Every finding on record at Hudson Bay Health and Rehabilitation

Based on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD); and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 2 of 7 sampled residents (Resident 10 & 6) reviewed for ADs. This failure place residents at potential risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included. Review of the facility's policy titled, Advance Directives and Advance Care Planning, dated 08/28/2025, indicated Residents have the right to self-determination regarding their medical care which includes the right to execute or refuse to execute advance directive(s) Further, the facility will inform, and provide written information (if applicable), to Residents or Resident Representative regarding the Resident's right to formulate, execute, and/or refuse either of an advance directive. 10. Each time the Resident is admitted to the facility, quarterly, and when a change in condition is noted in the Resident condition, the facility should review the advance directive and advance care planning [ACP] information. a. This review should focus on whether the existing advance directives and ACP match the current goals of care for the Resident. The social services director or designee should document this conversation in the medical records and assist as needed with updating the documents that need revision in accordance with state and federal requirements. Resident 10 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS, an assessment tool), dated 01/18/2026, indicated Resident 10 was alert and oriented. Review of the electronic health record (EHR) profile section documented Resident 10's son was the Power of Attorney (POA); however, no POA paperwork was available for review in the EHR. Record review of Resident 10's Multidisciplinary Care Conference, dated 01/27/2025, showed Resident 10 did not have an advance directive. During an interview on 03/18/2026 at 8:38 AM, Staff C, Social Services Manager, said the facility was behind on advance directives. Staff C said the Multidisciplinary Care Conference, dated 01/27/2025, addressing advance directives was the only information she was able to find for Resident 10. Staff C said Resident 10's advance directives should have been reviewed quarterly. During an interview on 03/18/2026 at 3:17 PM, Staff B, Director of Nursing/Registered Nurse, said advance directives should be reviewed at the care conference in case there were any changes. Resident 6 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 6 was alert and oriented. Review of Resident 6's EHR indicated Resident 6 had declined to formulate an Advance Directive on admission and did not have an AD on file. Record review of Resident 6's Comprehensive Care Conferences, dated 09/22/2025 and 06/18/2025, did not indicate Resident 6's ADs were addressed, and/or Resident 6 was offered a chance to formulate them. Review of Resident 6's Quarterly Clinical Evaluations, dated 03/17/2026, 12/16/2025, and 09/16/2025 did not indicate the facility addressed his advance directives. During an interview on 03/19/2026 at 10:44 AM, Staff J, Social Services Assistant, said advanced directives were typically addressed during care conferences. Staff J stated, The resident refuses care conferences. He says nothing has changed and refuses. Staff J said, after resident refused care conferences, she would ask the resident whether he would like to formulate an advanced directive. Staff J was unable to provide documentation of offering to readdress advance directives, and stated, it's more of a verbal. I can't force them to sign it. During an interview on 03/19/2026 at 12:13 PM, Staff B, Director of Nursing Services said the facility had identified an issue with Advance Directives as part of their QA (Quality Assurance) process, and going forward, the facility will apply a new system to addressing the issues. Refer to F 553 Reference WAC: 388-97-0280(3)(c)(i)

Based on interview and record review, the facility failed to refer 2 of 7 residents (Resident 7 & 13) to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR, an in-depth, person-centered evaluation for individuals with serious mental disorders and individuals with intellectual disability). This failure placed residents at risk of not receiving specialized services and a diminished quality of life. Findings included .Review of facility policy, revised 08/29/2025, titled Pre-admission Screening & Resident Review (PASRR) Process, documented, A positive level I PASARR screen necessitates an in-dept evaluation of the individual by the state-designated authority, known as a PASARR level two (II), which is to be conducted prior to admission unless otherwise authorized by such agency .Resident 7 was admitted to the facility on [DATE] with multiple diagnosis to include bipolar disorder (a mental health condition that causes extreme mood swings) and major depressive disorders (mood disorder characterized by persistently low moods). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 01/14/2026, showed Resident 7 was moderately cognitively impaired. Record review of Resident 7's PASARR, dated 05/21/2024, documented Resident 7 did not have a serious mental illness (SMI) indicator and documented that no Level II evaluation was indicated.Record review of Resident 7's PASARR, dated 11/19/2024, documented Resident 7 had a SMI, anxiety disorder, and a Level II evaluation referral was required. Review of Resident 7's electronic health record (EHR) did not show a Level II evaluation. Record review of Resident 7's PASARR, dated 12/16/2024, documented Resident 7 did not have a SMI indicator and documented that no Level II evaluation was indicated. Resident 13 was admitted to the facility on [DATE] with multiple diagnosis to include bipolar & anxiety disorder (mood disorder characterized by feelings of fear, dread, and uneasiness). The Quarterly MDS, dated [DATE], showed Resident 13 was cognitively intact. Record review of Resident 13's PASARR, dated 07/19/2023, documented Resident 13 did not have a SMI indicator and documented that no Level II evaluation was indicated.Record review of Resident 13's PASARR, dated 11/21/2023, documented Resident 13 had a SMI, bipolar disorder, and a Level II evaluation referral was required. Review of Resident 13's EHR did not show a Level II evaluation.Record review of Resident 13's PASARR ,dated 07/12/2025, documented Resident 13 had a SMI, mood disorder, and documented that no Level II evaluation was indicated.In an interview on 03/18/2026 at 2:49 PM, Staff C, Social Services Director, reviewed Resident 7's and Resident 13's PASRR evaluations and said all the evaluations were not completed correctly and Resident 7 & Resident 13 needed to have a Level II PASARR evaluation completed. Reference WAC 388-97-1915(2)

Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 residents (Resident 10) reviewed for care conferences. This failure placed residents at risk of a diminished quality of life when not allowed to be involved and/or have a say in their long-term care needs.Findings included. Review of the facility's policy titled, Comprehensive Care Plans & Conference, dated 09/03/2025, indicated .4. The interdisciplinary team (IDT) responsible for developing and reviewing the care plan will include, at minimum: a. The resident's attending physician b. A registered nurse assigned to the resident c. A nurse aide familiar with the resident's cared. A member of the food and nutrition services staff e. The resident and, when appropriate, their representative .6. The facility will actively support resident engagement in the care planning process by:a. Explaining the assessment and planning process in understandable termsb. Scheduling meetings at times when the resident is most alert and able to participatec. Allowing adequate time for discussion and decision-makingd. Encouraging the resident representative to attend and contribute to care planning meetings.8. Participation may take various forms, including in-person attendance, phone calls, or video conferencing, depending on the residents' and representative's availability and preferences. Resident 10 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS, an assessment tool), dated 01/18/2026, indicated Resident 10 was alert and oriented. Record review of Resident 10's last Multidisciplinary Care Conference, dated 01/27/2025, showed Resident 10 attended with two family members. There were no care conferences for Resident 10 over the past 14 months.Record review of Resident 10's progress notes, dated 08/08/2026, documented RSA [Resident Support Services Assistant] called and spoke w/ [with] resident's son/POA [Power of Attorney] r/t [related to] CC [care conference] scheduling. Son states he will be out of town for work and unavailable for CC. Son asked RSA to call back when the next quarterly is do [sp] as he should be in town then. Record review of Resident 10's progress note, dated 01/19/2026, documented RSA called and spoke w/ resident's son/POA r/t Quarterly CC scheduling. POA stated he was in Montana for work until next month, then shortly after will be returning to Montana for work. POA stated he will call facility to schedule a CC when he isback [sp] in town. CC scheduling refused at this time.During an interview on 03/18/2026 at 2:33 PM, Staff C, Social Services Manager, said care conferences for residents were done quarterly, with a significant change, and annually. Staff C said if a POA was not available to attend we could connect with them on the phone. When asked about Resident 10's care conferences Staff C said Resident 10's son said he was out of town and wasn't available to set up a CC at that time. When asked if a CC was completed over the past year, Staff C said none had been done. Staff C said they attempted to set up one on 08/08/2025 but Resident 10's son asked if they could call back when the next quarter was due.During an interview on 03/18/2026 at 3:17 PM, Staff B, Director of Nursing/Registered Nurse, said care conferences should be done quarterly, with a change of condition, or at the resident's request.Reference WAC 388-97-1020 (2)(e)(f)

Based on observation, interview, and record review, the facility failed to ensure staff properly don (put on) personal protective equipment (PPE) for 2 of 3 sampled resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.Findings included. Record review of the facility's policy titled, Contact Precautions [infection control measures used to prevent the spread of infections that are transmitted through direct contact with an infected person or their environment] ., dated 09/10/2025, documented, .6. When a resident is placed on contact precautions, the staff should implement the following: .f. [NAME] appropriate PPE before or upon entry into the environment (e.g., room) of resident on contact precautions. Record review of the facility's policy titled, Transmission-Based Precautions [infection control measures used in healthcare settings for people with known or suspected infections that spread easily], revision date 09/11/2025, documented, .Enhanced Barrier Precautions (EBP): Refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities . In an observation and interview on 03/18/2026 at 9:26 AM, two resident name tags, placed above and below each other, were observed on the wall to the left of the entrance of room [ROOM NUMBER]. The top name tag had Resident 59's name. The bottom name tag had Resident 21's name. A sign was observed posted on the wall below Resident 21's name tag, that showed: CONTACT PRECAUTIONS.Doctors and Staff Must: Gown and glove at door. Staff G, Certified Nursing Assistant (CNA), was observed in room [ROOM NUMBER] adjusting Resident 21's legs on the wheelchair foot rests with no gown or gloves on. Upon exiting room [ROOM NUMBER], Staff G was asked about the Contact Precautions sign hanging below Resident 21's name. Staff G said she did not realize Resident 21 was on Contact Precautions. Staff G said they were supposed to wear a gown and gloves for residents on Contact Precautions. Staff G said the Contact Precautions sign was for Resident 21 because it was placed below her name. In an interview and observation on 03/18/2026 at 9:36 AM, Staff H, Licensed Practical Nurse, when asked about the Contact Precautions sign below Resident 21's name, said she did not know what Resident 21 was on Contact Precautions for. Staff H said the Contact Precaution sign should be for Resident 59 who had wound care. Staff G was observed in room [ROOM NUMBER] assisting Resident 59 in the bathroom with gloves on and no gown. Staff H went into room [ROOM NUMBER] and told Staff G she should have a gown on for care with Resident 59. Staff G said she thought the Contact Precautions sign was for Resident 21, not Resident 59, because the sign was hanging below Resident 21's name. Staff H said staff needed to gown and glove for residents on Contact Precautions and there may have been some confusion about which resident in room [ROOM NUMBER] was on Contact Precautions. In an observation on 03/18/2026 at 11:33 AM, the contact precautions sign posted to the entrance of room [ROOM NUMBER], below Resident 21's name, was removed. An EBP sign was observed posted above Resident 59's name that showed providers and staff must wear gloves and a gown for resident care activities such as providing hygiene and assisting with toileting. In an observation and interview on 03/18/2026 at 10:33 AM, a sign was observed posted on the wall to the left of the door entrance to room [ROOM NUMBER] that showed: CONTACT PRECAUTIONS.Doctors and Staff Must: Gown and glove at door. Staff I, CNA, was observed in room [ROOM NUMBER] changing linens on the bed with no gown on. Upon exiting room [ROOM NUMBER], Staff I was asked the process for PPE use for residents on Contact Precautions. Staff I said she talked to the nurse and was told the resident in room [ROOM NUMBER] was on precautions related to his wounds. Staff I said if she was not doing anything with the resident's wounds, she did not need to put on a gown. In an interview on 03/19/2026 at 10:43 AM, Staff F, Infection Preventionist/Registered Nurse (RN), said if a resident was Contact Precautions or EBP, the sign was posted on the wall above or below the resident's name that was on precautions. Staff F said the wrong sign was put up for room [ROOM NUMBER]. Staff F said it should have been an EBP sign, not a Contact Precautions sign, and it was put with the wrong resident's name. When asked about Staff G assisting Resident 59 in the bathroom without a gown, Staff F said Staff G should have had a gown on. Staff F said if a resident was on Contact Precautions, the staff should put on a gown and gloves upon entering the room. Staff F said Staff I should have had a gown on while in room [ROOM NUMBER]. In an interview on 03/19/2026 at 11:11 AM, Staff B, Director of Nursing/RN, said it was her expectation staff put on a gown and gloves when entering a room for a resident on Contact Precautions and during high contact activities with residents on EBP. Reference WAC 388-97-1320 (1)(a)

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled with open date for 1 of 2 medication storage rooms (East Medication Storage Room) and 1 of 3 medication carts (Medication Cart 4) reviewed for medication storage and labeling. This failure placed residents at risk of receiving expired and/or less effective medications, and a diminished quality of life.Findings included . Record Review of the facility's policy titled, Medication Storage & Labeling, dated [DATE], documented, .b. Multi-dose vials: i. Date when first opened; discard within 28 days unless manufacturer specifies otherwise.d. Insulin pens: .ii. Apply date opened and discard per manufacturer's timeframe (usually 28 days after open). In a joint observation and interview on [DATE] at 1:46 PM with Staff D, Resident Care Manager/Licensed Practical Nurse, in the East Medication Storage Room, the medication refrigerator was observed to have in it an undated, opened, multi-dose vial of TB protein derivative (a solution injected under the skin used to help diagnoses a TB [tuberculosis, an airborne infection primarily affecting the lungs] infection). Staff D said the TB vial should have been dated when it was opened and it was not. In a joint observation and interview on [DATE] at 9:53 AM with Staff E, Registered Nurse (RN), Medication Cart 4 was observed to have three undated, opened insulin (a medication used to lower blood sugar) pens (a device used to give insulin shots) in the top drawer of the cart. Staff E said the insulin pens were supposed to be dated when opened and they were not. In an interview on [DATE] at 12:19 PM, Staff B, Director of Nursing/RN, said it was her expectation multi-use vials and insulin pens were dated when they were opened. Reference WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 1 sampled resident (Resident 101) reviewed for death. This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included. Resident 101 was admitted to the facility on [DATE]. The Admission/5 day Minimum Data Set (an assessment tool), dated [DATE], documented Resident 11 was severely cognitively impaired. Record review of Resident 10's POLST (Portable Orders for Life-Sustaining Treatment, a medical order that documents a person's wishes for end-of-life intervention to health care facilities), dated [DATE], documented, .YES - Attempt Resuscitation/CPR [Cardio Pulmonary Resuscitation, a life-saving emergency technique used when a person's breathing or heart stops]. Record review of Resident 101's physician orders, dated [DATE] and discontinued [DATE], documented, FULL CODE [if a patient's heart stops or they stop breathing, healthcare providers will use life saving measures to resuscitate them, including CPR] . Record review of Resident 101's physician orders, dated [DATE] and discontinued [DATE], documented, DNR (no code) [Do Not Resuscitate, instructing healthcare providers not to perform CPR if a patient's heart stops or they stop breathing] . Record review of Resident 101's physician's orders, dated [DATE], documented, FULL CODE. Record review of Resident 101's Care Plan Report, date initiated [DATE], documented a Focus, [Resident 101] has a DNR POLST in place. Further review of the Care Plan Report, date initiated [DATE], documented a Goal, If [Resident 101's] heart stops or they stop breathing, CPR will not be initiated in honor of their code status wishes. In an interview on [DATE] at 8:04 AM, Staff B, Director of Nursing/Registered Nurse, said After Resident 101 was changed back to a full code on [DATE], the care plan was not updated, and it should have been. Reference WAC 388-97-1020 (2)(a)

Based on observation and interview, the facility failed to ensure food was served hot at a safe temperature. This failure to serve foods at proper temperatures placed resident at risk for decreased nutritional intake, food borne illness and a decreased quality of life. Findings included . The Center of Disease Control (CDC) indicated, Listeria infection (Listeriosis) are bacteria (germs) that can contaminate many foods including hot dogs. People who eat those foods can get infected with the bacteria . Listeria infection can be especially harmful for some people, including adults aged 65 or older, and people with weakened immune systems. The United States Department of Agrigulture (USDA), Food Safety and Inspection Service indicated, hot food should be held at 140 degrees or warmer. On 04/21/2025 at 11:43 AM, Resident 27 said her food was usually warm but not hot. On 04/24/2025 at 11:40 AM, hot dogs were removed from the cooking process and placed on the service line. The temperature of the hot dogs measured 160+ degrees Fahrenheit. The hot dogs were covered with a cookie sheet pan. At 12:37 PM, the remaining hot dogs', after the service line was completed, temperatures measured about 100 degrees Fahrenheit. Staff J, Culinary Manager, said the hot dogs were not warm enough. Reference WAC 388-97-1100 (1), (2)

Based on observation, interview and record review, the facility failed to ensure bed rails were securely fastened to the bed for 1 of 2 sampled residents (Resident 49) reviewed for accident hazards. This failure placed residents at risk for injury and/or entrapment. Findings included . Review of the facility's policy entitled, Restraints, revised 03/01/2024, documented, .Bedrails/Side Rails . 3. If the bedrail/side rail is used, the facility ensures correct installation, use, and maintenance of the rail(s) . Resident 49 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, an assessment tool, dated 04/05/2025, documented Resident 49 was alert and oriented. On 04/21/2025 at 2:46 PM, Resident 49's bed was observed with a quarter length bed rail on the left side of the upper bed. The bed rail was observed to be loose with about four to five inches of movement up and down and five to six inches of movement back and forth. Resident 49 said her bed rail was loose. Resident 49 said she told the staff three or four times, but they have not fixed it. Resident 49 said a CNA (Certified Nursing Assistant) told her they put in a request on the computer for maintenance to fix it, but they still had not. On 04/23/2025 at 12:05 PM, Resident 49's bed was observed with a quarter length bed rail on the left side of the upper bed. The bed rail was observed to be leaning out from the bed and loose, with about four to five inches of movement up and down and five to six inches of movement back and forth. The bracket attaching the bed rail to the frame of the bed was observed to be loose, wiggling about one inch around the bolt attached to the bed frame. At 3:10 PM, Resident 49 was observed lying in bed with the left side bed rail loose. Resident 49 said her bed rail was still loose and she has told staff three to four times, but it had not been fixed. At 3:16 PM, Staff H, CNA, said if there was equipment like bed rails, hoyer lifts, or anything that was broken or needed to be fixed, they would report it through TELS (an electronic work order system) and verbally tell maintenance. At 3:20 PM, Staff B, Chief Nursing Officer and Registered Nurse, said bed rails were installed by maintenance. Staff B said if a bed rail needed to be fixed or repaired, the staff would use TELS to report it to maintenance. Staff B went to Resident 49's room to look at the bed rail. Staff B said the bed rail was looser than it should have been and needed to be tightened. On 04/24/2025 at 11:05 AM, Staff B said a TELS work order was put in by a CNA on 04/15/2025 for the loose bed rail, but it had not been fixed yet. Staff B said she expected anything safety related, such as bed rails, were addressed right away and indicated it should have been fixed sooner. Reference WAC 388-97-2100 (1)

Based on observation, interview and record review, the facility failed to document/monitor targeted behaviors for 1 of 5 residents (Resident 48) reviewed for behavior-emotions. This failure to monitor targeted behaviors placed residents at risk for unmet psychosocial needs and a decreased quality of life. Findings included . Resident 48 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set assessment, an assessment tool, dated 02/13/2025, indicated Resident 48 was moderately cognitively impaired. Review of Resident 48's care plan, dated 05/20/2024, showed a focus area, Psychosocial/Mood/Behavior related to [Resident 48] has mood problem r/t schizophrenia, Depression, Visual Hallucinations, Auditory Hallucinations, Uncontrollable crying/tearfulness, Delusional thoughts, Agitation . 3. Behavioral supports Monitor for symptoms of anxiety, depression, or psychosis as evidenced by irritability, agitation, fidgeting, tearfulness, diminished sleep, worry and overall mood presentation. Document changes when observed and update care plans as needed. On 04/21/2025 at 3:18 PM, Resident 48, while interviewing cried several times during the interview in the initial pool process, when talking about her living situation, a fall, and activities. At 3:34 PM, Staff I, Licensed Practical Nurse, was alerted to Resident 48's crying episodes, upon completion of the interview. On 04/23/2025 at 9:14 PM, review of Resident 48's progress notes showed no mention of the above crying episodes on 04/21/2025. On 04/24/2025 at 9:28 AM, Staff I, when asked what she did with the information she was given regarding Resident 48's crying episodes, Staff I said she told Staff D, Resident Care Manager. At 1:59 PM, Staff D, said Resident 48's crying episodes should have been documented even if the episode was witnessed by another person. Staff D said monitoring helped with deterring and providing interventions for Resident 48. At 2:04 PM, Staff B, Chief Nursing Officer and Registered Nurse, said staff should document target behaviors by the end of their shifts. Staff B said documentation helped to track the behavior. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 1 of 4 sampled residents (Resident 38) reviewed for mood and behavior. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings Included . Resident 38 was admitted to the facility on [DATE] with diagnosis to include Post Traumatic Stress Disorder (PTSD, a mental health condition that can develop after someone experiences or witnesses a traumatic event). The Quarterly Minimum Data Set assessment, an assessment tool, dated 03/22/2025, documented Resident 38 was alert and oriented, had a diagnosis of PTSD, and was taking antipsychotic medication. Review of Resident 38's Comprehensive Care Plan, on 04/24/2025, did not show a Focus, Goal, or Interventions/Tasks related to PTSD. On 04/24/2025 at 10:38 AM, Staff F, Social Services Director, said if a resident had a diagnosis of PTSD, they should have a care plan in place. Staff F said she did not find a PTSD care plan and trauma informed care evaluation done for Resident 38 and there should have been. At 10:52 AM, Staff B, Chief Nursing Officer and Registered Nurse, said she expected PTSD care plans were in place for residents with a diagnosis of PTSD. After looking at Resident 38's electronic health record, Staff B said she did not see a PTSD care plan and there should have been one. Reference WAC 388-97-1020(1), (2)(a)(c)

Based on observation, interview, and record review, the facility failed to ensure medications were administered by professional standards of practice for 1 of 4 sample residents (Resident 38) reviewed for medication administration. This failure placed residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings Included . Review of the facility's policy entitled, Oral Medication Administration, dated 01/01/2018, documented, .Administration .6.e. Observe the resident ingest the medication. Resident 38 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set assessment, an assessment tool, dated 03/22/2025, documented Resident 38 was alert and oriented. On 04/23/2025 at 11:03 AM, Resident 38 was observed lying in bed with no staff present in the room. A white oval pill was observed on Resident 38's overbed table lying on a napkin. Resident 38 picked up the pill off the table and swallowed the pill with no nurse present in the room. When asked about the pill she just swallowed, Resident 38 said she took about 13 pills. Resident 38 said the nurse didn't stay with her while she took the pills because she had only 1 or 2 left. Staff G, Licensed Practical Nurse, entered the room and asked Resident 38 if she could take her blood sugar. When asked Staff G about the pill Resident 38 just took while unattended, Staff G stated, I'm sorry, I thought she was taking them when I walked away. Review of Resident 38's electronic health record did not show a self-medication administration evaluation had been completed. At 12:00 PM, Staff D, Resident Care Manager and Registered Nurse (RN), said medications are not supposed to be left at the bedside. Staff D said medications are supposed to be watched the entire time until they are swallowed. Staff D said Resident 38 did not have approval for self-administration of medications. At 12:13 PM, Staff B, Chief Nursing Officer and RN, said it was her expectation nurses observed residents take all their medication and not leave any at the bedside. Reference WAC 388-97-1300 (1)(b)(i), (3)(a)

Based on observation, interview, and record review, the facility failed to provide accurate medication administration for 1 of 5 sampled residents (Resident 1) reviewed for medication administration errors. This failure placed residents at risk for medical complications and diminished quality of life. Findings included . Resident 1 was admitted on [DATE] with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease (COPD), both of which make breathing difficult. The Minimum Date Set assessment, dated 05/02/2024, showed Resident 1 had moderate difficulty in making needs know and required maximum assistance for activities of daily living. <Medication Error 1> A physicians order, dated 04/26/2024, ordered predniSONE [a steroid that decreases inflammation] Oral Tablet 10 milligrams [mg] [Prednisone] Give 40 mg by mouth one time a day for COPD exacerbation [an acute increase in the severity] for 2 Days AND Give 20 mg by mouth one time a day for COPD exacerbation for 2 Days AND Give 10 mg by mouth one time a day for COPD exacerbation for 2 Days. The April 2024 and May 2024 Medication Administration Record (MAR) showed the administration dates for Prednisone 40 mg's were documented for administration to occur on 04/27/2024 and 04/28/20204. The administration dates for Prednisone 20 mg were documented for administration to occur on 04/29/2024 and 04/30/2024. The administration dates for Prednisone 10 mg would have been for administration to occur on 05/01/2024 and 05/02/2024. A nurses note, dated 04/30/2024 at 10:29 AM, showed Staff C, Registered Nurse (RN), documented in the Electronic Medical Record (EMT), the provider was notified of a medication error in relation to the Prednisone taper. The taper was started with the 10 mg instead of with the 40 mg. This error was found by Staff C when reviewing the medication card for the Prednisone. A physician order, dated 04/30/2024, was received by Staff C with a new Prednisone taper as follows: predniSONE Oral Tablet 10 MG [Prednisone] Give 40 mg by mouth one time a day for COPD exacerbation for 3 Days AND Give 20 mg by mouth one time a day for COPD exacerbation for 3 Days AND Give 10 mg by mouth one time a day for COPD exacerbation for 3 Days. The April 2024 and May 2024 MAR showed the administration dates for Prednisone 40 mg's were documented to occur on 04/30/2024, 05/01/2024, and 05/02/2024. The administration dates for Prednisone 20 mg were documented for administration to occur on 05/03/2024, 05/04/2024, and 05/05/2024. The administration dates for Prednisone 10 mg were documented to occur on 05/06/2024, 05/07/2024, and 05/08/2024. An Incident Report, dated 05/01/2024, identified the Prednisone taper had been initiated backwards. Instead of initiating with the 40 mg leading dose of the taper and ending with the 10 mg dose, the taper was initiated starting with the 10 mg dose and would have ended with the 40 mg dose. The report showed Staff D, Licensed Practical Nurse (LPN), responsible for the error, was provided with education on the correct sequencing of Prednisone tapers. A nurses note, dated 05/03/2024 at 5:26 PM, showed Staff C documented in the EMR, Patient started new Prednisone taper on Wednesday, but it was not administered properly. Patient did not receive proper dosages at the beginning of the taper. Would you like to restart it? On 09/04/2024 at 12:19 PM, Staff B, Director of Nursing Services, said she had been notified by Staff C of the medication errors. Both errors were made by Staff D. Upon the first error, Staff D was educated on the correct way to administer a Prednisone taper. Upon the second error, Staff D was again re-educated and asked to schedule a time for medication pass observation. Staff D declined and their employment was discontinued. <Medication Error 2> A physicians order, dated 04/26/2024, ordered Fluticasone-Salmetrol Inhalation Aerosol 230-21 MCG/ACT, ADVAIR [an inhaler used to open airways] 2 puff inhale orally two times a day for Chronic Obstructive Pulmonary Disease. On 07/23/2024 at 4:41 PM, Collateral Contact 1 (CC 1) provided a time stamped photograph, dated 05/10/2024 at 10:31 AM, of the ADVAIR inhaler used by Resident 1. The photograph showed the back of the inhaler with a dial that read 84. CC 1 indicated the number represented the number of doses left in the inhaler. Record review of Resident 1's April 2024 and May 2024 MAR showed documentation for the administration of the Fluticasone-Salmetrol Inhaler twice daily for 14 days. This was equal to 68 puffs of inhaled doses. On 08/19/2024 at 2:54 PM, Staff G, LPN, said some of the inhalers used have a countdown feature at the back of the inhaler and others do not. The ones that have the dosage count down at the back are reliable. On 09/05/2024 at 1:45 PM, Staff F, Pharmacist, said the number on the back of the ADVAIR inhaler indicates the number of doses that should be left for a month long supply of 120 doses. When asked if the inhaler was given as ordered for 14 days at two puffs twice a day with the inhaler reading 64 doses left, Staff F said yes. Staff F said if the resident did not receive the doses as ordered, this could mean they could experience exacerbated symptoms of COPD. On 09/09/2024 at 2:00 PM, after reviewing the discrepancy of the ADVAIR Inhaler, Staff B said education would be provided to nursing staff to prevent further errors. Reference WAC 388-97-1060 (3)(k)(iii)

Based on observation and interview, the facility failed to maintain the cleanliness of the vent covers in 1 of 1 facility kitchen. This failure placed residents at risk to consume food not prepared in a sanitary manner and a diminished quality of life. kitchen vent covers reviewed for kitchen. These failures had the potential to affect all residents who consumed food and may cause a diminished quality of life. Findings included . On 06/06/2024 at 10:05 AM, the overhead vent covers (located over the food prep areas) were observed with lint trapped between the grilles. The stove hood filters appeared to be greasy and had some lint between the grilles. At 2:07 PM, when asked what was in the overhead vents above the food prep area, Staff F, Dietary Manager, said it looked like lint. After looking at the slats of the hood filters over the stove, Staff F said it looked like lint and the slats were not put in correctly. Staff F said maintenance was responsible for cleaning the overhead vent covers. Staff F said they contracted the cleaning for the hood filters, and they come out about every six months. Reference WAC 388-97-1100 (3)

Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan addressing limited mobility for 1 of 6 sampled residents (40) reviewed for comprehensive care plan related to mobility. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 40's comprehensive care plan, dated 05/20/2024, did not address a plan of care for contractures to the left arm. On 06/03/2024 at 11:47 AM, Resident 40 was observed with a contracted left arm that had decreased range of motion. When asked about the resident's ability to use his arm, Resident 40 said his contracture had gotten worse. On 06/05/2024 at 9:12 AM, Staff C, Licensed Practical Nurse, said there were no interventions in place to care for Resident 40's contracted left arm. On 06/06/24 at 10:36 AM, Staff B, Chief Nursing Officer and Registered Nurse, said there was nothing in the resident's care plan that reflected a plan to care for Resident 40's contractures. Reference WAC 388-97-1020 (1), (2)(a)

Based on observation, interview and record review, the facility failed to ensure food preferences were honored for 1 of 3 sample residents (114) reviewed for food preferences. This failure placed residents at risk for not having their food preferences honored and a diminished quality of life. Findings included . Resident 114 was admitted to the facility on [DATE]. The admissions Minimum Data Set assessment, dated 05/24/2024, indicated Resident 114 was cognitively intact. The Diet History & Preferences, dated 06/03/2024, indicated Resident 114 had cereal dislikes: Cream of Wheat, Grits, Malt-O-Meal and Oatmeal. On 06/03/2024 at 12:12 PM, Resident 114 was observed receiving her lunch and stated, Gross. At 3:27 PM, Resident 114 said her lunch had vegetables on it that she did not like. Resident 114 said she had spoken with the dietician, the dietary manager, and had told the aids; but they kept giving her food she disliked. On 06/07/2024 at 9:18 AM, Staff F, Dietary Manager, said they tried to serve residents their preferences but if they did not get a menu from the nursing staff for that resident, they would serve the resident the main meal. Resident 114 was observed showing Staff F the hot cereal. Staff F said it was oatmeal. After reviewing the resident's preferences, Staff F said she would be sure this did not happen again. Reference WAC 388-97-1120 (3)(a)

Based on observation and interview, the facility failed to ensure the floor was inspected where medication was found in 1 of 3 resident hallways (East) reviewed for safe environment. This failure placed residents at risk for an unsafe living environment and a diminished quality of life. Findings included . On 06/05/2024 at 1:51 PM, an unidentified resident was observed saying loudly, to an unidentified staff, there was a pill on the floor. The pill was picked up by the unidentified staff. Staff D, Registered Nurse, told the unidentified staff to hand her the pill and she would take care of it. Staff D looked at the pill and stated, It's Zoloft [an antidepressant]. At 2:52 PM, a partial blue colored pill was observed on the floor by the nurse's station along the edge of the carpet and floor of the dayroom. At 2:54 PM, when asked what was on the floor, Staff E, Resident Care Manager and Licensed Practical Nurse, said it looked like a pill. Staff E said he could not tell what it was because it did not have a marker. Staff E said he would have expected staff to search the area and made sure no other pills were on the floor. At 3:01 PM, Staff B, Chief Nursing Officer and Registered Nurse, said if a pill was found on the floor, she would expect staff to look around the area to ensure nothing else was around there. Reference WAC 388-97-3220 (1) .

Based on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nursing assistant for 3 of 3 agency nursing assistants (Staff C, D & E) reviewed for nursing aide registry. This failure placed residents at risk of unmet care needs and care being provided by unqualified nursing assistants. Findings included . 1) Staff C was scheduled to work at the facility through a Staffing Agency as a Certified Nursing Assistant on 04/22/2023. 2) Staff D was scheduled to work at the facility through a Staffing Agency as a Certified Nursing Assistant on 05/05/2023. 3) Staff E was scheduled to work at the facility through a Staffing Agency as a Certified Nursing Assistant on 06/26/2023. On 09/08/2023 at 12:15 PM, when asked to review Staff C's, Staff D's, and Staff E's registry verification, Staff B, Registered Nurse, and Chief Nursing Officer, said she would need to contact the staffing agency to have copies of agency staff's registry verification sent. Staff A said it was part of the staffing agencies contract to provide this information prior to scheduling agency staff to work. Staff B said they had not kept up on this since losing their Human Resource Manager. Staff A said going forward, there was a plan in place to obtain agency staff registry verification prior to them arriving to work. On 09/08/2023 at 3:29 PM, the staffing agency sent registry verification for Staff D (126 days after scheduled to work at the facility). On 09/08/2023 at 4:56 PM, the staffing agency sent registry verification for Staff C (139 days after scheduled to work at the facility), and Staff E (74 days after scheduled to work at the facility). Reference WAC 388-97-1660 (3)(c)

Based on observation and interview, the facility failed to ensure the required Type 1 essential electrical system (EES) and generator was in place and operational prior to accepting residents to a ventilator unit where an emergency electrical power system would be needed to maintain life support equipment in the event of a power outage for 3 of 3 sampled ventilator residents (116, 119 & 300) reviewed for emergency electrical power system. This failure placed Resident 116, Resident 119 and Resident 300, all dependent on life support equipment, at risk for loss of life. An Immediate Jeopardy was called on 05/02/2023 at 2:40 PM when the facility failed to have adequate emergency electrical system including emergency life support to residents on ventilators in case of a power outage. The immediacy was removed on 05/04/2023 at 5:30 PM after residents, dependent on the emergency electrical system, were removed from the facility. Findings included . 1) Resident 116 was admitted to the facility on [DATE]. Resident 116's medical record showed the resident required life supporting equipment, a ventilator, to sustain life. 2) Resident 119 was admitted to the facility on [DATE]. Resident 119's medical record showed the resident required life supporting equipment, a ventilator, to sustain life. 3) Resident 300 was admitted to the facility on [DATE]. Resident 300's medical record showed the resident required life supporting equipment, a ventilator, to sustain life on an as needed basis. The daily census sheet, dated 05/02/2023, showed a census of 62 residents. The census included three current residents and one pending admission requiring ventilator equipment (life support breathing machine). On 05/02/2023 at 11:00 AM, the three residents (Resident 116, Resident 119 and Resident 300) were observed on the ventilator unit. On 05/02/2023 at 11:13 AM, Staff A, Administrator, said the facility started taking admissions into the new ventilator unit on 04/03/2023. At 11:51 AM, Staff A said he had never contacted the State's Construction Review Services (CRS) regarding opening a new ventilator unit. Staff A said he had outlets changed/added to the generator without involving CRS review or approval. The State Fire Marshall (SFM) said the facility failed to have a Type 1 electrical system. The SFM said there was a lack of fuel to operate the generator for the required 96 hours. At 12:46 PM, Staff E, Administrator in Training, said the amount of diesel fuel for the generator was approximately 5 gallons onsite. Staff E said the rate of fuel consumption, gallons per hour, was unknown. On 05/03/2023 at 9:00 AM, Staff A said the calculated burn rate was approximately one gallon per hour for the generator. At 11:00 AM, Staff A indicated a virtual inspection was conducted by CRS related to their electrical system and generator. On 05/04/2023 at 9:40 AM, CRS said the facility did not have a Type 1 EES system required to operate life sustaining equipment. Staff C, Facility Consultant, said the facility did not investigate the life safety codes and other components that needed to be done prior to opening a ventilation unit. Staff C said they were not aware of CRS. (An email was sent to Staff A from the State Agency, dated 11/15/2022 at 2:28 PM, noting an application would need to be completed with CRS for any modifications made to the nursing home; and this was the first step to take in the process of having a ventilator unit.) At 5:30 PM, the last resident requiring life sustaining equipment was observed being moved to a facility that could support their emergency life support needs. Refer to LSC Survey, dated 05/08/2023, E007-Emergency Preparedness Program Patient Population and K918-Electrical System - Essential Electric System Reference WAC 388-97-2200 (2)(a)(d)(3)(4)(b)(5)(a)(b), -2160 (2)

Based on interview and record review, the facility failed to ensure new residents were given and explained admission documents for 15 of 15 sampled residents (2, 4, 5, 6, 8, 16, 18, 21, 24, 28, 32, 36, 47, 110 & 119) reviewed for resident rights. This failure placed residents and representatives at risk of not being fully informed of their rights as residents, unmet care needs, and a decreased quality of life. Findings included Record review of a blank admission packet, undated, showed the following forms should have been included: Bed-hold Policy, Resident Rights, How to File Concerns/Grievances, Firearm Policy, Key Personnel List, Smoking Policy, Resident Trust Fund Authorization, SNF (Skilled Nursing Facility) Determination on Admission, and Notice of Privacy Information Practices. Record review of Electronic Health Record (EHR) showed the following residents did not receive written information, on admit or thereafter, pertaining to resident rights and services during their stay at the facility: Resident 2 Resident 4 Resident 5 Resident 6 Resident 8 Resident 16 Resident 18 Resident 21 Resident 24 Resident 28 Resident 32 Resident 36 Resident 47 Resident 110 On 05/04/23 at 2:53 PM, admission documents, including documents pertaining to resident rights, were requested for Resident 2, Resident 4 and Resident 119. On 05/05/23 at 9:00 AM, referencing the admission documents requested on 05/04/2023 at 2:53 PM, Staff A, Administrator, stated, I apologize. We have looked, and we just don't have them. At 11:57 AM, when asked about the admission documents they said they did not have for Resident 2, Resident 4 and Resident 119; Staff A stated, It is a broken system. We are aware. We are trying to make it all electronic. Staff C, Corporate Consultant, stated, That's part of our standard operating procedures. We should have them. Reference WAC 388-97-0300

Based on interview and record review, the facility failed to ensure residents were provided information regarding filing a complaint concerning suspected violations of State and Federal nursing facility regulations and failed to ensure residents were provided a list of names, mailing and email address and phone numbers of State Agency, informational agencies and advocacy groups in a manner they understand for 10 of 10 sampled residents (6, 7, 14, 19, 34, 45, 47, 255, 260 & 261) reviewed for notices and contact information. These failure placed residents and representatives at risk of not being fully informed of their rights, ways to file a complaint, ways to access advocacy groups, and a diminished quality of life. Findings included . Record review of a blank facility Admission Agreement- Resident Rights, page 10, undated, notes, 33. The Resident has a right to receive information from agencies acting as client advocates and be afforded the opportunity to contact the agencies. On 05/04/2023 at 11:00 AM, during a Resident Council group interview, the following residents were asked the following questions with their answer (see below): Resident 6 Resident 7 Resident 14 Resident 19 Resident 34 Resident 45 Resident 47 Resident 255 Resident 260 Resident 261 --When asked if they knew how to contact and/or file a complaint with the State Agency, the residents stated, No. --When asked if they knew how to contact the State Long-Term Care Ombudsman, the residents stated, No. --Resident 47 stated, We met the Ombudsman, but we don't know how to contact her. Record review of Electronic Health Record (EHR) the same residents listed above did not receive the following written information: --Notice indicating a resident can file a complaint with the State Agency regarding a suspected violation of State or Federal nursing facility regulations. --Information containing contact information for filing complaints concerning any suspected violation of State or Federal nursing facility regulations. --Information providing a list of names, mailing and email addresses, and telephone numbers of pertinent state regulatory, informational agencies and advocacy groups. On 05/05/2023 at 9:00 AM, referencing requested admission documents which included the documents pertaining to resident rights, Staff A, Administrator, stated, I apologize. We have looked, and we just don't have them. At 11:57 AM, when asked if they were certain they did not have resident right documents for residents, Staff A, Administrator, stated, It is a broken system. We are aware. We are trying to make it all electronic. Staff C, Corporate Consultant, stated, That's part of our standard operating procedures. We should have them. Reference WAC 388-97-0300 (7) (c)(d)

Based on observation, interview and record review, the facility failed to thoroughly assess, identify the resident's risk for skin deterioration, and provide necessary care and services to prevent a new pressure ulcer from developing for 1 of 4 sampled resident (#1) reviewed for pressure ulcers. This failure placed residents at risk for skin deterioration, change in health condition, and a diminished quality of life. This caused harm to Resident #1 when an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed) pressure ulcer to the sacrum (bony structure at the base of the lumbar vertebrae and connected to the pelvis) was developed in the facility. Findings included . The facility's skin integrity policy, updated (MONTH) 2019, showed staff were to inspect residents skin daily with completion of activities of daily living. Change in the skin was to be reported to the Licensed Nurse (LN). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 08/19/19, documented the resident had modified independence with daily decision making skills, rejected care daily, and required two person extensive assistance with bed mobility and toileting. The MDS showed the resident had impairment with range of motion in both legs, was incontinent of bowel, was at risk for pressure ulcers and was admitted with a Stage 4 pressure ulcer. The Care Area Assessment Summary, dated 08/19/19, showed the resident had behavioral symptoms that were triggered and addressed in the resident's care plan. Resident #1's Braden scale (a risk assessment tool of pressure ulcer development) score, dated 08/12/19, showed the resident was at high risk of developing pressure ulcers. Resident #1's pressure ulcer care plan, initiated 08/12/19, showed interventions including, If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Resident #1's Baseline care plan, initiated 08/13/19, showed interventions including,Skin at risk turn/reposition routinely. A nurses progress note, dated 08/13/19, documented, Pt (patient) also has an open blistering area on the sacrum. A nurses progress note, dated 08/14/19, documented, Pt sacral (sacrum) wound is still intact with minimal SS (sero-sanguineous-fluid that may be pale red or pink in color) drainage. A nurses progress note, dated 08/20/19, documented, Coccyx (tailbone) wound is deep and pink. A nurses progress note, dated 08/21/19, documented, Sacral wound cleansed with saline, silver cream applied and covered with small island dressing. A nurses progress note, dated 08/22/19, documented, Sacral wound cleansed with saline, silver cream applied and covered with small dressing. A nurses progress note, dated 08/23/19, documented, Sacral wound cleansed with saline, silver ointment applied and small island dressing. Review of nurses progress notes, dated 08/24/19 through 09/06/19, did not document sacral wound. Review of the resident's (MONTH) 2019 and (MONTH) 2019 physician orders, dated 08/12/19 through 09/07/19, did not show orders for the sacral wound. Review of the resident's (MONTH) 2019 and (MONTH) 2019 Treatment Administration Record (TAR), dated 08/12/19 through 09/07/19, did no show treatment orders for the sacral wound. The (MONTH) 2019 TAR documented weekly skin audits were not completed on 08/13/19, 08/20/19 and 08/27/19, as the resident had refused. Review of Resident #1's (MONTH) 2019 and (MONTH) 2019 TAR and (MONTH) 2019 and (MONTH) 2019 Medication Administration Record [REDACTED]. Review of nursing progress notes, dated 08/12/19 through 08/27/19, did not show attempts to follow-up on skin assessments and identify if new skin issues had developed. The weekly skin audit, dated 09/03/19, documented the skin audit was completed and showed a minus sign, indicating no new skin impairment. A nurses progress note, dated 09/07/19, documented, Noted new skin area to coccyx 7.5 cm (centimeter) x 4 x 0.2 cm, 80% eschar (dead tissue that is hard or soft in texture, usually black, brown or tan in color), 15% slough (non-viable yellow, tan, gray, green or brown tissue) and 5% granulation (pink red moist tissue that fills an open wound when it starts to heal). The wound was classified as an unstageable pressure ulcer. The facility investigation, dated 09/07/19, documented a staff statement noting to have provided wound care to left thigh, right second toe and right ischium (lower and back part of hip bone) on 09/03/19, 09/04/19, 09/05/19 and 09/06/19. The staff statement noted no coccyx wound. The investigation documented, Resident has a specialty pressure reduction mattress that is very deep and visualization of the coccyx/left buttock is limited during routine right ischium wound care. The investigation conclusion showed the unstageable pressure ulcer developed as a result of unrelieved pressure to the coccyx. A Wound Clinic note, dated 09/11/19, documented the sacrum as a Stage 4 pressure ulcer measuring 6.5 cm x 5.5 cm x 3 cm with a heavy drainage with a strong odor and necrotic tissue (dead tissue). The tendon, muscle and adipose (fatty) tissue was exposed and the surrounding tissue was scarred. Resident #1's Resistive to care (wound care, incontinence care) care plan was initiated on 09/19/19, 39 days after the resident had triggered for refusals of care. Resident #1's Limited physical mobility related to weakness, [MEDICAL CONDITION] care plan was initiated on 09/19/19, 39 days after admission. Review of Resident #1's medical record did not show refusals and alternative methods were attempted, including behavioral support services, to address the resident's refusals of care. On 10/02/19 at 11:25 AM, Resident #1's wound was observed during wound rounds with the Wound Clinic Clinician and Staff C, Licensed Practical Nurse (LPN). The [DEVICE] dressing was observed to the sacrum area and right ischial area. The Wound Clinic Clinician measured the sacrum wound as 6 cm x 4 cm x 1 cm with moderate amount of drainage, no odor, and undermining (the destruction of tissue extending under the skin edges) was present. Resident did not complain of pain. A small amount of slough was noted to the wound edges and wound bed. The wound bed had moderate areas that were pink and moist. The Wound Clinic Clinician said the sacrum wound was a Stage 4, and the resident was on a low air loss mattress (a lateral rotation mattress system used for residents with high risk of developing pressure ulcers). Resident #1 was observed to have contractures to both legs. At 2:03 PM, Staff D, Nursing Assistant, said the resident refused to be turned and repositioned, and incontinence care. Staff D said she notified the nurse when the resident refused. At 2:09 PM, Staff C said the resident was not always compliant with care including turning and repositioning in bed, routine wound care and medications. Staff C said he had recently started working at the facility and did not know how Resident #1's new wound developed. At 3:00 PM, Resident #1 said he did not refuse to be turned and repositioned. The resident said staff would come in and answer call lights, and would leave to get help and not return. The resident said he felt staff had trouble positioning him due to his leg contractures. They have not figured out how to position me. The resident said he could not adequately move himself in bed to relieve pressure. The resident said he was told he had a new wound on his buttock. The resident said he did not know how the wound occurred as he could not feel waist down. At 3:30 PM, Staff I, Nurse Practitioner, said he had not seen the wound as the resident had refused to be examined. Staff I said he did not know why the resident was refusing care. Staff I said he felt the resident had underlying behavioral problem causing him to refuse care. Staff I said the plan was to continue monitoring his behaviors. On 10/03/19 at 11:30 AM, Staff E, Registered Nurse (RN), said there was no system in place to monitor and ensure residents were turned and repositioned every two hours. At 12:30 PM, Staff F, LPN and Resident Care Manager (RCM), said Resident #1 refused care including wound care and turning and repositioning. When asked if the refusals were evaluated, Staff F said he was not sure and he did not have an answer. Staff F said turn/reposition routinely meant NAs were to turn the resident every two hours. When asked how turning and repositioning was monitored, Staff F said they just implemented a few days ago for NAs to be able to chart every two hours for the residents that were care planned to be turned and repositioned every two hours. Staff F was unable to provide documentation showing Resident #1 was turned and repositioned every two hours prior to the new pressure ulcer to the sacrum. At 12:45 PM, Staff G, LPN, said she provided wound care on 09/06/19 for Resident #1. Staff H said she was unable to visualize the coccyx area as they were unable to turn the resident due to his contractures, and the air mattress made it difficult to turn the resident. At 1:30 PM, Staff B, Director of Nursing Services and RN, said it was expected for staff to document refusals and notify the family and the physician. Staff B said she expected staff to continue to attempt to provide care. Staff B said Resident #1 could be accusatory and had asked family to assist with his care. Staff B said Resident #1 was very particular and had his own views and beliefs and had certain people he did not want to care for him. When asked if the refusals were evaluated, Staff B stated, That I would need to look into. Staff B said she would refer to Staff F, RCM, who was working in the facility at the time. Staff B said she expected when LNs were doing wound care, they should be visualizing the areas. Staff B said staff should have been able to visualize the sacral area when providing incontinence care. When asked about behavioral monitoring, Staff B said they had changes in the social services department recently and was unsure if behavioral monitoring was implemented. Reference: WAC 388-97-1060(3)(b

Based on observation, interview and record review, the facility failed to ensure recommended behavioral health care and services were provided to create an environment promoting emotional and psychosocial well-being for 1 of 1 sampled residents (#14) reviewed for behaviors. This failure placed residents at risk for loss of life, hopelessness, and a diminished quality of life. This caused harm to Resident #14 when the facility failed to remove potentially dangerous items from Resident #14's room, failed to provide consistent monitoring of the resident after returning to the facility and failed to establish interventions to ensure the resident's safety. This failure resulted in an immediate jeopardy on 09/05/19. The immediacy was removed on 09/06/19, when the facility put monitoring and interventions in place to protect the resident and provided education to the staff. Findings included . The facility's policy entitled Suicide, updated (MONTH) (YEAR), showed suicide was more prevalent among the elderly as an age group and the importance for facility staff to have an understanding of the factors which may lead to suicide, the signs and symptoms of suicidal behavior and appropriate intervention strategies to include the following: * Frequent thoughts about suicide and/or suicidal threats are reason for concern * Of individuals who threaten suicide, 80 percent eventually kill themselves * After the immediate crisis has passed, the next step is to focus on the appropriate intervention * One important role which staff plays is the day-to-day monitoring of the resident for clues of suicidal behavior and for access to weapons by which threats can be carried out * Monitor for potential signs of suicidal thoughts or gestures * Implement interventions such as: One to one staffing or other care until other interventions can be put in place; seek in-patient psychiatric evaluation and care; and/or arrange for in-house psychiatric evaluation. Resident #14 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #14's PeaceHealth Southwest Medical Center (discharging facility) History and Physical report, dated 06/21/19, listed the resident's history of present illness, .Per the patient, 10 days ago, on 06/11 (19) she fell out of her trailer door on to her right hip and back but her brother thought she was trying to kill herself and wouldn't help her up or take her in the ED (emergency department). She then decided to kill herself for the last couple of nights by overdosing on heroin. After her initial overdose didn't work she doubled the amount, which didn't work, so she the tripled the amount. Then she ran out of money . Resident #14's Southwest Medical Center patient face sheet, dated 06/21/19, listed the resident's (most recent) hospital admission [DIAGNOSES REDACTED]. Resident #14's Level 1 PASRR (Pre-Admission Screening and Resident Review), dated 06/27/19, a screening tool to determine the most appropriate services for residents admitted to nursing facilities with serious mental illness or developmental disabilities, showed the resident met the requirement for an exempted hospital discharge. The form showed no Level II evaluation was indicated at that time of the resident's facility admission, due to the exempted hospital discharge, however, the Level II was required if the scheduled discharge (more than 30 days) from the nursing facility did not occur. The resident's stay exceeded the 30 day exemption. No Level II PASRR or referral to the PASRR coordinator was found in Resident #14's medical record. Resident #14's (MONTH) 2019 Medical Administration Record showed the resident was prescribed the following medications: [REDACTED]. A GeroMedical Psychological Services referral form, dated 07/03/19, showed Resident #14 was referred by the facility physician to receive mental health services for the following signs/symptoms: anxiety, [MEDICAL CONDITION], restlessness and depression. No documentation of a mental health consultation was found in Resident #14's medical record. On 09/03/19 at 10:59 AM, Resident #14 was observed to be tearful when speaking of her son who she said passed away two years earlier. The resident said she was taking an antidepressant, but felt it was not effective. The resident said she was [MEDICAL CONDITION] and seemed to just get lost a lot. The resident said she had asked staff for access to mental health services, but to date had not received any assistance. A nursing progress note, dated 09/04/19 at 5:57 PM, showed Resident #14 had told staff she might as well kill herself as her family will. A nursing progress note, dated 09/04/19 at 5:58 PM, showed the facility placed Resident #14 on 1:1 (one staff to one resident) observation and called 911. The resident's physician directed staff to monitor the resident and remove the 1:1 if the resident made no statements of self-harm or suicidal ideation for 24 hours. A nursing progress note, dated 09/04/19 at 6:44 PM, showed Resident #14 was sent to the hospital after she had made multiple statements to staff, I maze (sic) well kill myself and I would be better of (sic) dead. The note showed, During interview pt (patient) also has questionable body movement, of rocking, fidgeting, restlessness Pt has hx (history) of suicide attempts and heroin abuse. PCP (primary care physician) called and updated .she stated that she has an exacto knife (hobby/craft knife) and also has scissors within reach at bedside . Between 09/04/19 at 6:45 PM to 09/05/19 at 7:31 AM, no nursing progress notes were found in Resident #14's medical record showing what time the resident returned from the hospital or the resident's status upon her return to the facility. A nursing progress note, dated 09/05/19 at 7:32 AM, showed Resident #14 was sent to the hospital, 09/04/19, at approximately 7:30 PM, due to suicidal tendency/thoughts. The note showed the resident did have an exacto knife and scissors at her bedside, which was locked away in a closed drawer when pt left facility to be transported to ED (emergency department). On 09/05/19 at 3:21 PM, Resident #14 said she had been transferred to the hospital for statements of self-harm and upon her return to the facility she had not met with any staff, including Social Services, to discuss her recent hospital stay and/or statements of self-harm. The resident said she was still in possession of the exacto knife and scissors locked in her bedside drawer, which she had the key to. No staff where observed in or within line of sight of the resident's room during the resident interview. Between 09/05/19 at 7:31 AM to 09/05/19 at 3:42 PM, no documentation was found in Resident #14's medical record showing the resident's status upon her return to the facility, the resident's care plan was updated and interventions implemented by the facility and/or monitoring of the resident. At 3:48 PM, Staff Y, Licensed Practical Nurse (Licensed Practical Nurse), the nurse responsible for the Resident #14's direct care, said she was aware the resident was sent to the hospital the previous day (09/04/19) for suicidal statements. Staff Y said the resident was on frequent checks, and being monitored every two hours. Staff Y was unable to provide any other information regarding the resident's status following her hospital stay. At 3:51 PM, Staff D, LPN and Resident Care Manager, said evening nursing staff reported Resident #14 had made statements about hurting herself and was sent to the hospital. Staff D said he was uncertain what treatment the resident received at the hospital, as the facility was unable to find the hospital report. Staff D was unable to provide any interventions that had been put in place by the facility following the resident's return from the hospital. At 3:58 PM, Staff L, Registered Nurse (RN), said she had been told by the evening nurse Resident #14 was sent to the ED for making suicidal statements and upon her return, required frequent checks to monitor the resident. When asked the definition of frequent checks, Staff L stated, I think they would be every 15 minutes. Staff L reviewed the resident's medical record and was unable to provide documentation the resident was placed on alert or was being monitored by staff. Staff L said she was unable to find any documentation of the resident's 09/04/19 hospital visit. At 4:20 PM, Staff X, Certified Nursing Assistant (agency), said frequent checks were safety checks conducted every 30 minutes or every two hours as ordered. Staff X said these safety checks would be documented on a sheet of paper kept at the nurse's station. At 4:22 PM, Staff L said if a resident returned from the hospital for threats of self-harm, staff would call for a report from the ER nurse why the resident was sent back, take any paperwork sent back with the resident and document in a progress note what was done in the ER and what was ordered to be done at the facility. Staff L said she was not aware of any facility protocol for suicide watch and said this was left to the discretion of nursing staff. At 4:22 PM, Staff A, Administrator, said she had met with Resident #14 after staff had notified her the resident had a plan to harm/kill herself. Staff A said the resident denied making these statement, however, staff were concerned as the resident, with a known history of past suicide attempts, had a knife and pair of scissors in her room as well as silverware at her bedside and a call light string which the resident could use to harm herself. Staff A said the resident was sent to the hospital and returned to the facility about 9:00 PM the same evening. When asked the resident's status following her return to the facility, Staff A said she was out of that loop and relied on her staff, including the Assistant Director of Nursing, to ensure the resident was being monitored. Staff A said upon the resident's return to the facility, she would expect the resident to be placed on alert, Social Services staff to follow-up with the resident and frequent monitoring of the resident. Staff A was unable to confirm if any of these interventions had been put in place following the resident's return from the hospital. At 4:26 PM, Staff F, LPN, said frequent checks meant the resident required checks every two hours. Staff F said she would chart this in a progress note, as there was no other place to document this. At 4:36 PM, Staff B, RN and Assistant Director of Nursing, said the hospital did not send paperwork back with the resident and was unable to produce this documentation. Staff B said she would have expected the resident to have had a psychosocial evaluation at the hospital and was uncertain if this had occurred. Staff B said she would expect facility management to have consulted with the hospital to discuss the resident's condition before the resident returned to the facility, however, was unsure if this had happened. When asked what training staff received for suicide prevention, Staff B said she had not received any training in this area during the four years she had worked at the facility. Staff B said she was uncertain if resident still had the knife or scissors in her possession and was not aware of the interventions in place following the resident's return to facility. At 5:05 PM, Resident #14 said the exacto knife and scissors had recently been removed, after the immediate jeopardy had been called, from her room by staff. The resident said she could have harmed herself if she had wanted to, as these items had been in her room all day. On 09/06/19 at 10:10 AM, Staff C, Staff Social Services Director said she met with Resident #14 this morning concerning the statements made by the resident to harm herself. Staff C said she had not meet with the resident yesterday (09/05/19), as Staff A and nursing staff were managing the resident and her threats to harm herself. When asked if she had made any mental health referrals on behalf of the resident, Staff C said she had made a referral with the facility contracted mental health provider on 07/03/19, however, was unaware if the resident received these services. Staff C said she did not typically follow-up with the resident or mental health provider after making mental health referrals. Staff C said she did not believe the resident had received any mental health services during her facility stay. Associated WAC 388-97-1060(3)(e)

Based on observation, interview, and record review, the facility failed to provide timely dental services for 1 of 1 sampled residents (#22) reviewed for dental services. This failure placed residents at risk for continued dental problems, nutritional compromise, health complications and a diminished quality of life. The facility's failure to provide Resident #22 with emergent oral care and necessary dental services caused harm to the resident. Findings included . Resident #22 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool, dated 07/14/19, documented the resident was moderately cognitively impaired and required extensive assistance with activities of daily living. A nursing progress note dated, 06/20/19 at 10:51 PM, showed Resident #22, .refused breakfast meal d/t (due to) tooth pain. [MEDICATION NAME] applied to teeth/gums, but pt (patient) became anxious d/t the [MEDICATION NAME] making his throat numb; he then began calling out and panicking, thinking he could not breathe . A nursing progress note dated, 06/22/19 at 12:19 AM, showed, .Pt continues to have c/o (complaints of) head pain and mouth and teeth pain . A nursing progress note dated, 06/23/19 at 7:15 AM, showed Resident #22, slept through most of the night except for when he starts asking for pain medications . A nursing progress note dated, 06/24/19 at 12:07 PM, showed, Pt c/o headache pain, possible r/t dental issue . A nursing progress note dated, 06/25/19 at 10:24 PM, showed Resident #22, .General chronic pain and headache . A nursing progress note dated, 06/26/19 at 11:00 AM, showed, Called (resident representative) about dental care options patient has no dentist he sees on a regular basis VA (Veteran's Administration) doesn't cover dental Long term insurance Medicaid has not been followed up on from family at this time Will follow up accordingly with appropriate parties . A nursing progress note dated, 06/27/19 at 7:48 PM, showed, Pt states that he has tooth pain in the L (left) side of his mouth, and that it feels swollen. MD (medical doctor) notified of possible infection and waiting for reply/possible orders for abx (antibiotic). A nursing progress note dated, 06/28/19 at 7:30 AM, showed, MD wrote new order for [MEDICATION NAME] (antibiotic) for possible infection . A nursing progress note dated, 06/28/19 at 10:36 AM, showed, Pt continually yells out into the hallway, even when all needs appear to have been met .Pt states that he has tooth pain in the L side of his mouth, and that it feels swollen. MD prescribed [MEDICATION NAME] for possible infection which was started this morning . A nursing progress note dated, 06/28/19 at 4:04 PM, showed, Pt in extreme pain and pointing at the L side of his mouth. Pt started abx this morning for possible infection in mouth. Pain is not being managed with available PRN pain medication. Pt is screaming, crying, hitting himself and staff, and thrashing. Pt is being sent via AMR (America Medical Response transportation) to PHSW (PeaceHealth South West) ED (emergency department) for further evaluation. MD notified . A PeaceHealth South West After Visit Summary, dated 06/28/19, showed Resident #22 was seen at the ED for dental pain. The resident was given a new order for pain medication, directed to continue current antibiotic use and to follow-up with both his primary care physician and any local dentist to recheck and establish care within three days. A nursing progress note, dated 06/28/19 at 9:20 PM, showed, pt returned to facility 6/28 (19) .Additional instructions; call MD in 3 days, call any local dentist in 3 days, send to ED asap if s/sx (signs and symptoms) worsen. A nursing progress note, dated 07/12/19 at 2:29 PM, showed Social Services staff had faxed a referral for Resident #22 to New Day Dental on 07/12/19, 11 days after the recommended ED discharge order of three days. A nursing progress note, dated 07/18/19 at 10:31 PM, showed Resident #22, OOF (out of facility) for dental apt (appointment) this AM; bite adjusted .dentist suggested seeing oral surgeon for removal of teeth; indicates that several teeth, though not infected at this time, will sooner or later become a problem; none are abscessed at this teim (sic) . A Sleep Dentistry of Vancouver/New Day Dental clinical note, dated 07/18/19, showed Resident #22 was seen for dental pain with LR (left rear) tooth when chewing. The resident received treatment and was referred to seek follow-up treatment at the V[NAME] A handwritten Fort Vancouver Post Acute Clinical Report form (somewhat illegible due to handwriting and poor quality), dated 07/18/19, showed a new order for, .needs teeth brushed-lots of plaque consider Dr. Wong .dental clinic for teeth removal .they likely will cause problem sooner or later will flare up. A physician progress notes [REDACTED].#22's Assessment/Plan included mouth pain, (resident) was treated for [REDACTED]. Poor dentition. F/U (follow-up) dental care pending. No documentation was found in Resident #22's medical record of any a follow-up dental appointment after 07/18/19. On 09/06/19 at 9:37 AM, Staff C, Social Services Director, said part of her job responsibilities was scheduling resident appointments. Staff said she had made Resident #22's dental referral to New Day Dental on 07/12/19, however, could not find the original referral she had received from nursing. Staff C said she tried to make appointments as quickly as possible, usually one to two days after receiving the referral. Staff C said she had recently received and reviewed the resident's paperwork from his (MONTH) (2019) dental appointment and until now, was unaware the resident required any follow-up treatment. Staff C said a second, follow-up appointment for dental services should have been made for the resident. Staff C said she would have made this referral if she had received the paperwork from the dental provider sooner. At 10:24 AM, Staff B, Registered Nurse/Assistant Director of Nursing, said Staff C was responsible for scheduling dental and follow-up dental appointments. Staff B said she would have expected Resident #22's dental appointment to have been made earlier than 11 days following his 06/28/19 ER visit. Staff B stated, Somewhere in the mix, a follow-up appointment was missed and fell through the cracks. Staff B said the facility's process for resident follow-up appointments could use improvement. On 09/09/19 at 3:36 PM, Staff B said she would expect staff to do a full assessment and contact the resident's physician when a resident had complaints of oral pain. Staff B reviewed Resident #22's medical record and said the first documentation the resident's physician was advised of the resident's dental pain was on 6/27/19. Staff B said she would not expect the resident to wait seven to eight days with oral pain before receiving treatment. Staff B said she would have expected staff to have notified the physician within 24 hours or less of the resident's dental pain. Staff B stated, It breaks my heart to know we failed the resident. Reference WAC 388-97-1060 (3)(j)(vii)

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (#1) reviewed for quality of care. This failure placed residents at risk of medical complications, hospitalization s and a diminished quality of life. This caused harm to Resident #1 when a Licensed Nurse (LN) removed an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) without ensuring the urinary catheter balloon was completely deflated causing injury (bleeding and hospitalization ) to the urethra (a tube that carries urine out of the bladder to outside of the body). Findings included . Resident #1 was admitted at the facility on 04/02/19 with [DIAGNOSES REDACTED]. Resident #1's medical records showed a baseline care plan was not developed. Resident #1's (MONTH) 2019 physician orders [REDACTED]. -Change Foley catheter on 04/05/19 one time only for 1 day. -D/C (discontinue) Foley catheter on 04/16/19 one time only for 1 day. -Foley 16 french (size of catheter) A review of the (MONTH) 2019 Treatment Administration Record showed the column for 04/05/19 was blank. A nurses progress note, dated 04/07/19 at 4:49 PM, documented, When aspirating balloon only 5 ml (milliliters) would release, I attempted to re-inflate and aspirate balloon again 7 ml released. There was minor tension. Cath (catheter) came out and bubble was still inflated applied pressure to control bleeding. Resident #1 was sent to the emergency room (ER). Resident #1's medical records showed the resident returned to the facility on [DATE] with a new foley catheter in place. The urine color was pink. A physician progress notes [REDACTED].#1 had acute urethral bleeding with blood clots. The urine color was described as bright red. Suspect acute injury with arterial bleed. Resident #1 was sent to ER for further evaluation. On 06/25/19 at 12:45 PM, Resident #1 said he was able to partially see the LN pulling the catheter and then she stopped. Then there was a tug, then there was another tug, then yanked, ripping it out big and I screamed. The resident said the LN stood for approximately one minute in shock. The resident said there was blood on his gown, linens, on the floor and wall. The resident stated, It was like a fountain. The resident said the LN padded him with whatever she could get her hands on. The resident told the LN to call the ambulance. The resident said he was in pain, fear, shock and was scared. On 06/27/19 at 10:05 AM, Staff C said she attempted to deflate the indwelling catheter balloon twice and aspirated 7 ml of fluid total. Staff C said she felt minor tension and continued to remove the catheter. Staff C said the resident started to bleed and he expressed pain. Staff C said she did not know how much fluid was in the balloon as it was placed at the hospital. Staff C said she would have expected the balloon to contain about 10 ml or 15 ml of fluid, but continued with the catheter removal in spite of aspirating less than she would have expected. Staff C said she could not have done it differently given the situation. On 07/08/19 at 11:45 AM, Staff F, LPN, said she would expect, at a minimum, a urinary catheter balloon to hold 10 ml of fluid. Staff F said she would check the balloon size on the catheter prior to removal if the balloon size was not documented in the medical record. Staff F said she if she encountered tension during catheter removal, she would stop, call another nurse to assist or she would notify the physician. At 3:45 PM, Staff B, Registered Nurse and Director of Nursing Services, said she would cut the catheter cord to ensure the catheter balloon was fully deflated if she felt tension. Staff B said she expected staff to stop if tension was felt, reassess, ask another nurse to assist and notify the physician if tension was still present. Staff B said she did not expect for staff to remove a urinary catheter if less than 10 ml was aspirated. Staff B said Staff C should not have pulled the catheter when she obtained 7 ml of fluid and felt tension. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure timely treatment and monitoring was provided to prevent development and worsening of pressure ulcers for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This failure placed residents at risk of worsening skin impairment, a change in health status, pain and a diminished quality of life. This caused harm to Resident #1 when pressure ulcers developed and/or worsened after being identified, and the resident was sent to the hospital on [DATE], two days after being discharged from the facility. Findings included . Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set, an assessment tool, dated 04/11/19, documented the resident required extensive assist with bed mobility, was always incontinent of bowel and bladder, and had one stage 2 (partial thickness loss) pressure ulcer and one unstageable (full thickness tissue loss) pressure ulcer. Resident #1's medical record did not show a baseline care plan was developed for impairment to skin integrity. Resident #1's Braden scale (an assessment tool used for assessing pressure ulcer risk), dated 04/01/19, showed a score of eight indicating the resident was at very high risk for pressure ulcer development. A nurses progress note, dated 04/02/19, documented, foam dressing is used to protect right dorsal (back) foot [DIAGNOSES REDACTED] (redness), tx (treatment) order for [MEDICATION NAME] soaked gauze twice a day to right heel. Resident #1's Admission/Readmission nursing evaluation, signed and dated 04/03/19, documented the resident did not have pressure ulcer(s). A late entry nurses progress note, dated 04/05/19, created on 04/17/19, documented the resident had an open sore on coccyx (buttock) area, cleaned with NS (normal saline) and placed bandage, patient has bandage on right heel, elevating right foot. Resident #1's medical records did not show the physician and the family were notified of the open sore to buttock area identified on 04/05/19. A Skin and Wound Evaluation, dated 04/09/19, documented a stage 2 pressure ulcer to coccyx measuring 4.0 centimeters (cm) by 4.5 cm. A Skin and Wound Evaluation, dated 04/09/19, documented right heel wound measuring 2.1 cm by 3.1 cm. Resident #1's physician orders [REDACTED]. The (MONTH) 2019 Treatment Administration Record (TAR) showed pressure ulcer treatment to the buttock area and the right heel was started on 04/10/19, five days after the buttock pressure was identified and nine days after the right heel wound was identified. Resident #1's medical record showed the resident was discharged home on[DATE] and did not show a referral to home health for wound care services. The hospital medical records, dated 04/13/19, documented, R (right) posterior with a 4 by 5 cm decubitus ulcer, skin breakdown, foul smelling . R (right) heel 3 cm ulcer. A facility's investigation statement, dated 4/15/19, documented on 04/05/19 slight opening-pencil tip in size discolored area all around. A facility's investigation statement, dated 04/16/19, documented on 04/05/19 I noticed a nickel sized sore on her coccyx area. On 04/22/19 at 3:57 PM, Resident #1's family member (FM) said the resident returned home on 04/11/19. The resident had a dressing to the coccyx area. FM said when she removed the dressing, there was strong, foul odor. FM said she observed an open wound. FM said it was new, and the facility had not communicated with her regarding this wound. FM said the wound had a dark yellowish looking wound bed and the area around it. FM said it was approximately 6 cm by 6 cm. FM said the facility did not assist with home health wound care services. FM said Resident #1 was sent to the emergency roiagnom on [DATE] related to the wound. On 04/26/19 at 12:35 PM, Staff D, Registered Nurse, said she completed the admission nursing assessment for Resident #1 on 04/03/19. Staff D said the resident did not admit with a pressure ulcer to coccyx. Staff D said the coccyx area looked purplish in color. Staff D said Resident #1 had a foam dressing to her right heel, and she did not remove the foam dressing to assess. Staff D stated, No treatment was started. I should have looked at it. I did not think of anything else. At 1:51 PM, Staff C Resident Care Manager and Licensed Practical Nurse, said Resident #1 did not admit with a pressure ulcer to coccyx. When asked about Resident #1's coccyx wound noted on 04/05/19, Staff C said he was made aware of it on 04/08/19 and he assessed the wound on 04/09/19. Staff C stated, It looked like there was a pressure ulcer that had gotten worse. The center was dark in color and the surrounding area was pink with superficial skin open. Staff C said the physician and family were not notified, and there was no monitoring and treatment started until 04/10/19. Staff C said it was expected for the nurse who identified a new skin issue to notify the physician and family. Staff C said the nurse should have obtained treatment orders from the doctor, and the wound should have been on the TARs for treatment and monitoring. Staff C indicated he did not know as to why the above was not done timely. Staff C said the resident admitted with right heel wound and had treatment orders in place. Staff C said the orders for the heel never made it to the TARs for treatment and monitoring. Staff C said no treatment was provided to the right heel until 04/10/19. Staff C said treatment and monitoring should have provided from day of admission. At 2:15 PM, Staff B, Director of Nursing Services, said when a new skin issue was identified, it was her expectation for floor nurses to complete a skin assessment, notify the doctor, obtain treatment orders, input the orders, initiate an investigation and provide treatment and monitoring. Staff B said Resident #1 was not admitted with a pressure ulcer to her coccyx. Staff B said she was made aware of the coccyx wound on 04/09/19. Staff B said on 04/05/19 the coccyx wound was identified as an open sore, and staff failed to notify the physician, family, facility management, initiate an investigation and put treatment and monitoring in place. Staff B said the coccyx pressure ulcer was acquired at the facility and could have been avoided. When asked what interventions were in place to prevent skin impairment, Staff B stated, From the looks of it, there was none. Staff B said the facility identified a problem with the admissions process including skin assessments getting completed timely. Reference WAC 399-97-1060(3)(b)

Based on interview, and record review, the facility failed to ensure sufficient preparation and orientation were provided for a safe and orderly discharge from the facility for 1 of 3 sampled residents (#1) reviewed for discharge requirements. This failure placed residents at risk for an unsafe discharge without community support to meet resident care needs. This caused harm to Resident #1 when the facility failed to initiate a referral and/or coordinate with home health for wound care services and the resident was sent to the hospital two days after discharge from the facility. Findings included . Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set, an assessment tool, dated 04/11/19, documented the resident required extensive assistance with bed mobility, was always incontinent of bowel and bladder, and had one stage 2 (partial thickness loss) pressure ulcer and one unstageable (full thickness tissue loss) pressure ulcer. A Skin and Wound Evaluation, dated 04/09/19, documented a stage 2 pressure ulcer to coccyx measuring 4.0 centimeters (cm) by 4.5 cm. A Skin and Wound Evaluation, dated 04/09/19, documented right heel wound measuring 2.1 cm by 3.1 cm. A review of the resident's medical record did not show documentation of discharge planning involving the interdisciplinary team and the resident's representative. The medical record did not show a discharge care plan was developed. Resident #1's medical record showed the resident was discharged home on[DATE]. A discharge transition plan, dated 04/11/19, showed home health services for wound care was not included. The record did not show a referral was made to home health for wound care services and wound care teaching was provided to the resident's representative. On 04/22/19 at 3:57 PM, Resident #1's family member (FM) said the resident returned home on 04/11/19. The resident had a dressing to the coccyx area. FM said when she removed the dressing, there was a strong, foul odor. FM said she observed an open wound. FM said it was new, and the facility had not communicated with her regarding this wound. FM said the wound had a dark yellowish looking wound bed and the area around it. FM said it was approximately 6 cm by 6 cm. FM said the facility did not assist with home health wound care services. FM said Resident #1 was sent to the emergency roiagnom on [DATE] related to the wound. On 05/17/19 at 12:55 PM, Staff C, Resident Care Manager, said it was identified the resident needed resumption of home health services for wound care. Staff C said social services was responsible for sending in a referral for home health services. Staff C said discharge planning was discussed in daily morning meetings. At 1:40 PM, Staff F, Social Services Director, said she was not aware the resident needed home health services for wound care. Staff F said she did not order home health services for wound care for Resident #1. Staff F said if nursing provided the wound care needs, she would have sent in the referral. At 2:50 PM, Staff B, Director of Nursing Services, said the resident's discharge needs should have been re-evaluated when wounds were identified. Staff B said a referral for home health should have been sent. Staff B stated, We missed all the opportunities to make it a safe discharge. When asked if the resident's representative was prepared and oriented for discharge, Staff B stated, No. I think we could have prepared the representative better than the way it was done. Staff B said they were aware there was a gap in communication and had a system breakdown. Reference: (WAC) 388-97-0120 (1) (2) (3) (a)

Based on observation, interview and record review, the facility failed to ensure staff followed and implemented abuse and neglect policies and procedures for identifying, reporting, investigating and protecting residents for 1 of 4 sampled residents (#266) reviewed for abuse and neglect. This failure placed residents at risk of abuse and neglect. The facility's failure to immediately identify, report potential abuse and neglect to state agency as required, failure to initiate immediate investigation and failure to protect residents from potential abuse/neglect constituted an immediate jeopardy on 11/08/18. The immediate jeopardy was removed on 11/13/18 when the facility reeducated staff on responding to abuse and neglect allegations. Findings include . The facility's policy entitled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property Prohibition, updated (MONTH) (YEAR), documented the following: Injuries of Unknown Source: An injury is classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury was not observed by a person or the source of the injury could not be explained by the resident: and 2. The injury is suspicious because of the extent of the injury or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed alone as a particular point in time or the incidence of injuries overtime. Investigation a. The Center conducts a thorough investigation of allegations of mistreatment neglect or abuse including injuries of unknown source . Reporting and Response b. The Center reports allegations and substantiated occurrences of abuse, neglect, exploitation, misappropriation of property, or injuries of unknown source to the state survey and certification agency and appropriate state agency and law enforcement official in accordance with state regulation. Resident #266 was admitted to the facility on [DATE] with multiple diagnoses. The Minimum Data Set, an assessment tool, dated 11/06/18, documented, the resident was moderately cognitively impaired, required extensive assistance in activities of daily living including toileting and bed mobility and was frequently incontinent of urine and stool. On 11/07/18 at 10:29 AM, Resident #266's family member said the resident had a scratch inside her genital area and had vaginal bleeding on Saturday (4 days ago). The family member said staff told her they found a scratch on the residents' genital area. A review of facility's Incident and Accident log showed the incident was not logged. Resident #266's medical records showed no documentation of the incident. On 11/08/18 at 12:21 PM, Staff I, Licensed Practical Nurse (LPN), said Resident #266 had vaginal bleeding on Saturday. Staff I stated, Was menstrual like, she notified the doctor and was told to monitor. Staff I said she was made aware of Resident #266's vaginal bleeding by a therapist who told her the resident had wiped after using the bathroom and she saw the blood. Staff I stated, I did not look at her before I called the doctor because she was up in her wheel chair. Staff I said she did not report to state hotline nor her supervisor because the resident was not complaining and if I felt something was wrong. Staff I said she did not document the incident as she was late getting out and could not chart. Staff I said Resident #266's family member told her the resident had no vaginal bleeding in the two years the family member took care of the resident, had no history of it and it was the first time it had occurred. At 12:50 PM Staff E, LPN, said he was told in report by the night shift nurse, on 11/04/18, Resident #266 had a scratch on her groin and to monitor for vaginal bleeding. Staff E said the resident should have been on the active list for incidents, and stated, It's an incident. It's not normal for someone of her age. At 2:53 PM, Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), said she was not aware of the incident until a bit ago, Staff I, told me around 1:40 PM. Staff B said it was her expectation for staff to have called the hotline, notified her, made a progress note, placed the resident on alert, and called the physician. Staff B said we would have investigated on that day. The resident should have been sent out for full assessment. She is not 100% cognitively there. When asked if failure to rule out abuse placed other residents at high risk of abuse, Staff B stated, Yes. I have sent (Staff I) home now. I have called it now, started investigation and we are providing training. At 4:09 PM, when notified of the concerns and the failure to follow and implement the abuse policy, Staff A, Administrator, stated, I understand how severe it is. On 11/09/18 at 8:31 AM, Staff J, Occupational Therapist, said on 11/03/18, Resident #266 transferred to toilet, the resident wiped and when the resident wiped in front, she noticed bright red blood. The resident denied it happening before. Staff J said she told the nurse and left the resident in the wheelchair or bed. Staff J said later a nursing assistant (NA), who she could not recall the name, said they saw the bright red blood and commented on the resident's age and that she didn't have a period. When asked why she did not report this to the state agency, Staff J said her thinking at the time was it was a nursing issue, like a tear, had no baseline of behavior, there was nothing related to bleeding in the resident's history she knew of and resident didn't act concerned. When asked what training she had on abuse, Staff J said yearly abuse training through genesis and not at the facility. At 11:44 AM, Staff K, NA, said she worked with Resident #266 on 11/03/18. Staff K said Resident #266 had blood in her attends when she changed her. A therapist helped the resident to the bathroom and the therapist then told Staff K the resident was having vaginal bleeding. Staff K stated, I changed her after the nurse told me to go look at the bleeding. I opened the attends and I saw blood. I saw a big scratch/cut about an inch on her labia. It looked like fresh blood, like menstrual period. The nurse did not come in to look. At 1:08 PM, Staff B said it was her expectation only licensed staff to complete a perineum assessment and not to delegate to a NA. Staff B stated, The nurse should look at it. Staff B said the nurse should have assessed Resident #266. The resident should have been sent out. We send (residents) out if unsure. Staff B said Staff I no longer worked for the facility. Reference WAC 388-97-0640(2)

Based on observation, interview, and record review, the facility failed to ensure residents received a therapeutic diet as ordered and received adequate fluids for 2 of 4 sampled residents (#265 & 266) reviewed for nutrition and hydration. This failure placed residents at risk for dehydration and health complications. This caused harm to Resident #266 when she was admitted to the hospital with [REDACTED]. Findings include . 1) Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 11/06/18, documented the resident was moderately cognitively impaired and required extensive assistance with eating and drinking. On 11/07/18 at 10:14 AM, Resident #266's family member said she was unsure if the resident was getting enough to drink. At 3:13 PM, Staff F, Licensed Practical Practice (LPN), said Resident #266 was sent to the emergency room due to low blood pressure, lethargy and possible dehydration. On 11/08/18 at 10:31 AM, Staff C, Resident Care Manager (RCM) and Registered Nurse (RN), said Resident #266 was admitted to the hospital for dehydration and altered mental status. A physician progress notes [REDACTED].#266 including to monitor fluid and nutrition intake. Check BMP. No monitoring of fluid intake was found in the resident's medical chart. Resident #266's Nutritional Evaluation, dated 11/02/18, identified fluid consumption <1000 milliliters (ml) daily, estimated fluid needs 1875-2200 (25-30ml/kg/bw), fluid intake inadequate, and dry sticky lips and mouth. Nutrition interventions included Encourage po (by mouth) fluids 240-480 ml per meal and in between related to <1000 ml daily. The nutritional problem care plan, initiated on 11/02/18, documented interventions including to offer liquids (including thick liquids) between meals. The potential risk for dehydration or potential fluid deficit care plan was only initiated on 11/07/18. Resident #266's (MONTH) (YEAR) fluid intake entries showed 4 out of 7 days the resident's fluid intake was 880 ml or less per day, which was below the estimated fluid needs for the resident. Resident #266's physician orders [REDACTED]. Please add additional fluid intake into PCC (Electronic Health Record) every day shift. The order start date was 11/06/18, 6 days after the physician plan to monitor fluid and nutrition intake and 5 days after the dietician identified inadequate fluid intake. On 11/13/18 at 1:02 PM, Staff C said the facility team reviewed residents' notes during clinical, utilization review, Medicare, and patients at risk meetings. Staff C said Resident #266 was not reviewed at any of those meetings. Staff C said the team reviews residents' fluid intake when a change in condition, including altered mental status, was identified. Staff C said the physician plan for Resident #266 was a great plan, but was not carried out. At approximately 1:20 PM, Staff B said the facility team reviewed residents' medical records including physicians' notes and dietician notes at clinical meetings, and it was expected for staff to interpret physicians' plans as orders and if they were unclear staff should contact the physician. Staff B said staff should have reviewed the physician progress notes [REDACTED]. Staff B said Resident #266 was at high risk of dehydration and dietician recommendations should have been implemented timely. Staff B said Resident #266 was not reviewed in clinical and patients at risk meetings on 11/02/18, and on 11/05/18, the clinical meeting did not occur. When asked if not having clinical meetings contributed to the failed timely implementation of interventions for Resident #266, Staff B stated, Yes. Staff B said Resident #266 was admitted to the hospital due to dehydration and altered mental status. Failure to implement interventions as ordered by offering sufficient fluid to Resident #266 caused harm when Resident #266 was admitted to the hospital with [REDACTED]. 2) Resident #265 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 48-hour Baseline Plan of Care documented the resident was alert and oriented. Physician orders, dated 10/31/18, documented a diet order of CCHO (carb controlled), renal (a diet generally low in sodium, protein, and phosphorus), and regular texture. Resident #265's nutritional care plan, initiated 10/31/18, documented interventions for the resident be provided and served the diet as ordered. On 11/06/18 at 11:50 AM, Resident #265 was observed receiving a lunch tray. At 12:08 PM, Resident #265 said he had received the wrong tray. At 12:09 PM, the wrong tray was removed from Resident #265's room. At 12:17 PM, Staff Z, Dietary Manager, said a new tray request for Resident #265 had not been made. At 12:25 PM, Resident #265 was still waiting for his correct tray. Staff D, Staff Development Coordinator (SDC) and Registered Nurse (RN), said the tray would be coming on another cart. At 12:29 PM, Resident #265 said he still didn't have his lunch tray. At 12:30 PM, Staff Y, Certified Nursing Assistant (CNA), said to make sure they give the right tray to the right resident they look at the slip of paper on their tray showing the resident's name and room number. Staff Y said she passed the lunch trays in the hallway for Resident #265. When asked how Resident #265 ended up with another resident's tray, Staff Y stated, I don't know. At 12:42 PM, Resident #265 said he was told the kitchen had run out of what he had ordered, and he had to order salad and soup. Resident was observed with a taco salad and split pea soup. Resident #265 said the same thing had happened with his dinner tray the previous night. The resident said he ate the non-[MEDICAL TREATMENT] diet because they took so long to get mine and I was hungry so I just ate it. It was good, probably because it wasn't a no salt dinner. On 11/14/18 at 9:36 AM, when asked about the process to ensure residents receive their diet as ordered, Staff B stated, Diets are being reviewed by the kitchen manager. The kitchen manager checks the trays and the aides (nursing assistants) check the tickets. When informed of the situation with Resident #265's tray, Staff B stated, That's not good at all. There should have been some frontline people that should have fixed it. If the nurse was informed, I would expect the resident to be put on alert. When asked how this could have affected the resident, Staff B stated, Diets are specific to co-morbidities. Reference WAC 388-97-1060 (3)(h)-1060 (3)(i)

Based on observation, interview and record review, the facility failed to ensure received residents received medications in a timely manner for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This failure placed residents at risk of delayed interventions and treatment, increased side effects and a decreased quality of life. This failure caused harm to Resident #2 when he experienced increased tremors. Findings include . 1) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/06/18 at 11:18 AM, 4:43 PM and on 11/07/18 at 8:29 AM and 11:02 AM, Resident #2 was observed with moderate tremors and occasional jerking movements in both arms and legs. The resident was observed grimacing, lying crossways on his bed and said he did not feel like he could get up due to the tremors. At 11:18 AM, the resident said he had not received his long acting [MEDICAL CONDITION] medication since he came to the facility. The resident said he told a nurse and a provider and was told they would look into it. Resident #2 said he felt like he was having increased tremors and body movements, and the tremors made it more difficult for him to walk. Resident #2 said he did not feel as steady as he usually did and felt his therapy progress had slowed because of it. A progress note, dated 10/31/18 at 8:07 PM, documented patient states was taking [MEDICATION NAME] ER (extended release/long acting) and [MEDICATION NAME] immediate release (short acting) prior to his admission to the facility. There was no documentation indicating the provider was notified. A provider note, dated 11/01/18 at 5:38 PM, documented, Presently, patient states he is not getting his [MEDICATION NAME] .Patient was on [MEDICATION NAME] in addition to [MEDICATION NAME]. Re-start [MEDICATION NAME] 100 mg one every day. Continue [MEDICATION NAME] 25-200 one tablet 4 times a day. Monitor . A hand-written provider order, dated 11/02/18, documented, [MEDICATION NAME] tablet 100 mg one by mouth every AM for [MEDICAL CONDITION]. The order was date and time-stamped and showed the order was received and pharmacy notified on 11/06/18, 4 days after the order was written and 7 days after the resident informed staff he needed the medication. The resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 11/08/18 at 3:20 PM and 11/09/18 around 10:50 AM, Resident #2 was observed with no tremors. Resident #2 said he made good progress with walking after his tremors decreased from the med they started this week and he would be going home the next week. On 11/09/18 at 9:38 AM, Staff E, Licensed Practical Nurse (LPN), said he had notified the provider of the resident's request for his long acting [MEDICATION NAME] via an inter-office communication form and placed the form in the provider's box. At 9:51 AM, Staff E said resident progress notes were reviewed daily by the Inter-Disciplinary Team (IDT) and indicated the IDT should have followed up on documentation in Staff E's 10/31/18 progress note. On 11/14/18 at 10:19 AM, Staff D, Registered Nurse (RN) and Assistant Director of Nursing Services, said the facility had recognized there was a problem receiving timely physician paper orders and had not fully implemented a new process as of this time. Staff D said if an ordered medication was not available in the facility's medication storage unit, he would expect staff to contact the pharmacy and order it stat. Staff D stated, That was a long wait. Not receiving the long acting medication for [MEDICAL CONDITION] in addition to the short acting medication caused the resident harm when his tremors increased and he felt his progression towards discharge was delayed. Reference WAC 388-97-1060 (3)(k)(iii)

Based on interview, observation, and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for 2 of 4 sampled residents (#1 & 2) reviewed for dignity. Failure to answer call lights that resulted in incontinence, placed residents at risk for diminished self-worth, humiliation, embarrasment, decreased quality of life and lack of dignity. This caused harm to Resident #1 and #2. Findings include: A facility policy, dated March 2017, documented each resident had the right to be free from mistreatment, neglect and are not subjected to abuse by staff, other residents, volunteers, consultants, family members, and others who may have unsupervised access to residents. Employees are to provide goods and services to residents in a manner to avoid physical harm, pain, mental anguish, and/or emotional distress. 1) Resident #1 was admitted to the facility on [DATE] with multiple diagnoses. The Minimim Data Set (MDS), an assessment tool, dated 9/25/17, indicated the resident was alert and oriented and required limited assistance with activities of daily living. The facility investigation, dated 9/26/17, documented Resident #1 had to wait at times for toileting causing her to have accidents. On 9/29/17 at 3:16 p.m., Resident #1 said she was keeping a log on the issues she experienced in the facility. Resident #1's log documented having to wait for call lights to be answered and having accidents due to not getting to the bathroom in time. Resident #1 stated she had stopped drinking so much water because of fear of having an accident. At 3:30 p.m., Resident #1 stated, My call light was not being answered and I wet myself and had to wear underwear and a sheet in bed until my husband could bring me clothes. It made me feel horrible was very humiliating. I shouldn't have to have an accident. 2) Resident #2 was admitted on [DATE] with multiple diagnoses. The MDS, dated [DATE], indicated the resident was alert and oriented and required extensive assistance with activities of daily living including transfers, walking dressing, toileting and personal hygiene. On 10/13/17 at 2:06 p.m., Resident #2 stated, I waited 2 hours during the day and I had an accident. I cried and I was so embarrassed. It has happened twice this week. Resident #2 was observed to be very tearful. At 2:45 p.m., the Director of Nursing Services (DNS) stated, The goal is for the resident not to have a situation with incontinent episode. (Staff) are doing their best to get to them as soon as they can to prevent an accident. I don't think it's intentional. I wouldn't want anyone to soil themselves. Will it happen, realistically, yes. Sometimes they aren't able to get there before they go to the bathroom. It takes time to get someone to help. Reference WAC 483.15(a)-0860 (1)(a)

Based on interview and record review, the facility failed to provide an environment that was free from accident hazards for 1 of 4 sampled residents (#1) reviewed by accidents. Failure to provide adequate supervision while a resident was in a sit to stand lift, placed residents at risk of pain, bruising and injury. This caused harm to Resident #1. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 9/25/17, indicated the resident was alert and oriented and required limited assistance with transfers. On 9/29/17 at 3:30 p.m., the resident was observed with a large bruise under her right arm and a light bruise under her left arm. On 10/13/17 at 3:43 p.m., the resident's family member stated, I came to visit and she showed me bruises under her arms and told me she was left on the lift for an amount of time. The facility investigation, dated 9/26/17, documented Resident# 1 reported being put in the mechanical lift and left there while the caregiver went to get supplies. This caused bruising underneath her arms which were observed. Documentation noted Nursing Assistant (NA1) admitted to leaving Resident #1 in the lift, left to get supplies, and realized it was the wrong thing to do. At 2:45 p.m., the Director of Nursing Services indicated residents being assisted with a lift should not be left alone. At 4:24 p.m., the Administrator stated, We were not told until the 26th (about the incident). We immediately started an investigation. Reference WAC 483.25(h)(1)-1060 (3)(g)

Based on interview and record review, it was determined the facility failed to ensure proper treatment and care for 1 of 2 sampled residents (#1 & 2) with intravenous devices when they failed to implement consistent policies for care and maintenance of peripherally inserted central catheter (PICC) lines. This failure caused harm to Resident #1 when, while providing care, the internal lining of the PICC catheter ruptured, resulting in a ? inch tear and partially severed catheter tip. Findings include: Resident #1 was admitted to the facility on [DATE] for rehabilitative therapy following surgery to the left shoulder. The resident was cognitively intact and able to make her needs known. The resident was admitted with a Peripherally Inserted Central Catheter (PICC) through which intravenous (IV) antibiotics were to be administered. A PICC is a specialized catheter used for long-term IV therapy. The PICC is inserted into a vein in the upper arm and advanced until the tip of the catheter is located just above the right atrium (upper chamber) of the heart. On 10/15/13 at 1:30 p.m., the Director of Nursing (DON) provided the facility's PICC flushing procedure, dated 10/1/2005. The policy directed staff "if resistance is met when flushing, no further attempts to flush should be made, and the appropriate infusion staff will be contacted." The DON reported formal training for PICC line care not was provided during orientation. The nurses were expected to learn skills from the other nursing staff and be "checked off" as each new skill was performed. On 10/16/13, at 10:07 a.m., the Assistant Director of Nursing (ADON) verified that while several different policies regarding PICC lines were available in the facility, the nursing staff were expected to follow the "ProPac Pharmacy" policy. The "ProPac Pharmacy IV Policies & Procedures" page 89, stated, "Disinfect connection device with alcohol wipe; connect 10 cubic centimeter (cc) syringe containing normal saline to catheter device; aspirate (to remove by suction) slowly for blood return to ensure patency (unobstructed) of catheter; flush with normal saline; disinfect connection device; administer medication. "Page 115 stated, "Central venous catheters should have blood return aspirate before being used." Page 88 stated, "If resistance or lack of blood return arise at any time during flushing, stop the infusion and consult IV nurse specialist or physician." The ADON reported, "Our policy is to stop and reposition the resident if resistance is met. If that doesn't work, the nurse should change the dressing. You won't find the dressing change in our policy, that's my fault. We tell the nurses that's what they should do because that's what we learned from the Kaiser IV team when they did our education. I would expect a nurse to follow that protocol if there was an occlusion. I would expect the nurse to flush gently, not forcefully." The ADON acknowledged there could be some confusion among the nurses because inconsistencies were present in the three policies (two written/ one unwritten) expected to be followed by the nursing staff regarding PICC lines. The written facility policy directed the nurse to flush the PICC with saline while the "ProPac" policy directed the nurse to aspirate blood prior to flushing with saline. All three policies directed the nurse to stop if resistance was met during flushing and no further attempts to flush should be made. The nurse was directed to notify appropriate infusion staff. The unwritten policy directed the nurse, upon meeting resistance, to reposition the resident. If resistance was still met, the nurse was directed to change the dressing. On 8/21/13 at 3:45 a.m., Licensed Nurse (LN) G documented, "PICC flushed with difficulty, required cathflow treatment due to complete occlusion at 10:00 a.m." Cathflo is a medication instilled into a PICC line to break up clots. A doctor must be notified about the clogged PICC line, and an order must be given before Cathflo can be used. Subsequent nursing notes indicate the resident's PICC line was easily flushed following the Cathflo. On 8/24/13, at 6:30 p.m., Licensed Nurse (LN) C documented in the resident's chart, "PICC patent and flushed well upon stopping her IV antibiotic this a.m." An affidavit written by LN D, dated 10/16/13, reported she was the medication nurse on 8/24/13 from 6:00 p.m. to 10:00 p.m. LN D reported, "I applied gentle pressure in order to flush the PICC line but felt resistance so I stopped." LN D wrote, "I then reported to LN A that I felt resistance when attempting to flush her PICC line." On 8/25/13 at 2:10 a.m., LN A documented in Resident #1's chart, "Med nurse tried to set up IV antibiotics at the beginning of shift. PICC would not flush. I came in to try as well. The first try, nothing happened. The second try, a small amount did go through and the patient said she could feel the coolness of the saline. So, I pushed a little more and the flush started going smoothly, but the patient said she felt a "pop" and then pain in her arm below the PICC site. I could not see anything that could be causing pain in this area, but she stated that it was very painful and began to sob. I called another nurse to help me evaluate. There were still no signs of infiltration (fluid leaking outside of IV and into the surrounding tissue), so the other nurse proceeded to pull back the plunger. He got blood return. He then tried to push the flush just a little and the PICC site started bleeding. The patient was in tears and continued to complain of pain. I call the on-call MD. The decision was made to transfer the patient to Sunnyside (hospital) to have the PICC evaluated and replaced if needed." On 10/16/13, at 11:15 a.m., the DON was asked why LN A and B did not follow the facility's policies directing the nurse to aspirate blood from the PICC line prior to flushing and to stop immediately if resistance was met. LN A attempted to flush the resident's PICC line twice after the medication nurse met resistance, resulting in three attempts to flush a PICC line after meeting resistance. Checking for blood return was done by LN B after the three failed attempts to flush the PICC. LN B flushed a fourth time after the resident complained of pain and began crying. The DON stated, "I think the nurses did what they were supposed to do under the circumstances." On 10/22/13, at 3:45 p.m., LN A was interviewed by phone. LN A stated the facility provided no formal training for PICC lines. The facility expected new nurses to perform PICC line flushing while another facility nurse observed. If the nurse overseeing the procedure approved the technique, the new nurse was then able to perform PICC line procedures independently. LN A stated a binder of policies and procedures was kept at each nurse's station. She stated she did not know if the policies were "ProPac Pharmacy's" or the facility's. LN A stated, "The med nurse told me she was unable to flush the resident's PICC line. I attempted to flush the line but it didn't go so I stopped. I repositioned her and then tried to flush. It started going and I was able to get about ? of the flush in. The resident said, "Wait. Stop. I'm having pain." She told me she felt a "pop". She indicated the pain was about 2 inches below the insertion site. She said it was still hurting after I stopped. I don't know why it would hurt that far from the insertion site. LN B assessed the PICC line. He aspirated blood and flushed. The resident said she was having pain so he stopped and we called the doctor. The doctor said to send her to the hospital. I don't feel I used excessive force when I flushed. Maybe there was a weak spot in the PICC line." LN A stated, "I don't remember if I aspirated the PICC line before I flushed it. I'm fairly new to nursing and PICC lines. I was taught in school to aspirate first." An affidavit written by LN B, dated 10/17/13, stated, "LN A stated she was trying to flush an occlusion (blood clot) from the patient's PICC when the patient felt pain in her arm and felt a "pop" and at that point LN A immediately stopped. Upon assessment of the PICC site no infiltration, redness, or bleeding was noted and the PICC line appeared to be intact. When interviewing the patient she stated she felt a sharp pain a few inches below the PICC insertion site in the inner aspect of the right upper arm, but the pain had subsided from the initial onset. I palpated the site without any pain noted and then tried to aspirate from the PICC line and got return of blood. Patient was asked if pain was note (sic) and she denied any. I then attempted to advance the plunger very gently and pain was noted and procedure was stopped, blood was noted from the insertion site of the PICC. At this point I advised LN A notify the on-call MD." Resident #1 was admitted to the hospital ED on 8/24/13 at approximately 10:30 p.m., for assessment on her PICC line and possible replacement. On 8/24/13, at 11:12 p.m., LN E, the hospital Vascular Access Nurse, documented in Resident #1's chart, "Patient's PICC right arm discontinued due to hole in catheter, most likely from a hard push." At 11:33 p.m., the ED Medical Social Worker (MSW) documented, "Vascular Access Nurse comments that in her [AGE] years of doing this work she has not seen a PICC line in such bad shape-apparently it appears as if the SNF (skilled nursing facility) staff "jammed" meds into the line." The MSW reported meeting with Resident #1to discuss the resident's request for assistance with a smooth transition back to the facility. MSW documented, "Patient is somewhat fearful of retaliation at facility." At 11:43 p.m., LN F, the ED Care Manager, documented, "Telephone call to admissions coordinator to relay concerns about state of PICC line and suspected improper use of equipment when flushing and/or administering medication. Admissions coordinator appears very concerned, states she will escalate this issue to their DON." On 10/16/13, at 2:26 p.m., Resident #1 was interviewed by phone. The resident stated, "On the night I went to the hospital, they were three hours late with my antibiotic. That was not acceptable. The first nurse had trouble with my PICC line so another nurse came in an tried to flush it. She pushed on the plunger until I yelled and heard a "pop". They finally sent me to the hospital. The hospital was going to send me back to the nursing home and have me come in the next day to have a new PICC line put in. I said no because I was afraid. The IV nurse who pulled out the PICC line said she had never seen anything like it. There was a hole in the PICC line that was big enough for me to see. I was afraid to go back because I was concerned they were going to punish me for telling the hospital about my PICC line. I was very ill and felt very vulnerable. I was afraid they might not give me my medications or give me the wrong ones. If they are this negligent with my PICC line management then how do I know they are going to give me the right meds?" The resident stated, "No one from the facility talked to me about my concerns. When I got back, I called my daughter and told her I wanted to get out of there right away. I told them the morning of the 27th that I was leaving in 10 minutes and I did." On 10/17/13, at 1:40 p.m., LN F was interviewed by phone. LN F reported, "The patient was worried about retaliation from the facility. She was also concerned about having the staff do anything with her PICC line." At 3:25 p.m., LN E was interviewed by phone. LN E stated, "The PICC line had an internal tear about ? inch long, tearing the peripheral tip. When you see a PICC line with a tear like that it usually means someone flushed too hard. An internal hole in a PICC line doesn't just happen. I've really never seen anything like this in the [AGE] years I've been doing this." On 10/22/13, at 4:00 p.m., LN A stated, "The hospital IV department sent a thick packet about PICC line care. There was a copy at each nurse's station. We were told it was FYI and we could read it when we had time. There was no sign-off sheet saying we read it. This week the DON sent out a memo saying if a PICC line is sluggish we are to stop and call the doctor for an order for [REDACTED]." The facility's failure to provide adequate training and consistent policies for PICC lines caused physical and psychological harm and unnecessary hospitalization to Resident#1 when the licensed nurses attempted to flush the resident's PICC line after meeting resistance. .