Every finding on record at Lacey Post Acute & Rehabilitation

.Based on observations, interviews and record review, the facility failed to implement appropriate infection control practices when providing wound care for 1 of 3 sampled residents (Resident 1) reviewed for wound care. This failure placed residents at risk for a pressure ulcer wound infection, delayed wound healing, and a diminished quality of life.Findings included.Record review of the facility policy titled, Clean Dressing, undated, indicated, Clean technique involves strategies used in resident care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies. In an observation on 08/11/2026 at 2:31 PM, Staff C, Licensed Practical Nurse (LPN), was asked to perform wound care on Resident 's sacral wound (area of the lower back and upper buttocks). Staff C entered room with scissors and a clear solution in a plastic cup, she said was to pack the wound. Staff C laid the scissors directly on Resident 1's bedding providing no barrier and sat the cup of solution on top of the nightstand. Staff C then removed the soiled dressing from Resident 1's sacral wound area and discarded the soiled dressing. Staff C picked up a package of dry dressings and pulled out a stack of 4x4 gauze. Staff C proceeded to pick up a bottle of wound cleanser and spray both the gauze and inside wound surface and place the wound cleansing spray bottle on top of the nightstand. Staff C opened a wound packing strip bottle (used to fill the inside of the wound) and packed the wound to fill the open space. Staff C used the scissors to cut the packing strip, closed the bottle and laid the scissors on the bed surface again with no barrier. Staff C completed Resident 1's wound care and placed the contaminated scissors on top of the infection control cart in the hallway. Staff C did not change her gloves during the wound dressing change. In an interview on 08/11/2026 at 2:46 PM, Staff C, LPN, said they had not received specific wound care training at the facility. Staff C said that she learned about wound care in nursing school. Staff C said she was not aware she had contaminated the wound during the dressing change. In an interview on 08/11/2026 at 2:53 PM, Staff B, Director of Nursing and Registered Nurse (RN) said she would expect the nurse to perform a clean dressing change without cross contaminating the wound bed. In an interview at 3:17 PM, Staff A, Administrator and RN, said the wound had been treated with antibiotics for an infection and would expect the nurse performing wound care to use a clean procedure to prevent wound contamination and infection. Reference WAC 388-97-1320(5)

Based on interview and record review, the facility failed to notify the State Ombudsman of the transfer to hospital and/or discharge from the facility for 2 of 2 sampled residents (Residents 3 and 124) reviewed for discharge and hospitalization. This failure placed residents at risk of not knowing their rights during discharge and a diminished quality of life.Findings included. Record review of Resident 3's Electronic Health Record (EHR) showed Resident 3 was admitted to the facility on [DATE], and was cognitively intact. Record review of Resident 3's Discharge Minimum Data Set (MDS, an assessment tool), dated 07/11/2026, documented Resident 3 had an unplanned discharge to a Short-Term General hospital on [DATE] with return anticipated. Record review of Resident 3's EHR showed no documentation that the State Ombudsman had been notified of the transfer to the hospital and subsequent discharge from the facility. Resident 124 was admitted to the facility on [DATE]. Record review of the Admissions MDS, dated [DATE], showed Resident 124 was cognitively intact. Record review of Resident 124's Discharge MDS, dated [DATE], documented Resident 124 had an unplanned discharge to a Short-Term General hospital on [DATE] with return anticipated. Record review of Resident 124's EHR showed no documentation that the State Ombudsman had been notified of the transfer to hospital. In an interview on 07/22/2026 at 11:26 AM, Staff Q, Social Services, said the facility had not been notifying the ombudsman about hospital transfers and discharges since April 2026. In an interview on 07/22/2026 at 12:04 PM, Staff A, Administrator In Training, said the facility had new social workers who did not know they were supposed to notify the ombudsman of residents transfer and/or discharges. Reference WAC 388-97-0120 (5)(b)(i)

Based on interview and record review, the facility failed to obtain physicians order for air mattress/settings, ensure air mattresses were on and functioning and were included in residents care plan and assessments for 3 of 3 residents (Resident 71, 72 & 116) reviewed for quality of care; and the facility failed to initiate the bowel interventions for 1 of 6 residents (Resident 72) reviewed for constipation. These failures placed residents at risk for adverse outcomes, wound deterioration and a decreased quality of life.Findings Included . AIR MATRESSES Resident 71 was admitted to the facility on [DATE]. Record review of the Admissions Minimum Data Set (MDS, an assessment tool), dated 07/01/2026, showed Resident 71 was cognitively intact and was at risk of developing a pressure ulcer (an injury to the skin caused by long-term, uninterrupted pressure on a specific area). During an observation on 07/21/2026 at 3:18 PM, Resident 71 was observed lying in bed on an air mattress. The air mattress pump was observed to be turned off. Record review of Resident 71's electronic health record (EHR) did not show a physician's order for an air mattress, air mattress settings, care plan or assessment for the use of an air mattress. During an interview and observation on 07/21/2026 at 3:22 PM, Staff G, Licensed Practical Nurse (LPN), observed Resident 71's air mattress pump and turned it on. When asked how Staff G would know that the mattress was functioning as required, Staff G stated they would know the mattress is functioning, if the light is on and its running. Resident 72 was admitted to the facility on [DATE]. Record review of the Admissions MDS, dated [DATE], showed Resident 72 was cognitively impaired and had one unhealed pressure ulcer. Review of Resident 72's EHR did not show a physician's order for air mattresses settings, an air mattress care plan or assessment for the use of an air mattress. During an observation and interview on 07/21/2026 at 3:27 PM, Resident 72 was observed to be lying in bed on an air mattress. The air mattress pump was set on standby. Staff K, Registered Nurse (RN), observed the air mattress pump and hit the power button to turn the pump on. Resident 116 was admitted to the facility on [DATE]. Record review of the Admissions MDS, dated [DATE], showed Resident 116 was moderately cognitively impaired and was at risk of developing a pressure ulcer. Record review of Resident 116's nurses progress notes, dated 07/01/2026, documented, Pressure reducing mattress noted. Record review of Resident 116's physicians order dated 07/19/2026, documented, APM [Alternating Pressure Mattress] but did not have resident specific settings to be used. During an observation on 07/21/2026 at 3:16 PM, Resident 116 was observed lying in her bed with the air mattress setting set on firm. During an interview and observation on 07/21/2026 at 3:24 PM, when asked what the recommended therapeutic setting for Resident 116's air mattress was, Staff G said Resident 116's mattress was set to Resident 116's level of comfort. During a joint interview on 07/22/2026 at 2:34 PM, Staff K, Regional Director of Operations, said a physician's order with mattress settings, care plan and assessment were to be obtained if a resident was determined to need an air mattress. Staff C, Director Of Nursing/Registered Nurse, said staff were to ensure that air mattresses used by residents were on and functioning. Reference WAC 388-97-1060(3)(b) BOWEL PROTOCOL Resident 72 was admitted to the facility on [DATE]. The 5-day Minimum Data Set, dated [DATE], indicated Resident 72 was severely cognitively impaired. Review of Resident 72's care plan, dated 07/12/2026, the resident requires toileting assistance r/t [related to] dependence with toileting ADL [activities of daily living]. Review of Resident 72's bowel movement task sheet, dated 07/03/2026 to 07/22/2026, documented, Resident 72 did not have any bowel movements from 07/03/2026 at 9:43 PM till 07/11/2026 at 9:59 AM. Review of Resident 72's Medication Administration Record, dated July 2026, did not have any documentation of a bowel intervention. During an interview on 07/22/2026 at 1:46 PM, Staff O, Licensed Practical Nurse (LPN), said the nursing assistants documented BMs in the EHR. Staff O said if a resident did not have a BM within 72 hours of the last BM, then the bowel protocol would be initiated. During an interview on 07/22/2026 at 1:49 PM Staff M, Unit Manager/LPN, said if the EHR dashboard indicated a resident did not have a BM in three days nursing would initiate the bowel protocol. When asked about Resident 72 not having any BMs earlier in the month, Staff M said Resident 72's daughter provides care from time to time. Staff M said Nursing Assistants should follow-up with Resident 72's daughter to see if they did bowel care so they could document. Reference WAC 388-97-1060(1)(2)(c)

Based on observation and interview, the facility failed to secure medications in 1 of 4 sampled treatment carts (400 hall treatment cart) reviewed for medication storage. This failure placed residents at risk of misappropriation of medication and a diminished quality of life. Findings included. Record review of the facility policy, titled, Medication Storage, undated, documented, . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. In an observation on 07/19/2026 at 9:58 AM, the 400 hall treatment cart was observed in the 400 hall unlocked. No nursing and/or facility staff were observed in the hallway or within view of the treatment cart. A resident was observed walking down the hall past the cart. Surveyor was able to open all five drawers of the unlocked treatment cart with access to multiple tubes and bottles of creams and ointments, to include a prescription labelled medication, nystatin topical powder (a prescription antifungal medication). In an interview on 07/19/2026 at 10:06 AM, Staff I, Licensed Practical Nurse (LPN), was asked to observe the unlocked 400 hall treatment cart. Staff I said she did not know the process for locking treatment carts. Staff I said she did not know if she had a key to unlock the cart and did not want to lock in case they could not get it open. Staff I then left the cart unattended and unlocked. In an interview on 07/19/2026 at 10:12 AM, Staff H, LPN, said treatment carts should be locked whenever they walked away from them. Staff H said every nurse had a key to their treatment cart. When asked about the unlocked 400 hall treatment cart, Staff H said it should have been locked. In an interview on 07/19/2026 at 10:13 AM, Staff E, Staff Development/Infection Preventionist/Registered Nurse (RN), said she just locked the 400 hall treatment cart, stating, It was supposed to be locked. In an interview on 07/20/2026 at 2:14 PM, Staff B, Regional Director of Clinical Operations/RN, said she expected medication carts were locked when no one was at the cart and/or in the hallway near the cart. Reference WAC 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to ensure food items were labeled and dated when opened in 3 of 4 Resident Nourishment Refrigerators and failed to ensure proper hand hygiene was completed for 1 of 2 dining rooms (Horizon Point, upstairs) reviewed for dining. This failure placed residents at risk for food borne illness, the spread of infection transmission, and a deceased quality of life. Findings included . NOURISHMENT REFRIDGERATORS Record review of the facility policy, titled, Foods Brought by Family/Visitors, revised 03/31/2026, documented: 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with resident's name, and the use by date as appropriate. 7. The nursing staff and/or resident/resident representative/family is responsible for discarding perishable foods on or before the use by date. 8. The nursing and/or food service staff must discard any foods prepared for the resident that shows obvious signs or potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). During an observation on 07/19/2026 at 10:25 AM, the resident food nourishment refrigerator on the first floor, was observed with the following expired, opened items: One box of Dominos pizza containing left over pizza slices, with a use by date of 07/15/2026. One packaging of partially eaten Walmart Rotisserie chicken, with a use by date of 07/09/2026. One plastic to go container with chicken salad sandwich, unlabeled. One small plastic tupperware container with stew, unlabeled. One 8 oz (ounce) Creamy Clam Dip opened at the top, unlabeled. During an observation on 07/19/2026 at 10:33 AM, the resident nourishment refrigerator on the second floor, was observed with the following expired, opened items: Two small kitchen made salads, with a use by date of 07/14/2026. One small partially eaten Panera Break soup cup, undated. One small tupperware container with egg salad, undated. One large partially consumed Starbucks orange beverage, with use by date of 07/06/2026. During an observation on 07/19/2026 at 11:50 AM, the second floor dining room/pantry refrigerator, was observed with the following unlabeled items: One large Crockpot with partially eaten stew, undated. In an interview on 07/19/2026 at 1:15 PM, Staff T, Dietary Manager, said the resident nourishment refrigerators were maintained by the kitchen staff. Staff T said he had educated dietary staff on the proper way to store and label food brought from outside, and cleaned out all expired items. In an interview on 07/22/2026 3:20PM, Staff C, Director of Nursing/Registered Nurse (RN), said she expected food items in the nourishment refrigerators to be labeled accurately per policy and to be discarded by the use by date. Reference WAC 388-97-1100 (3) HAND HYGIENE Review of the facility's policy, titled Assistance with Meals, dated 10/01/2021, documented, .All residents: . 4. Employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Dining Room Residents: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. Review of the facility's policy, titled Hand Hygiene, undated, documented, .5. a. Use an ABHR [alcohol based hand rub] .iv. After touching a resident or the resident's immediate environment. In an observation on 07/19/2026 between 12:16 PM and 12:30 PM, Staff L, Certified Nursing Assistant, was observed assisting three unidentified residents with eating lunch in the Horizon Point dining room. Staff L was observed to peel a banana and hand it to the first resident. The first resident's hands touched Staff L's ungloved hands. Without performing hand hygiene, Staff L then went to a second resident at a different table and picked up the resident's utensils to assist with her meal. Staff L then picked up the second resident's garlic bread with ungloved hands and fed the bread to the resident. Without performing hand hygiene, Staff L then walked to a third resident, picked up their utensils, and assisted him with eating his meal. Staff L was then observed to return to the second resident's table, picked up her fork, and assisted her with her meal. Staff L then took a napkin off the table in front of the second resident, picked up something off the table and threw it away with the napkin. Staff L then went back to the second resident and assisted her with her drink, without performing hand hygiene. Staff L then went to the first resident and repositioned blankets on his lap. Without performing hand hygiene, Staff L was then observed to return to the second resident, pick up the garlic bread with bare hands and assist the resident to eat the bread. Staff L then picked up a dirty plate from the first resident, placed it on a cart, then returned to the third resident to assist him with his lunch. Staff L was observed to then move her braided hair over her shoulder, scratch her head, then assisted the second resident to eat the garlic bread with her bare hands without performing hand hygiene. In an interview on 07/19/2026 at 12:31 PM, when asked about the process for hand hygiene while assisting residents with eating their meal, Staff L said she should have washed her hands in between helping each resident. Staff L said she didn't know she should not touch the bread with her hands. In an interview on 07/19/2026 at 12:36 PM, Staff E, Staff Development/Infection Preventionist/RN, said staff should perform hand hygiene in between assisting each resident with eating, after adjusting blankets, and should wear gloves to feed bread. Staff E said the resident's food should not be touched with bare hands. In an interview on 07/20/2026 at 2:14 PM, Staff B, Regional Director of Clinical Operations/RN, said she expected hand hygiene to be completed while assisting residents with dining in between residents and after hands were contaminated. Staff B said food was not supposed to be touched with bare hands. Refer to F550 Reference WAC 388-97-1100(3)

Based on observation, interview and record review, the facility failed to conceal a urinary catheter bag with a privacy bag for 1 of 3 residents (Resident 141) reviewed for dignity; and failed to provide eating assistance in a manner that promoted resident respect and dignity for 1 of 2 dining rooms (Horizon Point, upstairs) reviewed for dining. This failure place residents at risk for diminished self-worth, embarrassment, and a deceased quality of life. Findings included . Review of the facility's policy title, Dignity, dated [DATE], documented, POLICY: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. DEFINITIONS: . is the right of a person to be valued and respected for their own sake, and to be treated ethically. SPECIFIC PROCEDURES/GUIDANCE 14. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered. Resident 141 was admitted to the facility on [DATE]. Review of Resident 141's care plan, dated [DATE], documented, the resident requires an [sic] urinary foley catheter. intervention: maintain catheter privacy bag. During an observation on [DATE] at 9:29 AM, Resident 141 was lying in bed on her back. An uncovered catheter bag was observed on the left side of the bed just below Resident 141's lower extremity and was observed to have yellowish colored fluid visible from the hallway. During an observation on [DATE] at 9:16 AM, Resident 141 was lying in bed on her back. An uncovered catheter bag was observed located on the left side of the bed just below her left lower extremity and appeared to have yellowish colored fluid. During an observation on [DATE] at 9:38 AM, Staff M, Unit Manager/Licensed Practical Nurse, told an unidentified nurse, Can we get her a privacy bag. During an interview on [DATE] at 9:53 AM, Staff M said catheter bags were supposed to be covered with privacy bags. DINING Review of the facility's policy title, Dignity, dated [DATE], documented, POLICY: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 5. e. provided with a dignified dining experience. Review of the facility's policy, titled Assistance with Meals, dated [DATE], documented, .Dining Room Residents: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. In an observation on [DATE] between 12:16 PM and 12:30 PM, Staff L, Certified Nursing Assistant, was observed assisting three unidentified residents with eating lunch in the Horizon Point dining room. Staff L was observed standing to the left of the first resident that was sitting at a table and assisted him with his meal. Staff L then walked to a second resident at a different table and while standing to the left of the resident, assisted the resident with utensils to eat her meal. Staff L then walked back to the first table, picked up utensils for a third resident and assisted him with eating his meal while standing. Staff L then went back to the second resident and stood to assist her to eat her lunch. Staff L was observed to continue to walk between the two tables and assist three residents to eat their lunch while standing throughout the meal. In an interview on [DATE] at 12:31 PM, when asked about the process for assisting residents with eating their meal, Staff L said she should have sat down to assist the residents. In an interview on [DATE] at 12:36 PM, Staff E, Staff Development/Infection Preventionist/RN, said staff should not stand next to resident to assist when feeding them. Staff E said staff should be sitting to assist residents to eat. In an interview on [DATE] at 2:14 PM, Staff B, Regional Director of Clinical Operations/RN, said she expected staff to sit while assisting residents with dining. Refer to F812 Reference WAC 388-97-0180(2) and 388-97-0860(1)(a)

Based on observation, interview, and record review, the facility failed to complete and/or obtain an assessment, consent, and/or physician's order for 1 of 1 sampled resident (Resident 39) reviewed for physical restraints. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life.Findings included. Review of the facility's policy titled, Physical Restraints, undated, documented . 5. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. 8. Restraints will only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Resident 39 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 05/04/2026, documented Resident 39 was cognitively intact. In an observation on 07/19/2026 at 11:20 AM, Resident 39 was observed lying in bed with bolsters (a mattress or sleeping pad featuring raised edges, cushioned walls, or built-in side bumpers) along both sides of the mattress. In an observation on 07/20/2026 at 2:26 PM, Resident 39 was observed lying in bed leaning to the left side with bolsters along both sides of the mattress. In an observation on 07/21/2026 at 2:16 PM, Resident 39 was observed lying in bed with bolsters along both sides of the mattress. In an interview on 07/21/2026 at 3:40 PM, Resident 39 said she did not remember anyone talking to her about if it was ok with her to have the bolsters on her bed. Review of Resident 39's Electronic Health Record (EHR) did not show an assessment, consent, and/or physician order related to bolsters on the sides of the mattress. In an interview on 07/22/2026 at 1:28 PM, Staff J, Unit Manager/Licensed Practical Nurse (LPN), said if they used bolsters on a resident's bed, they would get a physician's order. Staff J said an assessment was not needed for bolsters. Staff J said they had a lot of difficulty with Resident 39's bed. Staff J said he did not see a physician's order for the bolsters for Resident 39 stating, something was missed. In an interview on 07/22/2026 at 3:04 PM with Staff D, Assistant Director of Nursing/LPN, Staff A, Administrator in Training, and Staff K, Regional Director of Operations, Staff D said if a resident used bolsters on their bed, they would do an IDT (interdisciplinary team) review to validate if it restrained them. Staff K said they would complete an assessment for a potential restraint if bolsters were used on a bed. After looking at Resident 39's EHR, Staff D said she did not see that an assessment, IDT review, or a physician's order was completed for the bolsters. Staff A and Staff K went to look at Resident 39's bed. After looking at the bed, Staff K said she thought Resident 39 needed a mattress and someone grabbed the mattress with bolsters and gave it to her. Staff K said a resident should have a need for bolsters, stating, I don't think she needs those bolsters. Refer to F656 Reference WAC 388-97-0620 (1)(4)(a)(b)

Based on interview and record review, the facility failed to accurately complete the Admission's Minimum Data Set (MDS), an assessment tool, for 1 of 3 residents (Resident 87) reviewed for resident assessments. This failure to accurately complete assessments placed residents at risk of having unidentified and unmet care needs, and a decreased quality of life. Findings included. Resident 87 was admitted to the facility on [DATE] with multiple diagnoses to include Chronic Obstructive Pulmonary Disease (COPD, a long-term lung condition causing blocked airflow and breathing problems) and respiratory failure (when your lungs cannot send enough oxygen into your blood or cannot clear out enough carbon dioxide). The admission MDS, dated [DATE], indicated Resident 87 was alert and oriented. The MDS did not document Resident 87 was receiving oxygen therapy and required a CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep your breathing airways open while you sleep).Review of Resident 87's care plan, dated 07/09/2026, documented, RESPIRATORY DISEASE: The resident has a chronic respiratory disease with increased risk for shortness of breath, ineffective airway clearance, hypoxia [low blood oxygen], activity intolerance, and respiratory compromise related to COPD; ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA; ASTHMA; OSA [obstructive sleep apnea - causes pauses in breathing and disrupts rest]; OXYGEN DEPENDENT.Review of Resident 87's physician's order, dated 07/08/2026, documented, supplemental oxygen at 2 LPM [liters per minute] via nasal cannula continuously every shift.Review of Resident 87's physician's order, dated 07/08/2026, documented, CPAP: to be managed by patient using home settings while resting in bed. Assist to don mask if needed. every shift. During an interview on 07/22/2026 at 10:46 AM, Staff P, MDS Coordinator/Registered Nurse, said Resident 87 started oxygen therapy on 07/08/2026 and was on it through 07/21/2026. Staff P said Resident 87 started the CPAP on 07/09/2026 and was using it through 07/21/2026. Staff P said both should have been coded on the MDS.Reference WAC 388-97-1000 (2)(o)

Based on observation, interview, and record review, the facility failed to develop and/or complete a comprehensive care plan for 3 of 3 sampled residents (Residents 7, 6, and 39) reviewed for diabetes mellitus (a medical condition characterized by an inability of the body to regulate its blood sugar levels) and for 1 of 1 sampled resident (Resident 39) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included. DIABETES <Resident 6> Review of the facility's policy titled, Fingernails/Toenails, undated, documented .1. Review the resident's care plan to assess for any special needs of the resident.5. Unless otherwise permitted, do not trim the nails of diabetic residents. Resident 6 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], documented Resident 6 was severely cognitively impaired, had diabetes mellitus, and was on insulin (a prescription medication used to lower blood sugar levels). Record review of Resident 6's Diabetes Mellitus care plan, date revised 05/19/2026, did not show a goal and/or intervention related to diabetic nail care. Record review of Resident 6's Kardex (a nursing documentation system used to provide a quick summary of patient care needs), dated 07/21/2026, did not show Resident 6 was diabetic and/or directives related to diabetic nail care. <Resident 39> Resident 39 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 39 was cognitively intact, had diabetes mellitus, and was on hypoglycemics (a prescription medication used to lower blood sugar levels). Record review of Resident 39's Diabetes Mellitus care plan, date revised 05/06/2026, did not show a goal and/or intervention related to diabetic nail care. Record review of Resident 39's Kardex, dated 07/20/2026, did not show Resident 39 was diabetic and/or directives related to diabetic nail care. In an interview on 07/21/2026 at 1:20 PM, Staff R, Certified Nursing Assistant (CNA), said if a resident was diabetic, the nurse had to cut their nails. Staff R said if a resident was diabetic, it would be in the Kardex. In an interview on 07/22/2026 at 12:20 PM, Staff S, CNA, said they got information on care needs for residents in the Kardex or their care plan. Staff S said she did not know what the process was for trimming a resident's nails if they were diabetic. Staff S said if a resident was diabetic or if it was unsafe to trim their nails it would be in the Kardex. In an interview on 07/22/2026 at 1:16 PM, Staff J, Unit Manager/LPN, said only nurses do nail care for diabetic residents. Staff J said information on nail care for diabetic residents should be in the Kardex. Staff J said information on the Kardex comes from the care plan. After looking at the EHR for Resident 6 and Resident 39, Staff J said he did not see diabetic nail care in their Kardex or a care plan specific to diabetic nail care. In an interview on 07/22/2026 at 3:23 PM, Staff D, Assistant Director of Nursing/LPN, said it was not within the scope of practice for a CNA to do nail care on diabetic residents. Staff D said diabetic nail care should be in a resident's care plan. After looking at Resident 6 and Resident 39's EHR, Staff D said their care plans did not include diabetic nail care. <Resident 7> Resident 7 was admitted to the facility on [DATE] with multiple diagnoses to include diabetes mellitus. The 5-Day Minimum Data Set (MDS – an assessment tool), dated 07/02/2026, indicated Resident 7 was alert and oriented. Review of Resident 7's electronic health records (EHR) documented Resident 7 had type 2 diabetes mellitus with hyperglycemia (high blood sugar) for which they were administered sliding scale insulin and had their blood sugar checked. No focus area for diabetic related care was included in the care plan. During an interview on 07/22/2026 at 12:15 PM, Staff M, Unit Manager/Licensed Practical Nurse (LPN), said the MDS Coordinator and the IDT (interdisciplinary team) were responsible for working on the care plans. When asked who specifically wrote the care plan, Staff M said she was not sure. During an interview on 07/22/2026 at 12:35 PM, Staff D, Assistant Director of Nursing/LPN, said the unit manager, registered dietician, or the person responsible for the area needing care planned would write the care plan. PHYSICAL RESTRAINTS Review of the facility's policy titled, Physical Restraints, undated, documented .14. Care plans for residents using a restraint will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptoms(s). 15. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. In an observation on 07/19/2026 at 11:20 AM, Resident 39 was observed lying in bed with bolsters (a mattress or sleeping pad featuring raised edges, cushioned walls, or built-in side bumpers) along both sides of the mattress. In an observation on 07/20/2026 at 2:26 PM, Resident 39 was observed lying in bed leaning to the left side with bolsters along both sides of the mattress. In an observation on 07/21/2026 at 2:16 PM, Resident 39 was observed lying in bed with bolsters along both sides of the mattress. Record Review of Resident 39's Comprehensive Care Plans did not show a Focus, Goal, or Intervention related to a bolstered mattress. In an interview on 07/22/2026 at 1:28 PM, Staff J, Unit Manager/LPN, said if they used bolsters on a resident's bed, they would get a physician's order and add them to the resident's care plan. Staff J said he did not see a care plan for the bolsters for Resident 39 stating, something was missed. In an interview on 07/22/2026 at 3:04 PM with Staff D, Assistant Director of Nursing/LPN, Staff A, Administrator in Training, and Staff K, Regional Director of Operations, Staff D said if a resident used bolsters on their bed they would put it in their care plan. After looking at Resident 39's EHR, Staff D said she did not see a care plan was completed for the bolsters. Reference WAC 388-97-1020(1)(2)(a)

Based on interview and record review, the facility failed to provide care with activities of daily living (ADL) for dependent residents to include bed baths and/or showers for 1 of 3 residents (Resident 5), reviewed for ADLs. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves.Findings included.Resident 5 was admitted to the facility on [DATE]. The Admission/5-day Minimum Data Set, an assessment tool, dated 06/26/2026, indicated Resident 5 was alert and oriented.During an interview on 07/19/2026 at 2:28 PM, Resident 5 said he was supposed to get showers on Wednesday and Saturdays. Resident 5 said he did not get any showers last week. Resident 5 said they offered him a shower and told him they would get him at 7 PM. Resident 5 said they didn't come back until 8:30 PM, therefore he said he refused the shower.Review of Resident 5's Kardex (a quick-reference summary of current patient care needs), indicated Resident 5's shower/baths were on Wednesday and Saturday evenings.Review of Resident 5's shower task sheet, dated 06/23/2026 through 07/21/2026, indicated Resident 5's showers were scheduled for Wednesday and Saturday evenings. The shower task sheet did not document showers were offered on the following Wednesdays and Saturdays: 06/24/2026, 06/27/2026, 07/1/2026, 07/4/2026, 07/8/2026, 07/15/2026, or 07/18/2026. Review of Resident 5's shower task sheet, dated 06/23/2026 through 07/21/2026, documented Resident 5 refused showers on 6/23/2026, 06/25/2026, 07/11/2026, and 07/16/2026.Review of Resident 5's shower task sheet, dated 06/23/2026 through 07/21/2026, documented on 06/24/2026, 07/08/2026, and 07/15/2026, Resident 5's shower was Not Applicable. Review of Resident 5's shower task sheet, dated 06/23/2026 through 07/21/2026, had no documentation for 07/18/2026.During an interview on 07/21/2026 at 2:02 PM, Staff N, Shower Aide/Nursing Assistant (NA), said resident shower days were determined by their room assignments. Staff N said if the resident was out of the building on an appointment or other activity the NA would mark not available in the electric health records (EHR). Staff N said marking not available would trigger the EHR and remind us to re-approach the resident later for their showers. Staff N said NAs should not be documenting not applicable. Staff N said they have trained NAs not to use not applicable.During an interview on 07/22/2026 at 9:15 AM, Staff M, Unit Manager/Licensed Practical Nurse, said NAs should not be documenting not applicable because it did not trigger the missed shower. Staff M said NAs should document not available, when residents were not in the facility, because it will let us know to give the shower later. Staff M said they have trained on this and will have to again. While reviewing Resident 5's shower task, Staff M said they should not be using the not available because it did not tell them the reason. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview and record review, the facility failed to identify, assess and intervene for a significant weight gain for 1 of 2 sampled residents (Resident 11) reviewed for nutrition. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.Findings Included . Record review of the facility policy titled, Weight Assessment and Intervention, dated 10/01/2021, documented: 4. Any weight change of 5% [percent] or more (unless otherwise specified in the resident's care plan or physician's order) since the last weight will be retaken for confirmation. If the weight is verified, nursing will immediately notify the physician/practitioner and dietary team. 5. The designated dietary staff will review the weight records (based on frequency of weights) to follow individual weight trends over time.a. The treatment team will evaluate negative trends whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight change will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100]:a. 1 month - 5% weight change is significant; greater than 5% is severe.b. 3 months - 7.5% weight change is significant; greater than 7.5% is severe.c. 6 months - 10% weight change is significant; greater than 10% is severe. Resident 11 was admitted to the facility on [DATE], with multiple diagnoses, to include Congestive Heart Failure (a serious condition where the heart cannot pump blood well, leading to fluid buildup, shortness of breath, and tiredness). The Modification of Annual Minimum Data Set, and assessment tool, dated 05/15/2026, indicated Resident 11 was moderately cognitively impaired. In an interview on 07/19/2026 at 10:36 AM, Resident 11 said she had not spoken with anyone regarding a change in her nutritional status. Resident 11 stated, I have been gaining weight. Resident 11 said she used to eat larger portions, but no longer does. Review of Resident 94's Electronic Health Record (EHR), documented the following weights had been taken: 07/01/2026- 237 pounds06/01/2026- 232 pounds05/01/2026- 205 pounds04/27/2026- 206.5 pounds03/02/2026- 204 pounds02/16/2026- 186.8 pounds Resident 11's weight showed she weighed 205 pounds on 05/01/2026, and when weighed again on 06/01/2026, Resident 11 weighed 232 pounds. This demonstrated an actual weight gain of 37 pounds, or 13.17% in 30 days. No documented weights had been retaken for confirmation. Record review of Resident 11's EHR did not document any adjustment to dietary plan, communication with dietitian, alert charting, weigh gain being addressed by an Interdisciplinary Team (IDT), or an updated care plan. In an interview on 07/22/2026 at 2:17 PM, Staff J, Unit Manager/Licensed Practical Nurse, said it was the facility's practice to verbally or electronically communicate weight loss or gain to the provider, and to initiate alert monitoring. Staff J said he would expect such weight variance to be documented and addressed but was unable to find any documentation regarding Resident 11's weight gain. Staff J stated, I can't say we have done an alert for her weight gain. In an interview on 07/22/2026 at 3:20 PM, Staff C, Director of Nursing/Registered Nurse, said Resident 11 should have been reweighed, and the provider should have been notified on the same day. Staff C said she was unsure how Resident 11's weight had gone unaddressed. Reference WAC 388-97-1060(3)(h)

Based on observation, interview, and record review, the facility failed to ensure medications were administered by professional standards of practice for 1 of 1 sampled resident (Resident 15) reviewed for medication administration. This failure placed residents at risk for medication errors, negative outcomes, and a diminished quality of life.Findings included.Record review of facility's policy titled, Medication Administration Guidelines, dated January 2023, showed, 20. The resident is always observed after administration to ensure that the dose was completely ingested.Resident 15 was admitted to the facility on [DATE]. The Reentry Minimum Data Set (an assessment tool), dated 06/21/2026, documented Resident 15 was moderately cognitively impaired. During an observation and interview on 07/19/2026 at 9:43 AM, Resident 15 was observed in her room, seated in her wheelchair next to her bedside table which had five tablets on the table and one tablet in a small plastic cup with applesauce. When asked what medications she was taking, Resident 15 was unable to say the names of the medications she was taking or what they were for. Resident 15 asked this writer to get her some more applesauce so she could finish taking the rest of her medication. During an interview and observation, Staff U, Registered Nurse (RN), said she had administered medication to Resident 15. Staff U observed the medications on Resident 15's bedside table and said the medications were Resident 15's morning medications. In an interview on 07/22/2026 at 1:55 PM, Staff C, Director of Nursing/RN, said it was the expectation that nurses prepared residents' medications, locked the medication cart, went to the resident and explain the medication being administered and stayed with the resident while they took the medication until the resident was done. Reference WAC 388-97-1300 (1)(b)(i)(ii),

. Based on interviews and record review, the facility failed to hold enteral feedings (Method of delivering liquid nutrition directly into the stomach), for 1 of 3 (Resident 2) residents reviewed for enteral feeding. This failure placed residents at risk of receiving unnecessary enteral feedings and the potential for a diminished quality of life.Findings included. Record review of facility policy titled Enteral Feedings , dated 10/01/2021, documented Enteral feedings will be administered in accordance with the physician/practitioner order and as reflected in the resident's Advanced Directive if known. Resident 2 was admitted to the facility on [DATE], with multiple diagnoses for rehabilitation services. Record review of the 5-day minimum data set, an assessment tool, dated 04/12/2026, documented Resident 2 was moderately cognitively impaired. Record review of Resident 2's Physician orders dated 04/30/2026 showed an order to hold enteral tube feedings for a period of 30 days. Record review of Resident 2's May 2026 Medication Administration Record (MAR) showed Resident 2 had received enteral feedings on 05/08/2026, 05/09/2026,05/29/2026, and 05/31/2026. Record review of the facility alleged neglect investigation dated 06/01/2026, showed that the tube feeding was administered x 1 dose on 05/31/2026. No new order was found to resume the enteral feedings. In an interview on 06/16/2026 at 3:36 PM, Staff A, Administrator and Registered Nurse said the order to hold the tube feeding had fallen off the MAR and had restarted in error.

.Based on observation, interviews and record review, the facility failed to ensure that residents were dressed in personal clothing for 1 of 4 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for an undignified appearance and a diminished quality of life.Findings included.Record review of the facility policy titled, Resident Rights, undated, documented, 1. The Resident has a right to a dignified existence, self-determination, communications with and access to,persons and services inside and outside the Facility.In an observation and interview on 05/18/2024 at 1:20 PM, Resident 1 was sitting in a wheelchair with a nightgown on with no additional clothing or garments. Resident 1 stated he would much rather have his own clothes on, but was unsure of who could help him get dressed. In an interview on 05/18/2026 at 1:23 PM, Staff D, Licensed Practical Nurse (LPN) and Resident care coordinator (RCM), said Resident 1 should be wearing daytime clothing and not just a nightgown. In an interview on 05/18/2026 at 1:28 PM, Staff C, Nursing Assistant, said she did not see any personal clothing in the room for Resident 1. Staff C said she would normally put on personal clothes if she found them. Staff C said the facility had a loaner closet of clothing if a resident did not have their own clothes. Staff C said she was unaware if Resident 1 had clothing in his nightstand. In an interview on 05/18/2026 at 1:38 PM, Staff B, LPN, said that residents should be wearing their personal clothing if they have some, otherwise they could borrow some from the facility donated clothing. In an interview on 05/18/2026 at 1:56 PM, Collateral Contact 1(CC1) said that she had brought in personal clothing for Resident 1. CC1 said that Resident 1 hated those night gowns and would want to be dressed in his personal clothing. Reference WAC 388-97-0180(2)

.Based on interview and record review, the facility failed to ensure resident census and nursing hours were accurately posted and/or updated daily for 7 of 18 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and resident census information.Findings included. Record review of the facility policy titled, Posting Nursing Staffing, dated 10/06/2022, documented, Procedure-The facility will post the following information daily, at the beginning of eachshift. The posting shall include:a. The facility nameb. The current datec. The total number of staff and actual hours worked by the followingcategories of licensed and unlicensed nursing staff directly responsible forresident care per shift:i. Registered Nursesii. Licensed Practical Nursesiii. Licensed Vocational Nursesiv. Certified Nurse Aides In an observation on 05/18/2026 at 12:08 PM, the facility staffing document was dated 05/11/2026. In an interview on 05/18/2026 at 2:42 PM, Staff F, Staffing coordinator, verified the posted document was seven days old. Staff C said she was responsible for posting the daily staffing matrix, but she needed to work on doing this consistently. In an interview on 05/18/2026 at 2:44 PM, Staff E, Human Resource Director , said the staffing person was responsible for posting the staffing matrix daily. In an email interview on 05/19/2026 at 3:00 PM, Staff A, Administrator, said the nursing hours should be updated daily by the staffing coordinator. Reference WAC 388-97-1620(2)(b)(i)

.Based on interviews and record review, the facility failed to collaborate care and services and complete assessments for 1 of 2 residents (Resident 2) reviewed for dialysis (a procedure that acts as an artificial kidney, filtering waste products, toxins, and excess fluid from the blood). This failure placed residents at risk for compromised health outcomes and a diminished quality of life.Findings included.Record review of the facility policy, titled, End Stage Renal Disease (permanent kidney failure, requiring dialysis)-Care of the Resident, undated, documented, (5) The nursing facility staff will provide immediate monitoring and documentation of the status of the resident's condition and resident's access site(s) upon return from the treatment to observe for bleeding or other complications. (3.b) the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination, and collaboration. Resident 2 was admitted to the facility on [DATE], with multiple diagnoses to include dialysis The 5-day Minimum data set, an assessment tool, indicated Resident 2 was unable or unwilling to complete the assessment.Record review of Resident 2's electronic health record (EHR) showed Resident 2 had an AV fistula (connection between an artery and vein frequently used for dialysis) to her left upper extremity.Record review of Resident 2's EHR, dated March 2026 showed assessments completed for Resident 2 that documented that Resident 2 did not have an AV fistula or dialysis access site for the following dates:03/05/202603/07/202603/10/202603/12/202603/13/202603/14/202603/15/202603/17/2026Record review of Resident 2's medication administration record, dated March 2026, showed no assessments for Resident 2's AV fistula upon return from dialysis on dates 03/04/2026 to 03/10/2026.In an interview with Collateral Contact (CC 1) on 04/14/2026 at 4:22 PM, said Resident 2 arrived at the dialysis center on 03/16/2026 without the appropriate sling under the patient to assist with a safe transfer into the dialysis chair. CC 1 said Resident 2 was unable to receive dialysis services on that day. CC 1 said the facility was made aware of the incident and asked to reschedule for the missed dialysis on 03/17/2026. CC 1 said the facility was unable to arrange transportation for Resident 2 on 03/17/2026 and would receive her next scheduled dialysis on 03/18/2026. CC 1 said on the morning of 03/18/2026 she called the facility to remind them to place Resident 2 on the appropriate sling. CC 1 said Resident 2 showed up again to the dialysis center without the transfer sling under Resident 2 to safely transfer her into the dialysis chair, and dialysis center staff did a 4 man lift to ensure Resident 2 received dialysis that day.Record review of Resident 2' s care plan showed no interventions listed for the specialty transfer sling to be used for dialysis until 03/17/2026.In an interview and record review on 04/21/2026 at 11:59 AM, Staff A, Administrator and Registered Nurse said the nurses should be doing assessments on return from dialysis services. Staff A was unable to find assessments in the EHR. Staff A also said she would expect the assessments completed in the record to be accurate. Staff A said the facility should have made sure the sling was under Resident 2 to ensure safe transfer into dialysis chair.Reference WAC: 388-97-1900 (1)(6)(a-c)

.Based on interviews and record review, the facility failed to provide goods and services to residents that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1of 4 sampled residents (Resident 1) reviewed for neglect. This failure placed residents at risk of injuries related to falls and a diminished quality of life.Findings included.Resident 1 was admitted to the facility on [DATE], with multiple diagnoses for rehabilitation services. Record review of the 5-day minimum data set, an assessment tool, dated 03/24/2026, documented Resident 1 was moderately cognitively impaired.Record review of Resident 1's Electronic Health Record (EHR) showed Resident 1 had a fall from bed on 03/24/2026 at 9:15 PM, stating he needed to have a bowel movement.Record review of Resident 1's EHR showed Resident 1 had fallen from bed on 03/25/2026 at 1:06 AM, stating he needed to have a bowel movement.Record review of Resident 1's EHR showed facility intervention to include a 1:1 sitter for safety, until another intervention could be provided.Record review of Resident 1's EHR showed Resident 1 had a fall from bed on 03/25/2026 at 06:40 AM, stating he just wanted to get up and go to the bathroom.In an interview, and record review on 04/21/2026 at 11:59 AM, Staff A, Administrator and Registered Nurse said she had received a call from staff regarding multiple falls by Resident 1. Facility staff had indicated that Resident 1 was restless and confused, therefore implementing a 1:1 sitter for the safety of Resident 1, until another more sustainable intervention could be made. Staff A said that the dayshift nurse dismissed the 1:1 sitter during the morning shift change, leaving Resident 1 unattended. Staff A was unable to find a follow up assessment indicating that Resident 1 was no longer restless or confused, prior to his 3rd fall and removal of the 1:1 sitter. Staff A said she would have expected the nurse to reassess Resident 1 for safety before removing the 1:1 sitter.Reference WAC 388-97-0640 (1)

.Based on observations, interviews and record review, the facility failed to implement appropriate infection control practices when handling medication for 1of 3 (Resident 2) sampled residents reviewed for infection control and prevention. 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 policy titled, Infection Prevention and Control General Guidelines, dated July 2023, indicated, Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.In an observation on 03/16/2026 at 12:16 PM, Staff B, License Practical Nurse (LPN), entered Resident 2's room to the left side of their bed and said they had stomach medication to give her. Staff B opened two single dose packages with bare hands dropping each pill into their palm. Staff B then handed both pills directly from their hand into Resident 2's hand. Staff B instructed Resident 2 to place the dissolvable pills under her tongue.In an interview on 03/16/2026 at 12:17 PM, Staff B said he should have used gloves or a medication cup instead of handling the medication with his hands. Staff B said they were just in a hurry.In an interview on 04/07/2026 at 11:59 AM, Staff A, Administrator and Registered Nurse, said she would expect nurses to wear gloves when handling medications. Reference WAC 388-97-1320 (1)(a)

.Based on observations, interviews, and record review, the facility failed to ensure that residents were treated with dignity and respect for 2 of 4 (Resident 2 and Resident 3) sampled residents reviewed for quality of care. This failure placed residents at risk for negative outcomes to mental and psychosocial well-being and a diminished quality of life.Findings included.Resident 2 was admitted to the facility on [DATE], with multiple diagnoses for rehab services. Record review of the 5-day Minimum Data Set (MDS, an assessment tool), dated 03/11/2026, showed Resident 2 was alert and oriented.In an observation and interview on 03/16/2026 at 12:16 PM, Resident 2 stated she was waiting for stomach medication. During the interview, Staff B, License Practical Nurse (LPN) entered the room to the side of Resident 2's bed and stated, hey honey I got your pills. Staff B then opened the package of 2 pills and said, here honey put these under your tongue.In an interview on 03/16/2026 at 12:20 PM, Resident 2 said that no one asked her about her name preference but would prefer not to be called honey. Resident 3Resident 3 was admitted to the facility on [DATE], with multiple diagnoses for rehab services. The 5-day MDS, dated [DATE], showed Resident 3 was alert and oriented.In an observation on 03/16/2026 at 12:16 PM, Staff B walked by Resident 3 and said, hey love do you need anything since I am here? Resident 3 responded no and Staff B said, ok love and left the room.In an interview on 03/16/2026 at 12:21 PM, Resident 3 said she usually goes by her birth name and was not asked about her preference to be called by any other name.In an interview on 03/16/2026 at 12:17 PM, Staff B said both Residents like to be called by their given names. Staff B said they just tend to call residents more endearing names. Staff B said they were not aware of any facility policy or professional standards to only call residents by their preferred names.In an interview on 04/07/2026 at 11:59 AM. Staff A, Administrator and Registered Nurse said that staff should only call residents by their preferred name. WAC 388-97-1080(2)

.Based on interviews and record review, the facility failed to ensure that residents were free from unnecessary drugs for 1 of 4 (Resident 1) sampled residents reviewed for unnecessary medications. This failure caused Resident 1 to be given psychotropic medication without prior consent. This failure placed residents at risk for increased side effects and a diminished quality of life.Findings included.Resident 1 was admitted to the facility on [DATE], with multiple diagnoses to include anxiety (a mental and physical state characterized by intense, and persistent worry or fear) and depression ( a serious mental disorder characterized by persistent sadness, loss of interest in activities, and low energy). The 5 -day Minimum Data Set (MDS, an assessment tool), dated 03/04/2026, showed Resident 4 was alert and oriented.Record Review of Resident 1's physician order, dated 03/02/2026, showed Haldol (medication to treat mental health conditions) 2 mg (milligrams) orally once daily, to be held until physician order was clarified for accuracy.Record review of Resident 1's March 2026 electronic medication record (EMAR) showed Resident 1 received Haldol on 03/07/2026 without consent for Haldol.In an interview on 03/18/2026 at 1:56 PM, Collateral Contact 1 said her mom (Resident 1) was not supposed to be given Haldol due to a concern with hand tremors.In an interview on 04/07/2026 at 11:59 AM, Staff A, Administrator and Registered Nurse (RN), reviewed Resident 1's medication orders and confirmed that Resident 1 was given Haldol without consent. Staff A said a consent should have been completed prior to giving the psychotropic medication. Reference WAC 388-97-1060(3)(k)(i)

Based on interview and record review, the facility failed to ensure residents were administered oxygen according to the provider orders for 1 of 3 sample residents (1) reviewed for respiratory care. This failure resulted in harm to Resident 1 when their oxygen was not maintained at the ordered rate and the resident experienced hypoxia (low oxygen blood levels) and requried hospitalization . This failure placed residents at risk for shortness of breath, unmet care needs and a decreased quality of care. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including hypersensitivity pneumonitis (a rare immune system disorder affecting the lungs, resulting in irreversible damage to the lungs.) The discharge Minimum Data Set, an assessment tool, dated 07/03/2023, showed Resident 1 had no cognitive impairment, required extensive assistance with activities of daily living and required oxygen therapy prior to and during their stay at the facility. The Physician Orders for Life-Sustaining Treatment (POLST), dated 06/25/2023, documented Resident 1 did not want resuscitation in the event of cardiac arrest. Resident 1 did want selective treatments, such as medical treatment and intravenous (going into a vein) fluids. The physician orders, dated 06/29/2023, showed oxygen was ordered at 5 liters per minute via nasal cannula continuously. The care plan, dated 07/13/2023, documented Resident 1 had an altered breathing status due to hypersensitivity pneumonitis. Oxygen would be at 5 liters per minute via nasal cannula (a tube delivering oxygen through the nose) continuously. Provider notes, dated 07/17/2023, documented Resident 1 was seen for an acute visit due to increased confusion. Family members (FM) reported staff had titrated (slowly reducing the liters of oxygen) Resident 1's oxygen down to two liters during the night. FMs also found the O2 (oxygen) machine was not working. The note showed the resident was eventually titrated back up to five liters. O2 saturations (a measure of oxygen in the blood) levels were stable but the resident remained confused. The resident had severe lung disease and was at risk for respiratory failure and metabolic acidosis (acid builds up in the body). Resident 1 was transported to the hospital due to the low oxygen blood levels during the night shift. The medical record did not have any nursing notes regarding the oxygen reduction and FMs concerns. The medical record showed resident had no alterations in oxygen documented. On 09/13/2023 at 1:40 PM, Staff D, Licensed Practical Nurse (LPN), said they did not care for Resident 1. Staff D said they would not change oxygen or titrate oxygen unless there was an order. Staff D said residents should be monitored very closely while adjusting the oxygen. If there were ever any concerns they would contact the doctor. At 2:39 PM , Staff C, Licensed Practical Nurse (LPN) and Resident Care Manager, said they were aware of the incident with Resident 1's oxygen. Staff titrated the oxygen down from the resident's regular rate. Resident 1 did not have an order for titration. Staff C said they were unsure why staff did this. Staff should have contacted the doctor to discuss the concerns. Staff C said the provider felt this oxygen reduction resulted in Resident 1's hospitalization . Staff C said nursing staff did get education on oxygen administration after the incident and there had been no further events. At 2:59 PM, Staff A, Administrator and Registered Nurse, said they were aware of an incident with Resident 1's oxygen. A medication error investigation was completed. Staff titrated the oxygen down from the resident's regular rate. Resident 1 did not have an order for titration so staff should not have titrated the resident. Staff should have contacted the doctor to discuss the concerns. Staff A said oxygen reduction resulted in Resident 1's hospitalization . Staff A said nursing staff did get education on oxygen administration. At 4:15 PM, Collateral Contact (CC), Family Member, said Resident 1 had a uncommon lung disease which had no cure. Resident 1 had been dealing with respiratory issues and required a stay in the facility. The resident was received five 5 liters of oxygen continuously. Resident 1 reported to CC staff were discussing the amount of liters the resident received. Staff started messing with the liters putting Resident 1 on liters below the provider orders. CC said Resident 1 voiced concerns to the facility. When CC came into the facility, they also voiced concerns to the facility. CC said Resident 1 eventually began to become hypoxic and they were very worried Resident 1 would not make it. CC said the back and forth with staff and lowering of Resident 1's oxygen caused the resident tremendous stress and discomfort. CC said staff did not call the provider to discuss their concerns. The resident was transported to the hospital and was admitted due to hypoxia. CC said the resident passed away shortly after the hospitalization . On 09/14/2023 at 1:00 PM, Medical Provider (MP) said they happened to stop into the facility on [DATE] and found Resident 1's oxygen had been reduced during the night. MP was unsure why staff had done this. MP said staff were not receptive to the education on Resident 1's oxygen needs. Staff had not notified the provider of any of the changes nursing staff performed. MP decided Resident 1 required hospitalization due to hypoxia from the titration of oxygen. Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to prevent an avoidable accident for 1 of 3 sampled residents (#1) reviewed for accidents. This failure resulted in Resident #1 sustaining a fall with serious injury and placed residents at risk for identified concerns not being addressed. This caused harm to Resident #1. Findings Include: Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS), a comprehensive assessment tool, dated 7/12/17, documented Resident #1 required physical assistance with transfers, dressing, eating, and toilet use. Resident #1 was assessed as not steady, only able to stabilize with human assistance for moving from seated to standing positions, moving on and off the toilet, and surface to surface transfers. Resident #1 used a wheelchair as a mobility device. Resident #1's Care Area Assessment (CAA) for falls was completed on 1/23/17. The CAA assessment documented, difficulty maintaining sitting balance. There was no documentation on the CAA worksheet addressing rationale, care plan decision, or interventions for this problem. Resident #1's fall care plan, dated 5/2/17, did not have a documented intervention addressing the identified problem, difficulty maintaining sitting balance. Resident #1's medical record documented, on 9/25/17 at 8:00 p.m., Resident #1 fell out of his wheelchair and fell face first onto the ground. Resident #1 sustained an injury to the right eye causing it to swell shut. A skin tear over the right eyebrow was sustained in the fall. Resident #1 was sent to the Emergency Department for evaluation of a head injury and anticoagulant (blood thinner) use. Emergency Department records, dated 9/25/17, documented Resident #1's right eye was swollen shut and unable to be opened, and a laceration with Steri-Strips (skin closure device) in place above right eyebrow. Resident #1 was diagnosed with [REDACTED]. On 9/26/17 Resident #1's fall care plan was revised to include, Do not have resident hold objects or bathing supplies while he is being assisted to and from shower/room; Education of resident and staff on wheelchair safety and the need to move wheelchair slowly related to residents balance and coordination. A review of the facilities Incident Report, dated 9/30/17, documented Nursing Assistant (NA) A was quickly wheeling Resident #1 back to his room after a shower. NA A requested Resident #1 to hold his bathing supplies on his lap. On the way to Resident #1's room they rounded a corner and abruptly stopped. Resident #1 fell forward out of his wheelchair sustaining injury to his face. NA A stated, I may have been going too fast. On 10/02/17 at 3:45 p.m., Resident #1's right eye was observed swollen shut. Resident #1 had bruising around both eyes extending down the right side of his face and neck. Resident #1 stated he was thrown out of his wheelchair while being pushed back from the shower. Resident #1 said he continued to have pain to his right eye and right knee. Resident #1 said, (NA A) should not have made me hold that stuff. Without holding on, I can't balance. On 10/02/17 at 4:45 p.m., the Director of Nursing (DON) said the MDS Nurse was responsible for filling out the CAA workseet for all nursing related care areas. The DON said NA A was moving quickly back to Resident #1's room because she had additional showers to complete. The DON stated we should not have allowed the resident to hold supplies in his lap. Failure to provide care to address an identified concern resulted in an avoidable accident. This caused harm to Resident #1. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review the facility failed to provide necessary care and services to support residents receiving [MEDICAL TREATMENT], for 1 of 38 current sampled residents (#96) reviewed for care and services. These failures placed the resident at risk for unidentified complications and diminished quality of life. It was also determined the facility failed to obtain urgent medical evaluation and services for 1 of 1 sampled Residents (#36) who experienced a significant change of condition. This failure resulted in harm to Resident #36 when the facility failed to obtain immediate medical care when the resident demonstrated increased weakness, decreased hand dexterity and change in mental status. <Resident #36> Resident #36 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#36's care plan initiated on 07/13/16 indicated that the resident was, At risk for falls due to impaired balance/poor coordination, unsteady gait, history of falls, and potential medication side effects. Furthermore, the resident's care plan focus area indicated the resident was care planned for, ASA (aspirin) therapy to treat risk of [MEDICAL CONDITION] ([MEDICAL CONDITION] (blood clot in extremities)), at risk for adverse effects. On 12/07/16 at 10:46 a.m., Resident record review indicated Licensed Nurse (LN) K documented in the resident's nursing progress notes on 09/12/16 at 3:15 p.m.; Patient had an unwitnessed fall in her bathroom around 1320 pm. Patient stated she was transferring from wheelchair to toilet and her leg gave out.Patient stated she bumped her head against the waste paper basket. Records also indicated on 09/13/16 at 2:08 a.m., LN K documented in the resident's nursing progress notes, Patient continues with increased weakness, having difficulty with hand dexterity. Needed some assistance with eating, as she was unable to get the food on the fork at breakfast. Patient says and feels that her legs are not holding her when she attempts to stand. Patient is needing more assistance with transfers. Will request referral to therapies. No latent injuries noted from falls. No change noted from neuro checks. On 09/13/16 at 4:41 p.m., LN L documented that the Advanced Practice Nurse Practitioner (ARNP) was in to see the resident and a new order was sent for physical therapy. On 09/13/16 at 9:30 p.m., LN L documented in Resident #36's nursing progress notes, Resident having episodes of confusion per family. On 09/14/16 at 1:41 p.m., LN K, Patient unable to distinguish between spoon and knife. Having difficulty in getting food on spoon or fork, having difficulty getting thoughts out. Increased weakness in lower extremities. Patient says she just does not feel right and knows something is wrong .Family here and wanted patient to be assessed at St. Peters hospital. The change in mental status and hand dexterity started over the weekend. Patient did have a fall on Monday. On or about 12/08/16 review of Resident #36's hospital records indicated on 09/14/16 the resident was admitted to the hospital. Resident records stated, admitted on [DATE] with waxing/waning speech problems and mild mental status changes .she was found to have a large left acute on chronic subdural hematoma (bleeding on the brain). A left frontal subdural drain (tube placed into skull to drain bleeding) was inserted at the bedside. Further record review of hospital records indicated the resident was admitted to the hospital with [REDACTED]. On 12/12/16 at 10:21 a.m., LN C indicated that a neurological check is checking for anything outside of the resident's baseline behavior including hand dexterity. LN C reviewed Resident #36's progress notes for the dates of 09/12/16-09/14/16 and indicated the nursing progress notes were contradicting themselves for the neurological assessments being normal, however, later noting the resident was having increased weakness and difficulty with hand dexterity. On 12/12/16 at 12:13 p.m., the Director of Nursing (DNS) indicated that a neurological check will check the resident's level of consciousness, if they are orientated to time and place, motor movement, and any unusual observations. The DNS indicated it is the responsibility of the LN that is working the cart on the resident's hall. The DNS indicated following reviewing the resident's progress notes for the dates of 09/12/16-09/14/16 that the resident had a, definite decline in her mentation on 09/13/16. <Resident #96> A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 10/13/16, indicated Resident #96 received [MEDICAL TREATMENT], a process for removing waste and excess water from the blood and is used for people with kidney failure. His admission [DIAGNOSES REDACTED]. A review of a nurse progress note dated 10/9/16, revealed Resident #96 was readmitted from the hospital and identified a fistula in left arm for [MEDICAL TREATMENT]. A fistula is a surgically created connection between the veins and the arteries and is used to connect the patient to the [MEDICAL TREATMENT] machine. The facility nursing procedure titled, Assessment of Arterio Venous Shunts, Fistulas & Grafts was reviewed. It explained the purpose of the assessment is intended to facilitate early detection of complications and any abnormalities should be reported to the physician. It then listed step by step the procedure for checking the thrill (a buzzing sensations when touched) and bruit (a swooshing sound when listened to with a stethoscope). The assessment should be completed at a minimum every 24 hours and recommended documentation of assessment on the Treatment Administration Record (TAR). In an interview on 12/9/16 at 10:15 a.m., Resident #96 reported staff looked at his fistula the days he goes to [MEDICAL TREATMENT] and that he goes four days a week. A review of Resident #96's Renal Insufficiencies care plan listed the intervention, dated 4/6/16, to check access site for lack of thrill/bruit, evidence of infection, swelling, or excessive bleeding per facility guidelines. In an interview on 12/9/16 at 10:25 a.m., Licensed Nurse (LN) D reported [MEDICAL TREATMENT] fistulas are checked every shift for trill and bruit and the results are documented on the TAR. At 10:45 a.m., a review of Resident #96's December 2016 physician order [REDACTED]. LN D looked in the TAR and physician orders [REDACTED]. In interview at 11:30 a.m., LN C stated the thrill and bruit should be monitored at least once a day, the nurse that sends him out to [MEDICAL TREATMENT] charts this assessment in the progress notes. She went on to state when Resident #96 readmitted from the hospital the admitting nurse missed putting the orders in to assess the fistula and that was why it wasn't on the TAR. A review of a form titled, [MEDICAL TREATMENT] Communication Form, since readmission 10/9/16, included two sections with Section 1 to be completed by the facility nurse and then sent with the resident to [MEDICAL TREATMENT]. It includes a section titled [MEDICAL TREATMENT] and had a box to check indicating thrill/bruit, if absent, action taken. This section of the form was not completed the following days: 12/1/16, 11/16/16, 11/3/16, 11/2/16, 10/19/16, 10/18/16 and 10/15/16. A review of the progress notes, since readmission on 10/9/16, revealed 46 of 65 days did not include documentation that an assessment of the fistula site had been done. This failure to assess the [MEDICAL TREATMENT] fistula, at the minimum daily, placed the resident at risk of complication detection being delayed and potential loss of usable fistula.

Based on observation, interview and record review, it was determined the facility failed to aggressively identify and pursue/provide timely discharge assistance for 1 of 1 sampled residents (#36) reviewed for medically related social services. The failure to advocate for a timely discharge resulted in harm to Resident #36. Resident #36 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#36's care plan initiated on 08/09/16 indicated that the resident, Shows potential for discharge and patient, relative, or representative expresses wish for discharge to ALF (assisted living facility) for assistance with additional care needs. This care plan indicated that interventions were to, Assess future placement setting to determine if resident's needs can be met, discuss with patient, family, and/or representative the discharge planning process, review progress toward discharge during scheduled meetings. On 12/06/16 at 8:43 a.m., Resident #36 stated I feel like I have been committed and they just haven't told me yet. I have been here for 6 months for a broken shoulder and graduated therapy and haven't been to therapy for a while. The resident further indicated that she, sits here and weeks turned into months there is no one to talk to. The resident indicated that she has been getting anxiety attacks and sadness. The resident indicated that she has talked to Social Services and they, seem to understand but nothing seems to move. Resident #36 stated that when she was first admitted she was on the first floor for rehabilitation and has been since moved to the second floor, the resident stated, They put me up there and now I feel like I have been forgotten about . During this conversation, the resident was observed to be tearful. Resident #36 looked to the ground and fidgeted with items on her table moving them around. Resident #36 indicated that she missed the noise of people and the lights and excitement of Christmas. The resident indicated that she went to the Christmas tree only to find that it too was only decorated with white lights. Resident #36 indicated that she wanted nothing more than to be in her own private home/apartment and on her own. The resident further indicated that she did not feel old enough or sick enough to be in a nursing home or assisted living facility. On or about 12/08/16 at 10:00 a.m., Resident #36 was observed to be in the activity room independently reading the newspaper. The resident inquired about the process of her discharge, when the state surveyor explained to her the process of the state survey and that it was being looked into, the resident became tearful and indicated that she had hoped she would have been discharged by now. Resident #36 indicated that she was saddened by the fact that she would have to spend Christmas at the facility. Resident #36 was observed to be tearful and wiping tears from her eyes. Resident #36 indicated that she just felt like she could cry for having to, be in this place. On 12/07/16 at 10:46 a.m., Resident record review indicated that on 07/22/16, the Social Services (SS) documented at 3:18 p.m., MSW (master in social work) met with patient and family for scheduled care conference, therapy, nursing, and SS also in attendance; patient's goals is to return home where she lives alone .MSW suggested having therapy do a home assessment prior to patient's discharge to assess for safety. Resident record review indicated that on 07/26/16, the Physical Therapist (PT) documented at 11:09 a.m.; Home evaluation performed at patient's apartment .the environment leaves the patient at high risk for further injury and re-hospitalization . Family is attempting to clear apartment of clutter and hazards. Further Resident record review indicated that no follow up to the home evaluation had been documented in the resident's progress notes. On 12/07/16 at 10:46 a.m.; Resident record review indicated that on 09/22/16, the SS documented at 10:24 a.m., Resident #36 we know you look forward to your discharge. It means being prepared to a new residence. You are on target with accomplishing your mobility goals. You are on target with accomplishing your self-care goals . On 12/07/16 at 10:46 a.m.; Resident record review indicated that on 10/03/16, Licensed Nurse (LN) C documented at 5:28 p.m., Talked with Resident #36 today and asked her why she was having trouble sleeping. She stated because I sit up and worry all night. This nurse asked her why she was so worried about and she wants to go home. On 12/07/16 at 10:46 a.m.; Resident record review indicated that on 10/10/16, the SS documented at 12:35 p.m., Resident and MSW met with a representative from East Haven Villa ALF to complete an assessment for that facility; Resident was pleasant and receptive to the assessment process; Resident is hesitant to move to an ALF state that she doesn't feel old enough for an ALF. On 12/08/16 at 11:15 a.m.; the SS indicated that Resident #36 has been referred to the Department of Social and Health Services (DSHS) Home and Community Services (HCS) for the discharge process and that the resident has a Community Choice Guide (CCG) who is in charge of her placement process. The SS indicated that Resident #36 went to the East Haven ALF in October 2016; however, declined that facility. The SS indicated that the resident has not been to any other facilities since. The SS indicated that the resident would be able to live in a private apartment and have an in-home caregiver check in on her if an apartment was found. The SS indicated that she meets with the CCG on a weekly basis; however, they (the CCG) are working on the placement and referral process for discharge. On or about 12/12/16 at 10:55 a.m.; the Resident's Son indicated that he isn't the resident's Power of Attorney or decision maker, as the resident is her own responsible party, he is simply there to be a support and to help transport. The son indicated that he had wished the process of a discharge to a ALF was explained better and what to expect in an ALF was explained better to the resident as then she may be better receptive that that idea. The son indicated that he wasn't entirely sure with what was going on with the resident's discharge. The son indicated that recently the resident has been more resistant to go on outings, not because she doesn't want to necessarily leave; but because she doesn't want to return back. On 12/19/16 at 9:02 a.m.; Resident #36's HCS Social Worker with DSHS was contacted. She indicated that there is ongoing contact with the SS; however, they (HCS) also require the assistance of the facility to help with the discharge process as well. The HCS worker indicated that only in the last few months has the communication improved.

Based on interview and record review the facility failed to ensure for 1 of 3 sampled residents (Resident #129) that accurate ongoing assessments were conducted and interventions were implemented to provide timely necessary treatment and services to ensure a resident without a pressure ulcer, who was at risk for developing pressure ulcers, did not develop one, and to promote timely treatment to promote wound healing when a pressure ulcer developed. This failure resulted in the development of a painful, ongoing pressure ulcer causing harm to the resident and placed the resident at risk of developing a serious infection to the underlying bone. Findings include: Resident #129 was admitted from a hospital to the facility on [DATE]. The resident had been hospitalized for [REDACTED]. The resident's history included a motor vehicle accident [AGE] years prior, leaving her with several scars, including scarring on her right buttock. Prior to 9/2/13, Resident #129 lived alone and was independent with all activities of daily living. The resident was treated at the hospital for an intestinal infection with loose stools. She had a feeding tube placed at the hospital and continued to receive nutrition via the feeding tube at the facility until it stopped functioning in mid-December and the resident demonstrated she could tolerate taking food by mouth. The Minimum Date Set (MDS), an assessment tool, dated 10/17/13, documented Resident #129 was alert and usually able to understand others. She had difficulty communicating or finishing thoughts but was able to make herself understood if prompted or given time. The resident was non-ambulatory and dependent on facility staff for extensive assistance with all activities of daily living, including extensive assistance of two persons for transfers and bed mobility. Resident #129 experienced a 23 pound weight loss during hospitalization , approximately 18% of her body weight which put her at risk for skin breakdown. The facility did not identify the recent weight loss on the MDS (10/17/13) which indicated the resident had not experienced weight loss of 5% or more in the last month or 10% or more in the last 6 months. The MDS (10/17/13) documented Resident #129 was at risk of developing pressure ulcers but did not currently have any pressure ulcers or other ulcers, wounds or skin problems. According to "Decubitus (pressure) Ulcers Treatment & Management," (Revis & Geibel, Medscape, 10/12/12), "The hip and buttock regions account for 67% of all pressure sores with ischial tuberosity, trochanteric, and sacral locations being most common" and "the commonly encountered ischial tuberosity ulcer" is caused by prolonged sitting. The hospital record indicated that on 10/9/13 Resident #129 received a wound nurse consult for "pink blanchable area over previous scar on (right) buttock." The resident's "buttock/peri area" was documented by the Certified Wound Ostomy Nurse to have "light pink/red skin over buttock near anus no open areas" related to incontinence and "associated [MEDICAL CONDITION]." On 10/10/13, the Assistant Director of Nursing (ADON) documented Resident #129 arrived at the facility via stretcher and noted old scarring, including scarring to the "right buttock." The note stated, "Wears a brief and has incontinence of bowel with history of loose stools," and reported "skin intact." On 12/18/13 at 9:45 a.m., when asked about Resident #129's pressure ulcer, the ADON said when the resident was admitted , she had dense scar tissue on her right buttock which eventually "turned purple and opened up. ...It wasn't clear to us what was going on." The ADON said the Wound Team (Director of Nursing Services (DNS), the ADON and Licensed Nurse (LN) C The Advanced Registered Nurse Practitioner (ARNP) served an as-needed advisory role). The ADON stated the team was "not sure if it's a pressure ulcer because it's not over a boney prominence." The ADON further stated facility staff did not document stages of pressure wounds except when performing MDS assessments, using the Resident Assessment Instrument (RAI). The facility "Skin Practice Guide" (SPG) included the Pressure Ulcer Prevention Pathway (PUPP) which indicated documentation for an identified pressure ulcer should include location, length, width, depth and identify wound stage. The PUPP defined "tunneling" as a canal or passage under the wound surface that travels in one direction. "Undermining" was defined as tissue destruction underlying intact skin along margins of a wound; it can travel in more than one direction. The facility pressure ulcer monitoring tool, "Pressure Ulcer Healing Chart (PUHC)" did not measure wound depth or identify wound stages. The PUHC measured length x width in squared centimeters and indicated the presence of slough (loose, light colored necrotic tissue) or eschar (dense, dark colored necrotic tissue). Additional wound assessment information was documented in the progress notes but did not include wound staging. Assessments of Resident #129's right buttock were documented in the progress notes as follows: The first indication of redness to Resident #129's right buttock was on 10/19/13 , when staff documented, resident "has a red spot on right sacral area. Applied Z guard (skin protectant paste) and relieved pressure with reposition (every 2 hours.)" The resident "denies any pain or discomfort at this time." On 10/20/13, "Z-guard applied to buttock with red blanchable area noted. Frequent repositioning performed, however, patient removes pillows used for repositioning and support." On 10/21/13, "(Resident) has reddish spot on her lower back. She was repositioned off of it and z-guard was placed on it." From 10/22 through 10/26/13, there were no notes addressing the reddened area on Resident #129's buttock. There was no documentation on 10/27/13 related to the reddened area on Resident #129's buttock, or references to repositioning to relieve pressure on the area, until a note at 10:00 p.m. which stated, "(Resident) has a quarter size erythemic (reddened) area on buttocks that is being treated with z-guard skin protectant and repositioning (every 2 hours)." The record indicated the resident had signs and symptoms of pain requiring pain medication. On 10/30/13 at 7:45 a.m., the DNS documented, "Right buttock assessed this am by skin team. Scar tissue to right buttock with superficial skin opening to center previously noted purple area. ...ARNP made aware. ...care plan updated to turn side to side to tolerance." At 1:36 p.m., the DNS documented, "Area to right buttock measures 2 x 1.5 cm (centimeters) to purple area. Entire scar area measures 5 cm." On 11/1/13, the DNS documented, "Scar site continues to digress despite intervention. Area now measures 3 cm in circumference. Tissue to wound is thin yellow slough covering, with purplish color to 2 cm of wound bed. Scant bleeding noted during assessment. APM continues, therapy to provide gel cushion to wheelchair once available. Patient has roho cushion currently on wheelchair. Right buttock wound not on pressure point in sitting position, area not on bony prominence. Scar decline likely related to poor skin integrity and compromised circulation." On 11/12/13, the DNS documented, "Area measures 2.5 cm x 1.5 cm. thin trace of black tissue ...entire wound bed covered by slough." On 11/18/13, the DNS documented, "Area measures 3.2 x 2.3 area covered with thin yellow slough, eschar trace remains ...minimal drainage." On 11/19/13, the ADON documented, "Patient continues to have an open pressure ulcer to right upper buttock, continues to be 2.5 cm x 1.5 cm with a greater depth of 0.5 cm yet area is improving. ...Patient denies pain at site. ...Patient is noted to remove positioning pillows and scooting self to back at times for comfort." On 11/26/13, the wound measured 3.2 x 2.7 cm with slough covering the entire base, eschar present, and 2 cm undermining. Dressing had moderate drainage. On 11/27/13, the wound dressing was "saturated heavily with serosanguinous discharge. ... Wound base was covered with yellow slough except for an area of eschar. ...swelling and light pink area developing around outer upper right edge. ...(Resident) expressed discomfort during dressing change." On 11/28/13, the wound was 4 cm x 3.5 cm x 1 cm deep with tunneling present and a "light amount of foul smelling drainage." On 11/30/13, the wound bed was yellow, had a "foul odor," the dressing was "saturated with drainage," and the resident stated the wound was painful during the dressing change. On 12/2/13, the ADON documented, "Pressure ulcer to right buttock ...100% covered in yellow slough. Area measures 3.5 x 3 cm with a 1.5 cm depth. 1.5 cm undermining present at 5 o'clock." At 1:19 p.m., "(Resident) has been agitated today and states the ulcer in her buttocks hurts when ...dressing changed ...there is an odor to the wound and the drainage is yellow in color. Pt has been up in her wheelchair for meals and when in bed repositioned frequently." At 2:42, the ADON documented, "Received new order for wound consult. Certified wound nurse to be contacted and appt made." On 12/9/13, the DNS documented, "Area measures 2.5 x 3 cm x 2.5 in depth at center, wound undermining..." Orders were received for a wound device (wound vac which applies negative pressure to the area) to be applied. The wound device was implemented by staff at the facility on 12/11/13. On 12/11/13 at 4:59 p.m., the ADON documented "wound to right buttock (Stg III for MDS purpose)... Wound measures 2.5 cm x 2.5 cm with a 1.5 cm depth and a 4cm undermining 11 o'clock to 1 o'clock. 25% yellow slough at wound base." On 12/18/13, the ADON documented "...wound continues to be improving with increased granulation tissue at base. Measure 2.2 x 2.2 cm with a 1.5 cm depth and 4 cm undermining 10-2 o'clock yet undermining appears to be filling in at edges. Serosang drainage in the wound vac canister ... Stated 'ow' when foam dressing was first placed yet no further pain." <Pressure Ulcer Treatment Orders> On 10/30/13: Z-guard to right buttock scar area. Cover with Mediplex dressing. Change daily. End date 11/7/13. On 11/7/13: Z-guard to right buttock pressure area. Cover with [MEDICATION NAME] bordered foam dressing. Change daily and as needed. End date 11/12/13. On 11/12/13: Cleanse right buttock wound with normal saline. Cut [MEDICATION NAME] square to size of wound. Cover wound with [MEDICATION NAME], cover site with Mediplex foam dressing. Change daily and as needed. End date 11/18/13. On 11/18/13: Cleanse right buttock wound with normal saline. Cut mesalt square to size of wound and cover with foam bordered gauze. Change daily and as needed. End date 11/21/13. On 11/21/13: Cleanse right buttock wound with normal saline, apply isosorb paste to base of wound. Cover with foam bordered gauze every 2 days. End date 11/26/13. On 11/26/13: Dakins ? strength wet to dry dressing to right buttock wound twice daily. Apply dressing to wound bed only, minimize contact with surrounding skin. End date 11/27/13. On 11/27/13: Wet to dry dressing to right buttock wound. (Wet solution not identified.) Change twice daily and as needed. End date 12/2/13. 12/6/13: Dakins ? strength solution wet to dry to right buttock wound. Cleanse site with normal saline then pack with moistened Dakins to necrotic tissue only twice daily. End date 12/9/13. On 12/9/13: Dakins ? strength solution. Apply to right buttock ulcer topically twice daily. Cleanse site with normal saline then pack lightly with moistened Dakins gauze. Apply to necrotic tissue only. End date 12/13.13. On 12/9/13: Wound vac (Negative Pressure Wound Therapy (NPWT)) to right buttock wound. Change dressing Monday, Wednesday, Friday and as needed for dislodgement. Start date 12/11/13. The facility Skin Practice Guide defined NPWT as the creation of a vacuum at a well-sealed wound site. <Repositioning, Pressure Relief and Pain> According to "Decubitus (pressure) Ulcers Treatment & Management," (Revis & Geibel, Medscape, 10/12/12), "Regardless of the choice of support surface, turning and repositioning the patient remain the cornerstones of prevention and treatment (of pressure ulcers) ...even in the presence of a specialty surface or bed." According to "Fundamentals of Nursing," (Wilkinson, Treas & Davis, 2010, page 850), frequent repositioning is "one of the most important interventions for preventing pressure ulcers" and patients at risk for pressure ulcers should be repositioned at least every two hours. Patients with little subcutaneous tissue "might need to be repositioned more frequently. At-risk individuals who are chair bound should be repositioned every hour or taught to shift their weight every 15 minutes." Use of support surfaces which redistribute body weight, such as specialty wheelchair cushions or alternating pressure mattresses, should be "coupled with an effective turning and repositioning schedule." The PUPP indicated the care plan for a resident with diminished mobility should include a "turn/reposition schedule." For Resident #129, neither the care plan nor the nursing assistant care directive identified a turn/reposition schedule or identified a specific frequency for repositioning. Resident #129's care plan for activities of daily living, dated 10/11/13, instructed staff to "Encourage and/or assist to reposition frequently." The care plan, for "an unstageable area to the right buttock," dated 10/30/13, stated, "Patient to be turned side to side to tolerance. Notify LN (licensed nurse) if patient refuses. Re-approach if refuses. ...Use pillows and/or positioning devices as needed." The undated care directive for nursing assistants instructed staff: "Turn and/or reposition frequently. Bridge patient when on back in bed to decrease pressure to right buttock wound. Encourage side to side to tolerance." There was no care plan for Resident #129 addressing resistance to repositioning and related need for education in order to assist the resident to make informed choices about care and help her understand the consequences of refusing repositioning. Nor was documentation located in the resident's medical record to indicate staff attempted to ascertain the resident's reason for resisting efforts to reposition her or offer alternative measures such as positioning devices. Random progress notes and nursing assistant care logs documented repositioning the resident off her right buttock. There was no documentation if the resident was consistently repositioned and/or when she refused repositioning. On 12/18/13 at 1:37 p.m., Resident #129 was observed lying on her back on top of the covers in bed. A thin pillow was placed a few inches under the resident's right side; her right sacral area (the region of the pressure ulcer) appeared to be making contact with the bed surface. On numerous occasions throughout each day of the survey, Resident #129 was observed lying on her back in bed. In most instances, one or two thin pillows were lying to one side or both sides of the resident and were never observed to support repositioning off the pressure ulcer. At no time were positioning devices other than pillows observed. Observation of the mattress on Resident #129's bed revealed it was a motorized Joernes P.R.O. (Pressure Redistribution Optimization) ES2. It felt firm and dense when pressed manually. There were settings on the motor for comfort (1-5), mode (autofirm, therapy, and alternate) and cycle time (5, 10, and 15 minutes). The product information literature for the Joernes P.R.O. ES2 indicated the mattress had 15 adjacent horizontal air-filled sections for actively alternating pressure and was "appropriate for up to uncomplicated Stage III or Stage IV pressure ulcers based on individual patient assessment." The mattress could also be used without the motor and the alternating pressure function. The mattress literature further stated, "Patients should be turned and repositioned per an individual turning schedule or per facility policy." The mattress did not have a "low air loss" function which, according to the National Pressure Ulcer Advisory Panel Support Surfaces Initiative, 1/29/2007, "provides a flow of air to assist in managing heat and humidity (microclimate) of the skin." On 12/2/13, the ADON documented Resident #129 was "to receive air mattress today." No documentation was located to verify when the P.R.O. ES2 mattress, or any other specialty mattress, was placed on the resident's bed. On 12/18/13 at 10:29 a.m., Nursing Assistant (NA) C said, "When we lay (Resident #129) down we lay her on one side." NA C said staff lay the resident on alternate sides, using pillows to keep her off her back but the resident pulls the pillows out and ends up on her back. On 12/18/13 at 2:25 p.m., Physical Therapist (PT) B and the surveyor examined Resident #129's wheelchair. PT B stated it was a standard wheelchair with no tilt function for pressure relief, with a standard cushion having no special pressure relieving properties. PT B said the resident was currently receiving therapy to assist with self-propelling. When asked, PT B said she was unaware of any plans to procure a wheelchair with a tilting function. On 12/19/13 at 11:48 a.m., NA A, said Resident #129 liked to be up in her wheelchair around people and spent a fair amount of time in her wheelchair each day. NA A said when the resident was in bed staff tried to lay the resident on her side using a pillow for repositioning, or on her back with one pillow under each side to "bridge the resident off her coccyx." NA A said Resident #129 often expressed pain by saying "ow, ow ,ow." NA A said the resident was able to communicate pain location when staff asked yes/no questions citing different body areas. NA A said the location the resident identified most often was the right buttock. NA A said, "We say, 'bottom?' and she says yes." On 12/19/13 at 9:00 a.m., during medication observation with LN A, Resident #129 was observed in her wheelchair near the medication cart in the hall. The resident was grimacing and repeatedly said "ow." LN A asked Resident #129 if her bottom hurt and the resident said yes. LN A said, "Sometimes she is very clear and can say where it hurts. We also observe behaviors like facial grimacing or a furrowed brow." LN A said staff ascertained pain location by asking yes/no questions and said, "The area that seems to cause the most discomfort is her bottom. ...She is so thin and can't reposition herself." On 12/23/13 at approximately 10:00 a.m., during a telephone interview, Resident #129's Family Member (FM) said that during her stay at the facility, Resident #129 had 3 different beds. The FM said the resident started with a regular non-air mattress with no motor, then an air mattress with a motor, then a non-air mattress with bolsters to prevent falls, then back to the air mattress with a motor "because of the wound on her bottom." The FM could not recall the dates when the mattress changes occurred. The FM further stated, "They try to reposition her in bed but she won't stay. It really aggravates the wound when she's in the wheelchair. She says 'ow,ow, ow.' We ask, 'Is your bottom sore?' and she indicates that it does. She can usually answer correctly." Resident #129's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 500 mg every 6 hours from 12/1 to 12/17/13 and 650 mg every 6 hours from 12/18 to 12/19/13. [MEDICATION NAME] 50 mg as needed: 1-2 times on December 2, 4, 5, 10, 11, 13, 14, 15; and 3 times on December 1, 3, 6, 7, 8, 9, and 12. On December 9-11 she also received [MEDICATION NAME]. Beginning 12/16/13, Resident #129 received [MEDICATION NAME] 25 mg routinely every 4 hours, and 25 mg as needed for "increased pain" which she received on December 17, 18, and 19. On 12/19/13 at 3:30 p.m., in reference to resident #129's right buttock ulcer, the DNS said, "We didn't think it could be a pressure wound because it's not in the usual area. We are treating it as a pressure ulcer but it's a wound anomaly to me." When asked how the settings on the motor for the resident's mattress were determined or monitored, the DNS said the settings were standard and did not require monitoring. The DNS was unable to identify how the settings were determined or where the "standard" settings were documented. The RAI definitions of pressure ulcer stages included: Stage III: Full thickness tissue loss. Bone, tendon or muscle is not exposed. Slough may be present and may include tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present and often includes tunneling. On 12/20/13 at 9:34 a.m., during a dressing change, with two surveyors, the DNS, the ADON and the ARNP present, the pressure ulcer on Resident #129's right buttock was observed to be located to the right of her sacrum. The ulcer measured 2 x 2 cm with a 1.5 cm depth and approximately 4 cm area of undermining in the direction of the resident's spinal column. Full tissue thickness loss was observed with a 1.0 cm area of yellow slough near the center of the ulcer. The wound vac canister contained a small amount of drainage. During the dressing change, the resident said "ow" three or four times. She was observed to be quite thin with little subcutaneous fat. Just prior to the dressing change, the resident was observed to be positioned on her back with two thin pillows: one on each side, placed partially under her back. The DNS said the pillows were to provide a "bridging" effect to keep the resident off her coccyx. When the surveyor noted that the ulcer was to the right of the coccyx and the pillow appeared to create, not relieve, pressure to the ulcer, the DNS agreed that might not be effective. When asked if the resident was on a specific schedule for repositioning, the DNS said, "No, we don't have turn schedules." The ARNP said, "We are calling this a wound, not a pressure ulcer," and said she did not think pressure was a factor because the ulcer was "not in a usual site for a pressure ulcer." On 12/24/13 at 1:20 p.m., four days after the survey team exited the facility on 12/20/13, the ADON sent an additional document to the surveyor by facsimile: a medical report from the Wound Care Clinic. The report, dated 12/24/13, signed by the physician, indicated this was Resident #129's first visit to the clinic. The resident was accompanied by the ADON. The report documented pressure ulcer measurements of 1.9 x 1.3 x 1.6 cm with 4.1 cm undermining and stated, "This patient has a stage 3, possible stage 4 ulcer of the right ischial tuberosity with possible osteo[DIAGNOSES REDACTED]. ...There is necrotic tissue in the skin and subcutaneous tissue. There are calcium deposits in the wound itself in the area of the patient's prior scar. The wound extends down to the gluteus muscle..." The wound was surgically debrided including "100% of the wound [MEDICATION NAME] skin, subcutaneous tissue, fascia, and muscle, and calcifications in the wound." When the resident was admitted to the facility on [DATE], her skin was intact. On 10/30/13, the resident developed a superficial pressure ulcer over her right ischial tuberosity (a bony prominence) which eventually progressed to a Stage 3. Although facility staff identified the resident to be at risk for developing a pressure ulcer, they failed to accurately identify the type of wound, consistently implement and evalutate the effectiveness of interventions according to facility policy. Although the resident was non-verbal and counld not voice a reason for resistance to repositioning, the facility failed to ascertian the reason for resisting efforts to reposition or offer alternative measures. The resident's resistance to repositioning and turning was documented as early as 10/20/13. Additionally, staff failed to clearly identify the ulcer over the resident's right ischial tuberosity as a pressure ulcer, and did not identify that sitting in the wheelchair could specifically aggravate and worsen the ulcer. These failures resulted in the development of a painful, ongoing Stage 3 pressure ulcer causing harm to the resident. .

Based on interview, record review and observation, the facility failed to have sufficient numbers of staff to provide and supervise care for residents for 15 of 24 residents (#s 169, 164, 131, 94, 37, 83, 172, 56, 165, 66 176, 166, 18, 40 and 152), and 1 of 3 family members (Resident 9), interviewed during the survey. The facility did not have sufficient staff that were experienced in providing timely and necessary care to residents. The care provided was not supervised in a manner to provide consistency in therapeutic approaches to avoid actural harm. Staff did not adequately assess, evaluate or document information needed to formulate effective and timely interventions. The harm resulted from failure to develop strategies to minimize refusals of care, provision of timely pain management, wound care, delayed response to calls for assistance including timely toileting and incontinent care and delivery of basic activities of daily living causing feelings of frustration, and a diminished quality of life. Findings include: 1) During interviews with residents and a family member, residents complained of problems with receiving care or assistance from staff due to a lack of sufficient staffig. On 02/12/13 at 12:04 p.m. Resident #131 stated there is often, "Only one person on this hall with 18 residents; sometimes I have to wait 35 minutes when I am already wet; usually the evening shift seems short, people call in; if (they are) short, there are no showers; in 28 days (I had) only 5 showers." At 2:15 p.m., Resident #169 stated the "weekends are bad" and he went without getting his medications and waits were long. On 02/13/13 at 9:52 a.m., Resident #172 stated the facility was short staffed on the weekends. "I usually see two aides for the whole three rows" (the facility has three hallways on the first floor). The resident was admitted on the weekend after hip surgery. The resident said the day of her admission, after she waited 20 minutes to be assisted to the bathroom, she walked to the bathroom on her own. The following Monday she told the physical therapist, "I was up walking all weekend because no one was here to help me." At 2:15 p.m., Resident #83 stated (the facility was) "consistently short, the ones (staff) who are here are good." He stated he returned to the facility in the evening after an outing to find a visitor unable to open the entrance door and no staff available to assist her. At 5:30 p.m., Resident #40's spouse stated his wife required extensive assistance with activities of daily living including toileting and transferring. He said he spoke to the Administration about his wife not having her compression stockings on daily, waiting for her call light to be answered and not receiving toileting assistance in a timely manner. The spouse explained a nurse told his wife she would have to wait until the NA returned from dinner to assist her to the bathroom. Resident #40 could not wait and "had a bathroom accident "including bowel and bladder. On 02/14/13, at 1045 a.m. Resident #166 was observed in her room with her bathroom door open. The resident said "I have to poop and if you don' t get in here I am going myself." The surveyor asked her if she put her call light on. The resident replied, "Yes, I do but no one is coming." The call light was observed to be on. At 4:45 p.m., Resident #166 was observed in her room seated in her wheelchair with the meal tray on her bedside table. She yelled out in a frustrated tone, "Hey! I asked for coffee so long ago and no one is bringing it!" The resident stated she needed coffee with her dessert. No staff were observed in the halls. On 02/15/13 at 9:30 a.m., Resident #176 stated she was admitted evening prior at 6:00 p.m. She said after her arrival to the facility, she was left alone in her room, not oriented to her room or the use of her call light. She said she was not offered dinner, provided water or her medications that were due. Resident #176 stated she was to receive her scheduled anti-anxiety medication and was concerned about side effects of missed doses to include a panic attack. She said the facility did not provide her with her scheduled medication that evening. Resident #176 also stated her room had not been cleaned, trash was not emptied or provided with fresh water "all day." Resident #176 stated as a result of the facility's admission process, she felt hopeless and abandoned. Per review of the facility's admission report, 3 additional admissions occurred that afternoon/evening. (additional information about this resident and staffing related dignity issues, see F241) On 02/15/13 on the evening shift, two NA staff were working on the first floor, not on the "Active Employee List" provided by the facility. Staff Member D, Staff Development Coordinator stated the NAs were from the Gig Harbor Manor Care facility assisting the Lacey facility. She stated, "we have access to them because they work at a Manor Care facility. " Resident #18 was a resident with multiple [DIAGNOSES REDACTED]. She required extensive assistance with activities of daily living. On 02/16/13 at 12:00 noon, the daughter of Resident #18 stated her mother was last toileted at 6:30 a.m. At 10:45 a.m., she realized her mother urinated and was wet. She asked the facility staff for assistance to clean her mother. Resident #18 waited 25 minutes longer (until about 11:10 a.m.) for assistance from an aide to get her clean and dry. The resident's daughter stated the weekends are "hellish" because there was "no staff available." She said she worried about her mother getting urinary tract infections and high or low blood sugars related to the lack of care. She stated she never saw her mother given a snack even though Staff Member L, Registered Dietitian approved snacks. She stated staffing was worse on weekends, and "we don't know when meals will be served." She stated she did her mother's laundry for 2 main reasons. First, she felt the facility had her mother wear her clothes for too long. Second, she was able to monitor how often her mother was soiled from not being provided timely incontinent care. She stated her mother's clothes were so saturated with urine that after laundering the clothes through the wash multiple times, the clothes still smell of urine. On 02/21/13, Resident #83 and his significant other stated staffing was the biggest problem on a daily basis. They stated they did not want to ask for help because the Nursing Assistants (NAs) have said they were short staffed. The resident and significant other felt bad asking the NAs for assistance as there were other residents worse off. Residents 169, 164, 94, 37, 56, 165, 66 and 152 also shared comments during Stage 1 interviews about insufficient staffing, including comments such as: the facility was short staffed daily; whenever there was a call in, there were no replacements; needed more NAs as they are very overworked; hardly ever saw the aides; they were understaffed; one NA cared for 18 resident rooms. On 02/26/13 at 5:45 p.m., during the exit conference with the residents, family members and staff, Resident #45 stated the facility opened the second floor (for admissions) before they had enough staff to meet the resident's needs. Resident #45 stated "there is not enough help up here for us" and "they can't open the upstairs dining room because they don't have the staff." She stated the aides frequently had to borrow aides from the first floor to complete the resident care needs making for long wait times. Resident #40's spouse stated his wife was told to wait until a staff member came back from their lunch break before she could use the bathroom. He stated "my wife had to poop on herself, because there is not enough help." Resident #40 required assistance with a mechanical lift to meet her transfer needs. Resident 40's spouse stated "they are supposed to use two people to transfer my wife, and there is frequently only one person." On 02/21/13 at 10:55 a.m., Staff Member B, the corporate resource nurse stated their staffing issues were not related to turnover as much as growing the census. She stated they tried to manage the growth in census with hiring and training employees for the increasing patient census. She stated it was a struggle to staff the facility with the increasing census. Staff Member B stated the staffing concern was not a Quality Assurance Committee issue, merely discussed "nearly every day" among Administration staff. During the course of the survey, multiple resident admissions were observed, even though staffing was acknowledged as "a struggle." The "Active Employee List" provided by the facility included 110 staff. Of those 110 employees, 21 (19% of total) were hired since January 1, 2013 and 26 (24% of total) were hired in the past 3 months. 2) Refer to 42 CFR 483.10(b)(4), F-155 Right to Refuse: Formulate Advance Directives for failure to assess the reason for resident refusal or offer alternative treatments in 1 of 1 resident (#41) investigated for refusal of care. This failure did not allow him to maintain or attain the highest practicable physical, mental and psychosocial well-being in the context of making the refusals and caused harm through skin breakdown and unnecessary pain. 3) Refer to 42 CFR 483.15(g)(1), F-250 Provision of Medically Related Social Service for the failure to provide medically related social services to attain the highest level of physical, mental and psycho-social well-being for 1 of 1 resident (#41) investigated for social service support. The facility did not provide support for psychological adjustment difficulties related to grief about life changes and did not mitigate the circumstances causing the refusals of care. The failure to address the adjustment difficulties placed Resident #41 at risk for worsening depression and increased the likelihood he would refuse care. Failure to address the reasons for his refusal of care led to weight loss and skin breakdown, which resulted in a serious decline in health, infection and pain. 4) Refer to 42 CFR 483.20(d)(k)(1), F-279 Develop Comprehensive Care Plans. The facility failed to use the results of the assessment to develop the resident's comprehensive plan of care. For 6 of 29 residents (#41, 40, 163, 94, 20, & 146) reviewed in the areas of accidents, nutrition, skin condition, hospice and medication use, and for 4 of 4 units, the facility failed to develop a comprehensive care plan for each resident that includes resident specific interventions to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 5) Refer to 42 CFR 483.25, F-309 Provide Care/Servies for Highest Well Being. The facility failed to review, revise, and correctly implement plan of care for 3 of 36 (#'s 41, 48 and 63) residents reviewed in Stage 2 of survey. 6) Refer to 42 CFR 483.25(c), F-314 Treatment/Services to Prevent/Heal Pressure Sores. The facility failed to prevent avoidable skin breakdown and failed to treat pressure sores promptly for 1 of 3 residents (#41) reviewed having a stage III or greater pressure sore. This failure resulted in harm for Resident #41 who developed 3 avoidable pressure sores. 7) Refer to 42 CFR 483.25(h), F-323 Free of Accident Hazards/Supervision/Devices. The facility failed to implement planned interventions and adequate supervision for safe transfer techniques for 1 of 7 residents (#48). This failure resulted in harm by causing significant bruising and pain to the back of Resident #48 hands and wrists. .

Based on observation, interview, and record review the facility failed to review, revise, and correctly implement plan of care for 3 of 36 (#'s 41, 48 and 63) residents reviewed in Stage 2 of survey. Findings include: Resident #41 Resident #41 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The primary reason for his admission was for rehabilitation services to gain strength. His BIMS (Brief Interview of Mental Status) score was 14 on his MDS (Minimum Data Set) dated [DATE]. Resident #41 expired on [DATE]. Pressure Ulcers On the initial Minimum Data Set (MDS) completed on [DATE], Resident #41 was assessed to be at risk for pressure sores, but having no pressure sores at that time. On [DATE] a care plan was developed to address the risk of skin breakdown. The care plan was updated on [DATE]. The care plan stated that Resident #41 was "At risk for alteration in skin integrity related to non-compliance with preventative measures, impaired mobility, Diabetes, declines incontinent care, poor nutrition." The interventions identified included floating heels as able and to observe skin condition with ADL care daily; report abnormalities. His condition generally declined after admission and on [DATE] hospice care was initiated related to a [DIAGNOSES REDACTED]." On [DATE] the hospice "start of care clinical note" documents "dried crusted wounds on toes of left foot, likely from pressure of blanket." Per record review, on [DATE], a "dime sized open area" was noted on Resident #41's right buttock. It was classified as a pressure ulcer on [DATE]. On [DATE] a second pressure ulcer was noted, also located on his sacrum. By [DATE], the two ulcers had enlarged and merged into one pressure ulcer. On [DATE] Resident #41's care plan was updated to include care related to skin breakdown, nearly 1 month after the first pressure wounds were identified. Failure to update the care plan as Resident #41's skin condition changed delayed treatment and might have caused him unnecessary pain. (See related F 314 Pressure Sores) Pain Recognition and Management Per the initial Minimum Data Set (MDS) completed on [DATE], Resident #41 was assessed to have pain (intensity ,[DATE], frequency: rarely). He was taking no scheduled pain medication, but was using prn (as needed) pain medication. The MDS stated that no non-medication interventions were being used. He did not trigger for pain on the Care Area Assessment (CAA). On [DATE] a care plan was developed to address Resident #41's pain. The goal was to reduce the incidence of breakthrough pain by 1) adjusting times of ADL (activities of daily living) and treatment activities so they occur after [MEDICATION NAME] (reduce/eliminate pain) benefits have been achieved, and 2) Report any non-verbal expressions of pain (ie moaning, grimacing.....). On [DATE] a Physical Therapy Summary note by Staff GG, Physical Therapist it stated Resident #41's ambulation is limited by "fatigue and residual pain R (right) front abdomen. The abdominal pain is long standing according to patient and is ,[DATE] to palpation (touching the body part to assess it) and ,[DATE] pain with gait/transfers and increased activity level. Pain etiology (cause) is unknown. Nursing aware of R quadrant pain." The care plan for pain was not updated. On [DATE] a Social Service progress note by Staff G, Social Services Director stated that Resident #41's abdominal pain is historical for resident. Further, a Physical Therapy Summary note by Staff GG relates Resident #41 is spending 90% of the day in bed and the resident stated that he stays in bed because of his abdominal pain. Further, the note stated "Rehab team has discussed all of this with nursing but no change." The care plan for pain was not updated. On [DATE], three months after the documentation of ongoing significant pain, Resident #41's care plan was updated to include pain related to gout. On [DATE] it was updated to include pain related to skin breakdown. It was never updated to address abdominal pain. Failure to re-assess and revise his care plan caused Resident #41 unnecessary pain. Unnecessary Medications On [DATE] the admission MDS, Resident #41 was assessed to have no [MEDICAL CONDITION], no behaviors, and no rejection of care. He was not using any anti-depressant medication. Severity score for mood was zero (no issues with mood). On [DATE] [MEDICATION NAME], an anti-depressant was ordered and started for loss of appetite and depression. On [DATE], [MEDICATION NAME], an anti-depressant was ordered and started for [MEDICAL CONDITION]. On [DATE] a care plan was developed by Staff C for "indicators of depression/sadness." One of the interventions of that plan was to "Evaluate effectiveness and side effects of medications for possible decrease/ use of anti-depressants in the past but stops taking them." There was no documentation this intervention was ever done after the care plan was developed. On [DATE] [MEDICATION NAME], an antipsychotic was started on an as needed basis. None was given until [DATE]. Per the physician, the indicator for use was "agitation and anxiety." On the pharmacy review, the pharmacist indicated that the indicator for use was "[MEDICAL CONDITION]." Per interview of Staff G on [DATE] at approximately 1:30 p.m. and Staff C at approximately 8:30 p.m. the indication for use of [MEDICATION NAME] was "refusal of care." The care plan was not updated at that time nor was implementation of the existing care plan to monitor for side effects and effectiveness done. Per Staff C on [DATE] at approximately 8:30 p.m. Resident #41 had requested to discontinue his anti-depressant medications in December and that this was done on [DATE]. The care plan was not adjusted to reflect the changing medications. Resident #48 Resident #48 was admitted [DATE] with respiratory problems and dementia. The MDS dated [DATE] identified Resident #48 required extensive assistance of two people for transfers, toileting and bed mobility. During an interview on [DATE] at 11:31 a.m., Resident #48 was observed to have several dark to light purple discoloration covering the back of both hands and approximately 2 inches of his wrists. When asked how he obtained the discoloration, he replied the "bruises are from when they (the staff) transfer me; they (the staff) grab my hands." Resident 48 had told the staff not to transfer him by grabbing his hands. "(I) bruise easily and they hurt." A review of a facility investigation regarding a hand bruise found [DATE] indicated the bruising was caused from how the staff was transferring him. The result of the investigation was to remind staff not to pull on the resident's arms and allow him to push off the bed himself or to use the caregivers arm for support. The care plan or Kardex was not revised to reflect this information to prevent reoccurrence. On [DATE] at 2:45 p.m., an interview with Staff C, Director of Nurses (DNS), was conducted. The DNS verified the transfer care plan was not updated for Resident #48. The staff had no direction on how to properly transfer Resident #48 and prevented further injury and pain. Resident # 63 Resident # 63 was admitted [DATE] with [DIAGNOSES REDACTED]. Per record review care plan in place on [DATE] for At risk behavior symptoms including declining care. The goals for the resident were to accept care and medications as prescribed with interventions as follows. Engaging the resident in conversation about previous occupation, California, or other topics, Offer to call resident's sister or brother-in-law, Offer resident papers to fill out or write on, provide resident with newspaper, and Use consistent approach when giving cares. On [DATE] at 9:50 a.m. observed resident refusing medication from Staff FF,LN. When asked Staff FF stated there was no behavior monitoring because that was not normal behavior for resident. Per record review of Nursing Progress notes and MAR indicated [REDACTED]. Per record of the Nursing Progress Notes not one of the care planned interventions were attempted during or after the refusals. .

Based on observation, interview, and record review, the facility failed to ensure 4 out of 15 (#'s 41, 48, 20,63) sample residents were provided necessary care and services to maintain highest practicable level of well-being. The failed practice resulted in actual harm to resident # 41 and #48. Findings include: Resident # 41 Resident #41 was admitted on [DATE] with multiple diagnoses, including Diabetes Mellitus II (DM), Gout, history of Urinary Tract Infection [MEDICAL CONDITION] and [MEDICAL CONDITION]. His primary reason for admission was for rehabilitation therapy and strengthening. Per the initial MDS completed on [DATE], Resident #41 was assessed to have pain (intensity ,[DATE], frequency: rarely). He was taking no scheduled pain medication, but was using PRN (as needed) pain medication. The MDS stated that no non-medication interventions were being used. The pain did not interfere with daily activities and sleep. He did not trigger for pain on the Care Area Assessment (CAA). On [DATE] a care plan was developed to address Resident #41's pain. The goal was to reduce the incidence of breakthrough pain by 1) adjusting times of ADL (activities of daily living) and treatment activities so they occur after [MEDICATION NAME] (reduce/eliminate pain) benefits have been achieved, and 2) Report any non-verbal expressions of pain (ie moaning, grimacing.....). Neither of these interventions was found on the Kardex. Per review of the Medication Administration Record and physician orders, [MEDICATION NAME] 325 milligrams PRN (regular strength Tylenol, by brand name) was the only pain medication ordered until [DATE] when [MEDICATION NAME] ,[DATE] milligrams (mg) was ordered. On [DATE] a Physical Therapy Summary note by Staff GG, Physical Therapist stated Resident #41's ambulation is limited by "fatigue and residual pain R (right) front abdomen. The abdominal pain is long standing according to patient and is ,[DATE] to palpation (touching the body part to assess it) and ,[DATE] pain with gait/transfers and increased activity level. Pain etiology (cause) is unknown. Nursing aware of R quadrant pain." The care plan for pain was not updated. On the MDS completed on [DATE], Resident #41 was assessed to have pain (intensity ,[DATE], frequency: occasionally). He was taking no scheduled pain medication, but was using PRN pain medication on occasion. The MDS stated that non-medication interventions were not being used. The pain did not interfere with sleep but did interfere with daily activities. He did not trigger for pain on the Care Area Assessment (CAA). On [DATE] it was noted in the medical record Resident #41 complained of pain in lower abdomen. A KUB (an x-ray test that is used to diagnose or investigate conditions in lower section of the digestive tract) was done and no significant findings were noted. On [DATE] a Social Service progress note by Staff G, Social Services Director stated that Resident #41's abdominal pain is historical for resident. Further, a Physical Therapy Summary note by Staff GG relates Resident #41 is spending 90% of the day in bed and the resident stated that he stays in bed because of his abdominal pain. Further, the note stated "Rehab team has discussed all of this with nursing but no change." On the MDS completed on [DATE], Resident #41 was assessed to have pain (intensity ,[DATE], frequency: occasionally). He was taking no scheduled pain medication, but was using PRN pain medication. The MDS stated that non-medication interventions were not being used. The pain did not interfere with sleep or with daily activities. He did not trigger for pain on the Care Area Assessment (CAA). On [DATE] Resident #41's care plan was updated to include pain related to gout and on [DATE] it was updated to include pain related to skin breakdown (25 days after the skin breakdown was noted). On [DATE] a staff member noted in the progress notes the resident is less agitated and more willing to accept care when pre-medicated for pain. The MAR reflects the following pain medication received by Resident #41: * [DATE] - [DATE]: No doses of Tylenol and 2 doses of [MEDICATION NAME] * [DATE] - [DATE]: No doses of either Tylenol or [MEDICATION NAME] * [DATE] - [DATE]: No doses of Tylenol and 3 doses of [MEDICATION NAME] * [DATE] - [DATE]: 10 doses of [MEDICATION NAME] (all but 2 given after the pressure ulcer was discovered) * [DATE] - [DATE]: 21 doses of [MEDICATION NAME]; On [DATE] at approximately 8:30 p.m. Staff C, Director of Nursing Services stated the underlying causes of pain were not been established for Resident #41. She speculated that it was possibly gout [MEDICAL CONDITION], but she said she didn't know if he [MEDICAL CONDITION] or not. Although the care plan focus initiated [DATE] contained an intervention to adjust ADL and treatment times to occur after [MEDICATION NAME], and a staff member noted at the beginning of February the resident was more willing to allow care after receiving a pain med, the residents pain medications were not ordered to occur prior to care until [DATE], 3 days before he died . The facility failed to effectively manage Resident #41's persistent pain. The abdominal pain was not addressed in the care plan and non-medication interventions were not attempted throughout his stay at the facility. Despite frequent documentation that the abdominal pain was a significant and ongoing deterrent to daily activities, the drug regimen was not re-assessed to possibly include alternative dosing schedules, such as having pain medication on a routine basis or before scheduled activity. Further, the facility did not take note of the resident's increase in use of his pain med starting in January nor did the facility complete a new assessment of the residents overall pain and attempt alternate interventions when it appeared his pain became more frequent. The facility could have positioned his drug schedule to anticipate his pain instead of waiting for him to ask for it. Resident #48 ? Resident #48 was admitted [DATE] with lung problems, depression and dementia. During an interview on [DATE] at 11:31 a.m., Resident #48 was observed to have several dark to light purple discoloration covering the back of both hands and approximately 2 inches of his wrists. When asked how he obtained the discoloration, he replied the "bruises are from when they (the staff) transfer me; they (the staff) grab my hands." Resident #48 had told the staff not to transfer him by grabbing his hands. "(I) bruise easily and they hurt." A review of the resident chart was conducted. There was no assessment or care plan that identified the resident's bruises. The transfer care plan dated [DATE] documented to transfer the resident with one person guidance and physical assist. The second transfer care plan dated [DATE] had an intervention dated [DATE] to transfer the resident with two people and have him step pivot with walker from bed to chair. A review of a facility investigation regarding bruises found [DATE] on Resident #48's hand indicated the bruising was caused from how the staff was transferring him. The result of the investigation was to remind staff not to pull on the resident's arms and allow him to push off the bed himself or to use the caregivers arm for support. The care plan or Kardex was not revised to reflect this information to prevent reoccurrence. On [DATE] at 3:19 p.m., Staff T, a License Nurse (LN), was interviewed regarding the facilities skin assessment process. A weekly skin assessment was performed in accordance with each residents individual shower schedule. The Certified Nursing Assistant (CNA) documented on the shower sheet any skin issues identified. The CNA gives this to the LN. The LN reviewed the sheet and if there is a new skin issue the LN will take action. If a bruise was identified, the LN was to fill out an incident report and an investigation is initiated. Other skin issues (excluding pressure ulcers) go on a "body audit sheet" and were tracked weekly. On [DATE] at 3:20 p.m., Staff S, a LN, was interviewed regarding the facilities skin assessment process. A skin assessment was done on the residents scheduled shower day. The CNA will place on the "skin worksheet" of what they observed and the LN will follow up. The LN was responsible for updating the Treatment sheet. If a new bruise was identified, a "new skin sheet" and incident report was done. On [DATE] at 2:45 p.m., Staff C, the Director of Nurses (DNS) was interviewed regarding the facilities skin assessment process. Residents' skin was assessed upon admission and weekly. The "skin audit sheets" were used for all skin concerns except pressure ulcers and bruises. New bruises were to have an incident report done and placed on alert for three days. The facilities alert board was reviewed for January and February. Resident #48 was not placed on alert or a progress note documented in his medical record. There was no incident report done. The facility failed to follow their policy on new bruises identified and to update Resident #48's care plan which resulted in actual harm of new bruises on both of his hands and wrists and pain. Resident #20 Resident #20 was admitted [DATE] with [MEDICAL CONDITION], urinary tract infection and heart problems. A review of the physicians orders revealed the resident received [MEDICATION NAME] (a medication to thin blood) daily. [MEDICATION NAME] required frequent monitoring of blood levels and adjustment in the medication dosage to achieve a therapeutic International Normalized Ratio (INR). The goal for this resident's INR level was between 2XXX,[DATE].0. On [DATE] the INR was 2.4. The physician ordered to continue the same dosage of [MEDICATION NAME] and to check the resident's INR on [DATE]. On [DATE], the resident developed green sputum and was started on an antibiotic. On [DATE] at 2:00 p.m. the resident coughed up some blood in his sputum. The physician was notified and ordered a blood test to check resident's INR level. On [DATE] at 9:11 a.m.( 17 hours after the test was ordered) the physician was notified of the INR level at 8.0. The physician ordered Vitamin K "one time only for PT/INR critical high (Vitamin K is used to reverse the high INR level)." Per record review of the MAR, and the [MEDICATION NAME] flow sheet the physician ordered INR test [DATE] at 2:00pm, the MAR documentation on [DATE] at 8:30 p.m. INR level of 2.4, per [MEDICATION NAME] flow sheet [DATE] at time "a.m." INR level 8.0. The resident's critical high level was not reported to the physician until [DATE]. On [DATE] at 3:00 p.m., the DNS was interviewed regarding the facilities policy on [MEDICATION NAME] therapy. The facility had a machine to check INR levels. The LN was to check the INR level, notify the physician, and obtain orders prior to administrating the next scheduled dose of [MEDICATION NAME]. The INR results were to be recorded on the [MEDICATION NAME] flow sheet. If the INR level is high, the LN is expected to re-check to ensure accuracy. The LN is responsible to notify the physician when an antibiotic is ordered to check if the INR should be monitored more closely. A review of the resident's chart was done. The physician was not notified of the resident starting an antibiotic on [DATE]. There was no care plan to identify the risks involved for [MEDICATION NAME] therapy. On [DATE] at 9:42 a.m., Staff S, a LN, was interviewed regarding the facilities [MEDICATION NAME] policy. The LN was responsible to check the INR level when ordered by the physician. When an INR is due to be checked, the computer system will alert the LN. The LN was responsible to notify the physician when an antibiotic is initiated. The facility failed to develop a plan of care for a resident on [MEDICATION NAME] to identify the risks involved for medication therapy. The resident had an order to obtain an INR on [DATE]. There is no documentation that indicates the time it was taken. The physician was not notified until 17 hours after the original order was given. After receiving the INR results of 8 the physician ordered Vitamin K on [DATE] at 9:11 a.m. This medication was not given. The resident was unable to swallow the medication. Then resident expired on [DATE]. Resident # 63 Resident # 63 was admitted [DATE] with diagnosis's including Acute Systolic [MEDICAL CONDITION], Hypertension and Advanced dementia. Per record review admission MDS stated refused care ,[DATE] days. On [DATE] at 9:50am Staff FF, LN was observed attempting to give resident morning medication. Resident was lying in bed and stated she didn't want to sit up and didn't want to take the pills. Staff FF tried 3 times to give medication asking the resident if she was sure she didn't want medication, then left room. Staff FF was asked if there were any behavior monitoring for this resident she stated no because this is not her normal behavior. Per record review of MAR and Nurse Progress notes resident has refused medication and or care 18 times since admission on [DATE]. Two of residents morning medications are for [DIAGNOSES REDACTED]. On [DATE] at 3:30 p.m. Interview with Staff M,(Director of Care Delivery) stated after a resident refused any medication for hypertension she would expect vital signs be taken on the resident, but was unable to show any blood pressures had been taken on resident #63 since [DATE]. .

Based on observation, record review and interview, the facility failed to use the results of the assessment to develop the resident's comprehensive plan of care. For 6 of 29 residents (#41, 40, 163, 94, 20, & 146) reviewed in the areas of accidents, nutrition, skin condition, hospice and medication use, and for 4 of 4 units, the facility failed to develop a comprehensive care plan for each resident that includes resident specific interventions to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Findings include: Resident #41 Resident #41 was admitted on [DATE] for rehabilitation services to gain strength. Nutrition Per the initial Minimum Data Set (MDS), an assessment tool completed on 09/19/12, Resident #41 was assessed to need a nutrition care plan per the Care Area Assessment section. On that MDS, no weight loss was noted. Resident #41's weight was 167 lbs. No comprehensive plan of care was developed for Resident #41. Resident #41 had continued nutrition risk factors, including poor intake and weight loss. His diet was adjusted twice to try to encourage intake but no comprehensive care plan for nutrition was developed to address this change in nutrition status. Hospice At admission, the care plan developed for Resident #41 included potential for discharge to an assisted living facility (ALF). The care plan goal was to discharge Resident #41 to an ALF with wife, and that transportation would be arranged, future placement settings would be assessed and any special equipment needs would be investigated for the ALF. After admission, Resident #41 did not participate in therapy, had frequent pain and generally declined. Between 10/30/12 and 11/15/12, Resident #41 lost 25 lbs. On 10/24/12 Staff G documented that the discharge plan for Resident #41 was to remain in a long term care facility. Resident #41's condition continued to decline and on 12/12/12 hospice care was initiated. The resident's care plan was not updated to this change in care status. Resident #40 Resident #40 was admitted on [DATE] with multiple diagnoses, including several that placed her at nutrition risk: history of urinary tract infection [MEDICAL CONDITION], dementia, depression, pressure ulcers and adult failure to thrive. On the MDS dated [DATE], the CAA triggered that a care plan should be developed to address potential nutrition risk. No comprehensive care plan was developed for Resident #40. Resident #163 Resident #163 was admitted [DATE] with liver problems and two unstageable pressure ulcers (a ulcer that is covered by non-viable or dead tissue and the wound bed is not visible) on the left thigh. The MDS dated 02/03/13 identified the resident is able to feed self with set up and supervision assist. The Registered Dietician (RD) assessment dated [DATE], identified her as having poor nutritional intake of food and the need for healing her significant skin breakdown. The RD directed staff to offer frequent small meals, provide snacks between meals and to follow a specific fluid restriction of 1200 cubic centimeters (cc) of fluid in a 24-hour period. An interview on 02/19/13 at 5:15 p.m., with the RD the care plan for nutrition was reviewed. There was no care plan in place to address her needs. This place Resident#163 at risk for potential weight loss, decreased healing and receiving more fluids then the physician ordered. Resident #94 Resident #94 was admitted [DATE] with kidney problems, nutritional concerns (including protein [MEDICAL CONDITION]) and dry gangrene on both hands and right toes. The MDS dated [DATE] indicated the resident required supervision with set up assistance with meals. A review the CAA for nutrition directed staff to refer to the nutritional assessment and care plan for his nutritional needs. There was no nutritional care plan. The nutritional assessment dated [DATE] indicated he required a high protein renal diet with double protein portions to meet his kidney and healing requirements. Interviews with Resident #94 on 02/12/2013 10:27 a.m., 02/13/13 at 3:30 p.m., and 02/19/13 at 3:38 p.m. confirmed that he was not receiving double portions of protein. In an interview on 02/19/13 at 5:15 p.m. with the RD, she was aware that the resident does not receive his double protein portions on a consistent basis and the facility is "working on it." The facility failed to develop a nutritional care plan to adequately identify his nutritional needs which placed him at risk for delayed healing. Resident #20 Resident #20 was admitted in September 2012 with Urinary Tract Infection, [MEDICAL CONDITION], swallowing concerns, and risk for bleeding. The MDS dated [DATE] identified the resident had difficulty swallowing and was on a mechanically altered diet. The chart was reviewed. The RD identified the resident had swallowing issues and a fluid restrictions of 1000 cc per day. The CAA dated 10/02/12 directed staff to view his care plan dated 09/26/12 for nutritional needs. There was no care plan addressing Resident #20's nutritional requirements and fluid restriction. The facility failed to develop a care plan to adequately reflect the care needs required to safely maintain him at his highest practical level. Resident #146 Resident #146 was admitted in December 2012 with a bleed in his brain, anxiety, depression and hallucinations. The MDS dated [DATE] identified a BIMS of 15, the resident exhibited daily signs of disorganized thinking, inability to stay focused, feeling tired, and being restless. The resident also exhibited signs of depression and hallucinations. The MDS dated [DATE] indicated a care plan would be developed related to the resident receiving daily multiple [MEDICAL CONDITION] medications for the [DIAGNOSES REDACTED]. On 02/19/13 at 4:33 p.m., Staff C stated the staff were responsible reviewing each residents care plans regarding managing anxiety and depression. Resident's #146 care plan was reviewed with Staff C, and there were no specific goals, interventions, and approaches for his anxiety, depressions or hallucinations. The facility failed to implement a care plan directing staff on interventions to manage his anxiety, depression and hallucinations. Interviews: On 02/15/13 at 2:26 p.m. Staff M, Director of Care Delivery (DCD), was interviewed regarding the care plan process. The admitting nurse was responsible to place a few "standard approaches" on the care plan upon admission. The DCD was responsible to "individualize" the care plan. The goal was for the DCD to participate in the care planning conference within the first two weeks of admission to discuss the resident's concerns and goals. Staff M said the facility was "working on" this care plan process. On 02/16/13 11:20 a.m. Staff E, a DCD, was interviewed regarding the care planning process. The License Nurse on the floor was responsible to initiate the care plan and "obtain the generics." The DCD would "personalize" the care plan within two days. The facility was "working on" this process. On 02/20/13 at 1:30 p.m., Staff G, Social Service Director, said she was responsible to care plan resident's cognitive, mood, behavior, psychosocial well-being and discharge planning. Staff G stated the care plan was an interdisciplinary approach. .

Based on interview and record review, the facility failed to prevent avoidable skin breakdown and failed to treat pressure sores promptly for 1 of 3 residents (#41) reviewed having a stage III or greater pressure sore. This failure resulted in harm for Resident #41 who developed 3 avoidable pressure sores. Findings include: Resident #41 was admitted on [DATE] with a [DIAGNOSES REDACTED]. His primary reason for admission was for rehabilitation therapy and strengthening. On the initial MDS completed on 09/19/12, Resident #41 was assessed to be at risk for pressure sores, but having no pressure sores at that time. The MDS listed that a pressure reducing device was being used for Resident #41's bed and chair. On 09/12/12 a care plan was developed to address the risk of skin breakdown. The care plan was updated on 10/22/12. The care plan stated that Resident #41 was "At risk for alteration in skin integrity related to non-compliance with preventative measures, impaired mobility, Diabetes, declines incontinent care, poor nutrition." The interventions identified included floating heels as able and to observe skin condition with ADL care daily; report abnormalities. No interventions regarding ways to address the residents care refusal were noted on the care plan. His condition generally declined after admission and on 12/12/12 hospice care was initiated related to a [DIAGNOSES REDACTED]." On the MDS completed on 12/20/12 Resident #41 no longer walked and required limited to extensive assistance with most daily activities. Further, the MDS assessed Resident #41 to be at risk for pressure sores but having no pressure sores at that time. The MDS also noted that a reducing device was in use for his bed, but not his chair. On 01/10/13, the hospice nurse documented the hospice aide found a "dime sized open area" on the resident's right buttock. The Hospice nurse further documented Staff T, LPN Nurse Supervisor employed by the facility had been informed regarding the open area. No documentation from the facility is found until 01/17/13 when the facility "skin team" (consisting of both facility Direct Care Delivery managers) completed a PUSH (Pressure Ulcer Scale for Healing) form on the resident and noted an area on the right buttock. The PUSH form described the wound as "necrotic tissue measuring 2.1 - 3.0 centimeters squared (cm2)." Interview with Staff E, RN Direct Care Delivery and a member of the skin team, on 2/22/13 revealed the team was not notified about the area on resident #41's buttock until 01/17/13. When asked about the normal referral process if staff note a suspicious area, Staff E indicated a notice would be sent to the skin team so the team could immediately look at the resident's skin. When further asked if the team had been informed about resident #41's open area before 01/17/13, Staff E said "no." When asked how the team knew to look at the resident's skin on 1/17/13, Staff E stated "I'm not sure. A staff must have told one of us in passing." A review of the record showed no treatment was started for the pressure area and no documentation indicated the physician was alerted regarding the pressure ulcer. On 02/22/13, Staff E indicated a decision was made on 01/17/13 to attempt "offloading" (keeping the resident off the pressure area by turning him from side to side) although this resident had a documented history of refusing to stay off his back. Staff were also instructed to keep the resident clean and dry. On 02/06/13, the Hospice nurse documented a discussion with the facility staff regarding the resident's unwillingness to let staff do incontinent care. The nurse also noted the healing challenges for the open area due to the resident's resistance to accept incontinent care. Staff II, NAC (facility staff) indicated to the hospice nurse the resident seemed more open to care with male staff and older staff. The hospice nurse requested this information be placed on the residents care plan. Staff V, LPN Nurse Supervisor agreed. As of 02/22/13, this information could not be found on the care plan. On 02/06/13, the hospice nurse further noted "Patient was in a pool of urine where it took a towel to absorb the excess urine in the bed. Discussed the seriousness of the findings with Staff V who agrees to make sure patient would not be found in the same situation..." The Hospice nurse also documented "Instructed Staff V and Staff II that patient being left in pool of urine can exacerbate decline not related to HS (hospice) diagnosis" Offloading was attempted until 02/12/13 (26 days) although staff continued to document the resident didn't want to lie on his side. On 02/07/13 a second pressure area was noted on the sacrum. By 02/13/13, the two areas had merged into one pressure area. On 02/21/13 at approximately 11:00 a.m. Staff E stated he talked with Resident #41 about the importance of taking care of his skin. Staff E stated that offloading had not worked for Resident #41 so on 02/12/13 he talked to the resident and asked him if he would allow treatment. Resident #41 agreed to treatment so the physician was contacted to get an order for [REDACTED]. On 01/31/13 the hospice nurse noted in progress notes the Resident #41's left heel was "red, boggy." The hospice nurse instructed Staff D, RN to elevate Resident #41's heels. No further documentation was noted in the chart regarding the area on the heel. There is no mention on the Kardex regarding floating the heels. On 02/21/13 (22 days later) about 11:00 a.m. Staff E, a member of the skin team stated he had just assessed the heel and it had darkened color with intact skin and was "probably a deep tissue injury." He stated that if a facility nurse is notified of a new skin issue, that nurse needs to start a "skin sheet" to document the wound. If they suspect that the wound is pressure related they are supposed to contact a skin team member. On 02/22/13 at about 10:30 a.m. Staff E stated that if a nurse observes or is told about a red, boggy heel, he or the other skin team member should be told. He stated that he had not been informed Resident #41 had a possible pressure area on his heel until 2/21/13. On 02/11/13 Resident #41's care plan was updated to include care related to skin breakdown, nearly 1 month after the first pressure wounds were identified. Failure to accurately identify skin breakdown and treat it promptly caused Resident #41 to have further skin breakdown. This caused him increased pain and may have accelerated the decline in his condition. .

Based on observation, interview and record review, the facility failed to implement planned interventions and adequate supervision for safe transfer techniques for 1 of 7 residents (#48). This failure resulted in harm by causing significant bruising and pain to the back of Resident #48 hands and wrists. Findings include: Resident #48 was admitted [DATE] with lung problems, depression and dementia. During an interview on 02/12/13 at 11:31 a.m., Resident #48 was observed to have several dark to light purple discoloration covering the back of both hands and approximately 2 inches of his wrists. When asked how he obtained the discoloration, he replied the "bruises are from when they (the staff) transfer me; they (the staff) grab my hands." Resident #48 had told the staff not to transfer him by grabbing his hands. "(I) bruise easily and they hurt." The MDS dated [DATE] identified Resident #48 required extensive assistance of two people for transfers, toileting and bed mobility. The resident had two transfer care plans. The transfer care plan dated 09/24/12 documented to transfer the resident with one person guidance and physical assist. The second transfer care plan dated 09/22/12 had an intervention dated 10/09/12 to transfer the resident with two people and have him step pivot with walker from bed to chair. The Kardex directed caregivers to transfer resident #48 with a gait belt with one person assist, and to use a walker to step pivot from bed to wheelchair. On 02/20/13 at 4:00 p.m. Staff O, a CNA, was observed transferring Resident #48 in the bathroom. Staff O directed the resident to hold onto the grab bar with his right hand, as she used her right hand to go under his left arm and grabbed his left wrist/hand and with her left hand she held onto the front of the gait belt and directed him to stand. Resident #48 stood up and Staff O helped him place his left hand onto the grab bar as she proceeded to perform personal care. On 02/20/13 at 4:08 p.m., a follow up interview with Resident #48 was conducted. He remarked that he had to remind staff not to grab his hands when they transfer him. When asked how his hands and wrists felt, he stated "they (indicating his wrists and hands) do hurt at times." A review of a facility investigation regarding bruises found 11/22/2012 on Resident #48's hand indicated the bruising was caused from how the staff was transferring him. The result of the investigation was to remind staff not to pull on the resident 's arms and allow him to push off the bed himself or to use the caregivers arm for support. The care plan or Kardex was not revised to reflect this information to prevent reoccurrence. .

Based on record review and interview, the facility failed to assess the reason for resident refusal or offer alternative treatments in 1 of 1 resident (#41) investigated for refusal of care. This failure did not allow him to maintain or attain the highest practicable physical, mental and psychosocial well-being in the context of making the refusals and caused harm through skin breakdown and unnecessary pain. Findings include: Resident #41 was admitted on [DATE] for rehabilitation services to gain strength. On the MDS (Minimum Data Set) dated 09/19/12, he was judged to be cognitively intact, scoring 14 out of a possible high score of 15 for mental status. The MDS also indicated that he had no issues with mood and communicated well with clear speaking ability. Per Social Services assessment, he was his own decision maker, though he deferred to a family member for some decisions. The initial social services assessment on 09/17/12 by Staff G, Social Services Director noted Resident #41 had a history of [REDACTED]. If refusal of care occurred, per the assessment, Staff G would meet with Resident #41 as needed to educate him about the importance of achieving a certain level of independence in order to be able to live in an assisted living facility. On 02/20/13 at 8:30 p.m. Staff C, Director of Nursing Services, stated Resident #41 did not participate in therapy. She stated that on 10/01/12 Resident #41 was discharged from Occupational Therapy due to "non-participation." On 10/17/12, a Physical Therapy Summary documented by Staff EE, Director of Rehab - PT, physical therapy services were discontinued as the patient had not met goals due to "self-limiting behavior and inconsistent participation, variable mood and lack of energy/lethargy." Per record review, on 10/30/12 Staff G met with Resident #41 to discuss refusal of care. The meeting is documented in the progress notes, but no specific strategies to minimize refusals are documented there or elsewhere in the medical record as an outcome of the meeting. No care plan for addressing the refusal of care was developed, thus Resident #41 was disallowed the opportunity to have his physical and emotional needs met. On 02/20/13 at 1:30 p.m., Staff G said she was responsible to develop resident care plans for mood and behavior, but that the care plan was an interdisciplinary approach. Staff G further stated Resident #41 had a history of [REDACTED]. She stated she offered him mental health services through Senior Services, but he refused. His condition generally declined after 11/01/12 and on 12/12/12 hospice care was initiated related to a [DIAGNOSES REDACTED]." He continued to refuse food and incontinent care regularly. On 02/06/13, the Hospice nurse documented a discussion with the facility staff regarding the resident's unwillingness to let staff do incontinent care. The nurse also noted the healing challenges for the open area due to the resident's resistance to accept incontinent care. Staff II, NAC (facility staff) indicated to the hospice nurse the resident seemed more open to care with male staff and older staff. The hospice nurse requested this information be placed on the residents care plan. Staff V, LPN Nurse Supervisor agreed. As of 02/22/13, this information could not be found on the care plan. On 02/11/13 at approximately 5:15 p.m. Resident #41 was observed refusing his evening meal. He was in his room in at the time. Staff offered fluids and he took some. Staff member Q, RN Nurse Supervisor, stated he "often refuses" food. She stated they just keep offering. The facility failed to assess Resident #41 for refusal of care. They did not care plan strategies to provide care in a way he would accept. Social Services met with him only once about his refusing behavior. No alternative therapies were instituted after Occupational and Physical Therapy was discontinued due to non-participation. Suggested alternatives that might have mitigated refusals were not followed up. The Kardex (the resident-specific instructions for direct care staff) only had the information that the resident may refuse care, but nothing that indicated what to do if he did refuse. .

Based on observation, interview and record review, the facility failed to provide medically related social services to attain the highest level of physical, mental and psycho-social well-being for 1 of 1 resident (#41) investigated for social service support. The facility did not provide support for psychological adjustment difficulties related to grief about life changes and did not mitigate the circumstances causing the refusals of care. The failure to address the adjustment difficulties placed Resident #41 at risk for worsening depression and increased the likelihood he would refuse care. Failure to address the reasons for his refusal of care led to weight loss and skin breakdown, which resulted in a serious decline in health, infection and pain. Findings include: Resident #41 was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 09/17/12, in the initial Social Services assessment by Staff G, Social Services Director, it stated he had had a cardiac pacemaker placed during the summer of 2012. When he arrived at the facility in September, his primary reason for admission was for rehabilitation therapy and strengthening, as he had had some fainting episodes that resulted in a fall and had also had a UTI that had left him in a weakened condition. He had moved to the facility to be closer to his wife who lived in the assisted living facility next door. Staff G's assessment stated Resident #41 first entered a skilled nursing facility in April of 2012 and the move to this facility was his third skilled nursing facility since April. The resident's stated goal was to discharge to the assisted living facility to live with his wife. The assessment noted Resident #41 had a history of [REDACTED]. Per the assessment, if refusal of care occurred, Staff G would meet with Resident #41 to educate him about the importance of achieving a certain level of independence in order to be discharged to the community. On 02/20/13 at 8:30 p.m. Staff C, Director of Nursing Services, stated Resident #41 did not participate in therapy. She stated that on 10/01/12 Resident #41 was discharged from Occupational Therapy due to "non-participation." On 10/17/12, a summary documented by Staff EE, Director of Rehab - PT stated that physical therapy services were discontinued as the patient had not met goals due to "self-limiting behavior and inconsistent participation, variable mood and lack of energy/lethargy." Per progress notes, on 10/24/12, Staff G met with Resident #41 and informed him he did not have enough money to pay for an assisted living facility for both he and his wife. The possibility of finding a less expensive assisted living was discussed with Resident #41. On 10/24/12, Staff G documented that per Resident #41 and his family member, the future plan of care for Resident #41 was to remain in a long term care facility. This was a significant setback for Resident #41, who had expressed a desire to live with his spouse in the assisted living facility. Per record review, on 10/30/12 Staff G met with Resident #41 to discuss refusal of care. The meeting is documented in the progress notes, but no specific strategies to minimize refusals are documented there or elsewhere in the medical record as an outcome of the meeting. Thus, Resident #41 was disallowed the opportunity to have his physical and emotional needs met. On 11/06/12 a care plan was developed by Staff C (who is not a part of the social service staff) for "indicators of depression/sadness." One of the interventions to address the concern was for social services to "discuss feelings of sadness/hopelessness and option of appropriate channeling of these feelings...." There was no documentation this intervention was ever done after the care plan was developed. On 02/21/13, when asked if anyone had talked to the resident about why he refused care, Staff C did not answer the question directly. She stated "He had a lot of losses in the last year. He lost his independence, his health, his ability to live with his wife. He didn't feel he had anything left to live for." Between 10/30/12 and 11/15/12, Resident #41 lost 25 lbs. The facility attributed the weight loss to poor intake and refusal of meals. Prior to this time period, his weights had been stable and after this time period his weight stabilized at the lower weight. Staff L, Registered Dietitian met with Resident #41 around the time of the weight loss. She worked with him to improve his intake. Staff L did not document any recommendation to consider other alternatives to oral intake, such as a tube feeding. (See related tag F325 Nutrition) Per progress notes on 12/03/12, Staff G met with Resident #41 to discuss his weight loss. She alerted the resident he would need to consider whether he wanted to start using a tube feeding or to have a hospice consult. After a discussion with family members, the resident told Staff G he would accept a hospice consult. On 12/12/12 hospice care was initiated related to a [DIAGNOSES REDACTED]." Frequent refusal of incontinent care and positioning continued. On 12/12/12 the hospice nurse documented skin breakdown on his toes. On 01/10/13 the hospice nurse noted an open area on his right buttock. It was classified as a pressure ulcer on 01/17/13. On 02/07/13 a second pressure ulcer was noted, also located on his buttock. By 02/13/13, the two ulcers on his buttocks had enlarged and merged into one pressure ulcer. Resident #41's facility care plan judged him to be "at risk for alteration in skin integrity related to non-compliance with preventative measures, impaired mobility, DM, declines incontinent care and poor nutrition." (see related tag F314, Pressure Ulcer) Per Hospice progress note, on 02/06/13, the hospice nurse documented "Spoke with Staff II, evening CNA. Staff II indicated resident does much better with male staff or older staff when intimate care needs to occur." The progress note further stated that the resident's preference was discussed with Staff V, LPN Nurse Supervisor, who agreed to place this information on the resident's plan of care and work to get male staff with resident when possible. The facility care plan was not updated to reflect this preference, which could have negated some refusals of care. Further documentation from the hospice nurse stated that facility staff requires education related to addressing underlying reasons behind resident declining care rather than looking to medication to address the behavior. On 02/11/13 at approximately 5:15 p.m. Resident #41 was observed refusing his evening meal. He was in his room in at the time. Staff offered fluids and he took some. Staff member Q, RN Nurse Supervisor, stated he "often refuses" food. She stated they just keep offering. On 02/20/13 at 1:30 p.m., Staff G said she was responsible to develop resident care plans for cognitive, mood, behavior, psychosocial well-being and discharge planning. Staff G stated the care plan was an interdisciplinary approach. Staff G further stated Resident #41 had a history of [REDACTED]. She stated she offered him mental health services through Senior Services, but he refused. When asked how the facility supported Resident #41 through the life changes/losses he had experienced during the summer and fall of 2012, Staff G stated "He refused to meet about it. I met with him sometimes." When asked the question again, Staff G reiterated that Resident #41 had refused an outside mental health referral, but she did not define how staff within the facility helped him deal with life changes. The facilities "Mood and Behavior Practice Guide" stated "Report behavior and mood symptoms that present a safety risk to self or others, interfere with care delivery or are socially inappropriate or stressful to others" and "It is professional to regard these symptoms as treatable and not accept them as unavoidable. The goal is to work together to find the underlying cause." The facility was aware of Resident #41's significant life changes as well as his persistent refusal of care. Staff C attributed the refusals to the significant life changes. The facility failed to provide effective support to the resident about those life changes. While a referral to an outside agency for mental health was offered, in-facility social services support was rarely documented. A care plan was not developed to guide direct care staff about how to minimize the incidence of refusals and Social Services met with the resident only once about refusal of care. These refusals contributed to weight loss, skin breakdown and discomfort for Resident #41. .