facility monitored scabs Staff I stated, yes and acknowledged that these areas should have been identified on the skin check performed earlier in the day. Staff K (treatment nurse) added, We track any (skin issues) if present. Failure to accurately identify and monitor alterations in skin integrity detracted from staff's ability to determine causative factors, implement interventions to prevent further skin injury and assess whether areas are improving or declining. This placed the resident at risk for unidentified decline in wounds, infection and further injury. Additionally, review of the May 2017 Physicians Orders (PO) revealed a 09/13/15 order to apply Geri legs (stockinet applied over fragile skin for increased protection from injury) to bilateral legs daily, on in the a.m. and remove at HS (hour of sleep). According to the TAR the geri legs were to be applied at 8:00 a.m., and removed at 8:00 p.m. Observations on 05/10/17 at 11:56 p.m. revealed the resident lying in bed supine without geri legs in place. Similar observations were made on: 05/11/17 at 10:57 a.m., 11:43 a.m., and 2:21 p.m., 05/12/17 at 9:11 a.m., 10:24 a.m. and 12:08 p.m., 05/15/17 at 8:41 a.m., and 9:48 a.m. On 05/16/17 at 11:03 a.m. Staff I was present in the resident's room and acknowledged that the resident did not have geri legs on as ordered no and stated yes they should be. On 05/17/17 at 10:37 a.m. Resident #79 was again observed in her room without geri legs on. Staff B was present and acknowledged that the geri legs were not in place. Failure to provide interventions as ordered and that the resident was assessed to require, placed the resident at risk for further alterations in skin integrity. Reference: (WAC) 388-97-1060(1)(3)(b)

Based on observation, interview and record review it was determined the facility failed to prevent neglect, for one cognitively impaired resident who eloped out of 33 sampled residents (Resident #1) reviewed for elopement and wandering, related to lack of supervision. This failure placed all other residents at risk for being neglected and for elopement and resulted in an immediate jeopardy situation. Additionally the facility failed to timely and/or accurately assess 12 other (#8, 10, 13, 14, 15, 16, 17, 18, 20, 21, 27 and 28) cognitively impaired residents of 33 sampled residents reviewed for wandering. This failure prevented staff from knowing the extent to which residents were at risk for elopement placing them at risk for elopement and injury. In addition it was determined the facility failed for one (Resident#31) of 3 sampled residents reviewed for supervision of care planned transfer interventions, to implement mechanical transfers with required two-person assistance. This failed placed Resident #31 at risk for falls and injury. Findings include: Refer to CFR 483.13(c)(3) RESIDENT #1 Review of the facility's 2009 Elopement policy revealed, .Residents have the right to live at ease in a safe secure environment. The facility is responsible for ensuring that effective polices and procedures are developed and implemented to reduce the risk of elopement by residents .Elopement occurs when a resident leaves the premises or a safe area without authorization .any necessary supervision to do so. The policy said, Residents are assessed at the time of admission for the potential of elopement based on .prior history of wandering or elopement .impaired decision-making .impaired cognition with the ability to be mobile .use of a wheelchair. The policy included, A specific plan and interventions (including specific behavior patters) are developed and implemented from the time of admission .Residents who develop wandering behavior after admission are reassessed and appropriate interventions are identified in the plan of care . Resident #1 was assessed by staff as severely impaired for cognition, with [DIAGNOSES REDACTED]. Staff reassessed Resident #1 on the 12/05/2016 MDS for a Significant improvement in Resident #1's ability to perform ADL's including an increase in self-locomotion with a wheelchair. This recent assessment indicated Resident #1 required the limited assistance of only one person. According to the 03/15/2017 evidence of investigation Resident #1 eloped from the facility without staff knowledge. Review of Resident #1's historical records revealed the facility assessed Resident #1 on the Risk of Elopement/Wandering form on 04/15/15, 10/10/15 and 12/24/15 but not again until 07/08/16 seven months later at low or no risk for elopement. Included in the 03/15/2017 investigative documentation was an additional Risk of Elopement/Wandering Review form. The form included two dated assessments. One assessment dated [DATE] indicated Resident #1 was at no further risk of eloping despite the 12/5/16 significant change MDS indicating the resident was more mobile. The second assessment was dated after the elopement and indicated Resident #1 was at risk of eloping. Clinical record review revealed at least 12 other Residents, many of whom were observed self-propelling devices in the hallways during the investigation, (#8, 10, 13, 14, 15, 16, 17, 18, 20, 21, 27 and 28) were infrequently and irregularly assessed for their risk of eloping or wandering regardless of comprehensive assessment data obtained quarterly. Staff documented that residents were assessed as little as every seven months. When asked why the system was not intact on 03/28/2017 at 2:00 p.m. Staff C responded, There has been a lot of nurse management turnover and (the lack of routine assessment) is the repercussion. Resident #1's 08/14/2015 care plan included instruction to staff to, Anticipate and provide daily care ., observe for physical or non-verbal indicators of discomfort/distress and follow-up as indicated .determine resident's expectations and discuss .one person assist with transfers . There did not appear to be any care plan for elopement before 03/16/2017 and when asked staff did not provide evidence that a previous care plan existed despite Resident #1's improved mobility identified in December of 2016. Resident #1 was observed either in bed or up in a wheelchair slowly propelling during the course of the investigation. Interviewed on 03/28/2017 at 8:10 a.m. Resident #1, through a translator said, I want to go home with my husband. Recalling the 03/15/2017 elopement Resident #1 laughed and said, I can't remember. The bus driver helped me. He was nice and gave me help. No one here helped me. I just left. Resident #1 was unable to provide a timeline or other specifics about the incident. Review of the facility's 03/15/2017 evidence of investigation revealed Resident #1 was identified by staff as missing between 9:30 p.m. and 9:45 p.m. and a search was initiated around 10:00 p.m. Although Staff C indicated Resident #1 was definitely in bed at 8:30 p.m. on 03/15/2017 when Resident #1's roommate fell . Staff documented Police notified us NOT US - Notifying them, on a sticky note attached to the inside of the folder containing the investigative documents supporting staff were unaware Resident #1 left the facility. The Incident Follow-up & Recommendation Form included, Resident is (foreign language) speaking, does understand little English .Resident is alert .requires 1 person assistance with adl's (activities of daily living) and mobility via wheelchair. Bims (cognitive assessment score) Score 6. The facility interviewed Resident #1 upon return to the facility by local police, between 11:30 p.m. on 3/15/17 and 12:15 p.m. on 03/16/2017, from the Federal Way transit station 1.8 miles from the facility. Staff documented in the investigative file Resident #1 said they exited the facility through a door and acquired the assistance of a bus driver, to go home. Actual recreation of the incident revealed Resident #1's most likely route to the nearest bus stop was through the large parking lot of a nationally known medical provider and adjacent to a large apartment complex whose tenants used the same driveway repeatedly and rapidly. The distance was 0.3 miles. Review of the bus schedule at the bus stop revealed only the #187 bus would take Resident #1 to the transit station 1.5 miles away. Buses were scheduled to arrive at the bus stop at 9:00 p.m. and 10:00 p.m. There was no indication in the investigative documents the facility identified how or why Resident #1 exited the building. When asked if the facility identified how Resident #1 eloped, both Staff C and Staff K a Licensed Practical Nurse working in conjunction with the Administrative office, interviewed on 03/24/2017 at 11:15 a.m., said, We still don't know. When asked if Resident #1 and other residents were at risk for elopement Staff C replied, Yes. As a result of the failure to identify specific conditions under which Resident #1 eloped the facility was unable to implement specific interventions to ensure Resident #1 or other cognitively impaired residents did not elope. Observation of the facility on 03/24/2017 from 9:30 a.m. to 4:30 p.m. revealed four exterior doors that were not secure, a part of the alarm system or open and could remain open without staff being aware a resident exited the building. Several of the doors were observed to require a special key that if necessary staff could disengage and eliminate the alarm. The door in one of these areas, the laundry was observed to be wide open to a back driveway twice during the investigation. Additionally staff had placed tape over the enunciator panel at the 300 unit emergency exit and the panel at the nurse's station decreasing staff ability to hear the alarm if anyone exited the facility. The Maintenance Director Staff S, said in an interview on 03/24/2017 at 11:15 a.m., All doors alarmed. I check them first thing in the morning. Staff S was observed to remove the tape from the enunciator panel located at the 300 unit door. No staff admitted to fore knowledge of the direct care staff disabling the auditory portal of the alarm. Staff J, a Licensed Nurse who was working the night of Resident#1's elopement, said in an interview on 03/24/2017 at 1:45 p.m., I didn't hear the alarm. The facility did not assess Resident #1 or 12 other residents (#7, 8, 10,11, 12, 13,14, 15, 16, 17, 18, 19, 21, accurately or timely, protect Resident #1 from elopement on 03/15/2017, identify potential factors that allowed Resident #1 to elope unnoticed and be out of the facility for as long a four hours, develop a time line surrounding the events of the elopement, or review all of the circumstances surrounding Resident #1's elopement placing Resident #1 in immediate jeopardy and placing all other residents especially those who wandered and were cognitively impaired at likelihood for the same fate. RESIDENT #31 According to the 12/15/16 MDS Resident # 31 was able to make their own decisions and had [DIAGNOSES REDACTED]. The facility assessed Resident #31 to require extensive two-person physical assistance with transfers. According to the care plan two staff were to use a mechanical lift to transfer the resident. According to Resident #31 who was sitting in a wheelchair, on 03/27/2017 at 5:05 p.m., About a month ago only one staff transferred me to bed with the (mechanical) lift. Review of the facility's 03/20/2017 evidence of investigation revealed staff investigated and substantiated only one staff transferred Resident #31 using the mechanical lift on the day in question. The facility failed to follow care planned interventions for transferring Resident #31 placing the resident at risk for falls and injury.

Based on observation, interview and record review it was determined the facility failed, for one (Resident #1) of 33 sampled residents reviewed for investigation of elopement, to thouroughly investigate, identify potential factors and analyze all circumstances surrounding the incident. Failure to thouroughly investigate, identify potential factors and analyze all circumstances surrounding the incident related to the elopement placed Resident #1 and all other residents at risk for elopement, subsequent injury and death, and resulted in an immediate jeopardy situation. Findings included: According to the facility's undated Abuse and/or Neglect Investigation policy, Residents have the right to live at ease in a safe environment . 1.the administrator will appoint a representative to investigate the occurrence. 2.utilize the Investigative Questionnaire . 3. The representative will review the Incident Report for completeness . 5. The investigation shall include .A review of all circumstances surrounding the incident. 6.the resident(s) are protected during the course of the investigation to prevent recurrence . Resident #1 was assessed by staff as severely impaired for cognition, with [DIAGNOSES REDACTED]. Staff reassessed Resident #1 on the 12/5/2016 significant change MDS as significantly cognitively impaired but with an improved ability to perform ADL's including locomotion and required the limited assistance of only one person. Review of the facility's 03/15/2017 evidence of investigation revealed Resident #1 was identified by staff as missing between 9:30 p.m. and 9:45 p.m. and a search was initiated around 10:00 p.m. Staff documented Police notified us NOT US - Notifying them, on a sticky note attached to the inside of the folder containing the investigative documents. The Incident Follow-up & Recommendation Form included, Resident is (foreign language) speaking, does understand little English .Resident is alert .requires 1 person assistance with adl's (activities of daily living) and mobility via wheelchair. Bims (cognitive assessment score) Score 6. The facility interviewed Resident #1 upon return to the facility on [DATE] between 11:30 p.m. and 03/16/2017 12:15 a.m. by local police from the Federal Way transit station. Staff documented Resident #1 said they left the facility through a door and acquired the assistance of a bus driver, to go home. According to Staff C, interviewed on 03/28/2017 at 2:00 p.m. Resident #1 was in bed at 8:30 p.m. on 03/15/2017. It is unclear if any staff were aware of Resident #1's location after this time. Resident #1 was observed either in bed or up in a wheelchair slowly propelling during the course of the investigation. Interviewed on 03/28/2017 at 8:10 a.m. Resident #1, through a translator said, I want to go home with my husband. Recalling the 03/15/2017 elopement Resident #1 laughed and said, I can't remember. The bus driver helped me. He was nice and gave me help. No one here helped me. I just left. Resident #1 was unable to provide a timeline or other specifics about the incident. There was no indication in the investigative documents the facility identified how or why Resident #1 exited the building. When asked if the facility identified how Resident #1 eloped, both Staff C and Staff K a Licensed Practical Nurse working in conjunction with the Administrative office, interviewed on 03/24/2017 at 11:15 a.m., said, We still don't know. When asked if Resident #1 and other residents were at risk for elopement Staff C replied, Yes. As a result of the failure to identify specific conditions under which Resident #1 eloped the facility was unable to implement specific interventions to ensure Resident #1 or other cognitively impaired residents did not elope. Actual recreation of the incident revealed Resident #1's most likely route to the nearest bus stop was through the large parking lot of a nationally known medical provider and adjacent to a large apartment complex whose tenants used the same driveway repeatedly and rapidly. The distance was 0.3 miles. Review of the bus schedule at the bus stop revealed only the #187 bus would take Resident #1 to the transit station 1.5 miles away. Buses were scheduled to arrive at the bus stop at 9:00 p.m. and 10:00 p.m. Observation of the facility on 03/24/2017 from 9:30 a.m. to 4:30 p.m. revealed four exterior doors that were not secure, a part of the alarm system or open and could remain open without staff being aware a resident exited the building. Several of the doors were observed to require a special key that if necessary staff could disengage and eliminate the alarm. The door in one of these areas, the laundry was observed to be wide open to a back driveway twice during the investigation. Additionally staff had placed tape over the enunciator panel at the 300 unit emergency exit and the panel at the nurse's station decreasing staff ability to hear the alarm if anyone exited the facility. The Maintenance Director Staff S, said in an interview on 03/24/2017 at 11:15 a.m., All doors alarmed. I check them first thing in the morning. Staff S was observed to attempt to remove the tape from the enunciator panel located at the 300 unit exit door. No staff admitted to having fore knowledge of the direct care staff attempt to disable the auditory portal of the alarm. Staff J, a Licensed Nurse who was working the night of Resident#1's elopement, said in an interview on 03/24/2017 at 1:45 p.m., I didn't hear the alarm. Included in the investigative documentation was a Risk of Elopement/Wandering Review form. The form included two dated assessments. One assessment dated [DATE] indicated Resident #1 was at no further risk of eloping despite the 12/5/16 significant change MDS indicating the resident was more cognitively aware and more mobile. The second assessment was dated after the elopement and indicated Resident #1 was at risk of eloping. Review of the facility's 2009 Elopement policy revealed, .Residents have the right to live at ease in a safe secure environment. The facility is responsible for ensuring that effective polices and procedures are developed and implemented to reduce the risk of elopement by residents .Elopement occurs when a resident leaves the premises or a safe area without authorization .any necessary supervision to do so. The policy said, Residents are assessed at the time of admission for the potential of elopement based on .prior history of wandering or elopement .impaired decision-making .impaired cognition with the ability to be mobile .use of a wheelchair. The policy included, A specific plan and interventions (including specific behavior patterns) are developed and implemented from the time of admission .Residents who develop wandering behavior after admission are reassessed and appropriate interventions are identified in the plan of care . Clinical record review revealed at least 15 (Residents #1, 3, 7, 10, 13, 14, 15, 16, 17, 18, 20, 21, 23, 27 and 28) of the 33 sampled residents were infrequently and irregularly assessed for their risk of eloping or wandering regardless of comprehensive assessment data obtained quarterly. Staff documented that residents were assessed as little as every seven months. When asked why the system was not intact on 03/28/2017 at 2:00 p.m. Staff C responded, There has been a lot of nurse management turnover and (the lack of routine assessment) is the repercussion. The facility did not assess Resident #1 or 14 other residents accurately or timely, protect Resident #1 from elopement on 03/15/2017, identify potential factors that allowed Resident #1 to elope unnoticed and be out of the facility for as long a four hours, develop a time line surrounding the events of the elopement, include police information or review all of the circumstances surrounding Resident #1's elopement.

Based on observation, interview and record review it was determined the facility failed to thoroughly assess, monitor and provide interventions for an acute medical condition which caused Resident #230 to experience pain which limited his activities of daily living, ability to participate in therapy and general comfort. Additionally, the facility failed to identify, monitor, report and/or provide interventions for non pressure skin issues for two (#s 228 & 43) of three residents reviewed for non pressure skin conditions and one (#231) supplemental resident; failed to consistently assess, evaluate and/or implement Restorative Nursing Programs for Resident #s 16 & 142; and failed to follow up on abnormal laboratory results for Resident #123. These failures placed residents at risk for worsening skin condition, unmet restorative needs and missed medication adjustments. Findings include: Refer to: CFR 483. 25(k)(3)(i), F-281, Services Meet Standards PAIN AND NON PRESSURE SKIN RESIDENT #230 Resident #230 admitted to the facility on [DATE] with multiple medically complex [DIAGNOSES REDACTED]. According to www.ninds.nih.gov, [MEDICAL CONDITION] means nerve disease or damage. Areas of the body may become abnormally sensitive leading to an exaggeratedly intense or distorted experience of touch. In such cases, pain may occur in response to a stimulus that does not normally provoke pain. Severe symptoms may include burning pain (especially at night). Neuropathic pain is a common, symptom of sensory nerve damage and can seriously affect emotional well-being and overall quality of life. Often worse at night, neuropathic pain seriously disrupts sleep and adds to the emotional burden of sensory nerve damage. Resident #230 was newly admitted to the facility thus no Minimum Data Set assessment was available for review. However, hospital history and physical documents indicated, This pain is throbbing in character, 10/10 in severity. His usual [MEDICATION NAME] for chronic pain is 'barely touching it.' He was seen in the ER (emergency room ) . and was prescribed [MEDICATION NAME] to take in addition to his usual [MEDICATION NAME]. This seemed to be somewhat more effective. According to admission physician's orders [REDACTED].#230 was to receive [MEDICATION NAME] 600 milligrams (mg) three times daily to treat [MEDICAL CONDITION]. There were also POs for [MEDICATION NAME] (an opiode pain medication) four mg every three hours as needed for pain as well as an order for [REDACTED]. According to the Initial Data Collection Tool dated 01/29/16, the resident was assessed with [REDACTED]. This assessment did not indicate if pedal pulses were present or how far up the leg the [MEDICAL CONDITION] extended. Staff assessed the resident had no scrotal swelling at that time. 01/30/16 A progress note dated 01/30/16 at 7:26 a.m. indicted the resident, Complained of severe pain to left foot wounds and was medicated with [MEDICATION NAME] as ordered with good results. Able to sleep for short periods throughout the night. The resident was noted to be Pleasant and cooperative with care. Staff noted 2+ [MEDICAL CONDITION] to BLE (bilateral lower extremities) but did not note how far up the leg the [MEDICAL CONDITION] extended. At 9:50 p.m. staff documented, BLE 2+ [MEDICAL CONDITION]. Resident notified this LN (Licensed Nurse) his scrotum hurts, open blister noted measuring 3.5 cm x 1.5 cm . new orders to clean scrotum with normal saline and apply Alleyven dressing daily . There was no indication facility staff questioned or identified why the resident had acquired a blister to the scrotum. 01/31/16 On 01/31/16 at 2:53 a.m. staff documented the resident was, Restless and agitated at the beginning of the night. Complaining of severe pain to scrotum. Scrotum slightly [MEDICAL CONDITION]. Open blistered area to posterior scrotum reddened. One intact blister to scrotum also noted . Resident sitting up at the edge of the bed at this time. Reported open blistered area, 'my balls are sticking to the sheet' causing pain. Requesting to go to the hospital . According to the note, the resident, per his request, was transferred to the empty bed in his room with bilateral grab bars as it would be helpful for bed mobility. Staff failure to assess and determine grab bars would assist the resident with bed mobility on admission resulted in the resident having to request adaptive devices. According to an Occupational Therapy (OT) note dated 01/31/16, Bed mobility . with Mod A(assistance) attempted and need for Mod A x 2 to lift both lower extremity safely into bed due to scrotal swelling. According to a Physical Therapy (PT) note dated 01/31/16 at 1:02 p.m., Nursing was informed regarding (complaints of) (Pain Scale) of 10/10 on his genital area, said it was taken good care of already and MD was notified per nurse and .supine positioning was not completed due to increasing pain on his genital area . An additional PT note of the same date indicated testing was limited due to complaints of pain at a 10/10 on BLE (bilateral lower extremities) and genital area . On 01/31/16 at 5:06 p.m. nursing staff documented, Scrotum remains swollen, peri-care provided and area left to air dry as unable to place dressing on open blisters on scrotum. awaiting to be seen by MD sometime today. Medicated with PRN pain meds x 2 with some relief. Staff did not indicate if the resident's scrotum was more swollen than previously assessed or if it remained the same. Physician order [REDACTED]. In a telephone interview on 02/08/16 at 10:58 a.m. the resident's physician indicated that on the 01/31/16 assessment, the resident had [MEDICAL CONDITION] to a point above the knee and There was no serous drainage from the scrotum, the blister had already stopped draining . there was no serous drainage from the scrotum. A nursing note on 01/31/16 at 8:21 p.m. indicated, resident sitting by the edge of bed . c/o (complains of) pain to BLE. given [MEDICATION NAME] 4 mg with relief. New orders spirolactone (diuretic) . for increase [MEDICAL CONDITION] to BLE and [MEDICATION NAME] powder topical to scrotum . for redness . enlarged and swollen scrotum . There was no objective measurement of the scrotum which might enable staff to determine if the resident's condition was worsening or resolving. There were no identified interventions, such as elevation of the scrotum, which might decrease the swelling and provide relief to the resident. There were no identified interventions (such as daily weights) which would allow staff to determine effectiveness of the newly implemented diuretic. 02/01/16 A nursing note on 02/01/16 at 7:19 a.m. revealed the resident was noted, sitting up in chair at the beginning of the night and tolerating well. Complained of moderate BLE pain and was medicated with [MEDICATION NAME] with good results . BLE [MEDICAL CONDITION] noted, requires extensive two person assist for bed mobility, transfers and positioning. A nursing note dated 02/01/16 at 3:19 p.m. indicated, res c/o pain medicated [MEDICATION NAME] 4 mg with good relief . Res complain pain call pharmacy to get authorization number and the pharmacy replied the the res doesn't have a valid prescription and will contact the MD. Res aware the situation and provide Tylenol 650 mg (orally) PRN as alternative good relief. Review of Medication Administration Records (MARs) and pain monitoring documents revealed no [MEDICATION NAME] was administered from 7:30 a.m. to 5:30 p.m. on 02/01/16. There was a disparity between the Nursing note which indicated the resident was medicated with [MEDICATION NAME], when this was not reflective of the MAR. In addition, review of the MAR indicated [REDACTED]. The resident received no pain medication from 7:30 a.m. to 5:30 p.m. An OT note dated 02/01/16 indicated When the pt set on the RSC, pt stated, 'I can't sit on this my balls hurt. A PT note dated 02/01/16 at 4:24 p.m. indicated, Patient found sitting at the edge of the bed, unable to maintain his weight bearing status . patient unable to handle the pain secondary to swollen scrotum, transfer 2 person back to the bed . educated patient on the house doctor he has here and the rehab doctor we have here that can see him on Wednesday. There was no indication this resident was seen by a physician on Wednesday (02/03/16), nor any indication a more timely referral was made given the ongoing pain. 02/02/16 A nursing note on 02/02/16 at 12:06 a.m. indicated, Resident on alert for new med(ication) [MEDICATION NAME] . for increase [MEDICAL CONDITION] to BLE . There was no assessment of the effectiveness of this medication, or the extent of the resident's LE or scrotal [MEDICAL CONDITION]. A progress note dated 02/02/16 at 7:28 a.m. indicated the resident Complains of moderate to severe pain to BLE wounds and was medicated with [MEDICATION NAME] as ordered with fair results. Complained of breakthrough pain and requesting for pain medication after two hours. Resident sitting up in bed with legs dangling at the beginning of the night and tolerated well. Requests for assistance to return to bed when he is ready . assisted to turn and reposition in bed to position of comfort and elevate lower extremities to help alleviate his pain. While staff documented the resident received a new diuretic, there was no assessment as to it's effectiveness. While staff identified the resident had unrelieved breakthrough pain, there was no consideration to notify the physician for alternate approaches, nor did staff consider or administer the as needed [MEDICATION NAME] which was prescribed for [MEDICAL CONDITION]. An OT note dated 02/02/16 at 10:42 a.m. indicated Pt found seated (at) (Edge of Bed) c/o pain rated 10/10. Nurse notified. This note also indicated, Pt states he cannot (transfer) bed to w/c currently due to LB (lower body) pain caused by [MEDICAL CONDITION] and cannot follow . transfers . due to LB [MEDICAL CONDITION]. A PT note dated 02/02/16 at 12:48 p.m. indicated, Patient found sitting at the edge of the bed upon arrival, close to the very edge. Staff did not assess why the resident was sitting on the very edge of the bed or address this potential safety issue. The resident was observed on 02/02/16 at 10:45 a.m. to be sitting on the very edge of his bed, which he stated allowed his testicles to hang without pressure. The resident was noted at that time to demonstrate a pained facial expression, including clenched jaw and vocalization of pain to include moaning. In an interview on 02/02/16 at 10:51 a.m., Resident #230 indicated he had discomfort including pain and burning with no relief. The resident elaborated he had unrelieved pain in his scrotum, legs and feet. The resident indicated he had not received pain medication consistently the previous day as, they were out . The resident also stated, .it takes them an hour to get my pain medications. At 11:23 a.m. Resident #230 voiced complaints about testicular/scrotal swelling which interfered with his mobility. The resident elaborated he could not sit in his wheelchair. When asked if he participated in the facility's activity programs, the resident stated, I can't physically because of my swollen dingleberries (scrotum/testicles). The resident's statements correlated with the lack of [MEDICATION NAME] or Tylenol administration on 02/01/16. Pain flow records for 02/02/16 revealed the resident received the prn [MEDICATION NAME] every three to four hours from 12:05 a.m. through 9:30 p.m. On 02/02/16 at 11:30 p.m. nursing staff documented, Resident sitting at the side of the bed . Utilizing [MEDICATION NAME] 4 mg for pain to BLE with relief, continue on spirolactone for increase [MEDICAL CONDITION] to BLE . [MEDICATION NAME] powder applied to enlarged scrotum. In an interview on 02/04/16 at 12:58 p.m., Staff Y (Therapy Director) indicated that on 02/02/16, I went into (Resident #230's) room to open the window, he was sitting on the edge of the bed, he said he had to (sit on the edge of the bed) because his scrotum was swollen. While facility staff identified the resident consistently chose a position of comfort (sitting on edge of bed/wheelchair), they failed to consider this action exacerbated the resident's scrotal [MEDICAL CONDITION], which ultimately contributed to the resident's increased pain level. 02/03/16 A nursing note dated 02/03/16 at 3:56 a.m. revealed Treatment to scrotum continue . BLE [MEDICAL CONDITION] continue . Resident c/o pain, PRN pain medication administered as ordered with relief noted. There was no objective measurement regarding the resident's BLE or scrotal [MEDICAL CONDITION] to determine if the resident's condition was improving, deteriorating or remained the same. An OT note dated 02/03/16 indicated, Pt complaint of scrotum pain due to [MEDICAL CONDITION]. A Speech Therapy (ST) note dated 02/03/16 at 11:40 a.m. indicated the therapist addressed training use of external memory aide for recall of daily routine including pain, medication schedule. The ST documented, After explaining wait time requirement before the next med(ication) can be given he asked 'What if I need it sooner?' The documented ST plan was continue pain medication schedule to increase patient understanding of routine. There was no consideration by staff that the resident's pain regime was not meeting the resident's pain relief needs nor did they address the resident's concerns regarding needing more pain medication before it was due. Observation on 02/03/16 at 12:52 p.m. revealed the resident sitting in his wheelchair. A pillow was propped behind his back to allow him to position himself toward the front of the wheelchair. The resident complained of pain at a level 8. In an interview at that time the resident stated, My testicles still hurt like hell they've had better days. When asked why they were swollen the resident replied, Water retention one person said, hell I don't know, my legs are swollen too; my thighs and calfs, my dingleballs (scrotum/testicles). When asked if the swelling had gone down, the resident replied, not really, some doctor is supposed to see me today . Observation on 02/03/16 at 1:44 p.m. revealed the resident sitting at the edge of his bed, holding onto the grab bar with his left hand. In an interview at that time the resident was questioned regarding staff documentation that his pain was consistently in his lower extremities. The resident indicated when he complained of pain in his lower extremities, It's in my legs and testicles, testicles are my lower extremity! A progress note dated 02/03/16 at 4:33 p.m. indicated, LN has given [MEDICATION NAME] (every) three hours for pain medicated with some relief . Current wt this day shift 268.8 (pounds), scrotum area enlarged swollen . LN educated resident to elevate BLE up as much as possible during the day . A progress note on 02/04/16 indicated, treatment continued to enlarged scrotum. BLE [MEDICAL CONDITION] continue . Resident c/o pain, PRN pain medication administered with relief . Review of Pain flow sheet documents for 02/03/16 revealed the resident received the as needed [MEDICATION NAME] every three to four hours (12:30 a.m., 3:30 a.m., 6:50 a.m., 9:50 a.m., 12:50 p.m., 4:40 p.m., 8:40 p.m., 11:40 p.m.). There was no indication staff considered the [MEDICATION NAME] was not meeting his pain needs, interfered with his sleep, and that the resident continued to experience pain levels of 8 and requested pain medication prior to the every three hour limit. 02/04/16 Review of Pain flow records revealed the resident received PRN [MEDICATION NAME] on 02/04/16 at 2:40 a.m., 5:40 a.m., and 8:40 a.m. There was no indication facility staff considered the resident's pain was impacting his ability to sleep or perform his ADLs or that the physician should be notified regarding the resident's unmet pain needs. Observation on 02/04/16 at 9:22 a.m. revealed staff assisting the resident with positioning in the wheelchair, placing a pillow behind his back which allowed him to be positioned forward in the wheelchair. The resident was noted to say oww oww, that hurts . The resident hollered, Oh man! This sucks! The staff who assisted him stated, Yea, I know to which the resident replied, Not like I do . Observation on 02/04/16 at 9:51 a.m. revealed Resident #230 sitting on the front edge of his wheelchair, a pillow positioned behind him. At that time the resident moved his gown which revealed the resident's scrotum appeared to be the size of a small melon and hung approximately seven inches below the seat of the wheelchair. There were approximately six quarter to half dollar size drops of sero-sanguinous drainage noted on the floor beneath the wheelchair. Closer inspection revealed a slow but continuous serous drainage dripping on the floor from the scrotum. Serous weeping is a condition when the volume of interstitial fluid in an area exceeds it's capacity to retain it. At 9:55 a.m., Staff G (Resident Care Manager) was requested to perform an assessment of Resident #230. At 10:00 a.m., when asked by Staff G if a skin assessment would be acceptable, the resident replied, I don't give a (explicative) just make me feel better! My dingleberries (testicles) are killing me. At that time the resident made frequent complaints of pain regarding his scrotum, flinching and calling out when staff lightly touched the resident's scrotum. At 02/04/16 at 10:04 a.m., after a cursory inspection, Staff G stated, The penis and scrotum is grossly [MEDICAL CONDITION], there is maceration (moisture), tender to touch reddened, and serous drainage on the bottom (of the scrotum). Staff G then stated, What we need to start doing is to prop up the scrotum, it is dependent, the scrotum hanging well below the thigh level, the penis is so swollen the head is retracted. At 10:09 a.m. three new drops of straw colored fluid were noted on the floor under the resident. The RCM also noted this weeping and confirmed it was coming from the resident's scrotum which was markedly [MEDICAL CONDITION] and taught in appearance. With movement, at 10:17 a.m., the resident called out Owey, Owey!! Shoot me or give me [MEDICATION NAME]! Staff G stated he would try to get something long acting. At 10:18 a.m. Resident #230 stated, I've been in drastic pain for a week from my feet to my balls, I only care about one thing, pain. When asked, on a scale of 1-10 what his pain was, the resident replied, 10 plus. On 02/04/16 at 10:19 a.m. Staff G, with assistance from a CNA (Certified Nursing Assistant) repositioned the resident. Staff G directed the CNA to, Let (Staff O) know he is having pain . At 10:25 a.m. as the resident was transferred to bed, he stated I can't sit down my balls are in the way, you lift my legs. The resident then cried out, Ah man they're (testicles) killin' me! During the transfer the resident asked again about receiving pain medication but Staff O, who had just entered the room stated, Not until 11:40 a.m., he got it at 8:40 a.m. The resident stated, Goddamn they are sore, just another hour to go (for pain medication). During the skin assessment performed by Staff G, at 11:02 a.m., Resident #230 was noted to cry quietly, wiping away tears with his right hand. Additionally, during the skin assessment, Staff O was noted to hold the resident's right leg which allowed Staff G to perform the scrotal assessment. Staff O's fingers made indentations in the [MEDICAL CONDITION] in the upper thigh proximal to the groin, which remained three minutes after her fingers were removed. Staff G's documented skin assessment included, Rsd skin assessment completed by this RCM at the request of State Surveyor. Rsd found sitting up in w/c awake and alert and in no apparent distress . Staff G noted multiple skin issues and documented, Scrotum noted to be grossly [MEDICAL CONDITION] with moderate amount of serosanguienous drainage. Multiple open areas secondary to gross [MEDICAL CONDITION] noted on scrotum. Left anterior open area noted. Wound red, moist and superficial. Rt anterior wound measures 8.1 x 4.4 cm (centimeters) wound irregularly shaped and denuded of top lay of skin. Rt lateral posterior wound measures 1.5 x 0.2 cm. Wound bed red, moist and superficial. Multiple fluid filled blisters noted on scrotum. Posterior testicle noted to be bulbous and translucent to light. Res also noted to have 3+ [MEDICAL CONDITION] to bilateral lower extremities from toes to thighs. Rsd educated on importance of elevating his scrotum on a rolled wash cloth or pillow case and also elevating his legs while in bed and limiting amount of time spent sitting at the edge of his bed or being up in the wc to alleviate the [MEDICAL CONDITION] to both is scrotum and BLE. Rsd verbalized understanding and was noted to be receptive to this writers recommendations. In an interview after the skin assessment, Staff G said he knew there was scrotal swelling and [MEDICAL CONDITION] but not as extensive as what it was. Staff G stated, We will put it (the scrotum) up on towels if they are dependent they will remain swollen, if we elevate them it will reduce the swelling; [MEDICAL CONDITION] in legs, serous blister. Staff G then stated to Resident #230, We need to limit the amount of time you have your legs hanging off the bed. At no time did staff identify the significance of the resident's [MEDICAL CONDITION], how his positioning contributed to and worsened the scrotal [MEDICAL CONDITION] and pain, nor at any time did staff identify the need for interventions despite previous identification of blistering to the scrotum. Only after the RCM's assessment were POs obtained for [MEDICATION NAME] extended release twice a day to treat the resident's pain; the as needed [MEDICATION NAME] was changed to every four hours; staff were directed to elevate the resident's testicles; and an air bed was implemented. In an interview on 02/04/16 at 12:28 p.m. Staff G stated, Staff should have notified me of the magnitude of the situation. Staff G indicated he was not aware of the extent of the resident's scrotal swelling, pain and [MEDICAL CONDITION]. When asked if the resident looked like he was in pain, Staff G replied, Oh, definitely he's in pain . In an interview on 02/04/16 at 11:37 a.m. Staff B indicated staff should have identified, reported and acted on the grossly [MEDICAL CONDITION] scrotum with serous weeping and 3+ [MEDICAL CONDITION] to the groin. When asked what interventions were identified for the resident's scrotal [MEDICAL CONDITION], Staff B stated, We were having him elevate his legs. When asked how this helped the scrotum Staff B stated, It doesn't. When advised the resident was observed on multiple occasions from 02/02/16 through 02/04/16 sitting on the edge of his bed or wheelchair without benefit of leg elevation, Staff B stated, I saw that when I went into his room. When asked if staff should have care planned the immediate issues with interventions regarding BLE and scrotal [MEDICAL CONDITION], skin issues, contact precautions, Staff B answered yes. Failure to assess, monitor and implement interventions to treat a condition which caused the resident pain, limited his ability to perform activities of daily living, and prevented him from participating in therapy and leisure activities. This caused the resident not only physical pain, but also effected his quality of life and ability to improve his physical condition. RESIDENT #227 In an interview on 02/02/16 at 1:23 p.m. Resident #227 said yesterday I had a bad headache . I still have a headache . I get a headache when I don't get sleep, it's been two days. When asked what she used at home to treat the headache, Resident #227 replied [MEDICATION NAME] or Advil. On 02/02/16 at 1:30 p.m. Resident #227 put the call light on and told the responding nurse, Staff OO that she had had a headache since the day prior. Staff OO informed Resident #227 that she had an order for [REDACTED]. The resident asked, Why can't you get me [MEDICATION NAME]? and Staff OO, replied, I'll call and ask him. On 02/02/15 at 4:45 p.m. staff documented a progress note that Alert coherent and presents with bilateral LE (lower extremity) fracture, both in a cast, CMS check in good. PRN (as needed) pain med. given, at which time, Resident reports that she did not sleep all night, and that there has been so many people going and coming in to her room that It is giving me a headache, then went on to request that she does not want anyone coming in to her room so she can get some rest because I can not handle stress. I informed other staff to let her rest and not enter her room for a while per her request. She later spoke to a state survivor and during which this writer was called in because Resident is c/o HA (headache), with loud yelling voice states she has been asking for pain meds for long time and that she wanted something besides her [MEDICATION NAME]. Resident informed that her doctor will be notified, and a request for Excederin will be passed on to the doctor as she has multiple drug allergies [REDACTED]. Resident appears to have multiple complaints about her care, and she voiced it to multiple departmental heads. Will continue to meet demands as per her request . In an interview on 02/04/16 at 12:50 p.m. Resident #227 said I know you aren't supposed to bring meds in, but I called my friend and she brought in pain med and gave it to me and it helped. I took it yesterday. I don't know the name of it, I just took one. I told the nurse I wasn't getting anything here and I needed something for my headache. Review of the resident's record on 02/05/16 revealed no follow up notes or physician orders [REDACTED]. In an interview on 02/08/16 at 3:34 p.m. Staff C said the physician was notified of the resident's headache on 02/06/15 and was suppose to come in and see the resident. On 02/06/16 the resident received [MEDICATION NAME] for a headache with some relief. Additionally on 02/06/16 the resident indicated the [MEDICATION NAME] was effective for headache and she did not want any further changes to her pain medication. Staff C said Staff B would investigate further and provide additional information. On 02/09/16 at 9:12 a.m. Staff B said that Staff N called and got an order for [REDACTED]. NON PRESSURE SKIN ISSUES RESIDENT #228 Resident #228 admitted to the facility on [DATE] with care needs related to hypertension, falls and infection. Observation on 02/02/16 at 10:09 a.m. revealed the resident had dressings to her right upper calf, right lower calf and left lateral foot. The resident's lower extremities appeared to be [MEDICAL CONDITION]. Review of treatment records revealed instructions to staff: Left outer foot right knee open wound, cleanse with Normal Saline and apply [MEDICATION NAME] to periwound, cover with allyven change every other day and Right calf wound ulcer cleanse with saline, apply calcium alginate at periwound cover with abdominal pad, wrap with kerlix secure with paper tape change daily. Review of the facility notebook for skin and [MEDICAL CONDITION] revealed an [MEDICAL CONDITION] measurement sheet with Resident # 228's name, but this form was blank. The weekly skin integrity data collection sheets were done weekly but only mentioned open wound with no description of what type of wound (vascular, traumatic) or size. In an interview on 02/08/16 at 12:19 p.m., Staff O stated, They should be doing the [MEDICAL CONDITION] checks when they do the weekly skin assessments. Staff O indicated there should be some type of assessment regarding the progression of the identified wounds to ensure they were getting better. Staff O reviewed the progress notes and found no objective measurable assessment of the resident's non pressure wounds after admission. Some progress notes indicated minimal drainage no odor but no further measurements of the wounds to objectively assess improvement/decline. In an interview on 02/08/16 at 8:00 a.m., Staff P stated, If it's an open wound it still needs to be followed, some are surgical but they still need to be measured to verify improvement or decline. In an interview on 02/05/16 at 2:10 p.m. Staff B indicated the nurses on the floor completed the non pressure skin condition records and [MEDICAL CONDITION] assessments during the weekly head to toe skin assessments. RESIDENT #231 Resident #231 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to the admission assessment, Resident #231 was identified with a blister to the right forearm. According to weekly skin integrity data collection sheets, staff performed assessments on 01/23/16 and 01/30/16 and identified multiple open areas but didn't describe the size or appearance of these wounds. According to February 2016 TARS, for an open blister identified to the right mid forearm staff were to cleanse with saline, pat to dry and cover with dry dressing daily. Staff circled their initials on 02/01/16 and 02/02/16 and documented, healed, dry. Observation on 02/04/16 at 9:05 a.m. revealed the resident had a round circular area with a dry lifting scab on the right medial arm proximal to anticubital which Staff N measured as being 2.6 cm x 3.0 cm. The resident was also noted to have a previously unidentified issue to the left third toe which was described by Staff N as, A purple 0.5 cm x 0.5 cm round blood blister. Staff N was unable to explain why the treatment was discontinued when the wound was not resolved and was unaware of the blister identified on the resident's toe. Failure to complete objective assessments which track and trend current skin issues and identify new skin issues, detracted from staff's ability to ensure wound healing. RESIDENT #43 On 02/01/16 at 11:15 a.m. Resident #43 was observed with a left forearm scab which appeared to be a healing skin tear. The skin impairment was located under a metal bracelet. In addition, the resident had multiple bruising on the right hand and left forearm and wrist. Similar observations were noted on 02/04/16 at 10:32 a.m. at 02/05/16 at 10:14 a.m., Review of the incident log revealed no incident reports or investigations regarding the resident sustaining bruises or skin tears in the previous six months. Review of progress notes revealed the last nursing note was dated 12/09/15 and provided no information regarding the observed skin impairments. A 03/02/15 physician order [REDACTED]. Review of the weekly skin check list revealed the resident's skin check was scheduled for Wednesdays on day shift. Review of the Weekly Skin Integrity Data Collection sheets revealed the last three documented skin assessment were conducted on 12/09/15, 01/27/16 and 02/03/16. The facility failed to conduct weekly skin as ordered. In addition, the 01/27/16 and the 02/03/16 skin assessments indicated the resident refused skin (assessment) x 3. Staff failed to note the observed skin tear/scab or bruising to the resident's upper extremities. In an interview on 02/08/16 at 8:51 a.m. Staff F reviewed the documentation indicating the resident had been refusing skin checks and said the nurse should have had the aid tell the nurse when they were going into change the resident. Specifically regarding the left arm skin tear, Staff F said That should have been noted. RESTORATIVE RESIDENT #16 Resident #16 readmitted to the facility in 08/12. According to the most recent MDS dated [DATE], she had multiple [DIAGNOSES REDACTED]. She was assessed to require extensive assistance with most of her ADLs (Activities of Daily Living), to include dressing, and required total dependenc

Based on observation, interview and record review the facility failed to prevent pressure sores from developing for Resident #s 204, 88, 6 and 151, four of five sample residents reviewed for pressure sores. Failure to consistently implement care and services which residents were identified to require caused pressure ulcers to develop for Resident #204. Failure to clearly identify wound location and act on identification of wounds delayed the monitoring, treatment and/or healing of, and increased the risk for reccurance of pressure ulcers for Resident #s 88, 6, and 151. Additionally, the facility failed to accurately assess risk factors, identify specific preventative measures and monitor/evaluate the effectiveness of interventions. Findings include, but are not limited to: RESIDENT #204 Resident #204 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to this MDS, the resident was admitted without a Pressure Ulcer (PU) and required staff assistance to move sufficiently to relieve pressure over any one site. Record review on 11/10/11 revealed no evidence facility staff were aware of or treating any PUs. The resident's daily care delivery guide identified the resident had "skin risks" and directed staff to "turn, reposition every two hours." Observation on 11/10/11 at 10:30 a.m., 11:58 a.m. and 12:58 p.m. revealed the resident was lying in bed on her back. Similar observations were made at 1:20 p.m. and 2:05 p.m. Observations on 11/14/11 at 6:45 a.m., 7:50 a.m., 8:35 a.m. and 10:15 a.m. revealed the resident lying in bed on her back. Similar observations were made at 1:25 p.m. and 2:46 p.m. Observation on 11/15/11 at 8:48 a.m. revealed the resident lying on her back in bed. Similar observations were made at 9:35 a.m, 9:55 a.m., 11:10 a.m. and 11:37 a.m. Observations at 1:30 p.m. and 2:15 p.m. revealed the resident lying in bed, with a pillow beneath the left hip which promoted a slight position change to the resident's right side. Per surveyor request, a skin assessment was performed with Staff G on 11/15/11 at 2:17 p.m. at which time blood smears were observed on the resident's brief and two pressure ulcers were identified. According to Staff G, the wounds were, "two open areas...with beefy red wound base...on either buttocks...Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed)." Staff G described the resident at that time as "very immobile...". Observation on 11/16/11 at 7:45 a.m. revealed the resident on her back in bed. An air overlay mattress was noted on the bed. Similar observations were made at 8:05 a.m., 9:08 a.m., and 9:44 a.m. The resident was observed on her right side at 10:30 a.m. and 11:12 a.m. At 12:30 p.m. and 1:45 p.m. the resident was observed on her back. Observation on 11/17/11 at 8:20 a.m. revealed the resident lying in bed on her back. Similar observations were made at 8:56 a.m. and 9:30 a.m. At 10:11 a.m., the resident was observed positioned slightly on her right side. Similar observations were made at 10:48 a.m. and 11:35 a.m. At 12:09 p.m. and 1:00 p.m. the resident was asleep in bed, lying on her back. Similar observations were made at 1:55 p.m., 2:22 p.m. and 2:51 p.m. Observation on 11/18/11 at 8:12 a.m. revealed the resident in bed lying on her back. A skin assessment was performed by Staff G at 8:47 a.m. Staff G measured the identified buttock wounds as 1.5 x 0.8 centimeters (cms) on the right and 1.0 x 0.4 cm on the left. Staff G removed her gloves and prepared to place treatments on the wounds when her attention was called to an additional PU on the resident's right buttock identified by survey staff. According to Staff G, this PU was "0.6 x 1.0 cm proximal to the ischium." Failure to consistently reposition the resident to provide pressure relief resulted in the development of pressure ulcers for Resident #204. RESIDENT #88 According to the 10/10/11 MDS, Resident #88 had [DIAGNOSES REDACTED]. This MDS also identified the resident required a wheelchair for mobility and extensive assistance from staff for all ADLs, excluding eating. The 10/10/11 MDS and the Braden scale, dated 10/06/11, identified the resident was not at risk to develop PUs. Observation on 11/10/11 at 11:34 a.m. revealed Resident #88 in her wheelchair. Her feet were bare, resting on foot pedals. Her left heel was wrapped in a gauze dressing. Both feet were extremely dry with flaking skin. The resident stated she had "sores" on her heels and they sometimes hurt from touching the foot rests. A Podiatrist consult, dated 10/05/11, identified the resident had "compromised skin integrity" and bilateral "plantar heels with open areas at least 3 cm (centimeters) diameter...". The podiatrist identified "...heel areas showing excessive pressure from extended foot rest" and wrote an order for [REDACTED]." His treatment included the "debridement of loose skin." Weekly Skin Integrity Data Collection (WSIDC) forms, dated 10/08 and 10/15/11 did not identify the open areas the podiatrist had noted. The 10/22/11 WSIDC identified the "sole of foot peeling off" both feet, however there was no evidence the physician was notified or a treatment was obtained. There was no evidence interventions were implemented for the wounds identified by the podiatrist, or that they were monitored from 10/05/11 through 10/27/11. According to the PU Status Record, on 10/27/11 a Stage II PU was identified to the bottom of the resident's left foot. It measured 1.3cm x 2.4cm. A physician's orders [REDACTED]. The 10/29/11 WSIDC identified on the diagram of the body a "macerated sole of foot" on the right foot. The WSIDC, dated 11/05/11, also identified the "open area" to the right foot. Staff G, on 11/16/11 at 1:40 p.m., stated staff had incorrectly indicated the wound was to the right foot, when it was actually to the left foot. In an interview on 11/16/11 at 1:45 p.m., Staff G stated she was unaware of the podiatrist's note, dated 10/05/11, which identified open areas to both feet. She stated she had not reviewed the consult, and staff had not identified the open areas. She also stated she had not been aware of the PO to change the foot rests, and therefore was unaware of the pressure issues which placed the resident at risk for the open areas. When asked to explain how the podiatrist identified two pressure ulcers on 10/05/11, but facility staff failed to identify or address the PUs until 10/27/11, Staff G stated "I can't reconcile it, I don't know." Staff G also stated Resident #88 had been assessed as not at risk to develop pressure ulcers and therefore individualized interventions to prevent PUs had not been implemented. She indicated she "was surprised" the resident had developed PUs. In an interview with Staff B on 11/17/11 at 2:40 p.m., she stated she believed the podiatrist utilized "different terminology than nurses do. So, he'll call it a pressure ulcer, but maybe it's just dry, calloused skin." She was unable to explain the discrepancy between the podiatrist and facility observations. In an additional interview on 11/18/11 at 7:45 a.m., the DNS stated the nurse on duty the evening the podiatrist visited "failed to note the [MEDICATION NAME] order" and so did not review the note. When it was pointed out the [MEDICATION NAME] was not a PO, but rather an explanation of the treatment the podiatrist provided after he debrided the open areas, she stated, "There isn't a system to have people review the podiatry notes, they just get put on the chart. So, we missed it." RESIDENT #6 Resident #6 was admitted to the facility in 4/11 with [DIAGNOSES REDACTED]. This MDS also identified the resident had no PUs, however was at risk to develop PUs and required a turning/repositioning program. Observation of Resident #6 on 11/09/11 at 8:50 a.m. revealed her in bed eating breakfast. She stated she preferred to get out of bed for breakfast, but staff had been unable to get her up that morning. Additional observations on 11/10/11 at 1:15 p.m. revealed the resident in her room, sitting in her wheelchair. She stated she had a "pressure area" on her "bottom", and staff told her it was from sitting up for so long. She stated she attended [MEDICAL TREATMENT] three times a week and she had no choice but to sit while at her appointments. A nursing progress note, dated 8/27/11, revealed an open area was identified to the resident's coccyx. A PO was obtained for treatment, and the resident was "Referred to skin team to follow." The first Pressure Ulcer Status Record from the skin team was dated 9/07/11, ten days after the PU was identified. A care plan, reviewed quarterly, identified the "Potential for skin breakdown". Approaches to meet the goal of "Maintain intact skin integrity" included, "Do weekly skin assessments". A Weekly Skin Integrity Data Collection, dated 8/13/11, revealed the resident's skin was intact. The next WSIDC, dated 8/27/11, revealed the "New open area on right side buttock near coccyx". The next WSIDC was dated 9/17/11. The following entry on the WSIDC was undated and unsigned, and identified the open area as on the left buttocks. The 10/08/11 WSIDC also identified the open area to the left "buttock/thigh" and indicated on the body diagram the left side. The 10/15/11 WSIDC also identified on the body diagram the left lower buttocks as the site of the open area. Weekly Pressure Ulcer Status Records identified the PU to the right buttocks remained unchanged from 9/07/11 through 10/11/11. The 10/18/11 entry was signed and identified the wound as a stage II, however the size and characteristics of the wound were not completed. In an interview on 11/15/11 at 1:35 p.m., Staff G explained staff were to continue weekly skin checks, in addition to the skin team's weekly assessment of an identified wound. She explained the wound team met every Tuesday, and she expected a resident with a newly identified PU to be seen on the first Tuesday after the PU was identified. She was unable to explain the ten day delay between the identification of the PU and the first assessment by the wound team. When asked why some of the WSIDC forms identified the PU to the left buttock and some to the right, Staff G stated it was "an error". She stated the PU was always to the right buttock. She acknowledged the forms "need to be consistent" in order to ensure the resident was assessed accurately. She also stated Resident #6 occasionally refused skin checks, and she believed that was the case on the weeks a skin check was not documented. She verified there was no evidence the resident refused a skin check. Failure to ensure accurate assessments and monitoring of the resident's skin condition and PU placed her at risk to develop additional PUs, or to not receive the services required to treat the current PU. RESIDENT #151 Resident #151's closed record was reviewed and revealed an admission date of [DATE] from a hospital with [DIAGNOSES REDACTED]. The admission Progress Note, dated 8/31/11 at 12:00 p.m., noted Resident #151 required one person extensive assistance with ADLs and mobility and had multiple skin issues including, "thick callused skin to back of (R) (right) heel. Area is tender. Also noted blister intact to back of (R) LE (Lower Extremity)..." However, review of the 8/31/11 Nursing Admission Skin Assessment diagram revealed these wounds were on the left heel and LE, not the right as noted in the progress note. There was no evidence in the record staff identified or reconciled this descrepancy. A 9/01/11 Physical Therapy Evaluation identified the resident had a "pressure sore on left heel, pressure ulcer (Stage II) on right heel." A 9/08/11 Nutrition Assessment noted the resident to have skin impairments including a "left calf blister", which was contrary to the 9/11 Treatment Administration Record (TAR), which identified the blister to the right. Continued discrepant documentation regarding wound location detracted from staff's ability to monitor and track wound healing. The September TAR listed instructions to staff to apply Allevyn to the back of the "right" leg calf open area, and to change it every three days. The WSIDC, dated 9/04/11, indicated the "right" calf was healed. The facility was unable to provide evidence staff conducted assessments to the calf blister after 9/04/11 despite documentation that dressing changes occured through 9/13/11. The facility failed to assess the wound, including type and size. When the blister opened, the facility failed to assess the open area and failed to document ongoing monitoring of the ulcer until healed. Weekly Skin Integrity Data Collection sheets dated 9/04/11 and 9/18/11 noted "Callus right heel" with no further description. The WSIDC dated 10/02/11 noted "[MEDICATION NAME] R(ight) outer foot and heel, calluses." According to POs and TARs, the facility was applying [MEDICATION NAME] to the resident's right outer foot and right heel daily beginning 9/30/11. A 10/03/11 Podiatry visit document included an assessment of compromised skin integrity, a "1.5 cm closed intact blister... formation" on the right foot (lateral styloid process). The physician documented the "(R) foot needs padding/protection. Plan:...PT to wear moon boots or equivalent on feet especially (R) foot to protect affected area (R) foot." Facility staff initialed and dated the Podiatry visit as noted and reviewed on 10/06/11 but failed to assess the right foot wound described by the Podiatrist. Failure to objectively describe the location and size of this wound prevented facility staff from tracking it's progress or differentiating it from any other right foot wound. According to facility documents dated 10/03/11, "Pressure Ulcer site: Rsd admitted with lg dry calloused area on back of (R) Heel. Area has now softened. Measures 1.8 x 1.5 cm. no s/sx pain. Applying [MEDICATION NAME] BID - skin team will follow weekly until resolved. Spouse will bring in soft slippers. " Neither the initial "At Risk for Break in Skin Integrity" CP, dated 8/31/11, or the Comprehensive CP, dated 9/16/11, identified the actual skin impairments previously identified by the facility. The CP was updated on 10/03/11 to include "Calloused area Right heel with open area", and the approach of "Refer to skin team PRN, Treatment per order, Soft slippers and avoid use of shoes for now." This CP was not updated to include the Podiatrist identified right foot wound. The 10/05/11 Weekly Care Management Review (WCMR) revealed "Resident with new open area to right foot noted on 10/03/11. Area was admitted with thick callous like area. New orders for tx received." A 10/09/11 WSIDC listed, but did not assess, skin impairment to the resident's right foot heel, and right side foot. According to documents dated 10/11/11, the "...dark calloused area" was healed. Staff were to "encourage to wear heel protectors when in bed." A 10/11/11 Non Pressure Skin Condition Record revealed the callous with the open area on the back of the right heel was first observed on 10/03/11, and was "healed at this time". Neither document included an assessment of the pressure area to the resident's right outer foot. The 10/16/11 WSIDC noted "Area to R(ight) outer foot and heel with tx (treatment) unchanged." The week of 10/19/11 WCMR noted, "Open area (R) foot now healed." The facility discharged Resident #151 to an Adult Family Home (AFH) on 10/26/11. Facility discharge documents indicated the resident did not have any skin impairment, however according to the AFH admission assessment the resident was admitted with callousses on both heels and an unstageable pressure ulcer to the right outer foot, which measured 2 x 1 centimeters. .

Based on observation, interview, and record review the facility failed to provide necessary care and treatment to prevent a contracture for one of three sampled residents of four residents (Resident #129) who were observed with a contracture. This failure contributed to Resident #129's decreased mobility, limited range of motion and pain. Findings include: Resident #129 was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. program. In an interview on 11/15/11 at 10:00 a.m., Staff C stated she assessed the resident's hands and noted no limitation in July, 2011. Review of the resident's overflow record revealed a Medical Specialty visit dated prior to admission on 5/18/10. This note indicated Resident #129's extremities had no visible deformities, no cyanosis, clubbing or [MEDICAL CONDITION], and musculoskeletal "normal range of motion without obvious weakness." Resident #129's care plan, dated 8/02/10, and reviewed by the facility at least quarterly did not address the prevention of or development of contractures (is a permanent shortening of a muscle or joint resulting in a loss of range of motion). On 11/10/11 at 9:24 a.m., Resident #129 was observed with a potential contracture of a finger of her right hand with crusty, peeling skin on both palms. The resident indicated she ate and smoked with her right hand. On 11/14/11 at 1:46 p.m., Staff D was observed to ask the Resident to open her right hand. The resident, unable to fully extend the fingers of her right hand stated, "They're open as far as they can go." Staff D attempted to open the resident's right hand, and the resident said "Ow" and verified she experienced pain when she pushed. Staff D was unable to fully open the resident's right third finger or pinky. The inside of the resident's hand was observed to be dry and scaly. In an interview on 11/14/11 at 1:44 p.m., the Restorative Supervisor, Staff D, said Resident #129 was not on a restorative program but Staff D did quarterly summaries on all residents in conjuction with each MDS. Restorative notes dated 8/09/10 and quarterly thereafter did not address identification or prevention of development of contractures. A Rehabilitation Services Multidisciplinary Screening Tool, dated 11/15/11, indicated the resident was referred by the Restorative Supervisor for screening of her right hand, digits three and five, ROM. The Functional Screen revealed the resident demonstrated "...decreased ROM 3rd digit with tendon tightness and decreased ROM 5th digit with hard end feel. Patient is functional with R (right) hand for self care. No splinting indicated at this time due to hard end feel, but continue to monitor for changes." Once identified, the facility failed to ensure the resident received treatment and services to increase the ROM and/or to prevent further decrease. In an interview on 11/17/11 at 12:00 p.m., Staff E, the Occupational Therapist who completed the screening, indicated "splinting would not be beneficial and would not increase range (in pinky )", and "as for middle finger want to keep an eye on it" and would reassess "in a month or so." Staff E stated she had only screened the resident for splinting. ROM exercises or a plan to prevent further contractures had not been considered. Evidence that the contracture and decreased ROM were unavoidable was requested from the facility, however none was provided. Failure to provide services to ensure the resident did not develop a contracture and experience a reduction in ROM caused pain and limited range of motion. It also placed her at continued risk for decline. .