Every finding on record at Life Care Center of Kennewick

Based on interview and record review, the facility failed to protect the resident's rights to be free from verbal and physical abuse by Resident 1, for 2 of 7 residents (Resident 2 and 3) reviewed for abuse. This failure placed the residents at risk for additional verbal and physical abuse, serious pain and injury, and emotional distress.Findings included. Review of a policy titled, Abuse - Identification of Types, reviewed 04/01/2026, showed abuse was defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish, that included, but was not limited to, hitting, slapping, punching, biting, and kicking. Verbal abuse may be considered a type of mental abuse that includes the use of oral, written, or gestured communication or sounds, to residents within hearing distance. It has the potential to cause the resident to experience humiliation, intimidation, fear, shame, or agitation. Verbal Abuse Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including left sided paralysis (weakness) following a stroke (death of brain tissue caused by an interrupted blood supply to the brain), ataxia (lack of muscle coordination that causes poor balance and speech changes), and delusional disorders (a mental health condition that causes false beliefs based on an incorrect interpretation of reality). The 06/04/2026 comprehensive assessment showed Resident 1 was independent with activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 1 had no memory problems and were able to make their needs known. Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), peritoneal abscess (a walled-off pocket of pus inside the abdominal cavity), and an anxiety disorder (a mental health condition that caused intense, ongoing worry, fear, and physical tension). The 06/30/2026 comprehensive assessment showed Resident 2 was independent with ADLs. The assessment also showed Resident 2 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Record review of an investigation dated 07/19/2026, showed Resident 2 reported that on 07/18/2026, Resident 1 verbally attacked, threatened, sexually harassed, and yelled at them in the main dining room. They stated they felt threatened by Resident 1 and when they passed Resident 1 in the hallway, they called him a derogatory term referring to sexual orientation. Record review of a grievance form titled, Concern & Comment Form, dated 07/19/2026 at 8:00 AM, showed Resident 2 reported on July 18th, 2026, (Resident 1) verbally attacked, threatened, sexually harassed, and yelled at me in the main dining room.I feel threatened by (Resident 1) and when I pass them in the hallway, (Resident 1) calls me a (derogatory term referring to sexual orientation). During an interview on 07/27/2026 at 11:24 AM, Resident 2 stated Resident 1 was really abusive and very threatening. Resident 2 stated there was an altercation with Resident 1 when they went into the main dining room after their meal to watch television. They stated there were no staff in the dining room at that time. Resident 1 entered the dining room and began yelling at Resident 2, telling them to get out of the dining room. Resident 1 stated that was not the first time Resident 1 had been abusive toward them, however they did not report the previous incident to the staff. They stated during the first incident, both Resident 1 and Resident 2 were in the dining room and Resident 1 shoved a table into their abdomen and grabbed a television remote out of their hand. Resident 2 stated they were afraid at that time because they did not know what Resident 1 was capable of. Resident 2 stated the day after the second incident, the verbal abuse in the dining room, they were walking past Resident 1's room, and Resident 1 yelled out a derogatory term regarding their sexual orientation. Resident 2 stated they were angry, upset, and frustrated with Resident 1's behavior and filed a grievance with the staff. They stated Resident 1 had been removed from the facility for a little bit and they felt relieved. Resident 2 stated I felt verbally threatened and abused; it frustrating that I can't go in there (main dining room) after dinner without being called names. Physical Abuse Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including heart failure, kidney disease, and dementia (a decline in memory, thinking, and reasoning that interferes with daily life). The 07/07/2026 comprehensive assessment showed Resident 3 requires supervision/maximum assistance of one staff member for ADLs. The assessment also showed Resident 3 had a severely impaired cognition. Record review of an investigation witness statement dated 07/24/2026, showed Staff C, Registered Nurse, heard yelling and observed Resident 3 in the doorway of Resident 1's room. Resident 1 kicked Resident 3 in the leg. During an interview on 07/29/2026 at 8:41 AM, Staff C stated they were in the medication room and heard yelling in hall. They went to the residents with another nurse to attend to the residents. Staff C stated, I saw Resident 1 kick Resident 3. During an interview on 07/27/2026 at 3:26 PM, Staff B, Interim Director of Nursing, stated verbal abuse was the intent to cause psychosocial harm or threaten someone to cause bodily harm. They stated the grievance form reported by Resident 2 showed the incident was verbal abuse. During a follow-up interview on 07/29/2026 at 11:51 AM, Staff B stated the resident-to-resident altercation between Resident 1 and Resident 3 was physical abuse; Resident 1 was purposefully kicking to prevent Resident 3 from entering their room. During a concurrent observation and interview on 07/27/2026 at 3:55 PM, Staff A, Administrator, reviewed Resident 2's grievance form and stated the allegations listed on the form were incidents of verbal abuse. Staff A stated they were unsure if the resident-to-resident altercations were preventable. Reference: WAC 388-97-0640(1)

Based on interview and record review, the facility failed to ensure adequate supervision to prevent resident-to-resident altercations with Resident 1, for 2 of 7 residents (Resident 2 and 3) reviewed for accidents. This failure placed the residents at risk for continued resident-to-resident altercations, abuse, and dissatisfaction with their homelike setting.Findings included. Record review of a policy titled Incident and Reportable Event Management, revised 02/24/2026, showed the facility strives to provide an environment free from accident hazards and provides supervision to each resident to prevent avoidable accidents. An avoidable accident may have occurred because the facility failed to implement interventions, including adequate supervision, consistent with resident's goals, needs, care plan, and current professional standards of practice in order to eliminate or reduce the risk an accident. The facility would monitor the effectiveness of the interventions and modify the care plan as necessary, according to current professional standards of practice. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including left sided paralysis (weakness) following a stroke (death of brain tissue caused by an interrupted blood supply to the brain), ataxia (lack of muscle coordination that causes poor balance and speech changes), and delusional disorders (a mental health condition that causes false beliefs based on an incorrect interpretation of reality). The 06/04/2026 comprehensive assessment showed Resident 1 was independent with activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 1 had no memory problems and were able to make their needs known. Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), peritoneal abscess (a walled-off pocket of pus inside the abdominal cavity), and an anxiety disorder (a mental health condition that caused intense, ongoing worry, fear, and physical tension). The 06/30/2026 comprehensive assessment showed Resident 2 was independent with ADLs. The assessment also showed Resident 2 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including heart failure, kidney disease, and dementia (a decline in memory, thinking, and reasoning that interferes with daily life). The 07/07/2026 comprehensive assessment showed Resident 3 requires supervision/maximum assistance of one staff member for ADLs. The assessment also showed Resident 3 had a severely impaired cognition. Record review of Resident 1's care plan dated 02/19/2026, showed Resident 1 was to be monitored when in the hallway for interactions with others. Record review of a facility investigation dated 07/19/2026, showed Resident 1 and Resident 2 had a verbal altercation on 07/18/2026, while alone in the dining room. Resident 2 was verbally attacked, threatened, sexually harassed, and yelled at by Resident 1. Record review of a facility investigation dated 07/24/2026, showed Resident 1 and Resident 3 had a physical altercation on 07/24/2026 at the entrance of Resident 1's room, where Resident 1 kicked Resident 3 in the leg. During an interview on 07/27/2026 at 2:20 PM, Staff E, Registered Nurse, stated when the resident-to-resident altercation occurred between Resident 1 and Resident 3 on 07/24/2026, they were at the nurse's station with their back to the hallway. They stated they heard the commotion between the two residents, turned around, and saw Resident 3 in the hallway with Resident 1, near Resident 1's room. They stated they were aware that Resident 1 had been in altercations with other residents in the past. Staff E stated they did not know if there were any interventions on Resident 1's care plan or Resident 3's care plan related to supervision or prevention of resident-to-resident altercations. During an interview on 07/29/2026 at 8:41 AM, Staff C stated they were in the medication room and heard yelling in hall. They went to the residents with another nurse to attend to the residents. Staff C stated, I saw Resident 1 kick Resident 3. Staff C stated they were a newer nurse and was unsure if there were interventions in either Resident 1 or Resident 3's care plan for interventions related to supervision or prevention of resident-to-resident altercations. Staff C stated they tried to keep Resident 3 at the nurse's station because they followed staff and wandered in the hallways. During an interview on 07/27/2026 at 2:55 PM, Staff D, Nursing Assistant, stated on 07/18/2026, they were at the nurse's station and heard arguing in the dining room. They went to the dining room and saw Resident 1 yelling obscenities at Resident 2. There were no staff monitoring the residents in the dining room at that time. They stated Resident 1 was aggressive and intimidating towards Resident 2. Staff D stated there was nothing on the care plan or Kardex for interventions when Resident 1 had behaviors. They stated there were two residents (one being Resident 3) that resided in the same hall as Resident 1 that wandered. They stated they were so scared that Resident 1 would get their hands on those residents and hurt them. During an interview on 07/27/2026 at 3:26 PM, Staff B, Interim Director of Nursing, stated staff should have followed the care plan for Resident 1 to prevent the resident-to-resident verbal altercation with Resident 2. Staff B stated they did not agree that the resident-to-resident physical altercation between Resident 1 and Resident 3 could have been prevented. Cross reference to F600 for further information. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure infection control measures intended to mitigate the transmission of Respiratory syncytial virus [(RSV) a virus that causes infections of the respiratory tract) were consistently implemented for contact precautions (infection control measures used to prevent the spread of germs that include wearing gloves and gowns when entering an isolation room, and performing meticulous hand hygiene with soap and water) and droplet precautions (infection control measures used alongside standard precautions to prevent the spread of pathogens transmitted through large respiratory droplets) for 2 of 4 staff (Staff B and Staff D) reviewed for infection control. This failure placed the residents at risk for contraction of communicable diseases, illness, and death.Findings included. Review of the U.S Centers for Disease Control and Prevention guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 03/30/2026, showed the facility must ensure that there area sufficient resources, such as personal protective equipment [(PPE) protective clothing, helmets, goggles, or other garments designed to protect the wearer's body from injury or infection] to fully implement recommended infection prevention and control practices. To prevent the spread of the virus, apply appropriate precautions for symptomatic residents. The facility should implement universal masking (requirement for all individuals in the facility to wear a mask) for source control (physical actions taken to eliminate a focus of infection and stop the spread of pathogens). Review of a facility policy titled, Contact Precautions, revised 03/24/2026, showed contact precautions were intended to prevent transmission of pathogens spread by direct contact (person-to-person) or indirect contact with the resident or their environment, and requires the use of appropriate PPE, including gown and gloves before or upon entering the room. Prior to leaving the room, the PPE is removed and hand hygiene is performed. Review of a facility policy titled, Droplet Precautions, revised 03/24/2026, showed droplet precautions should be implemented to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Review of instructions for use for Arlington Scientific face shields, dated 06/2020, showed the face shield was a single use, one-piece face shield that should be properly disposed of after use. A general facility tour observation on 04/13/2026 at 10:38 AM, showed four PPE carts located on the 300 Hall. Each cart contained a slip of paper in the drawer that contained the face shields manufactured by Arlington Scientific, that showed Attention: Staff, use one face shield per shift, you may use same shield in two or more RSV + (positive) rooms. The same note was posted outside of the employee breakroom. During the same observation at 10:55 AM, showed a PPE cart located in the 100 Hall. There were two face shields hanging off the top of the cart, one with a staff member's name written on it, and a third face shield lying on top of the cart. During an observation on 04/13/2026 at 11:52 AM, Staff B, Nursing Assistant (NA), obtained a meal tray from a meal cart located in the 100 Hall. Staff B carried the meal tray to a resident room that was designated contact and droplet precautions. Staff B was wearing a face mask and put on a gown. They did not put eye protection (face shield or goggles) or gloves on. Staff B entered the resident's room, rearranged items on their bedside table, and set up the resident's lunch meal. Staff B walked to the door of the resident's room, removed their gown, and performed hand hygiene. As Staff B was exiting the resident room, Staff C, NA, handed them a second meal tray. Staff B took the meal tray to the resident on the far side of the room and placed part of their meal on their bedside table. Staff B was not wearing a gown, gloves, or eye protection. Staff B, upon exiting the room, performed hand hygiene. They did not change their face mask. During an interview on 04/13/2026 at 12:31 PM, Staff B stated their process for isolation (contact/droplet precaution) rooms included putting on a gown, gloves, and goggles. They stated they did not put on gloves when passing the meal trays in the contact/droplet precaution room because they were going to touch food and open milk for the residents. They stated when they exited a room, they removed their PPE and washed their hands; they left their goggles on. Staff B stated their goggles were reusable so they put them on top of their head. They stated they should not have taken the second meal tray from Staff C and should have put a gown on before taking it. Staff B stated the face shields hanging on the PPE cart were for staff to reuse. During an observation on 04/13/2026 at 12:15 PM, Staff D, NA, put on a gown, gloves, eye protection, and facemask outside a contact/droplet precaution resident room. They obtained a meal tray from the meal cart and entered the room. Staff D provided meal setup for the resident, exited the room, and was handed a meal tray for a neighboring room, while wearing the same PPE. Staff D used the doorknob, wearing the same soiled gloves, to open the neighboring resident room (also under contact/droplet precautions) and delivered the meal tray to the resident. Staff D removed their gown and gloves, pushed their goggles on top of their head, performed hand hygiene and left the resident room. Staff D did not change their face mask. During an interview on 04/13/2026 at 12:36 PM, Staff D stated the process should have been to take their gown off when leaving the first resident's room and putting on a clean gown before entering the second resident room. Staff D stated they were told they did not have to change their PPE if they were going from one precaution room to another. Staff D stated they should not have gone from room to room because they could reinfected the residents or spread the germs by not changing their PPE. Staff D stated they normally changed their mask between rooms but did not. During an interview on 04/13/2026 at 2:25 PM, Staff E, Infection Preventionist, stated the process for entering the contact/droplet precaution rooms included performing hand hygiene, putting on a gown, a face mask, goggles or face shield, and gloves. They stated when exiting the room, staff should remove their gloves, perform hand hygiene, then remove the gown, mask, and goggles/face shield. Upon exiting the room, staff should put on a clean face mask from the PPE cart. Staff E stated the goggles were single use and the facility ran out of them. They stated they did not have a lot of face shields and needed to make them work (reuse) until they received a new supply. Staff E stated they did not know the face shields were single use only. During an interview on 04/13/2026 at 2:39 PM, Staff A, Director of Nursing, stated the process for entering the contact/droplet precaution rooms included putting on a gown, gloves, face mask, and eye protection, either goggles or a face shield, and staff should remove all PPE prior to exiting the resident room. They stated the face shields were not reusable. Staff A stated the staff did not follow the process for infection control and PPE use. Reference: WAC 388-97-1320(2)(a)(5)(b)This is a repeat deficiency from 01/26/2026.

Based on observation, interview, and record review, the facility failed to implement written abuse policies and procedures for identification, protection and prevention of abuse for 4 of 6 residents (Residents 1, 2, 3, and 4) reviewed for abuse. This failure placed residents at risk of unidentified abuse, continued exposure to abuse and psychosocial harm. Findings included. Review of a policy titled, Unsafe Wandering and Elopement Prevention, reviewed 09/25/2025, showed the facility would implement interventions to mitigate and reduce identified risks. Additionally, the policy identified unsafe wandering to include entering into another resident's room could lead to an altercation. Review of a policy titled, Abuse-Prevention, Protection of Residents, reviewed 05/06/2025, showed the facility would identify, assess, care plan for appropriate interventions, and monitor residents with behaviors that may lead to conflict including wandering into another resident room or space. Additionally, the facility would ensure that all residents were protected by assuring ongoing safety and protection was provided for the alleged victim and other residents. Resident 1Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including Dementia with severe agitation (a progressive condition that causes confusion, restlessness, and aggression) anxiety and depression. The 12/22/2025 comprehensive assessment showed they were dependent on one to two staff members for activities of daily living (ADLs) and severe impaired cognition. Review of progress notes (PN) dated 12/31/2025, showed Resident 1 was found wandering freely on multiple occasions through the halls and nursing staff were notified. Review of a PN dated 01/04/2026, showed Resident 1 had wandered into resident rooms and they were uncomfortable with that. The PN also showed Resident 1 required a staff member to sit with them one-to-one for the duration of the shift. Review of a PN dated 01/05/2026, showed Resident 1 needed redirected on multiple occasions back to their room after wandering freely, unassisted into other resident rooms. Review of a PN dated 01/06/2026, showed Resident 1 was redirected over a dozen times including other resident rooms, who were confused and concerned about why Resident 1 was in their rooms. The PN also showed Resident 1 was found in a resident's room standing over them in their bed. Review of a PN dated 01/15/2026, showed Resident 1 had entered many resident rooms from 6:00 PM to 10:00 PM non-stop. Staff attempted to redirect and it was difficult to get Resident 1 to leave other residents' rooms. Review of a PN dated 01/20/2026, showed Resident 1 had been wandering all day and entered a resident's room on more than one occasion and upset that resident. The resident wanted a Stop sign barricade across their doorway to prevent Resident 1 from entering. Resident 1 resisted redirection each time. Review of a PN dated 01/23/2026, showed multiple residents had complained that Resident 1 was wandering into their rooms. During an observation on 02/18/2026 at 1:07 PM, Resident 1 was seen sitting in a chair at the Team 2 nursing station. After 15 minutes, Resident 1 stood up and began to wander down the hall and turn the corner out of sight (no staff member accompanied). During an interview on 02/19/2026 at 1:29 PM, Staff C, Registered Nurse, stated Resident 1 paced and wandered the halls often. Staff C stated Resident 1 would enter other resident rooms and staff were to redirect them back to their hall. Staff C stated Resident 1 has grabbed residents belongings before and for other residents' rooms the facility put up a stop sign barricade across their doorways to try and prevent Resident 1 from entering. During an interview on 02/19/2026 at 3:41 PM, Staff D, Nursing Assistant, (NA), stated they were to redirect Resident 1 when they observed them wandering back to their hall or their room. Staff D stated they were unaware of any incidents with Resident 1 and other residents. During an interview on 02/19/2026 at 3:50 PM, Staff E, Resident Care Manager, stated Resident 1 did wander and enter resident rooms and staff were to redirect them back to their hall. Staff E stated once Resident 1 was back to their hall or room they would get up and wander again. During an interview on 02/20/2026 at 1:49 PM, Staff F, Activities Director, stated Resident 1 constantly wanders into resident rooms. The staff attempted to redirect and remove them from the rooms. Staff F stated that when these incidents occurred, it would be upsetting for some of the residents. Staff F stated the female residents were more concerned about Resident 1 being in their room as there was more vulnerability and Resident 1 was very tall and could be dominant in appearance. Staff F stated they would document the occurrences in a progress note and also discuss them at the next morning staff stand-up meetings. Staff F stated the direction provided from the meetings was to continue to monitor and redirect Resident 1. Additionally, Staff F stated they had a separate encounter with Resident 1 when they attempted to redirect them, and Resident 1 followed them and put their hands on Staff F's forearms and stated, you are not going to like what I am about to do. Staff F stated they were able to radio for help and Resident 1 was moved away from them. Resident 2Review of the medical record showed Resident 2 was readmitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe], and heart failure. The 04/11/2025 comprehensive assessment showed they required supervision/dependent for ADLs, used a wheelchair for ambulation and had an intact cognition. During an interview on 02/19/2026 at 3:06 PM, Resident 2 stated they were aware of Resident 1 wandering into other resident rooms, as it was talked about in the facility. Resident 2 stated they had an altercation with Resident 1 at a nurse's station when they said good morning to Resident 2 and they walked up and grabbed their left breast. Resident 2 stated they did not want Resident 2 to grab them and told them to not to do that. Resident 2 stated staff came and escorted Resident 1 back to their hall. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including Post-Traumatic Stress disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event), anxiety and depression. The 01/15/2026 comprehensive assessment showed Resident 3 required dependent/setup assistance for ADLs of one to two staff members and had an intact cognition. During an interview on 02/19/2026 at 1:22 PM, Resident 3 stated Resident 1 had entered their room and sat on their bed. Resident 3 stated Resident 1 had pulled their blanket up and looked at their legs and they felt scared. Resident 3 stated they had a prior history of sexual trauma and Resident 1 gave them a weird feeling and they did not want them in their room. Resident 3 stated Resident 1 had entered their room on more than one occasion but had only sat on their bed once. Resident 4Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including heart failure, anxiety and depression. The 02/06/2026 comprehensive assessment showed Resident 4 required substantial/maximal assistance of one to two staff members for ADLs and had intact cognition. During an interview on 02/19/2026 at 4:18 PM, Resident 4 stated Resident 1 had entered their room on multiple occasions and they called the police. Resident 4 stated they did not know who Resident 1 was and told them to leave their room and they would not. Resident 4 stated they felt unsafe and afraid because of Resident 1 and they wanted to cry. During an interview on 02/19/2026 at 4:02 PM, Staff M, NA, stated Resident 1 was very difficult to watch. Staff M stated Resident 1 should have one staff member assigned to them every day to watch them. Staff M stated Resident 1 had continued to invade other resident rooms that would make the other residents upset and afraid. Staff M stated Resident 4 had become so afraid they called the police. Staff M stated they had informed nursing management of the concern Resident 4 had shared with them. Staff M stated the staff were consistently attempting to redirect Resident 1 away from resident rooms and back to their room and/or hallway by the nursing station. During an interview on 02/20/2026 at 1:59 PM, Staff G, NA, stated they were aware Resident 1 wandered into other resident rooms. Staff G stated they would redirect when they heard the other residents either yell or ask for Resident 1 to leave their room. Staff G stated they did not think that was a type of suspected abuse. During an interview on 02/20/2026 at 2:26 PM, Staff I, Maintenance Assistant, stated Resident 1 wandered a lot through the halls and even entered other resident rooms. Staff I stated the resident rooms Resident 1 entered would sometimes scare the other residents and they would redirect Resident 1 back to the nurse's station in their hall. Staff I further stated they did not inform anyone the other residents stated they were scared. During an interview on 03/04/2026 at 2:09 PM, Staff K, NA, stated types of abuse were verbal, physical, mental, financial, sexual and resident to resident could be if it was physical or verbal. Staff K stated unwanted touching may be sexual abuse and they would report to a nurse. Staff K stated residents who could not speak for themselves, staff would not know when an incident occurred with a wandering resident. During an interview on 02/20/2026 at 11:15 AM, Staff B, Director of Nursing, stated the initial investigation into Resident 1 and Resident 2's resident to resident altercation was not completed correctly as there were no residents that were interviewed. Staff B stated they continued the investigation and identified additional residents that had altercations with Resident 1 who had entered their rooms and did not feel safe. Staff B stated they placed the identified residents on psychosocial monitoring and updated care plans and trauma assessments. During an interview on 03/04/2026 at 3:12 PM, Staff A, Administrator, stated the facility did not follow the correct process for implementing the abuse prohibition policies. Reference WAC: 388-97-0640(1)(2)(6)(b)

Based on interview and record review, the facility failed to provide copies of medical records within two working days as required for 1 of 1 resident (Resident 5), reviewed for access to medical records. Additionally, the facility failed to ensure its medical records policy was consistent with regulations pertaining to skilled nursing facilities. This failure placed the residents and/or representative at risk of not being fully informed of services and treatments provided and violated their rights.Findings included. Review of the facility undated policy titled, Release of Resident Medical Records, [NAME], showed when the facility received a request for medical records, they were to have an authorization form completed and provide records for active resident within two working days and records for those who were not active residents within 15 days. Review of the medical record showed Resident 5 was admitted with diagnoses including after care for right hip dislocation, dementia (a progressive mental decline affecting memory, thinking and reasoning), and malnutrition (deficiency in nutrition intake). The 11/03/2025 comprehensive assessment showed Resident 5 required partial/dependent assistance of one to two staff members for activities of daily living and moderate impaired cognition. During an interview on 01/29/2026 at 5:46 PM, Resident 5's representative (RR), stated they had requested Resident 5's records and the facility would not provide them. Review of an email dated 02/04/2026, showed the RR requested Resident 5's records and they were not provided. Review of a facility document titled Authorization for Release of Information, showed the RR completed the document and provided to the facility on [DATE]. Further review of the documents showed the facility provided Resident 5's records on 02/21/2026, nine days later, despite being verbally requested prior to 01/29/2026. During an interview on 03/04/2026 at 1:52 PM, Staff M, Medical Records Director, stated the process for a records request was when a resident was a current resident the facility had two days to provide them. Staff M stated when the resident was no longer a current resident the facility had 30 days to provide the records. Staff M stated when they received the verbal request, they would provide the release of records form to be filled out and when the form was returned, they would process the records. During an interview on 03/04/2026 at 3:12 PM, Staff A, Administrator, stated they were unsure of the regulations for record requests. Reference WAC: 388-97-0300(2)(a)(b)

Based on interview and record review, the facility failed to prevent a resident-to-resident sexual altercation for 2 of 3 residents (Residents 1 and 2) reviewed for abuse. This failure placed residents at risk of abuse, psychosocial harm and emotional distress.Findings included. Review of the policy titled, Abuse-Prevention, reviewed 05/06/2025, showed the facility would prevent and prohibit all types of abuse, and have protocols to prevent sexual abuse. Resident 1Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that affects memory, thinking, and behaviors) anxiety and depression. The 12/22/2025 comprehensive assessment showed they were dependent on one to two staff members for activities of daily living (ADLs) and severe impaired cognition. Resident 2Review of the medical record showed Resident 2 was readmitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), and heart failure. The 04/11/2025 comprehensive assessment showed they required supervision/dependent for ADLs, used a wheelchair for ambulation and had an intact cognition. Review of a facility investigation report dated 02/25/2026, showed an investigation was initiated on 02/04/2026 when a witnessed resident to resident altercation occurred when Resident 1 had walked up to Resident 2 and grabbed their left breast at Team 3 nursing station. During an interview on 02/19/2026 at 1:41 PM, Staff L, Licensed Practical Nurse, stated they were present when Resident 2 spoke to Resident 1, then Resident 1 reached out and squeezed Resident 2's left breast. Staff L stated they removed Resident 1 from the altercation and walked them back to their hall and assisted them to a chair. During an interview on 02/19/2026 at 3:06 PM, Resident 2 stated when they were at the nurse's station Resident 1 had reached out and grabbed their left breast. Resident 2 stated they told Resident 1 do not do that and don't touch my breast and pushed Resident 1's hand off their breast. Resident 2 stated were angry during the altercation and felt violated. During an interview on 03/04/2026 at 2:36 PM, Staff B, Director of Nursing, stated Resident 2 did not have intent for Resident 1 to touch them and it was unwanted contact. Reference WAC: 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to ensure infection control measures intended to mitigate the transmission of Clostridioides difficile [(C. diff) a highly contagious bacteria that causes severe diarrhea and inflammation of the colon] were consistently implemented for contact precautions (infection control measures used to prevent the spread of germs that include wearing gloves and gowns when entering an isolation room, and performing meticulous hand hygiene with soap and water) for 1 of 2 staff (Staff D) reviewed for infection control. This failure placed the residents at risk for contraction of communicable diseases, illness, and death.Findings included. Review of a policy titled, Transmission-based Precautions [(TBP) additional precautions used with residents that are suspected or confirmed to have an infection] and Isolation Procedures, showed the facility would implement and utilize TBPs to mitigate the spread of infection. Contact precautions require the use of appropriate personal protective equipment (PPE), including a gown and gloves before or upon entering the resident room. Prior to leaving the room, hand hygiene is performed. During a concurrent observation and interview on 01/26/2026 at 9:14 AM, Staff D, Registered Nurse/Unit Care Coordinator, entered a resident room that had signage posted indicating the room was under contact precautions. The sign showed everyone must clean their hands with soap and water before entering/leaving the room, put on gloves and gown before room entry and discard before room exit. Staff D entered the resident room without washing their hands or putting on a gown and gloves. They spoke to the resident in the bed next to the window, who stated they were dizzy and had diarrhea. Staff D then spoke to the resident in the bed closest to the door. Staff D exited the resident room without performing hand washing with soap and water. They walked down the hall to the medication cart and obtained a straw from the top of the cart. Staff D re-entered the resident room, again without washing hands or putting on a gown and gloves and removed the paper from the straw for the resident in the bed closest to the door. Staff D picked up the resident's breakfast tray and exited the resident room with the tray. They walked down the hall to the back door of the kitchen and placed the tray on a tray cart located in the hall. They opened the door to the kitchen, closed the door, walked down the hall towards the employee lounge and stated they needed to wash their hands. Staff D opened the door to the employee lounge and entered the lounge. Staff D did not perform hand washing with soap and water during the observation. Staff D stated the precaution sign posted on the resident room applied to all staff for all residents in the resident room. They stated they did not touch the resident, just the meal tray. Staff D stated the resident was on contact precautions for an area of open skin. Staff D reviewed the sign posted on the resident door and stated the use of contact precautions applied to all staff and they should have followed the instructions on the sign. During an interview on 01/26/2026 at 9:24 AM, Staff E, Registered Nurse, stated the contact precaution signage was posted on Saturday, 01/24/2026 because the resident in the bed near the window had complaints of diarrhea and was suspect for C. diff. During an interview on 01/26/2026 at 9:45 AM, Staff C, Infection Preventionist, stated the use of contact precautions included putting on a gown and gloves before going into the room, and before exiting, the gown and gloves needed to be removed, and hands needed to be washed with soap and water. Staff C stated hand sanitizer was not effective against C. diff. They stated staff needed to follow contact precautions any time they entered the resident room, even if they were just answering the call light. During an interview on 01/26/2026 at 11:20 AM, Staff B, Interim Director of Nursing, stated when there was a precaution sign posted at the resident room, all staff needed to follow the instructions on the sign. They stated contact precautions included putting on a gown and gloves before entering the room, removing them before exiting the room, and for C. diff, washing their hands with soap and water before leaving the room. Staff B stated they expected all staff to follow the posted signs and to wash their hands with soap and water before leaving the resident room. During an interview on 01/26/2026 at 12:19 PM, Staff A, Administrator, stated all staff should be following the posted precaution signs before entering the resident room and washing their hands before exiting. Staff A stated staff were not following the process for infection control. Reference: WAC 388-97-1320(1)(c)(2)(a) This is a repeat deficiency from the Statement of Deficiencies dated 03/06/2025 and 04/02/2025.

Based on interview and record review, the facility failed to implement policies and procedures related to screening potential staff to ensure the protection of residents against abuse, neglect, misappropriation, and exploitation, as shown by review of Notification of Background Check (BGC) Result forms for 1 of 4 nursing staff (Staff B) reviewed for criminal background checks. This failure allowed staff unsupervised access to residents without a valid criminal background check, placing the residents at risk for abuse, neglect, misappropriation, and exploitation.Findings included. Review of the guidelines titled, Nursing Home Guidelines 'The Purple Book', dated 10/2015, showed the facility must have principles and procedures established and implemented for the employment of new staff members. It is the responsibility of the facility to conduct criminal history BGCs on all staff, including agency-contracted staff, who have unsupervised access to vulnerable adults, within 72 hours of hire date. The facility must ensure any staff, including the agency-contracted staff, are free from any disqualifying criminal history. Review of a policy titled, Abuse - Screening of Employees and Residents, reviewed 05/06/2025, showed the facility would screen staff for a history of abuse, neglect, exploitation, or misappropriation of resident property. Screening components include completing background checks. Record review of Staff B's, Interim Director of Nursing, personnel file showed they were an agency nurse, contracted to perform duties as the Interim Director of Nursing. Staff B's first day working unsupervised with residents was 12/04/2025. Staff B did not have a completed BGC until 01/21/2026, 48 days after their first day working with residents. During an interview on 01/20/2026 at 1:53 PM, Staff C, Accounting Clerk, stated the process for potential new hires included obtaining a BGC, prior to their first day of work, to ensure the applicant was not going to be a danger to the residents. Staff C stated they had provided a Washington State BGC authorization form to Staff B repeatedly, but they had not returned it. Staff C stated they did not inform Staff A, Administrator, that a Washington State BGC had not been completed. During an interview on 01/20/2026 at 2:31 PM, Staff A stated the purpose of a BGC was to ensure there were no disqualifying events on the BGC that would hinder employment or put the residents at risk for abuse and neglect. Staff A stated they were not aware that Staff B was working without a valid BGC. Staff A stated the process for screening with a BGC included completing the Washington State BGC prior to the new applicants hire date and/or start date and reviewing the BGC for eligibility before starting work. Reference: WAC 388-97-0640(2)(a)(b)

Based on interview and record review, the facility failed to maintain resident medical records that were complete, accurate, readily accessible, and systematically organized for 4 of 9 residents (Resident 1, 2, 3, and 4) reviewed for resident records. This failure placed the residents at risk for receiving care and services based on inadequate/inaccurate information. Findings included. Review of a policy titled, Health Information Management, reviewed 05/15/2025, showed the facility ensured all medical records were complete, readily accessible, and systematically organized. The Executive Director or a designee had overall responsibility for ensuring health information management records were maintained and completed in accordance with accepted professional standards and applicable law. The health information management record would reflect the total condition of the resident throughout their stay in the facility from admission to discharge. Resident 1Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), moderate protein-calorie malnutrition (reduced availability of nutrients that leads to changes in body composition and function), and diabetes (a group of diseases that result in too much sugar in the blood). The 10/17/2025 comprehensive assessment showed Resident 1 was dependent on one to two staff members for activities of daily living (ADLs) and had a severely impaired cognition. The assessment showed Resident 1 was receiving hospice care while in the facility. Review of the medical record showed Resident 1 was admitted to hospice services on 10/13/2025. The record showed there were hospice visit notes dated 10/13/2025, 10/21/2025, 10/23/2025, 10/24/2025, 10/31/2025, and 11/06/2025. There were no additional notes despite Resident 1's continued weekly hospice visits. Additionally, there were no facility provider progress/visit notes in Resident 1's medical record. Resident 2Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses including diverticulitis of the intestine (inflammation of irregular bulging pouches in the wall of the large intestine), heart failure, and muscle weakness. The 11/13/2025 comprehensive assessment showed Resident 2 required substantial/maximum assistance of one to two staff members for ADLs. The assessment also showed the resident had an intact cognition. During an interview on 12/16/2025 at 3:06 PM, Resident Representative for Resident 2 stated they did not receive any communication from the facility regarding the care Resident 2 was receiving. Review of Resident 2's medical record showed no facility provider physician progress/visit notes. Further review of Resident 2's demographic information showed no contact information for their representative/emergency contact. Record review of Resident 2's admission referral dated 11/05/2025, showed they listed their representative as their emergency contact with their name, address, and phone number. During an interview on 12/17/2025 at 12:47 PM, Staff F, Admissions Director, stated they were responsible for entering a resident's demographic information. After reviewing Resident 2's admission referral, Staff F stated the emergency contact information listed on Resident 2's admission referral should have been entered into the system. Resident 3Review of medical record showed Resident 3 was admitted to the facility with diagnoses including encephalitis (inflammation of the brain), severe intellectual disabilities, and difficulty swallowing. The 12/05/2025 comprehensive assessment showed Resident 3 was dependent on one to two staff members for ADLs. The assessment also showed Resident 3 had a severely impaired cognition. Review of Resident 3's medical record showed the most recent facility provider progress/visit note was dated 10/24/2023. Resident 4Review of the medical record showed Resident 4 was admitted to the facility on [DATE] with diagnoses including respiratory failure, heart failure, and diabetes. The 12/08/2025 comprehensive assessment showed Resident 4 required substantial/maximal assistance of one to two staff members for ADLs. The assessment also showed Resident 4 had an intact cognition. Review of Resident 4's medical record showed no documentation of a facility provider visit or progress note. During a concurrent observation and interview on 12/17/2025 at 11:43 AM, Staff E, Medical Records Director, stated the normal process for ensuring records were complete, accurate, and organized included receiving documents such as physician orders and lab results after the clinical team had reviewed them. Staff E stated after receiving the documents, they scanned them into the medical record. They stated for new admissions, they would receive their admission packet that contained the consent to treat and immunization consents, along with other additional admission documents. Staff E pointed to boxes of documents in their office and stated they were about six months behind with scanning documents. Staff E stated the medical records process was badly broken and the resident records should have been scanned into their records. During a concurrent observation and interview on 12/17/2025 at 11:54 AM, Staff B, Resident Care Manager (RCM)/Licensed Practical Nurse, stated they thought the facility providers charted their progress/visit notes in a different medical records system. Staff B reviewed the medical record for Resident 2 and stated they did not see any facility provider notes in their record. They stated normally, after the provider had a visit with the resident, the facility nurses would get a hard copy of the provider orders, the RCMs would review those orders, enter them into the medical record system, and the hard copy would then be scanned into the medical record. Staff B stated if they needed previous visit notes, they would have to have Staff E obtain them from an outside medical record system and that Staff E was the only staff member with access to that system. During an interview on 12/17/2025 on 1:24 PM, Staff A, Interim Director of Nursing, stated the facility was required to have provider notes in the resident record that needed to be readily accessible to staff. Staff A stated it was important to have an emergency contact listed for the residents. They stated it was a resident's choice to have an emergency contact and it was necessary to contact them when a resident has a change of condition. They stated the facility was not following their own policies for medical records. Reference: WAC 388-97-1720(1)(a)(i)(ii)(iii)(iv)(2)(a)

Based on interview and record review, the facility failed to identify a designated interdisciplinary [(IDT) a group of healthcare professionals from different disciplines to help people receive the care they need] team member, appointed as the responsible party for coordinating care and communication with hospice, and implement the written agreement that ensured effective communication, collaboration, and coordination of care between the facility and the hospice (a specialized type of care focused on providing comfort and support to individuals nearing the end-of-life) provider for 1 of 1 residents (Resident 1) reviewed for hospice services. This failure placed the residents at risk of not receiving necessary care and services at end-of-life.Findings included. Review of a policy titled, Hospice Coordination of Care, revised 09/03/2025, showed the facility must ensure that, under a written agreement with the hospice provider, the resident's facility plan of care included the most recent hospice of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility must designate an IDT member to communicate and collaborate with hospice representatives and other healthcare providers participating in the provision of care for the resident. The facility must obtain from hospice, the most recent hospice plan of care, hospice election form, and physician certification/recertification (documentation of a terminal illness with a life expectancy of six months or less) of the terminal illness. The resident's attending physician must write an order referring the resident to hospice and an order to admit the resident to hospice services. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), moderate protein-calorie malnutrition (reduced availability of nutrients that leads to changes in body composition and function), and diabetes (a group of diseases that result in too much sugar in the blood). The 10/17/2025 comprehensive assessment showed Resident 1 was dependent on one to two staff members for activities of daily living and had a severely impaired cognition. The assessment showed Resident 1 was receiving hospice care while in the facility. Record review of nursing progress notes (PN) dated 10/07/2025 at 11:34 AM, showed the Resident's Representative (RR) had agreed to initiate hospice services and a provider order was faxed to the hospice provider. A second PN dated 10/13/2025 at 11:06 AM, showed the hospice provider had admitted Resident 1 to hospice services and provided the facility with medications for Resident 1. Record review of Resident 1's medical record showed no documentation of a physician's order to admit to hospice services, physician certification of a terminal illness, Resident 1's hospice election form, or a plan of care that coordinated care between the facility and hospice services that identified the provider responsible for performing each/any specific services that were agreed upon. Record review of nursing PN's dated 11/21/2025 at 1:24 PM, showed Resident 1 was seen by hospice services. An assessment and wound care were completed. The record showed no hospice services were provided and/or documented after 11/21/2025. Record review of the facility wound care provider PN's dated 10/14/2025, showed they were providing wound care and treatments, including excisional debridement (cutting away of damaged, infected, or dead tissue) to Resident 1's left heel. The PN showed the facility wound care provider also provided wound cleaning and dressing orders for Resident 1's left heel, right heel, and right knee wounds. Record review of the facility's wound care provider PN's dated 11/25/2025, showed they continued to provide wound care and dressing change orders for Resident 1's right and left heel wounds. Additionally, they provided excisional debridement to Resident 1's buttock and tuberosity (the bones at the bottom of the pelvis that bear weight when sitting) regions. The PN showed additional dressing change orders for Resident 1's buttock, tuberosity, and dorsum (top surface) foot wounds. Record review of hospice wound care orders dated 11/25/2025, showed care and treatment of the right hip (tuberosity) wound included cleansing the area with wound cleanser or normal saline. Pat dry with a clean gauze and apply skin protectant around the wound. Apply a calcium alginate pad (a specialized pad that contains silver to inhibit bacterial growth and absorbs drainage from a wound) to the wound bed. Cover with one bordered super absorbent or dry dressing. A concurrent observation and interview on 12/16/2025 at 11:33 AM, showed Staff B, Resident Care Manager/LPN, and Staff C, Registered Nurse, completing wound care on Resident 1's tuberosity wound. There was a table in Resident 1's room that held a large quantity of wound care supplies. Staff B stated those were hospice supplies and the facility did not use them for wound care. Staff B stated the facility wound care provider had seen Resident 1 that morning and had obtained measurements of the wound. Staff C stated hospice services came twice a week to provide nursing care for Resident 1. They stated the facility changed the wound dressings every Tuesday, every other day, and as needed. Staff C cleansed the wound with saline solution, and Staff B placed a gauze pad soaked with Dakins solution (topical antiseptic) into the wound per the wound care provider order. They removed the gauze after five minutes, rinsed the wound with saline, patted dry, and applied a crushed medication into the wound, packed the wound with an antimicrobial (substances that kill or inhibit the growth of microorganisms) dressing, and covered the area with a silicone dressing (an advanced wound care product that creates a moist healing environment). Staff B stated they used the facility's wound care provider orders for Resident 1's wound care. During an interview on 12/16/2025 at 3:43 PM, Collateral Contact 1 (CC1), Hospice Case Manager, stated they were not aware that the facility's wound care provider was debriding Resident 1's wounds and providing treatment. They stated hospice services used an outside specialized wound care service that used images and measurements taken by the onsite hospice nurse to devise a wound management plan that included specialized wound care supplies to manage drainage and odors related to the non-healing wounds. CC1 stated the process for providing communication between hospice nursing and the facility included providing a verbal report to the facility nursing staff after each visit and providing the facility with a completed form with details of the visit. They stated hospice created an individualized plan of care for each resident upon admission to hospice services and provided that plan of care to the facility. CC1 stated they provided the facility with orders for Resident 1's care. During an interview on 12/17/2025 at 11:24 AM, Staff D, RCM/RN, stated they managed Resident 1's care. Staff D stated there was no designated person to coordinate hospice services. They stated the hospice provider did not provide the facility with a plan of care for Resident 1. They stated they followed the facility plan of care and would provide it to the hospice nurse if they needed it. Staff D stated the facility wound care provider completed all the care and orders for Resident 1's wounds and the hospice nurse was responsible for taking weekly wound measurements. They stated the process for communication with the hospice nurses included receiving both a verbal report and completed form after the hospice visit. After reviewing the form, they entered a nursing PN into the medical record and gave the form to medical records to scan into the resident's medical record. Staff D verified the last form scanned into Resident 1's medical record was dated 11/06/2025, despite Resident 1 receiving additional visits from hospice on 11/26/2025 and 12/04/2025. There was no documentation of a weekly visit from 12/05/2025 through 12/17/2025. During an interview on 12/17/2025 at 11:54 AM, Staff B stated the facility did not have a designated contact from the IDT to communicate with hospice. They stated the process for enrolling a resident in hospice services included speaking to the family, obtaining a physician order and referral to hospice. They stated hospice services would then assess the resident and provide orders and a medication comfort pack (medications used to manage end of life symptoms). Hospice services would also provide wound care orders. Staff B stated they did not know when hospice was in the facility as they made their own schedule. They stated hospice staff did not always provide a report to the RCM. Staff B stated the hospice staff always left a paper form and that form may contain new orders. They stated after reviewing the form and entering any new orders into the medical record, they would enter a progress note, then gave the form to medical records for scanning into the medical record. They stated Resident 1's medical record did not have a physician order for hospice services and they were not aware that hospice had a separate plan of care. They stated they did not know that hospice was required to provide a plan of care to the facility. Staff B stated hospice provided Resident 1's wound care supplies for their dressing changes and were not aware that they had a specialized wound care program. They stated they used house supplies for Resident 1's wound care. Staff B stated the hospice program was a completely broken process. During an interview on 12/17/2025 at 1:24 PM, Staff A, Interim Director of Nursing, stated the process for enrolling a resident in hospice services included completing their normal facility admission, then call and coordinate care and services with the hospice provider. They stated once the hospice provider completed their paperwork, they expected the hospice nurse to share their findings, new orders, and plan of care for that resident. Staff A stated they were required to follow the facility policies that were in line with the federal regulations. Based off the information provided, the facility did not follow their policies. Reference: WAC 388-97-1620(1)(2)(i)(ii)

Based on interview and record review, the facility failed to ensure residents Preadmission Screening and Resident Review ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) were accurately completed prior to admission and updated when new SMIs were identified and had the required Level II (a comprehensive evaluation by the appropriate state-designated authority) referral if residents had a positive Level I (a pre-screening evaluation for identifying SMI/ID/DD) PASARR for 6 of 6 residents (Residents 9, 43, 78, 31, 6, and 58 ) reviewed for PASARR and unnecessary medications. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs. Findings included. Review of the policy titled, Pre-admission Screening and Resident Review (PASARR), dated 09/26/2025, showed all applicants to the facility would have a Level I PASAAR for SMI, ID/DD, and/or related conditions prior to admission to the Nursing Home (NH) and if an SMI/ID/DD should be diagnosed after admission. If the Level I showed the resident had an SMI/ID/DD, then a Level II evaluation would be completed prior to admission. The policy additionally showed any resident who was diagnosed with a SMI/ID/DD after admission would be referred for a Level II evaluation. Resident 9Review of the resident's medical record showed they were admitted to the facility 09/03/2025 with diagnoses including anxiety (a feeling of worry, nervousness, or fear, often in anticipation of something unpleasant) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and a loss of interest in activities once enjoyed). The comprehensive assessment, dated 09/08/2025, showed Resident 9 had impaired cognition, depression, and an anxiety disorder. Review of Resident 9's PASARR dated 08/15/2025, showed Resident 9 had no SMI marked. Further review showed Resident 9's PASARR was marked no Level II evaluation required. Resident 43Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including anxiety and depression. The comprehensive assessment dated [DATE] showed Resident 43 had an intact cognition, depression, and an anxiety disorder. Review of Resident 43's PASARR dated 05/06/2025, showed Resident 43 had a positive SMI for a mood disorder. Further review showed Resident 9's PASARR was marked exempt from requiring a Level 2 evaluation due to a physician certifying that Resident 43 would be requiring less than a 30 day stay in the nursing facility. Additionally, the required Level II evaluation had not been completed as of 11/19/2025 (6 months after Resident 43's admission). Resident 78Review of the resident's medical record showed they were admitted to the facility with diagnoses including bi-polar disorder (a mental health condition characterized by extreme shifts in mood, energy, and activity levels that include periods of mania [highs] and depression [lows]), anxiety, and depression. The comprehensive assessment dated [DATE] showed Resident 43 had impaired cognition, bi-polar disorder, and an anxiety disorder. Review of Resident 78's PASARR dated 07/24/2024, showed Resident 78 had a positive SMI for a mood disorder and anxiety disorder. Further review showed Resident 78's PASARR was marked no Level II evaluation required. Resident 31 Review of the medical record showed Resident 31 admitted to the facility on [DATE], with diagnoses of dementia (a disease that causes the loss of thinking, remembering, and reasoning skills), affective disorder (a mental health condition characterized by prolonged and extreme shifts in mood, such as persistent sadness or excessive elation), restlessness (the feeling of being unable to relax or stay still, both physically and mentally) and agitation (a feeling of being tense, irritable, and restless, often accompanied by physical actions like fidgeting, pacing, or wringing your hands). Review of the comprehensive assessment, dated 09/15/2025, showed Resident 31 had severe cognitive impairment and required the assistance of one person for grooming, dressing, incontinent care, bathing and mobility. Review of the medical record showed a PASARR Level I dated 09/09/2025, for Resident 31, had a positive screening for SMI for the diagnosis of affective disorder, requiring a Level II evaluation. Further review of the PASARR form showed Resident 31 was marked for No Level II evaluation indicated, and the medical record showed no documentation of a completed Level II evaluation. Resident 6 Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with diagnoses including anxiety, bipolar disorder, and Fragile X Chromosome (a genetic disorder that leads to intellectual disability and developmental problems). The 10/30/2025 comprehensive assessment showed Resident 6 required substantial/maximum assistance of one staff member for toileting transfers and dressing: independent with eating and oral hygiene. The assessment also showed the resident had a moderately impaired cognition. Review of the medical record showed a PASARR Level I Review form was completed on 02/11/2025, 13 days after admission. The form showed Resident 6 had a positive screening for SMI indicators of bipolar and anxiety disorders and required a Level II evaluation. There was no documentation in the medical record that a Level II evaluation had been completed. Further review of the medical record showed a second PASARR Level I Review form was completed on 07/21/2025 that showed a positive screening for SMI indicators of bipolar and anxiety disorders, requiring a Level II evaluation. There was no documentation in the medical record that a Level II evaluation had been completed for the second PASARR screening. Resident 58 Review of the medical record showed Resident 58 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, and necrotizing fasciitis (a severe, rapidly spreading bacterial infection). The 09/04/2025 comprehensive assessment showed Resident 58 was dependent on one to two staff members for ADLs: setup assistance for eating and oral hygiene. The assessment also showed Resident 58 was cognitively intact. Review of the medical record showed a PASARR Level I Review form was completed on 08/26/2025 and had a positive SMI screening for mood and anxiety disorders, requiring a Level II evaluation. There was no documentation in the medical record of a Level II evaluation. During an interview on 11/19/2025 at 3:49 PM, Staff D, Social Services Assistant, stated there was currently no formal tracking system or process in place to monitor PASARR forms, including whether Level II referrals were sent or when results were returned. Staff D stated the PASARR information was only documented in a chart note and reviewed annually at care conferences. Staff D stated there was a breakdown with the Level II referral process. During an interview on 11/19/2025 at 3:49 PM, Staff F, Social Services Director (SSD), stated the process for PASARR's was for Social Services to ensure all new residents had a completed PASARR upon admission. Staff F stated the form was reviewed to determine whether a Level II evaluation was needed, and if so, the necessary paperwork was completed and faxed to the state designated authority. Staff F confirmed that Resident 9's Level I PASARR was incorrect on admission and should have been corrected immediately, and that Resident's 9, 43, and 78 should have had Level II evaluations completed and documented in their electronic records. During an interview on 11/20/2025 at 11:35 AM, Staff B, Director of Nursing Services, stated Social Services was responsible to ensure PASARRs were correct, and Level II referrals were sent when needed. Staff B stated Social Services reviewed all PASARRs on admission, corrected any inaccuracies, and ensured referrals were made. Staff B stated that since the change in SSDs there had been a gap in the process. Reference: WAC 388-97-1915(2)

Based on observation, interview, and record review, the facility failed to promote a dignified living experience for 1 of 3 residents (Resident 73) reviewed for resident rights. This deficient practice placed residents at risk for humiliation, diminished self-worth, and infection control concerns.Findings included . Review of the facility policy, Preventative Maintenance-Wheelchair, revised on 01/11/2023, showed all facility wheelchairs were to be cleaned and inspected for proper operations at least quarterly. Resident 73Review of the medical record showed Resident 73 admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body) of the right side, aphasia (brain disorder that affects how you speak and understand language), bipolar disorder ( mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), and need for assistance with personal care. Review of the comprehensive assessment, dated 11/13/2025, showed Resident 73 had moderate cognitive impairment and required the assistance of one to two staff members for grooming, dressing, toileting, transfers, and mobility. A concurrent observation and interview on 11/19/2025 at 11:40 AM, two flies were observed in Resident 73's room. One fly was hovering around the floor in front of Resident 73's feet and the other was sitting on the windowsill of the closed window. A fly swatter was observed on Resident 73's overbed table and when asked if there were flies in the room often, Resident 73 replied, Yep. During an interview on 11/19/2025 at 11:45 AM, a contracted Pest Control Vendor stated they came to the building monthly and had not received any complaints about flies. An observation on 11/20/2025 at 9:11 AM, showed Resident 73 sitting in their room in their wheelchair watching television, and four flies were flying around them. The flies landed on Resident 73's right leg, overbed table, and wheelchair arm rest. Resident 73's wheelchair was dirty with multiple pieces of dried white, yellow, and brown particles on the frame, wheels, foot pedals, and brakes. During an interview on 11/20/2025 at 9:35 AM, Staff H, Restorative Aide (RA), stated Resident 73 preferred to eat their meals in their room on their overbed table, and the night shift staff were responsible for washing wheelchairs. During an interview on 11/20/2025 at 9:44 AM, Staff I, Maintenance Assistant, stated they were unaware of any resident rooms having flies. During an interview on 11/20/2025 at 9:46 AM, Staff J, Nursing Assistant (NA), stated they started working at the facility in July 2025 as a housekeeper and flies had been in Resident 73's room since they started. Staff J stated Resident 73 dropped food at times when eating and their wheelchair needed to be washed. Staff J stated they did not know what attracted the flies in Resident 73's room. A concurrent observation and interview on 11/20/2025 at 1:15 PM, showed a fly swatter and a dead fly on Resident 73's overbed table. When asked if they had killed the fly with the fly swatter, Resident 73 stated, Yep. When asked if their wheelchair had been washed recently, Resident 73 stated, Nope. When asked if it bothered them to have a dirty wheelchair and flies in their room, Resident 73 stated, Yea. During an interview on 11/21/2025 at 10:40 AM, Staff B, Director of Nursing Services, stated there was previously a wheelchair washing schedule, but further investigation showed the night shift staff were not following it. Staff B stated the staff were picking wheelchairs they thought were dirty and needed to be washed, and there was no way to determine when the last time Resident 73's wheelchair was washed. Staff B stated Resident 73's wheelchair should have been kept clean and there should not have been flies in their room. During an interview on 11/21/2025 at 11:00 AM, Staff A, Administrator, stated they would be upset if they had to live with flies in their room and it's something no resident should have to deal with. During an interview on 11/21/2025 at 11:20 AM, Staff K, Maintenance Director, stated they recalled being told about flies in Resident 73's room a while ago, maybe in September, and was probably the one who gave them (Resident 73) the fly swatter. Staff K stated they had not received any further reports about flies and they did not go back to see if they were gone. Reference: WAC 388-97-0180(2)

Based on observation, interview and record review, the facility failed to ensure psychotropic (drugs that affect how the brain works, and cause changes in mood, awareness, thoughts, feelings, or behavior) medications were monitored for effectiveness using individualized, resident-specific targeted behaviors for 3 of 5 residents (Resident 9, 43, and 31) reviewed for unnecessary medications. This failure placed residents at an increased risk for experiencing medication-related adverse side effects and unmet care needs.Findings included . Review of a policy titled, Psychotropic Medication, Informed Consent Policy, dated 04/22/2025, showed behavior interventions were to be individualized, non-pharmaceutical approaches to care that were provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating residents' distress, as well as maintaining or improving a resident's mental, physical, or psychosocial well-being. Resident 9 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including anxiety (a feeling of worry, nervousness, or fear, often in anticipation of something unpleasant) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and a loss of interest in activities once enjoyed). The comprehensive assessment dated [DATE] showed Resident 9 had impaired cognition, depression, and an anxiety disorder. Further review showed Resident 9 required the assistance of one to two staff members for activities of daily living (ADLs). During an observation and concurrent interview on 11/21/2025 at 11:09 AM, Resident 9 was lying in bed watching television. Resident 9 stated they were sad at times related to their vision problems. Resident 9 stated when they felt down and sad, they needed people to talk to. Resident 9 stated they would like the staff to call their family when they were feeling sad because they always make me happy. Review of Resident 9's September 2025, October 2025, and November 2025 Medication Administration Records (MAR), showed a physician's order on 09/03/2025 for Sertraline (a brand of antidepressant medication) to be given for a diagnosis of major depressive disorder. Review of Resident 9's Care Plan (CP) dated 09/18/2025, showed Resident 9 had a mood problem related to a diagnosis of depression and staff were to monitor for any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions, or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness. Review of Resident 9's September 2025, October 2025, and November 2025 MARs showed a physician's order to monitor Resident 9 for loss of interest only. Further review showed no individualized, resident specific targeted behaviors were identified or monitored for effectiveness of the psychotropic medication. Resident 43 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including anxiety and depression. The comprehensive assessment dated [DATE], showed Resident 43 had an intact cognition, depression, and an anxiety disorder. Further review showed Resident 43 required assistance of one staff member for ADLs. During an observation and concurrent interview on 11/21/2025 at 11:15 AM, Resident 43 was lying in bed eating a snack and watching television. Resident 43 stated they were depressed and sad at times. Resident 43 stated they liked to go outside, feel the fresh air, and call their children when this happened. Resident 43 stated these things help them when they were in the pits (depressed/sad). Review of Resident 43's September 2025, October 2025, and November 2025 MARs, showed a physician's order dated 05/15/2025 for bupropion (a type of anti-depressant medication) to be given for a diagnosis of depression. Review of Resident 43's CP dated 05/22/2025, showed the resident had a mood problem related to a diagnosis of depression and staff were to monitor for any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions, or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness. Review of Resident 43's September 2025, October 2025, and November 2025 MARs showed an order to monitor Resident 43 for withdraw only. Further review showed no individualized, resident specific targeted behaviors were identified or monitored for effectiveness of the psychotropic medication. Resident 31 Review of the medical record showed Resident 31 admitted to the facility, on 09/09/2025, with diagnoses of dementia (a disease that causes the loss of thinking, remembering, and reasoning skills), affective disorder (a mental health condition characterized by prolonged and extreme shifts in mood, such as persistent sadness or excessive elation), restlessness (the feeling of being unable to relax or stay still, both physically and mentally) and agitation (a feeling of being tense, irritable, and restless, often accompanied by physical actions like fidgeting, pacing, or wringing your hands). Review of the comprehensive assessment, dated 09/15/2025, showed Resident 31 had severe cognitive impairment and required the assistance of one person for grooming, dressing, incontinent care, bathing and mobility. Review of Physician's Orders for November 2025 showed Resident 31 was prescribed Sertraline 50 milligrams [(mg) unit of measure] daily for depression (a mood disorder characterized by persistent feelings of sadness, a loss of interest in activities, and low self-esteem that interfere with daily life) and Risperidone [an antipsychotic (a type of medicine used to treat conditions that affect a person's ability to tell what is real and what is not) medication] one mg twice daily for bipolar disorder ( mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression). Review of the MARs for September 2025, October 2025, and November 2025 showed Resident 31 was monitored for behaviors of restless and withdraw. Review of the care plan updated on 09/23/2025, showed Resident 31 received antipsychotic medication related to their dementia and the interventions included monitoring for behaviors (no specific or individualized behaviors identified) and side effects to the medications. During an interview on 11/21/2025 at 11:15 AM, Staff G, Licensed Practical Nurse/Unit Manager, stated the behaviors monitored for a resident should match those identified on the resident's care plan. Staff G stated each resident receiving a psychotropic medication should be monitored with individualized, resident-specific targeted behaviors. Staff G stated staff were using the same generic behaviors and the same monitoring checklist for all residents on all psychotropic medications, regardless of diagnosis, symptoms, or intended therapeutic effect, instead of identifying and monitoring individualized, resident-specific targeted behaviors. Staff G stated the behaviors were not individualized for Residents 9, 43, and 31 and should have been. During an interview on 11/21/2025 at 11:35 AM, Staff B, Director of Nursing Services, stated behavior monitoring must be individualized and specific for each resident and each resident should have individualized targeted behaviors documented. Staff B stated the additional behaviors in the resident's care plans were auto populated and not individualized. Staff B stated Residents 9, 43, and 31 did not have individualized behaviors monitored and lacked specific interventions and the process was not followed. Reference: (WAC) 388-97-1060(3)(k)(i)

Based on interview and record review, the facility failed to follow professional standards of practice related to adding a new mental health diagnosis for 1 of 5 residents (Resident 31) reviewed for psychotropic (drugs that affect how the brain works, and cause changes in mood, awareness, thoughts, feelings, or behavior) medication use. This deficient practice placed residents at risk for unnecessary medications and unmet care needs.Findings included . Resident 31Review of the medical record showed Resident 31 admitted to the facility, on 09/09/2025, with diagnoses of dementia (a disease that causes the loss of thinking, remembering, and reasoning skills) and affective disorder (a mental health condition characterized by prolonged and extreme shifts in mood, such as persistent sadness or excessive elation). Review of the comprehensive assessment, dated 09/15/2025, showed Resident 31 had severe cognitive impairment and required the assistance of one staff member for grooming, dressing, incontinent care, bathing and mobility. Review of Resident 31's admission orders dated 09/09/2025, showed they were to receive Risperidone [an antipsychotic (a type of medicine used to treat conditions that affect a person's ability to tell what is real and what is not) medication] 1 milligram [(mg) unit of measure] by mouth twice daily for dementia without behavioral disturbance. Review of the medical provider visit Progress Notes (PN) dated 09/10/2025, 09/16/2025, and 10/10/2025, showed Resident 31 was evaluated to establish care as a new admission to the facility and review of their current medication management. There were no changes to Resident 31's medication regime or diagnosis list. Review of the Pharmacist Consultation Report dated October 2025, showed a recommendation to clarify the indication for use diagnosis for Resident 31's current order for Risperidone, as the one listed (dementia without behavioral disturbance) was not appropriate. Staff L, Advanced Registered Nurse Practitioner (ARNP) wrote the diagnosis bipolar on the report followed by their initials. Review of Resident 31's Physician's Orders dated October 2025, showed a new order was placed on 10/31/2025 for Risperidone 1 mg twice daily for the diagnosis of bipolar disorder. Review of the medical provider visit PN dated 11/11/2025 showed Resident 31 was evaluated for a routine follow-up with medication review. New orders were placed to discontinue Resident 31's thyroid medication, calcium, and vitamin supplements due to Resident 31's refusals. There were no changes made to Resident 31's diagnosis list. Review of the medical record dated 11/21/2025 showed there was no monitoring for behaviors related to the diagnosis bipolar disorder. During an interview on 11/21/2025 at 10:00 AM, Staff L stated they had not evaluated Resident 31 specifically for mental health when they added the diagnosis of bipolar disorder. Staff L stated the facility policy did not allow the use of antipsychotic medications to treat dementia, and they chose a diagnosis that was considered acceptable. During an interview, on 11/21/2025 at 10:40 AM, Staff B, Director of Nursing Services, stated the standard of practice was for residents to receive a mental health evaluation in order to add new mental health diagnoses, and that process did not happen for Resident 31. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure physician ordered physical therapy (PT) was received in a timely manner for 1 of 3 residents (Resident 34) reviewed for specialized rehabilitation services. This failure placed the resident at risk for decline in function and/or not achieving the highest practicable level of physical, mental, and functional well-being. Findings included . Review of a policy titled, Specialized Rehabilitative Services, revised 09/04/2025, showed the facility would ensure that each resident received specialized rehabilitative services to assist them to attain, maintain, or restore their highest level of physical, mental, functional and psychosocial well-being. Resident 34 Review of the medical record showed Resident 34 was admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial infection of the skin and underlying tissues) of the right lower leg, muscle weakness, and difficulty walking. The 10/08/2025 comprehensive assessment showed Resident 34 required moderate/maximum assistance of one staff member for activities of daily living. The assessment also showed Resident 34 had a moderately impaired cognition. Record review of a physician's order dated 09/12/2025, showed Resident 34 had an order for PT evaluation and treatment. Record review of the medical record showed Resident 34 received their initial PT evaluation and treatment plan on 09/17/2025, five days after their admission to the facility. During an interview on 11/20/2025 at 8:11 AM, Staff E, Director of Rehab Services, stated Resident 34 received their PT evaluation on 09/17/2025. They stated they did not have enough staff at the time of Resident 34's admission to complete the new admission evaluations. Staff E stated receiving an evaluation five days after admission was not the normal process, which included completing the evaluations within 24 to 48 hours after admission. During an interview on 11/21/2025 at 9:56 AM, Staff B, Director of Nursing Services, stated the process and their expectation for PT evaluations included completing them within 48 hours of admission, unless the resident was admitted on Friday, then the evaluation would be completed on the following Monday. They stated the facility was short on therapists at that time which caused the delay in obtaining the PT evaluation and treatment. During an interview on 11/21/2025 at 10:22 AM, Staff A, Administrator, stated PT evaluations should be completed within 24 to 48 hours of admission. They stated it was not an acceptable practice to complete a PT evaluation five days after a new admission. Reference WAC: 388-97-1280(1)(a)(b)(2)

Based on interview and record review, the facility failed to offer and/or provide an influenza (a common viral infection that attacks the lungs, nose, and throat) immunization for 1 of 5 residents (Resident 58) reviewed for immunizations and infection control. This failure placed the residents at risk for illness and transmission of communicable diseases. Findings included . Review of a policy titled, Influenza Vaccine Policy for Residents, revised 09/23/2025, showed residents would be offered an influenza immunization between October 1st through March 31st annually, unless the immunization was medically contraindicated or the resident had already been immunized during that period. The resident's medical record would include documentation that the resident or their representative was provided education regarding the benefits and potential side effects of the immunization and that the resident either received or refused the immunization. Resident 58 Review of the medical record showed Resident 58 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, and necrotizing fasciitis (a severe, rapidly spreading bacterial infection). The 09/04/2025 comprehensive assessment showed Resident 58 was dependent on one to two staff members for ADLs: setup assistance for eating and oral hygiene. The assessment also showed Resident 58 was cognitively intact. Record review of Resident 58's medical record showed no documentation of consent or refusal for the annual influenza immunization, no record that the immunization had been administered, and no education had been provided. During an interview on 11/20/2025 at 4:47 PM, Staff C, Infection Preventionist, stated the process for ensuring residents received the annual influenza immunization included offering it upon admission to the facility and/or during influenza season. During a follow up interview on 11/21/2025 at 9:19 AM, Staff C stated Resident 58 was not offered the influenza immunization upon admission because they were admitted in July. They stated they were unsure why Resident 58 was not offered the immunization in September when all residents were offered it. They stated they were unable to locate any documentation related to a consent or refusal for the influenza immunization. During an interview on 11/21/2025 at 9:53 AM, Staff B, Director of Nursing Services, stated the influenza immunization was offered to all residents on admission and during the respiratory season. They stated the process included obtaining consents from all long-term care residents prior to the start of the influenza season. Staff B stated Staff C should keep a spreadsheet of which residents were offered and/or received the immunization. They stated Resident 58 was missed because they were in and out of the hospital when the long-term care resident consents were obtained. Reference WAC: 388-97-1340(1)(2)(3)

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program that ensured insects (flies) were not congregating in rooms or on persons for 1 of 4 residents (Resident 73) reviewed for environment. This deficient practice placed residents at risk of infection and contributed to a less than homelike environment.Findings included. Review of the facility policy, Pest Control, revised on 07/09/2025, showed the facility's pest control program would provide frequent treatments to keep the facility free of pests, the facility's staff would monitor the environment for potential concerns, and all pest control problems would be reported to the Director of Maintenance promptly. Resident 73Review of the medical record showed Resident 73 admitted to the facility with diagnoses of hemiplegia (paralysis of one side of the body) of the right side and aphasia (brain disorder that affects how you speak and understand language). Review of the comprehensive assessment, dated 11/13/2025, showed Resident 73 had moderate cognitive impairment and required the assistance of one to two staff members for grooming, dressing, toileting, transfers, and mobility. An observation on 11/19/2025 at 11:40 AM, showed two flies in Resident 73's room, one hovering around the floor in front of their feet and the other sitting on the windowsill of the closed window. A fly swatter was observed on the overbed table. During an interview on 11/19/2025 at 11:45 AM, a contracted Pest Control Vendor stated they had not received any complaints about flies. An observation on 11/20/2025 at 9:11 AM, showed Resident 73 in their room watching television and four flies flying around them. The flies were observed landing on Resident 73's right leg, overbed table, and wheelchair. During an interview on 11/20/2025 at 9:44 AM, Staff I, Maintenance Assistant, stated they were not aware of resident rooms having flies. During an interview on 11/20/2025 at 9:46 AM, Staff J, Nursing Assistant (NA) stated they began working as a housekeeper in July 2025 and Resident 73's room had flies since then. An observation, on 11/20/2025 at 1:15PM, showed a fly swatter and a dead fly on Resident 73's overbed table. During an interview on 11/21/2025 at 11:00 AM, Staff A, Administrator, stated they were surprised to learn Resident 73's room had flies for that length of time and was something they should not have to endure. During an interview on 11/21/2025 at 11:20 AM, Staff K, Maintenance Director, stated they were aware of flies in Resident 73's room maybe in September and probably gave Resident 73 the fly swatter. Staff K stated they had not received additional reports about flies, and they did not follow up to see if the flies were gone from Resident 73's room.Reference: WAC 388-97-3360(1)

Based on interview and record review, the facility failed to provide notification of discharge to the Resident's Representative (RR) for 1 of 3 residents (Resident 1) reviewed for notifications. This failure placed the residents at risk of not having their representatives involved in their health care decisions, and a delay in care and services. Resident 1 Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including follow-up care for a surgical procedure, heart failure and dementia (a progressive disease that destroys memory and other important mental functions). The cognitive assessment dated [DATE] showed Resident 1 had a severely impaired cognition. Record review of a discharge summary progress note dated 08/31/2025, showed Resident 1 was discharged to another facility. During an interview on 09/11/2025 at 2:45 PM, Staff A, Licensed Practical Nurse, stated they had Resident 1 sign the discharge/transfer documentation for their transfer. Staff A stated Resident 1 was then picked up by the transfer van and taken to another facility. Staff A stated later in the day the RR arrived at the facility and inquired where Resident 1 was. Staff A stated they told the RR they were transferred to another facility. Staff A stated the RR became upset and stated they had not been notified Resident 1's discharge. Staff A stated they assumed they had been notified. During an interview on 09/11/2025 at 3:00 PM, Staff B, Director of Nursing Services, stated when a resident has an altered mental status the facility was to discuss and/or inform the residents' representatives of transfers or discharges, and for Resident 1 the process was not followed. During a telephone interview on 09/12/2025 at 9:19 AM, the RR verified they had not been notified of Resident 1's transfer to another facility. Reference WAC: 388-97-0320(1)(d)

Based on interview and record review, the facility failed to ensure staff implemented fall prevention interventions identified on the resident's care plan for 1 of 3 residents (Resident 1) reviewed for falls. This failure placed the residents at risk for repeated falls and injuries.Findings included. Review of a policy titled, Person Centered Care Planning, dated 09/05/2024, showed each resident would have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, that addresses the resident's medical, physical, mental, and psychosocial needs. The care plan would be developed and implemented to ensure consistency with implementation across all shifts. <Resident 1>Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including a brain injury with loss of consciousness, stroke (damage to the brain from an interruption of blood flow), and history of falling. The 06/30/2025 comprehensive assessment showed Resident 1 required substantial assistance of one staff member for activities of daily living. The assessment also showed Resident 1 had a memory problem and had a severely impaired cognition. Record review of a Fall Risk Evaluation dated 03/25/2025 showed Resident 1 was identified as high fall risk. Record review of Resident 1's care plan dated 03/25/2025, showed they were at risk for falls, with interventions including anticipating the resident's needs, placing the call light within reach, using a mechanical lift for transfers, and continuing to work with therapy for strength and balance. A care plan revision dated 06/13/2025 showed the nursing assistants (NA) would ensure the resident was kept in supervised areas while they were up in their wheelchair. Record review of a facility investigation dated 06/20/2025, showed a NA found Resident 1 on the floor in their room. The investigation showed the root cause of the fall was due to Staff B, a newly hired NA, that had left Resident 1 up in their wheelchair, unsupervised. During an interview on 08/14/2025 at 1:14 PM, Staff A, Director of Nursing, stated all NAs were trained to review the Kardex (a quick reference tool used by nursing staff to access vital patient information) for directives and updates to resident care. Staff A stated Staff B was newly hired and had just completed their orientation. They stated all new nursing staff received training towards reviewing the care plan and Kardex during their orientation and while training on the floor with other NAs. Staff A stated Staff B should have reviewed Resident 1's Kardex prior to providing care. Reference: WAC 388-97-1020(3)

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse for 1 of 3 residents (Resident 1) reviewed for abuse/neglect. This failure placed the residents at risk of experiencing fear, intimidation, mental anguish, and emotional distress. Findings included . Review of the Washington State guidance titled, Nursing Home Guidelines - The Purple Book, dated October 2015, showed verbal abuse was the use of oral, written or gestured language that willfully includes threats .within hearing distance of any resident regardless of their age, ability to comprehend, or disability; threats of harm; saying things to frighten a resident. Review of a policy titled, Abuse - Identification of Types, reviewed 05/06/2025, showed verbal abuse included the use of oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse included threatening residents, depriving a resident of care or withholding a resident from contact with family and friends. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including Fragile X syndrome (a genetic condition that causes intellectual disability, developmental delays, and characteristic physical features), bipolar disorder (a mental health condition characterized by shifts in mood, energy, and activity levels), and anxiety disorder. The 06/21/2025 comprehensive assessment showed Resident 1 required partial assistance of one staff member for dressing, independent with eating, toileting, and personal hygiene. The assessment also showed Resident 1 had a memory problem and had some difficulty with daily decision making. Record review of an investigation dated 05/25/2025, showed Resident 1 had requested their medication from Staff B, Licensed Practical Nurse. Staff B told Resident 1 they would have to wait because another resident was having a medical emergency. Resident 1 obtained a partial bottle of soda from their room, returned to the medication cart, and threw it at Staff B's head. Staff B told Resident 1 they committed assault and were going to jail. Resident 1 went outside after the incident to get some air and ultimately eloped from the facility. The investigation showed Resident 1 stated I just started focusing on Staff B saying I assaulted them and could go to jail, and I just left. During an interview on 06/24/2025 at 12:30 PM, Resident 1's Representative (RR) stated there was a nurse at the facility that had upset Resident 1. They stated Resident 1 had called them after they left the facility and was frantic. The RR stated Resident 1 was afraid of going to jail. During an interview on 06/25/2025 at 11:23 AM, Staff A, Administrator, stated at the time of the investigation, and with the information they had, they did not feel there was enough evidence to substantiate verbal abuse. Staff A stated with the additional information presented to them, they now recognized the incident as verbal abuse. Reference: WAC 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to identify avoidable accident hazards during a mechanical lift transfer for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1 experienced harm when they fell to the floor from the mechanical lift and sustained a hematoma (a collection of blood that forms outside of blood vessels, usually caused by an injury or trauma) and an abrasion to the forehead, requiring a transfer to the emergency room . Findings included . Review of a policy titled, Limited Lift Program (Safe Patient Handling), revised 09/19/2024, showed the facility would provide education upon hire and annually to staff on proper use of mechanical lifts in accordance with the manufacturer's guidelines. The education would also include the need to have two staff members present during the transfer. Additionally, manufacturer guidelines would be used to determine the type and size of sling that should be utilized when a lifting device was required. Review of the facility provided manufacturer's instructions for use for a Vive Healthcare Patient Lift Sling (the sling used with Resident 1 on 09/19/2024), received by the facility via email on 09/20/2024 at 2:06 PM, showed the sling was compatible with most floor lift models. Review of the Joerns Hoyer Lift (Hoyer HPL700 - used with Resident 1 on 09/19/2024) manufacturer's user instruction manual, dated 2024, showed the Hoyer HPL700 lift .is designed to be used in conjunction with the Hoyer range of slings. Additionally, there were several warnings regarding sling use, including: Hoyer recommends the use of genuine Hoyer parts. Hoyer slings and lifts are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses of a stroke with left arm paralysis (loss of muscle function), muscle weakness, and heart failure. The 07/24/2024 comprehensive assessment showed Resident 1 was dependent on two staff members for bed mobility (the ability to move in bed) and transfers between surfaces. The assessment also showed Resident 1 had an intact cognition. Review of Resident 1's care plan, dated 07/31/2024, showed the resident required two-person assistance for transfers with a Hoyer Lift (a mechanical lift used to transfer a resident between two surfaces) and bed mobility. Review of a facility investigation report showed on 09/19/2024 at 7:04 AM, Resident 1 was transferred from their bed to their wheelchair using the Hoyer Lift. The investigation showed the interdisciplinary team (a group healthcare professionals from different disciplines to help people receive the care they need) had established the mechanical lift sling had not been hooked appropriately to the Hoyer Lift which caused the strap to slide off, causing Resident 1 to fall out of the sling onto the floor. Resident 1's head hit the floor, and their right shin hit the edge of the Hoyer Lift. Resident 1 was moved from a face down position to a seated position on the floor. The resident was noted to have a hematoma to the head and complained of leg pain. Review of hospital records, dated 09/19/2024, showed Resident 1 had arrived at the emergency room for evaluation of injuries after falling out of a Hoyer Lift and hitting their head on the floor. Resident 1 was noted to have a large forehead contusion (a type of hematoma of tissue, damaged by trauma, causing localized bleeding that spreads into surrounding tissues) and was taking a blood thinner. Review of a written statement by Staff B, Nursing Assistant (NA), dated 09/19/2024 at 7:15 AM, showed Staff B hooked up (attached the sling loops to the Hoyer Lift hooks) Resident 1 to the Hoyer Lift and was in control of the Hoyer Lift. Staff C, NA, guided the resident to position them into their wheelchair. Staff B proceeded to lower Resident 1 into the wheelchair; next thing we knew, client (Resident 1) is on the floor. Review of a written statement by Staff C, dated 09/19/2024, showed Staff C had answered a call on their radio requesting assistance with a transfer. When Staff C entered Resident 1's room, the resident was already hooked up to the Hoyer Lift. Staff B and Staff C lifted the resident with the Hoyer Lift, while Staff C guided the resident's feet, Staff B opened the legs to the Hoyer Lift. Staff C placed Resident 1's wheelchair in place, and just as doing so, one of the sling straps slipped and the resident fell out of the sling onto their face. Review of a written statement by Staff D, NA, dated 09/19/2024, showed Staff D had responded to a call on the radio that there was a fall in Resident 1's room. They ran to the room and saw Resident 1 face down on the Hoyer Lift legs and floor. One strap of the sling was hanging on the lift, not connected. A concurrent observation and interview on 10/01/2024 at 3:47 PM, showed Resident 1 sitting in their room in their wheelchair. They had a large hematoma measuring 5.2 centimeters [(cm) a unit of measurement) by 6.1 cm on their forehead with a pea sized scab in the center of the hematoma. Resident 1 had significant faded purple/yellow facial bruising surrounding each eye, along the left cheek bone, and deep purple bruising measuring 5.1 cm by 11.0 cm on their neck. When asked if they felt they had a significant injury due to the fall, Resident 1 stated yes, I face planted out of the lift and had a CT scan [computed tomography (CT) - an imaging technique used to obtain detailed internal images of the body]. Resident 1 stated they were unable to remember if the sling had been attached to the lift correctly. During an interview on 10/01/2024 at 4:26 PM, Staff C stated Resident 1 was already hooked up to the Hoyer Lift when they went into their room to assist with the transfer. Staff C stated just as they went to grab onto Resident 1 to position them in their wheelchair, one of the sling straps (the leg strap) had slipped off the Hoyer Lift and Resident 1 fell off the sling. Staff C stated Staff B had strapped the resident to the Hoyer Lift before they entered the room; they were just assisting with the transfer. Staff C stated they had received safe Hoyer Lift training upon hire and right after the fall. Staff C stated they were instructed on how to hook up the sling and safely transfer a resident. They stated they were also trained to make sure the sling they were using matched the mechanical, but I don't know exactly which lift goes with which sling. During a follow-up interview on 10/03/2024 at 1:02 PM, Staff C stated they did not double check the straps on the sling prior to lifting Resident 1. Staff C stated they had not used the flat sling prior to using it to transfer Resident 1 and had not received any training on the use of that sling. Staff C stated they were hurrying that morning and did not double check the hooks for safety and I should have. During an interview on 10/01/2024 at 4:45 PM, Staff E, Licensed Practical Nurse, stated they had performed an assessment on Resident 1 after the fall on 09/19/2024. They stated when they entered the room, the sling was still hanging from the mechanical lift with three points of contact, not four points of contact. Staff E stated it looked like the sling had not been hooked up properly. They stated the sling they used was different than the normal slings. Staff E stated they had questioned the use of the sling but was told it was ok to use. Staff E stated they did not know where that particular sling came from and were unsure why staff had chosen to use that sling. During a concurrent observation and interview on 10/01/2024 at 5:20 PM, Staff A obtained a mechanical lift sling from a locked closet and stated that was the sling that was in use when Resident 1 fell on [DATE]. Observation of the sling showed a flat sling with four straps; each strap had four loops for attaching to the mechanical lift. There was no manufacturer identification on the sling. Staff A stated the sling had been donated by a family and going forward, the facility would use the sling for smaller residents because the sling was too small for the resident it was used on. Staff A provided the package insert/documentation that was in the bag with the sling. During an interview on 10/03/2024 at 12:11 PM, Staff B stated their normal process for using the Hoyer Lift was to call for a second person to help with the transfer. They stated they normally wait for the second person before hooking up the sling to the Hoyer Lift. Staff B stated the morning of 09/19/2024, they asked for assistance with the transfer over the radio. Staff B stated they made a mistake by hooking up Resident 1 prior to the second staff member coming into the room. Staff B stated Resident 1 asked if they were secure on the Hoyer Lift prior to lifting them, and both Staff B and Staff C assured Resident 1 they were secure. Staff B stated they remembered attaching all four straps to the Hoyer Lift and checking them to make sure they were on correctly. Staff B stated they proceeded to lift Resident 1 with the Hoyer Lift, and the strap came off the hook. Resident 1 had fallen on their front side and had a little cut on their forehead. Staff B stated they were very confused as they remember checking the straps before lifting the resident. They stated the sling they used that morning to transfer Resident 1 was the sling that had been assigned to the resident on the day they were admitted . Staff B stated they had not seen or used that sling prior to using it with Resident 1. They stated the sling was a full body, flat sling that did not have the cross straps for the legs. Staff B stated they had not been trained on the use of that type of sling. Staff B stated after the incident, they were pulled from the floor and sent home pending an investigation and had to demonstrate proper use of the sling prior to returning to work. Staff B stated after the fall, Resident 1 complained of a headache and was sent to the emergency room . During an interview on 10/03/2024 at 10:28 AM, Staff A, Director of Nursing Services, stated they had read the manufacturer's guidelines for use of the sling prior to putting it into service. During a follow-up interview that same day at 1:39 PM, Staff A stated the nursing assistants received mechanical lift training during their orientation and annual competency's. They stated Staff B needed more training, a refresher, because they only worked as needed and Staff B was just moving too fast that morning. Staff A stated the process for transferring a resident with a Hoyer Lift included two staff members, and they should always check the straps prior to lifting the resident. Staff A stated they did not provide training on that particular sling before putting it into use. They stated they felt staff would know how to use the sling and would not require additional training on the proper use of the flat sling. Staff A stated during the transfer of Resident 1 on 09/19/2024, one strap of the sling fell off during the resident's transfer and they were not sure why it fell off. Staff A further stated they checked the manufacturer's guidelines for the sling but did not check the manufacturer's guidelines for the Hoyer Lift to ensure they were safe to use together. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure that four-point restraints (a device used to support impaired posture that restricts a resident's freedom of movement) were applied in a safe manner, and failed to establish the medical need for the restraint, implement assessments, care planning, and supervision that focused on the specific restraint use for 2 of 2 residents (Residents 1 and 5), reviewed for physical restraints. This failed practice placed Resident 1 at serious risk of entrapment, strangulation, and death, and placed both Resident 1 and Resident 5 at risk for a decline in physical function, restriction of free movement, risk of injury, loss of dignity, and was determined to be an immediate jeopardy. On 08/23/2024 at 1:45 PM the facility was notified of an Immediate Jeopardy (IJ) at, F604 42 CFR S483.12(a)(2) Free from physical restraints, when a resident was observed with an improperly placed four-point chest restraint. It was determined that the IJ began on 08/23/2024 and the immediacy was removed on 08/23/2024 with an onsite verification from investigators. The facility removed the immediacy by implementing education with return demonstration for nursing staff on the proper use and placement of the four-point restraint, prior to their next scheduled shift. The facility initiated a supervisory plan to ensure Resident 1 would be observed and repositioned as needed and would not be left in an unsupervised area when up in their wheelchair (w/c) while the four-point restraint was on. The measures put in place by the facility ensured that the four-point restraint would be applied correctly. Findings included . Record review of a facility policy titled Physical Restraint Use, dated 12/29/2023, showed the following: An assessment must be completed and show that: A Least restrictive alternatives was used and not effective, type of device, frequency/duration and medical reason, A physician's order must be in place to include type, condition/medical symptoms. Where and how to apply and the time and frequency the device should be released. Care plan must include and be revised quarterly and as needed: Type, medical symptoms that warrant use, length of time to be used, time and frequency it should be released. Monitoring and supervision during use Documentation must include: Type, Medical symptoms being treated, reason for use, effectiveness in treating medical condition. An active plan to decrease usage or for the eventual removal, Interventions, including less restrictive alternatives that were attempted but ineffective, must be reevaluated Quarterly, and education to be provided when consent is obtained and PRN <Resident 1> Review of the medical record showed that the resident was admitted to the facility with diagnoses including severe intellectual disabilities (a condition that limits a person's mental functioning and skills, such as communication, self-care and social skills), and encephalitis (a serious condition that causes inflammation of the brain, which can lead to swelling and changes in neurological function). The most recent assessment dated [DATE] showed the resident required extensive assist of two staff members for activities of daily living (ADL's) and had severe cognitive impairment. The assessment further showed no restraint was used during the assessment period. Record review of a physician's order dated 06/26/2024 showed, tilt in space w/c with harness to aid in positioning. There was no justification to show the medical symptoms for use or directions for applying the restraint or the time and frequency the restraint should be worn. Record review of Resident 1's comprehensive care plan, dated 07/25/2024, showed there were no interventions for a specific type of restraint, medical symptoms to treat and to justify the use, length of time to be used, who was able to apply and release, where and how it was to be applied and used, and the time and frequency it should be released. Review of the medical record showed no initial assessment or ongoing reassessments had been completed for the four-point restraint. An observation on 08/20/2024 at 7:35 PM, showed Resident 1 in their room, behind a closed curtain not visible from the hallway. Resident 1 was seated in their w/c; the w/c was tilted back with a four-point restraint in the shape of an X placed across the torso (the central part of the body that includes the chest and abdomen) of the resident. The top of the restraint extended into two straps, one across each shoulder. Each strap was secured to the bars on the back of the w/c. The bottom of the restraint extended into two straps, one to each side of the hip area secured to the bottom of the wheelchair midway under the seat cushion. The restraint was loose with four inches of space between the resident's chest and restraint whuch incresed the risk of strangulation without proper placement. An observation on 08/22/2024 at 11:17 AM, showed Resident 1 in their room, behind a closed curtain not visible from the hallway. Resident 1 was seated in their w/c, tilted back, brakes unlocked with a four-point restraint to the chest attached by four black straps to the w/c. Resident 1's arms and legs were involuntarily moving which caused Resident 1 to slide down in their w/c with their bottom no longer at the back of the w/c seat cushion. The top portion of the four-point restraint was observed to be at the collar bone level and not at the chest level. The four- point restraint was loose with four inches of space between the resident's chest and restraint, placing the resident at risk for the restraint to slip up under their neck. An observation on 08/23/2024 at 9:05 AM, showed Resident 1 in their room, behind a closed curtain not visible from the hallway. Resident 1 was seated in their w/c, tilted back with a four-point restraint to the chest. The right bottom strap was not applied correctly and was over the resident's right arm (not under it) and was secured to the wheelchair. The four-point restraint was loose with five inches of space between Resident 1's chest and restraint which placed the resident at risk for the four-point restraint to slide upward under their neck. During an interview on 08/23/2024 at 9:11 AM, Staff P, Licensed Practical Nurse, (LPN)/ Unit Care Coordinator, observed Resident 1's four-point restraint and stated it was not applied correctly. Staff P released the right bottom strap and placed it under Resident 1's arm and tightened all four straps close to Resident 1's chest. Staff P stated that they had not had any training on the use or application of the four-point restraint and they should do some education with staff. Staff P further stated they had not done any ongoing assessments or tried any least restrictive devices, nor did they have a check and release schedule for Resident 1' s four-point restraint, Staff P stated, No one told me that I was supposed to. During an interview on 08/23/2024 at 9:18 AM, Staff N, Nursing Assistant (NA), stated they had not had any training on the application or use for Resident 1's four-point restraint. During an interview on 08/23/2024 at 9:31 AM, Staff M, NA, stated they had placed the four-point restraint on Resident 1 and was sure they had put the right strap under the resident's right arm and not over their arm. Staff M stated Resident 1 must have slid down in their w/c, the resident slides down a lot. Staff M stated the restraint slid up under Resident 1's chin and they had to pull the resident up. During a follow-up interview with Staff M on 08/23/2024 at 10:09 AM, Staff M stated when Resident 1 slid down and the restraint moved to the middle of Resident 1's neck, Staff M pointed to the mid windpipe area on their neck. During an interview on 08/23/2024 at 2:47 PM, Staff O, LPN, stated they were trained years ago on the four-point restraint with Resident 1's previous w/c but had no training on the new w/c and four-point restraint since it was ordered. Record review of a receipt showed Resident 1's current w/c was ordered and recieved in 2021. <Resident 5> Review of the medical record showed the resident was admitted to the facility with diagnoses of cerebral palsy (a group of neurological disorders that affect a person's movement and muscle coordination), epilepsy (a chronic brain condition that causes seizures, which are brief episodes of involuntary movements), and lack of expected normal physiological development (developmentally delay in psychological development or severe developmental delay). The assessment, dated 07/17/2024, showed the resident required extensive assistance of two staff members for ADLs and had severe cognitive impairment. The assessment further showed no trunk restraint was used during the assessment period. An observation on 08/25/2024 at 12:31 PM, showed Resident 5 sitting in their w/c in the dining room. Resident 5 had a four-point restraint on with four black straps attached to their w/c. The four- point restraint was loosely placed, the top two straps which were supposed to be applied over the shoulders and attach at the top of the w/c were lying across Resident 5's upper arms. Record review of a physician's order, dated 01/15/2024 showed, tilt in space w/c with harness to aid in positioning. The order did not include included the specific type of physical restraint to be used based upon the identified for the medical use to establishthe need for the restraint. Record review of Resident 5's care plan dated 05/02/2023, showed, the resident's care plan did not reflect requirements for the restraint or have direction for use for staff to follow. Review of Resident 5's medical record showed that the required initial and ongoing assessment had not been completed for the four-point restraint. During an interview on 08/24/2024 at 1:01 PM, Staff A, Administrator, stated their expectations for any restraint would be for the least restrictive alternative to have been tried first and the four-point restraint should have been the very last resort. Staff A stated they would expect the restraint to be care planned to include interventions, placement and safety precautions. Staff A stated they would expect ongoing evaluations, trainings and assessments quarterly, as needed and with any change in condition for the four-point restraint, including a medical diagnosis/symptoms support the use of the restraint. Staff A further stated their process was not at all followed correctly for Resident 1 and 5. Reference: WAC 388-97-0620(2)(d),(4)(a)(c),(5)(a)

Based on observation, interview and record review the facility failed to ensure food was served at a safe temperature for 1 of 3 resident's (Resident 48) reviewed for avoidable accidents. This failure resulted in injury and pain to Resident 48 and placed other residents at risk for serious harm and injury related to the unsafe temperatures of reheated food in microwaves. Additionally, the facility failed to ensure resident safety was maintained for 2 of 3 shower rooms in the transitional care unit (TCU and 300 hall) and 8 of 8 personal protection equipment (PPE) carts reviewed for accidents and hazards by securing potentially hazardous cleaning agents. These failures placed resident's at risk for harm in the event the cleaning agents were ingested or skin/eye exposure. The lack of a system to ensure safe food temperatures to prevent injuries from reheated food represented an immediate jeopardy. On 08/21/2024 at 3:38 PM the facility was notified of an Immediate Jeopardy (IJ) at, F689 42 CFR S483.25(d)(1), Free from accidents, when a cook and nursing assistant failed to ensure food was at a safe temperature after being reheated in a microwave. It was determined that the IJ began on 08/21/2024 and the immediacy was removed on 08/22/2024 with an onsite verification from investigators. The facility removed the immediacy by implementing education with return demonstration for dietary aides and cooks on the proper reheating process of food in a microwave. Nursing staff was educated to not reheat food or serve food that looks or feels hot. The education was to be completed prior to their next scheduled shift. The facility initiated a plan to remove all microwaves until staff education and return demonstration was completed for kitchen staff. The measures put in place by the facility ensured that no reheated food would be served until all kitchen and nursing staff were trained with return demonstration. Findings included . Record review of a facility policy titled Food Temperature Control, revised 06/28/2024, showed that food reheated in the microwave should not be served to the resident's above 150 degrees Fahrenheit (a unit of measure). <Resident 48> Review of the medical record showed that the resident was admitted to the facility with diagnoses of stroke (a loss of blood flow to part of the brain, which damages brain tissue) and aphasia (a language disorder that makes it difficult for people to communicate effectively with others). The comprehensive assessment dated [DATE] showed the resident required extensive assistance of one to two staff members for activities of daily living and required partial to moderate assistance with eating. Record review of Resident 48's care plan, dated 04/22/2024, showed that Resident 48 required assistance with meals. During an observation on 08/21/2024 at 12:43 PM, Resident 48 was in their wheelchair, assisted to the dining room table by their significant other. Resident 48 stated to Staff R, Nursing Assistant, (NA), they were hungry and would like their lunch. Staff R went to the kitchen and came back with a tray that had milk, juice, and a plate warmer (a hard plastic insulated cover that was placed under the plate with a lid on it to maintain the temperature.) There was steam coming from under the lid. Staff R set the tray on the table in front of Resident 48 and attempted to remove the plate from the plate warmer using their bare fingers. Staff R quickly dropped the plate back into the warmer. Staff R then again removed the hot plate from the warmer with their bare hands and placed it in front of Resident 48. Staff R did not alert Resident 48 that the food and plate were hot and walked away without assisting Resident 48 with eating. Resident 48 quickly grabbed their spoon and placed a bite of mashed potatoes and gravy in their mouth. Resident 48 immediately started flailing their arms and legs, reached for their juice and water, yelled to their significant other its, hot, its hot. Resident 48's significant other provided the resident with water and juice eight seconds after Resident 48 had placed the mashed potatoes in their mouth. Resident 48 continued to grimace in pain stating, that was hot, it burned my mouth. During an interview on 08/21/2024 at 12:48 PM, Staff S, Cook, stated they put Resident 48's plate of food in the microwave for a minute or more. Staff S stated they checked the temperature of the meat, vegetables, and mashed potatoes and all foods had a temperature of 165 degrees Fahrenheit. Staff S stated they did not log temperatures for reheated foods. Staff S further stated they did not have a process to follow for reheated food using the microwave. During an interview on 08/21/2024 at 12:52 PM, Staff R, NA, stated Did you see me burn my fingers on that plate? It was hot. Staff R stated there was no process for reheated foods coming out of the kitchen they just assume it was the right temperature. Staff R stated that the plate was pretty hot, it burned my fingers. Staff R further stated they should have taken the tray back to the kitchen and not served a plate that was that hot to the resident. A concurrent observation and interview on 08/21/2024 at 1:27 PM, showed the Advanced Registered Nurse Practitioner (ARNP) performed an examination on Resident 48's mouth. Resident 48 stated to the ARNP they felt a burning sensation in their mouth. The facility provider examined Resident 48's mouth and stated, I see a little area that had contact. There will be some sensitivity over the next two-three meals, and I will order you some mouthwash. A concurrent observation and interview on 08/22/2024 at 10:07 AM, showed a slight reddened, raised area to the right side of Resident 48's tongue. Resident 48 stated their sensitivity and pain was located on the right side of their tongue. Resident 48 stated their pain level was at a 1 out of 10 (a score of 0 means no pain, and 10 means the worst pain you have ever felt.) Resident 48 further stated they had to use milk in their oatmeal at breakfast to cool it off because their mouth was still sensitive. Record review of a provider visit dated 08/22/2024, showed Resident 48 was examined by [NAME] Basin Denture Care to follow up on the 08/21/2024 incident. The provider note showed Patient stated (their)denture does not hurt at all, (they) said (they) burnt (their) tongue when trying to eat (their) mashed potatoes. Facility scheduled the appointment to have them have (their) denture checked, gums look within normal limits. During an interview on 08/25/2024 at 12:22 PM, Staff A, Administrator, stated there were missed steps in their process, and it would be good to fix it. <Shower Rooms> During an observation on 08/20/2024 at 7:45 PM, the TCU shower room showed the door was unlocked and open to the resident hallway. In the shower room were cleaning agents (Oxivir TB - a cleaning agent that is hazardous if consumed or has contact with the eyes) solution in a spray bottle in an unsecured cupboard. On the floor in the shower room was also a container of Oxivir TB wipes. During an observation on 08/20/2024 at 8:10 PM, the shower room in the 300 hall showed an unlocked door. In the shower room was an unsecured bottle of Oxivir tb solution and a container of Oxivir tb wipes on the floor. Multiple follow up observations of the shower room in the 300 hall on 08/21/2024 at 8:30 AM, at 2:45 PM, at 4:55 PM, and on 08/22/2024 at 10:28 AM, showed the shower room door was unlocked with the Oxivir TB cleaning solution and wipes unsecured. <PPE Carts> An observation on 08/20/2024 at 7:55 PM, showed eight of eight PPE carts in the resident halls with Sani-Cloth Bleach Germicidal Disposable wipes (a hazardous cleaning agent) stored unsecured on the tops of the carts. Record review of the safety data sheet for the wipes showed the wipes posed a risk of injury to the eyes or skin if they came into contact with these areas. During multiple follow up observations of the PPE carts showed on 08/21/2024 at 10:19 AM, 08/22/2024 at 3:10 PM, 08/23/2024 at 10:46 AM, and 08/24/2024 at 4:30 PM, eight of eight PPE carts had unsecured Sani-Cloth Bleach Germicidal wipes stored on top of the carts in the resident halls. During an interview on 08/24/2024 at 4:45 PM, Staff B, Director of Nursing, stated all the cleaning agents should be stored in a secured manner such as in locked areas so that the residents were not able to get into contact with them. Reference: (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to provide timely care and services and perform assessments for 1 of 3 residents (Resident 1) reviewed for changes in condition. Resident 1 experienced harm when they had prolonged bladder pain due to urinary retention with a delay in treatment. Findings included . Review of the facility undated policy titled, Alert Charting, showed alert charting was to occur in the event of acute change in condition and was to be continued every shift for 72 hours. The alert charting list included new admissions. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (space around the spinal cord became too narrow which occurred most often in the lower back and neck), diabetes and urinary retention (bladder did not empty completely or at all). Resident 1 was hospitalized between 05/24/2024 to 06/07/2024 and had laminectomy surgery (created space by removal of bony growth on the edge of a bone and tissues associated with arthritis of the spine) on 05/26/2024. Review of Resident 1's comprehensive assessment, dated 06/10/2024, showed they had no cognitive impairments. Review of Resident 1's plan of care, dated 06/07/2024, showed they required one staff to assist with turning in bed, transfers and dressing. On 06/24/2024 at 11:25 AM, Resident 1 stated, they had not urinated during the day and evening shifts on 06/08/2024 and the night shift of 06/09/2024. The resident stated they had asked staff to figure out how they could urinate as they knew they had over the amount of urine needed to be catheterized. Resident 1 stated it was a horrible experience, no one was willing to help me, felt like I was going to explode with my bladder. Resident 1 stated it took forever to get the bladder scan done and to be catheterized and it hurt really bad, I even tried pushing out the urine. Resident 1 stated the Licensed Nurse the night of 06/09/2024 [Staff B, agency Licensed Practical Nurse (LPN)] did not do an assessment on them and only came into their room to administer pain medication. On 06/24/2024 at 11:37 AM, Resident 1's representative (RR), stated the resident was calling them at home several times during the night shift between 06/08/2024 to 06/09/2024. The RR stated the resident had so much pain in their bladder, which put additional pressure on their back surgical area. It was a couple of hours following the bladder scan before Resident 1 was catheterized. The RR stated the resident's bladder pain started at 11:00 PM on 06/08/2024. On 06/24/2024 at 11:45 AM, Staff C, Registered Nurse/Unit Care Coordinator, stated prior to them leaving the unit at 11:00 PM on 06/08/2024, NA staff had reported Resident 1 was having bladder pain and felt their bladder was full. Staff C stated they instructed Staff B at that time to do a bladder scan on Resident 1, and if needed Staff B would have to notify the on-call MD for a catheter order. Staff C also informed Staff B they had put Resident 1 on alert charting, thus the resident needed to be monitored closely. Staff C stated Staff B never informed Staff C they did not know how to operate the bladder scanner. Staff C stated Staff A, Nursing Assistant (NA), reported to them the morning of 06/09/2024 that Staff B did not know how to use the bladder scanner. Staff F, agency Licensed Practical Nurse, had reported they immediately notified the on-call physician when Staff F reported to work at 6:00 AM on 06/09/2024. On 06/24/2024 at 1:27 PM, Staff A, stated shortly after they arrived to work on 06/08/2024 at 10:00 PM, they checked on Resident 1, as they had cared for the resident the day before. Resident 1 stated they had not urinated since Staff A had cared for them the previous night. Resident 1 complained of abdominal pain and stated in the past they had to have a catheter (flexible tube used to empty the bladder) for not being able to urinate. Staff A reported Resident 1's concerns to Staff B, and Staff C, as they were both at the nursing station. Staff C then instructed Staff B to check on the resident and if they were not urinating a bladder scan (portable ultrasound device used to measure the amount of urine in the bladder) needed to be performed. The instructions by Staff C also included if Resident 1 was retaining urine the on-call physician needed to be notified to obtain orders to catheterize (insert a catheter into the bladder) the resident. Staff C then left the unit. Staff B checked on Resident 1 and stated the resident just seemed anxious. Pain medication was then given to Resident 1. Between 2:00 AM to 2:30 AM on 06/09/2024 Staff A again checked on Resident 1 who stated their abdomen still hurt and felt swollen. The resident still had not urinated, was sweaty and breathing hard. Staff A stated they immediately informed Staff B regarding the resident's condition. Staff A stated to Staff B, something needs to be done. Staff B responded they would check on it. At 4:00 AM on 06/09/2024 Staff A observed Resident 1 crying in pain and was extremely distressed. The resident was concerned their bladder was going to pop, and was unhappy Staff B had not done anything yet. Staff A and Staff D, NA, Resident 1's primary caregiver, questioned Staff B when they were going to do the bladder scan as per Staff C's earlier instructions. Staff B then got the bladder scan machine and asked Staff A if they knew how to operate the machine. Staff A replied it was not in their scope of practice. Staff B then obtained assistance from Staff E, LPN, who was working on another unit. The bladder scan was completed at 5:00 AM on 06/09/2024. Staff B did not notify the on-call physician or perform the catheterization on Resident 1. On 06/09/2024 at 6:00 AM Staff A reported to Staff C the events of the night regarding Resident 1 including the resident being in pain all night and delay in treatment. On 06/24/2024 at 1:50 PM, Staff D, stated as soon as they reported to work on 06/08/2024 at 10:00 PM Resident 1's call light was on. Upon responding to the call light Resident 1 complained about pain in their bladder, feeling miserable and uncomfortable. Staff D reported Resident 1's concerns to Staff C, who stated Staff B was going to do a bladder scan on the resident and if there was a large amount of urine the physician would be notified. Staff C then left the unit at approximately 11:00 PM. Thirty minutes later Resident 1 stated they were in much pain and felt pressure to their bladder area. Staff D informed Staff B of the resident's concerns. Resident 1 activated their call light every 30 minutes during the night asking what was going to be done regarding their bladder pain. At one point Resident 1 wanted to know the exact time Staff B was going to check on them. Staff B initially informed Staff D they did not know what time they would be completed with medications and treatments for other residents, but then stated 15 to 20 minutes. Staff D stated they did not know exactly what time Staff B saw Resident 1 but pain medication was administered to Resident 1 by Staff B. At approximately 4:00 AM on 06/09/2024 Resident 1 stated they were still in pain and had not urinated. Staff D reported the information to Staff B, who then went to get the bladder scanner machine. At 5:00 AM on 06/09/2024 the bladder scan was performed on Resident 1. The morning of 06/09/2024 Staff D stated they and Staff A reported to Staff C regarding the resident's pain throughout the night, delay in performing the bladder scan and the lack of knowledge Staff B had regarding the scanner. On 06/25/2024 at 9:43 AM, Staff B, stated they recalled NA staff reporting at 11:00 PM on 06/08/2024 that Resident 1 was having a hard time urinating. Staff B stated when Staff C left the unit at 11:00 PM on 06/08/2024, they instructed Staff B to monitor Resident 1, do a bladder scan if the resident continued to have difficulty urinating and notify the on-call physician to get an order for catheterization. Staff B stated they were unable to recall when they assessed Resident 1 as they had things to do with other residents that night. Staff B stated at some point during the night of 06/09/2024 NA staff had asked what time Staff B would be in to see Resident 1. Staff B stated they informed the NA they would see Resident 1 when they were finished with another resident. Staff B stated they did recall Resident 1 having bladder pain and stated they had not urinated for a long time. Staff B stated they asked Staff A if they knew how to operate the bladder scanner as they had never used the machine before. Staff B recalled the number on the scanner being high (showed large amount of urine in the resident's bladder), but they had not notified the on-call physician as the day shift Licensed Nurse had done that. On 06/24/2024 at 12:25 PM, Staff F, agency LPN, stated the bladder scan on Resident 1 was done at 5:00 AM on 06/09/2024 by Staff B with assistance from Staff E. Staff F stated they notified the on-call physician right after reporting to work at 6:00 AM on 06/09/2024. On 06/24/2024 at 2:10 PM, Staff G, LPN, stated they were pulled from another unit at approximately 6:30 AM on 06/09/2024 to catheterize Resident 1. Staff G stated Resident 1 was relieved when the catheter emptied over 1200 milliliters (ml) of urine from their bladder (normal bladder capacity in adults ranged from 300 to 400 ml). Staff G stated prior to the catheterization they had palpated the resident's bladder and it was rock hard, (possibly indicative of a problem with how the bladder muscle worked). Review of Resident 1's June 2024 Medication Administration Record, showed Resident 1 was not catheterized until 7:41 AM on 06/09/2024 (8 hours and 41 minutes following the resident's initial complaints of bladder pain). Oxycodone (narcotic medication) was administered to Resident 1 at 12:08 AM on 06/09/2024 by Staff B for a pain level of 6 which was effective, and Oxycodone was administered at 3:54 AM on 06/09/2024 by Staff B for a pain level of 8, which was ineffective. Pain levels were measured on a scale of zero being no pain to 10 being severe pain. Review of Progress Notes (PNs) in Resident 1's medical record, dated 06/09/2024 at 6:27 AM, by Staff F, showed the resident complained of not being able to urinate during the night shift. A bladder scan was performed at 5:00 AM on 06/09/2024 with a volume of 980 ml of urine in the bladder. The physician was notified and orders obtained to catheterize the resident. Review of Resident 1's PNs between 10:00 PM on 06/08/2024 to 6:00 AM on 06/09/2024 showed there were no assessments/monitoring of the resident by Staff B despite the resident's change of condition, new admission status and alert charting policy. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 03/20/2024.

Based on observation, interview and record review, the facility failed to identify incidents of verbal abuse in a timely manner, failed to protect the resident's right to be free from verbal abuse and take timely action to prevent further abuse as a State agency was not notified until 09/08/2023 (four months later) for 1 of 3 residents (Resident 1) reviewed for abuse. Despite multiple staff interviews of witnessed abuse to Resident 1 by their representative (RR) the abuse continued for four months which caused psychological harm to Resident 1 as displayed by the resident crying, asking why the RR was so mean to them and sadness. Findings included . Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses that included kidney and lung disease, and anxiety. Review of Resident 1's comprehensive assessment, dated 07/26/2023, showed they were cognitively intact (normal or sufficient mental processes such as thinking, judgment and planning); required extensive assistance by two staff for turning in bed, transfers, toilet use and personal hygiene; and required extensive assistance by one staff for dressing and was independent with eating with staff set-up. Review of Progress Notes dated 09/08/2023 at 8:45 AM and documented by Staff G, Administrator in Training, showed they had witnessed the RR verbally harass Resident 1 by aggressively saying to resident shut your trap. Resident 1 was visibly crying in their room during and after the encounter with the RR. The incident was reported by telephone to a State agency. Later at 11:15 AM Staff G went back to Resident 1's room to see how they were doing. Upon entering their room Resident 1 had their face pointed down towards their lap and appeared sad. When Staff G questioned Resident 1 regarding how they were doing the resident responded, I give [RR] my money, my credit cards, and I help [RR] buy car parts, and [RR] can't even say one kind word to me. Resident 1's statement regarding their finances involving RR was reported to a State agency. Review of a facility investigation report, dated 09/13/2023 at 10:30 AM, showed an investigation was initiated by staff due to four bruises on Resident 1's left arm being observed by a Licensed Nurse (LN). The investigation showed the resident stated they did not know how the bruising occurred, and denied any abuse by staff or visitors. As part of the facility investigation of the bruises of unknown origin written statements were obtained from 34 staff on 09/19/2023 asking the questions if they had witnessed any staff being rough or mean with Resident 1, or any observations of a visitor being rough with them. Seventeen of the 34 staff statements showed potential or actual verbal abuse to Resident 1 by the RR. The following are 13 of the 17 written statements, dated 09/19/2023, regarding the question of staff observations of a visitor being rough to Resident 1: 1) Staff A, Nursing Assistant (NA) - witnessed multiple times the RR calling Resident 1 names and yelling 2) Staff B, NA - RR had been verbally aggressive and had made Resident 1 cry 3) Staff C, NA - RR was verbally abusive, they raised their voice a lot when talking with Resident 1 4) Staff D, Physical Therapy Assistant - resident stated RR was mean to them, nothing physical 5) Staff E, NA - RR came into the facility often to visit Resident 1, heard RR yelling at the resident to get up even when they were not feeling well and did not want to get up 6) Staff F, Director of Rehab - verbally, and it was reported to a State agency 7) Staff G, Administrator in Training - not physically, just verbally, and it was previously reported to a State agency 8) Staff H, Physical Therapy Assistant - verbally, RR outside in facility parking lot 9) Staff I, NA - RR told the resident to get their butt out of bed or they were not going to see their dogs today, RR then left the facility 10) Staff J, NA - witnessed RR shout at the resident and be very controlling, they had cried multiple times and it was reported to nursing 11) Staff K, Registered Nurse (RN)/Resident Care Manager (RCM) - had heard yelling from the resident's room 12) Staff L, Maintenance Supervisor - verbally only, several times 13) Staff M, Occupational Therapy Assistant - not physically Staff P, RN/RCM, stated on 09/20/2023 at 3:20 PM, that some of the interviews they conducted were by telephone, thus they had to write the staff's response to the questions. Despite 17 interviews showing potential or actual verbal abuse, Staff P did not ask any further questions of staff to obtain additional information. On 09/28/2023 at 11:30 AM Staff P stated they had collected the above written statements by staff and turned them in to the Director of Nursing (DON) on 09/13/2023 as part of the investigation on the bruises to Resident 1's left arm. The DON had left on vacation on 09/15/2023 and would not return to work for three weeks. They stated the date on the written statements (09/19/2023) should have been 09/13/2023 as all the statements were obtained on the day the bruises were found on Resident 1. Based on the above statements the following interviews were conducted on 09/20/2023 with staff by the State investigator: Staff M stated at 12:30 PM, they arrived to work on 09/08/2023 and observed Resident 1 and the RR seated outside in the parking lot. The RR would come regularly to visit and bring the resident's dogs. Staff M opened their car window and heard RR say to Resident 1, You are a liar, you're not doing your therapy, you're lazy, what's going to happen is that you're going to be shipped to an old peoples' home in Yakima where no one would visit and no cable TV. Resident 1 was curled down in their wheelchair during the interaction and was defeated looking. Later that same day Staff M visited with Resident 1 and they just cried. Resident 1 was worried they were going to be kicked out of the facility and had no where to go. On another occasion Resident 1 stated they did not know why RR had to be so mean. Staff M stated the incident had been reported to Staff N, Social Services Assistant, who replied that a State agency was involved. In addition, Staff M stated that a neighboring resident had stated they heard the RR talking so badly to Resident 1. Staff H stated at 12:45 PM, Resident 1 and the RR would frequently sit outdoors in the parking lot between 8:00 AM to 9:00 AM for the resident to visit with their dogs. The end of July 2023 or the first of August 2023, Staff H witnessed the RR talking very loudly to Resident 1 stating that they needed to start doing this and that or the RR was not taking them home. Staff H stated they reported the incident to Staff N who replied a State agency was involved. Staff H stated, [RR] could fly off the handle like you can't believe. Resident 1 had a history of alcohol abuse and significant short term memory loss. Staff D stated at 12:50 PM, that approximately one month ago the RR had told Resident 1 they could not go home if they did not do therapy. Resident 1 was tearful and crying. Staff D questioned Resident 1 if they still wanted to go home with RR due to them exhibiting emotional distress. Resident 1 stated they did not have a choice as the RR had all their money and credit cards. Staff L stated at 1:10 PM, the RR was upset as Resident 1 would not get out of bed. When everyone left the room RR closed the resident's door. Staff L was walking down the hall and heard RR yelling at Resident 1 that if they ever expected to get out of the facility they needed to do what was expected. The RR was yelling loudly even with the door closed. Staff L stated they went to a LN at the medication cart and reported the RR was in the room with Resident 1 yelling at them. Resident 1 had only been in the facility for approximately six weeks when the incident occurred. Staff A stated at 1:20 PM, the RR had called Resident 1 a b***h multiple times when Staff A was in the room. The RR also told Resident 1 they were never going to walk again and would never get out of facility. The RR would take Resident 1 for visits out in the facility parking lot to see their dogs. At times when they came inside the building Resident 1 would be crying stating the RR had been mean to them. Staff A stated they had cared for Resident 1 ever since they were admitted to the facility. Staff A stated Resident 1 wanted to go home. Resident 1 wanted to protect the RR as they took care of them at home. Staff A stated they had witnessed incidents of yelling within the first month of Resident 1's admission which they reported to LNs who would brush it off. Staff B stated at 1:55 PM, an incident involving Resident 1 and the RR occurred the first week the resident was admitted to the facility. The RR demanded Staff B to get Resident 1 up every morning. The RR was verbally yelling at Resident 1 stating they needed to get up or the facility would kick them out. Resident 1 started crying when the RR left their room. Staff B stated they did not report the incident and didn't know what to do, maybe always like that, . felt it was none of [Staff B's] business. Staff F stated at 12:10 PM, they witnessed verbal abuse on 09/08/2023 involving Resident 1 and the RR. Staff F had informed the RR that Resident 1 was coming off therapy and they were regressing and not doing as well. The RR was very upset regarding the news. Staff F stated that in front of them, the RR stated to Resident 1, you didn't get your a** up, I can't afford to have you stay here. Resident 1 was visibly upset as they had been crying. Staff F stated it came up in the morning meeting right after the incident and Staff G stated they were going to call a State agency. Staff O, Licensed Practical Nurse, stated at 2:10 PM, they overheard Staff A telling a state investigator a while back the RR called Resident 1 a b***h. Staff O stated it was the RR's personality and how they showed their emotions. Staff O stated they did not think the RR was abusive to Resident 1. Staff P, RN/RCM, stated at 1:10 PM, they had heard the RR yell at Resident 1 which made them cry. Resident 1 had not told the staff they did not want the RR to visit them. Resident 1 stated during an interview on 09/20/2023 at 2:30 PM regarding their representative, I cry like any mother would, what [RR] doesn't yell at their mother .once in a while [RR] yells at me like any kid would yell at their mom. The resident was observed lying in bed in a private room. Staff Q, Administrator, stated during the exit conference on 09/21/2023 at 1:45 PM, Resident 1 was normalizing the verbal abuse by the RR based on the resident's history of being abused. Despite the continued verbal abuse over four months to Resident 1 by the RR review of their plan of care did not show any problem addressing the verbal abuse, nor was there a plan in place to protect Resident 1 from further abuse. Reference (WAC) 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure a resident was treated with dignity/respect in a manner that promoted the resident's choice to smoke independently without fear of intimidation or reprisal (an act of retaliation) for 1 of 2 residents (Resident 33), reviewed for the resident right to smoke cigarettes independently. Additionally, the facility failed to protect Resident 33 from ongoing staff reproach (the expression of disapproval or disappointment) when Resident 33 exercised their right to smoke cigarettes outside facility grounds. This failed practice of the violation of Resident 33's right to a respectful and dignified existence resulted in psychosocial harm to the resident who described they experienced feelings of humiliation, distress, frustration, harassment, anger, increased sadness, and were at risk for a diminishment of self-worth when choosing to smoke. Findings included . Review of the facility's policy titled, Non-Smoking Facility, revised 08/09/2022, showed the purpose of the policy was, To protect the public health and welfare by prohibiting smoking in the enclosed areas that make up the Nursing Home and on the other grounds of the Nursing Home. The policy further showed, Smoking is not allowed, at any time, inside or outside the building or on the property by residents, staff, or visitors ., that all staff would be provided education on the facility's smoking policy, and .upon identification of smoking non-compliance by resident family or visitors, staff will intervene immediately, providing instruction on the facility's non-smoking policy . Review of the facility's admissions documents (paperwork reviewed with the resident on admission to the facility) titled, Smoking Policy Communication, undated, showed The facility strives to provide a safe environment for resident who smoke tobacco products . Additionally, the communication stated that residents were not permitted to have any smoking paraphernalia (i.e. cigarettes, e-cigarette, vaping devices, lighters, matches, etc.) in their possession at any time during their stay. Furthermore, the facility's smoking policy communications stated that if the resident was non-compliant (not following the smoking rules) with the facility's smoking policy that it may result in the resident being involuntary discharged . Resident 33. Review of Resident 33's electronic medical records (EMR) showed they were admitted on [DATE] from the hospital after they had a fall with a diagnosis of long-term lower right and left leg wounds, anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), depression, and nicotine dependence. Review of Resident 33's comprehensive assessment, dated 06/01/2023, showed the resident was alert, cognitively intact, able to make their needs known, was easily understood by staff, needed extensive assistance with transferring, needed supervision with moving around in a wheelchair, and was a current user of tobacco products, and was currently still smoking off the property. The assessment further showed the resident was not taking any medications for their anxiety or depression. Review of Resident 33's history and physical from their hospitalization , dated 05/16/2023, showed that the resident was currently smoking cigarettes and had been smoking for the past [AGE] years. Record review of a smoking safety evaluation completed by the facility the day after Resident 33's admission, dated 05/26/2023 at 8:44 AM, showed Resident 33 had not attempted to keep smoking paraphernalia on their person or in their room, was following the smoking regulations of the facility and had demonstrated the ability to safely smoke with supervision. It was also noted that Resident 33 declined different alternatives offered by the facility, to quit smoking (such as a nicotine patch - a product that can help residents to quit smoking). Review of Resident 33's plan of care, dated 06/04/2023, showed the resident was an active smoker and the facility's goal for the resident was .will have no complication related to desire to smoke. During a concurrent observation and interview on 06/21/2023 at 4:08 PM, showed Resident 33 seated slumped over, reddened face, darkenned and sunken area of skin under their eyes with tears swelling up in their eyes and the corners of their mouth were turned downwards (frowning) when they talked about what they believed to be the continuous beratement (to be spoken to angril about something that was done wrong) that had occurred by facility staff for their choice to continue to smoke since the day of admission. The resident stated that they went from going just outside of the nursing home (since admission) to now smoking cigarettes off of the facility's property on the sidewalk, but felt they were constantly getting reprimanded (to tell someone officially that they had done something wrong) and harassed (subject to abusive pressure or intimidation) by facility staff. The resident stated that Staff F, Maintenance Director, and Staff C, Social Service Director (SSD), met with the resident on 06/19/2023 about their smoking even though they were smoking on the sidewalk (which is considered public property and off of the facility's property). The resident stated that both Staff F and Staff C came to their room and accused the resident of hiding smoking paraphernalia within their room, I told them that I had not been hiding the cigarettes in my room, that I had been smoking on the sidewalk and that I stashed (to store something safely and secretly in a specific place) my cigarettes and lighter in the bushes by the sidewalk. When Resident 33 was asked why they stashed their cigarettes/lighter in a bush, they explained it was because facility staff took their smoking paraphernalia the day they were admitted , and again a week ago after the facility staff saw the resident smoking outside on the sidewalk. The resident explained they did not have any other way to store their smoking paraphernalia since the facility staff would not give them their cigarettes/lighter when they went outside to smoke and facility staff informed the resident they could not have their smoking paraphernalia back until they were discharged from the facility. Resident 33 pointed from their room window to a spot across the parking lot 50 feet (measured by heel-to-toe steps with the Surveyors 12 inch foot) away next to the public sidewalk, where they stashed their cigarettes and lighter in a bush that was no longer there. The resident continued to explain her perception of the facility's recent actions. I mean (Staff F) tore out a bush to get back at me for smoking! Who does that? (tears rolling down Resident 33's cheek, lips trembling, with a confused look on their face). Review of Resident 33's Social Service Assessment, completed 06/05/2023, showed the resident's mood and behavior status as anxious, the resident would become upset quickly, and they wre upset about the smoking regulations. The policy had been discussed with the resident. Review of Resident 33's progress notes for May and June 2023 showed: 05/25/2023 at 3:35 PM, Staff C documented the resident was on the sidewalk smoking and Staff C discussed with the resident as the facility was non-smoking. Resident 33 was offered a nicotine patch, and they declined wanting the nicotine patch. 05/25/2023 at 5:11 PM, Staff D, Social Service Assistant (SSA), .confiscated (to take away as punishment or to enforce the law or rules) cigarettes and lighter and stored them away until resident is ready to leave facility. 05/31/2023 at 9:01 AM, Staff D documented that SSA was pulled out to the parking lot due to Resident 33 smoking a cigarette. Resident 33 stated they were out on the sidewalk (off the facility property) and could smoke. SSA stated as long as Resident 33 was at this facility they were not allowed to smoke. Resident 33 seemed annoyed and stated they would be calling their family. SSA explained again that as long as Resident 33 was a resident at the facility, there were not allowed to smoke. 05/31/2023 at 12:46 PM, Staff C documented, Resident very teary during initial discharge planning evaluation assessment .has not adjusted well due to not being able to smoke .smoking policy discussed with resident as (Resident 33) continues to want to smoke. Policy reviewed with resident and Social Services Director asked resident to sign smoking policy communication. Resident refused. 06/01/2023 at 1:32 PM, care management note showed Resident 33's goal to discharge home with home health. 06/08/2023 at 1:06 PM, care management note showed Resident 33 reported that they were homeless. 06/13/2023 at 5:14 PM, Staff C and Staff E, Licensed Practical Nurse (LPN), showed that both staff discussed with Resident 33 that they could not smoke on facility grounds and needed to turn in their cigarettes. Resident 33 informed both staff that they were smoking on the sidewalk. Staff asked the resident to turn in their cigarettes, and two packs of cigarettes and a lighter were turned in to the Director of Nursing Services (DNS). 06/19/2023 at 3:45 PM, Staff C documented they met with the resident in order to discuss concerns with smoking within facility grounds over the weekend. The resident denied the allegations and stated they did not have cigarettes in their room. Resident 33 stated they had cigarettes stashed outside of the facility grounds. The resident was reminded of the facility's non smoking policy. During a concurrent observation and interview on 06/22/2023 at 4:04 PM, Resident 33 stated that since the bush was torn out, they stashed their cigarettes andlighter with a neighbor that had a house right next to the nursing facility. Resident 33 stated that staff confiscated all the other cigarettes they had. The resident stated that even this morning when they signed out to go smoke outside they were told by Staff B, DNS, that the facility was a non-smoking facility, of course I know that, we all know that, it's just constant (tears coming down the resident face, grinding their teeth together, with a clenched fist in frustration), they are always questioning me, hounding me and shaming me for smoking every day. During a concurrent observation and interview on 06/23/2023 at 6:50 AM, outside the facility grounds where Resident 33 pointed out the bush where they stashed their cigarettes and lighter was previously located. Staff F stated that the bush was 10 ft wide by four ft deep and six ft high and was taken out on 06/21/2023. Staff F further stated that the bush was taken out due to it being overgrowing onto the public sidewalk and that another reason was that sometimes homeless would stash things in the bushes. An orange lighter and broken cigarettes were observed in the dirt spot where the bush had been. Additionally, Staff F stated that some staff in the facility smoke but have to go out to the sidewalk to smoke and that they had seen Resident 33 smoking out by the bush. During an interview on 06/23/2023 at 7:17 AM, Staff O, LPN, stated that when they smoked during their shift, they must go off of the facility's property to the sidewalk. Staff O stated that residents were not allowed to have smoking paraphernalia at all in the facility and that it was a non-smoking facility. During an interview on 06/23/2023 at 7:38 AM, Staff P, Medical Records, stated that they smoked during their shift but were not allowed to smoke on the facility's property and must go outside to the sidewalk, which was public property. Staff P further stated that facility residents were not allowed to smoke while they were a current resident at the facility. During an interview on 06/23/2023 at 8:40 AM, Staff R, Admissions, stated that all the admission documents like the smoking policy communication were reviewed and signed by residents after they arrived at the facility. Staff R stated that the smoking policy communication form was not given to Resident 33 before they entered the facility. Additionally, Staff R stated that all the admission forms (including the smoking policy communication form) were reviewed and electronically signed by the resident on 05/26/2023 (the day after Resident 33 was admitted ). Observations on 06/23/2023 at 9:17 AM showed Resident 33 outside on the sidewalk smoking with their Resident Representative (RR). Staff E, LPN Admissions Nurse, was observed to walk up to the resident and RR. Staff E stated, you know this is a non smoking facility. Resident 33 stated that they were not on the facility's property and were allowed to smoke on the sidewalk because it was public property. Staff E stated, Well I am a nurse and residents are not supposed to have cigarettes on them. Resident 33 stated, I don't have any, my (RR) does. Staff E stated (leaned forward and yelled in an accusatory manner), You're smoking one right now! Resident 33's RR then stated, We are not on the facility's property and on public property, what is wrong with you people, why do you keep doing this? Staff E stated Okay, fine! and proceeded to get into their car and drove off. During a concurrent observation and interview on 06/23/2023 at 9:24 AM, Resident 33 stared at Staff E (during their conversation and after the staff had left) crying. Why, why does this keep happening? This is ridiculous. Resident 33 and their RR stated that staff were continuously shaming and harassing the resident when they chose to smoke, even when they were following the rules and smoking off the facility's property. The resident stated that they were never informed prior to arrival at the facility that it was non-smoking and on 05/25/2023 they wanted to leave but they needed help with their medical care, so they signed the admission packet with the smoking policy communication form. If I wanted to be admitted I had to sign, or I was going to be pushed to the curb. Additionally, Resident 33 and their RR stated that they had seen multiple facility staff (from Resident 33's window, that faces the parking lot to sidewalk side of the facility) smoking on the sidewalk (the resident's mouth was wide open with a shocked look on their face, as they pointed at where they had seen staff smoking on the sidewalk). During an interview on 06/23/2023 at 10:32 AM, Staff F, stated that they remembered having a conversation with Resident 33 about smoking. Staff F stated that they went to the resident room after they had come back in from outside smoking and made sure that the resident did not have any smoking paraphernalia on them. Staff F stated that Resident 33 was off the premises (not on facility property) when they were smoking and did not have any smoking paraphernalia on them. Staff F stated that the resident had informed them that they were leaving their cigarettes and lighter in a bush outside and that after they had that conversation the bush was removed on 06/21/2023. I could see how (Resident 33) would think the bush got removed because (they) had stashed their cigarettes there. During a concurrent observation and interview on 06/23/2023 at 12:16 PM, Staff C and Staff D, stated they both discussed with Resident 33 concerns about their smoking while a resident in the facility, and that even on the resident's first day at the facility. Resident 33 was observed smoking outside. Staff C stated that the resident was anxious over a lot of stressors (death of their daughter, spouse and the loss of their home) in their life, they had a diagnosis of anxiety and smoked cigarettes as a coping strategy. Staff C stated that on the resident's first day at the facility (05/25/2023), they were informed about the non-smoking policy in the facility and Resident 33 wanted to leave (to not be admitted to the nursing home) because they were not going to be able to smoke. The resident decided to stay, and their cigarettes and lighter were confiscated and the resident was informed that they would get the cigarettes and lighter back when they discharged . Both Staff C and D stated that they constantly reminded Resident 33 every time they saw the resident coming in from smoking that the facility had a non-smoking policy and that residents could not have smoking paraphernalia on their person. Staff C stated yes Resident 33 did have the right to smoke and also to have their cigarettes if outside off of the facility's property, but that their process/policy was that residents were not allowed to have smoking paraphernalia on them or in their room. During an interview on 06/26/2023 at 11:22 AM, Staff E, stated that Resident 33 was not aware of the facility's non-smoking policy prior to their admission. Staff E stated that when Resident 33 was admitted , they denied wanting the nicotine patch so then review of the non-smoking policy was performed with the resident, which they were very upset about, and Resident 33 wanted to leave because they wanted to be able to smoke. Staff E stated that the normal process, for a resident that refused the nicotine patch and still wanted to smoke, would be to reapproach the resident about the nicotine patch and to inform the resident's medical provider, neither of which Staff E performed. Staff E stated that they had discussed the non-smoking policy on admission with the resident and on 06/23/2023 at 9:17 AM when they proceeded to yell at Resident 33 about smoking a cigarette on the sidewalk (outside of facility property). Staff E stated, Yes, I got a little upset (with Resident 33), I shouldn't have yelled at (Resident 33) or got upset. Staff stated that Resident 33 appeared distressed and upset about Staff E's conversation and that it was not the correct process, and that they should have remained calm. During an interview on 06/26/2023 at 1:31 PM, Staff M, Advanced Registered Nurse Practitioner, stated that they were not aware that Resident 33 had refused the nicotine patch, and that they were still smoking cigarettes. Staff M stated that if the resident had refused the nicotine patch and wanted to continue to smoke then they would have that right and Resident 33 was anxious so smoking would have been a coping strategy for their stress. During an interview on 06/27/2023 at 10:10 AM, Staff B, DNS, stated that they did not allow Resident 33 to check out their smoking paraphernalia when they go out to smoke and that the resident was allowed to smoke outside on the sidewalk. When progress notes from Social Services read and reviewed by Staff B, yeah, that would be very upsetting, and that they were not aware that Staff C and Staff D were constantly reminding the resident of the non-smoking policy after they would come in from smoking. Staff B stated that Resident 33 should have the right to their smoking paraphernalia, but that was against the facility's non-smoking policy. Staff B stated the process for smoking was not working for Resident 33 and that they have the right to smoke, and that Resident 33 should have access to their cigarettes and lighter. Review of Resident 33's medication administration record (MAR) for May and June 2023 showed that supplemental oxygen was ordered at two liters per minute (a unit of measurement for oxygen) on 05/29/2023, as needed, but had not been administered to the resident in May or June of 2023. During an interview on 06/27/2023 at 11:10 AM, Staff A, Administrator, stated that the policy did not specifically state to confiscate residents' smoking materials. Staff A stated that in Resident 33's case, they had received direction from their regional office to confiscate Resident 33's smoking paraphernalia and hold onto them until the resident discharged due to the resident having an as needed oxygen concentrator (supplies oxygen to the resident) in their room. Staff A stated that Resident 33 did not smoke in their room and did not bring the oxygen concentrator outside to smoke (as the resident had never used the oxygen while in the facility) but staff were not allowed to let Resident 33 have their cigarettes and lighter when they went out to smoke. Staff A stated that Resident 33 should not be continuously talked with about smoking every time the resident was noted to be smoking off of the facility's property. Staff A stated that Staff E's yelling at the resident and RR when smoking on public property was not the correct process and that the resident had the right to smoke on public property. Reference: WAC 388-97-0180(1-4)

Based on observation, interview and record review the facility failed to prevent an avoidable accident for one of three residents (#1) reviewed for accidents. This failure prevented the resident the necessary assistance and supervision to prevent injury. Failure to follow the resident's care plan, which required two people to assist with transfers, and follow the facility policy relative to the use of gait belts, resulted in harm to Resident #1. The resident sustained [REDACTED]. The left lower leg laceration scar was shaped like a curve (boomerang) that measured 5 inches. Findings included . Review of the facility policy/procedure for gait belt use, Chapter 9: Nursing Rehabilitation/Restorative Lippincott procedure for gait belt use revised 08/16/19. The purpose was gait belts are provided to assist staff to safely transfer or ambulate residents. Resident #1. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 09/26/19 comprehensive assessment showed the resident was alert, oriented and able to make needs known. The care plan dated 06/21/19 showed the resident required extensive assistance due to unsteady balance, and assistance of two staff for all transfers. Review of the initial 06/21/19 care plan showed ADL self-care performance deficit related to .[MEDICAL CONDITION], immobility, non-weight bearing on left leg the care plan was revised on 10/31/19. Additionally, the care plan showed the resident required a mechanical lift (Hoyer) with the assistance of two staff for transfers. The 11/27/19 incident report showed the resident sustained [REDACTED]. The resident was sent to the emergency room and treated with eight sutures to her left lower leg, and an order for [REDACTED].>During an interview with the resident on 12/17/19 at 10:45 AM, she stated that the staff used the mechanical lift with her at times but usually with two people to transfer her with the gait belt. On 11/27/19 at approximately 11:45 AM, the resident was in bed and wanted to get up for lunch. According to the resident, Staff A was insistent that she could get the resident up by herself and kept pulling on the resident to get into the wheelchair. The resident stated she wanted a second person to help get her up but Staff A stated she could transfer her. The resident stated that while the NA tried transferring her to the wheelchair she began to fall and barely made it into the chair. She stated that her left lower leg was caught on the side of the wheelchair and was bleeding. She was then sent to the hospital emergency department for treatment and did not want Staff A to come in her room again or care for her. The resident stated the near fall and resulting wound was Horrible and very much an inconvenience. An observation of the laceration on 12/17/19 at 11:15 AM, showed a closed laceration scar curved line to the left lower outer leg approximately 5 inches long (the facility stated 5 centimeters which equals 1.9 inches) with a wider scab and flaky dry skin to the lower end of the laceration. Instruction was to remove the sutures in 12 days. The resident cannot move her body in bed without assistance of staff. During an interview on 12/17/19 at 11:30 AM with Staff B, Registered Nurse/Director of Nursing Services, she stated that the incident with Staff A's transfer of the resident by herself determined the care plan was not followed. Staff B reviewed the care plan (revised 10/31/19) for transfer of the resident she saw the instructions to staff was to use a mechanical lift with two persons for transfers. Staff B stated she was under the understanding the resident required a two person stand and pivot with the use of a gait belt. During an interview on 12/17/19 at 2:23 PM, Staff A, NA, stated she was in a hurry to transfer the resident to her wheelchair and did not have another NA available and decided to hurry and transfer the resident without a gait belt by herself. Staff A explained she knew it was a wrong decision, which resulted in the resident obtaining a serious injury. Additionally, Staff A stated she believed the resident's leg was caught on the foot pedal which was in the up position when she transferred her. A 07/30/19 Patient Status Update written by the physical therapist showed the resident required a 2 person assist with bed mobility and transfers. The rehab comments stated that the patient was transitioning to maximum assistance of 2 with transfers (bed to wheel chair and back. Nursing can downgrade to total assistance with a Hoyer lift if needed. The clarification was not on the care plan or the instruction sheet for Resident #1's transfer nor was there clear instruction of when to use the Hoyer lift. Reference WAC 388-97-1060(3)(g) This is a repeat citation from SOD dated 03/05/19.

Based on observation, interview and record review, the facility failed to notify the residents' medical provider for two of two residents (#1,2) reviewed for physican notification. This failed practice resulted in actual harm for Resident #1 who did not receive required medical care in a timely manner. Additionally, this placed Resident #2 at risk of not receiving a medical evaluation to prevent health complications. Findings included . The facility policy dated 11/26/18 titled Changes in Residents Condition Status stated The attending physican will be notified of a change in the resident's medical condition. Resident #1. A review of the resident's record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's progress notes showed it was first documented on 04/04/19 at 4:00 PM the resident was observed moaning and dry heaving (the movement of the stomach without vomiting) by Staff I, Registered Nurse (RN). The resident reported to the RN that she was experiencing extreme pain and wanted to go to the emergency room (ER). There was no documentation that the resident's medical provider was contacted to report the residents complaints of extreme pain, dry heaving, and requested to be sent out to the hospital. Review of a progress note, dated 04/04/19 at 11:33 PM, showed Staff J, RN, documented the resident reported she wanted to be sent to the hospital for management of her nausea/vomiting and pain. Further, stated she had been having dry heaves for hours and was angry that she had not been sent to the hospital. Staff J contacted the facility Nurse Practitioner and received orders to send the resident to the ER for evaluation of her symptoms (twelve hours after they started). During an interview on 04/17/19 at 1:00 PM, Resident #1 stated she had started dry heaving on 04/04/19 at approximately 11:00 AM. She stated she had requested to have the physican notified numerous times as she felt she should go to the hospital. They just kept telling me they would contact the doctor but no one ever did. Review of the Resident #1's hospital record, dated 04/04/19, showed the resident had been diagnosed with [REDACTED]. The resident required surgery on 04/05/19 to manage her condition. During an interview on 04/12/19 at approximately 10:00 AM, the facility Nurse Practitioner stated she had been in the facility until about 3:00 PM on 04/04/19 and had not been notified of the resident's increased pain, dry heaving or request to be sent to the ER for evaluation. Resident #2. Review of the medical record showed he was receiving [MEDICAL TREATMENT] (to remove toxins from the blood) for end-stage kidney failure. A 03/25/19 communication form (SBAR) sent to the facility's Nurse Practitioner showed the resident had a bruise on the left side of the head at the temporal area. Following the notification, the resident was sent to the ER for an evaluation. During an interview on 04/12/19 at 10:00 AM, Staff C, RN, stated when she assessed the resident, there was a small raised circular area that looked like the initial hematoma (localized bleeding due to trauma or disease) and a web-like bruise extended down his face and around his eye on the left side. She stated Staff F, Nursing Assistant, had told her that Staff F saw the bruise on 03/23/19 and had reported it to Staff D, LPN, on 03/23/19. During an interview on 04/11/19, the facility's Nurse Practitioner stated when she learned of the hematoma on the resident's head, she had been concerned regarding possible bleeding in the brain and had wanted the CT scan (specialized type of X-ray) done. She stated, as the resident's health condition was fragile, the CT scan should have been done when the bruised area of the head was first found on 03/23/19, but she was not notified by nursing until 03/25/19. WAC 388-97-0320 Notify of Changes . Cross reference F684, Quality of Care, for further details regarding the care concerns for Resident #1 and Resident #2.

Based on observation, interview, and record review, the facility failed to thoroughly assess and provide timely medical treatment for one of two residents (#1) who were reviewed for care and services. The delay in treatment caused actual harm to Resident #1, as the resident did not receive needed emergency medical care and experienced reoccurring pain and nausea throughout the day on 04/04/2019, despite her repeated requests to be sent to the hospital for treatment of her condition. Findings included . Resident #1. Review of the medical record showed she was admitted to the facility on [DATE] for unrelieved nausea, vomiting, and pain. Other [DIAGNOSES REDACTED]. A review of the progress notes dated 04/03/19 at 11:24 PM , 04/04/19 at 5:42 AM, and 04/04/19 at 1:53 PM showed the resident was cognitively intact and was able to make her needs known to staff. A review of the resident's medical record showed on 04/04/19 at 4:00 PM the resident was overheard by Staff I, Registered Nurse (RN), moaning and dry heaving (movement of the stomach without vomiting). Staff I went in the resident's room and the resident was in extreme pain and wanted to be transported to the emergency room (ER) to receive IV pain medication. Staff I documented she had explained to the resident she had received medications for pain and nausea an hour prior and needed to wait a bit longer to see if that would control her pain and nausea. The progress note did not show that the resident's medical provider was notified of the residents pain or request to be transported to the emergency room for additional evaluation and treatment. During an interview 04/15/19 at 10:00 AM, Staff I stated she did not know the resident, but went into the room to check on her as she had overheard the resident moaning and dry heaving. The resident had requested to go to the hospital but Staff I explained to her that she needed to wait to see if the medications she had been given by Staff E, Licensed Practical Nurse, (the resident's primary nurse) would kick in. Staff I reported her conversation to Staff E and stated she would have expected the resident's nurse to follow up if needed. During an interview on 04/12/19 at 10:50 AM, Staff G, Nursing Assistant (NA), stated she had been the main caregiver for Resident #1 on the day shift on 04/04/19. Staff G stated the resident had asked her (Staff G) to go to the hospital, who then reported it to Staff E. Staff G also stated she had reported to Staff E at least four times during the shift, that the resident was having pain. During an interview on 04/12/19 at 11:30 AM, Staff H, NA, stated he had been the caregiver on the evening shift for Resident #1 on 04/04/19. Staff H stated the resident had her head over her trash can dry heaving throughout the shift. The resident had requested to go to the hospital which he reported to Staff E. Staff E informed Staff H to tell the resident there was nothing else she could do for her. Staff H further stated the resident was upset because she was not sent to the hospital. Review of a progress note, dated 04/04/19 at 1:53 PM, did not show documentation by Staff E that the resident had been requesting to go to the hospital or that the medical provider had been contacted. Furthermore, there was no documentation related to the residents dry heaving or increased pain. Review of a progress note, dated 04/04/19, at 11:33 PM, showed the resident reported to Staff J, (RN), that she was continuing to have nausea, dry heaves and pain. The resident expressed concern that she had not been sent to the ER earlier in the day for her symptoms when she had requested and stated I have my rights. Staff J documented that additional medication was given but did not relieve Resident #1's pain or dry heaving. The facility's Nurse Practitioner was contacted by Staff J and verbal orders were received to transport the resident to the ER for evaluation of her condition. Review of the 04/04/19 hospital emergency record showed the resident was admitted to the hospital on [DATE] with a urinary [MEDICATION NAME] (solid particles that may cause pain) in her right ureter (tube that transports urine from the kidney to the bladder) and a right-sided kidney stone. The resident's condition required surgery on 04/05/19. During an interview on 04/17/19 at 10:00 AM, Resident #1 stated she had started having extreme nausea, dry heaving, and pain at approximately 11:00 AM on 04/04/19. The resident stated her symptoms continued to recur throughout the day. The resident also stated she had requested numerous times to be sent to the hospital, but no one would listen to me. She stated she was told that the hospital would not take her for her nausea. The resident stated she had asked the day nurse, Staff E, to call the doctor and have him send her to the hospital. However, the resident stated Staff E did not do as she requested, I was shocked that no one would send me to the hospital and I suffered all day long. Further, the resident stated that when the night nurse came on duty, she told Staff J, RN, I will call 911 myself if I have to, I was so miserable. During an interview on 04/15/19 at 1:00 PM, Staff E stated she had given the resident medications for nausea and pain on 04/04/19. Staff E further stated she had not been notified by Staff I, Staff H, or Resident #1, regarding the request of Resident #1 to be sent to the hospital for unrelieved pain and nausea. During an interview on 04/11/19 at 10:00 AM, the Nurse Practioner, (NP) stated she had been in the facility on 04/04/19 until approximately 3:00 PM but had not been notified of the resident's nausea, continued dry heaves, severe pain, or request to go to the ER. The NP stated her expectation was that the medical provider was informed of any residents' requests for emergency care or change in condition. During an interview on 04/15/19 at approximately 4:00 PM, the Director of Nursing (DON) stated she was not told that the resident wanted to go to the emergency room until approximately 11:30 PM when she was called by Staff J. The DON further stated she would expect a resident to be sent to the hospital if they requested to go. WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure avoidable pressure ulcers were prevented for ten of ten residents (#35, 363, 364, 47, 55, 17, 20, 48, 24, 40) reviewed for pressure ulcers acquired in the facility. This failure resulted in actual harm for: * Recently admitted Residents #363, 364, 47, and 48, who developed Stage III pressure ulcers, * Recently admitted Resident #55, who developed an Unstageable pressure ulcer, * Long term Resident #24, who developed a Stage II pressure ulcer which progressed to an Unstageable pressure ulcer, * Long term Residents #35, 17, 20, and 40, who developed multiple Stage II pressure ulcers, related to a lack of accurate and timely assessments, lack of preventive measures, treatments not completed as ordered. This failure resulted in Substandard Care for these residents. Findings included: The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Stages: Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage II: Partial thickness Partial thickness loss of dermis (the thick layer of living tissue below the epidermis) presenting as a shallow open ulcer with a red pink wound bed, without slough (A layer of dead tissue separated from surrounding living tissue). (MONTH) also present as an intact or open/ruptured fluid filled blister Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Additional Categories/Stages: Unstageable: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (a dry tan, brown or black scab) in the wound bed. Suspected Deep Tissue Injury - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Review of the 11/10/17 facility policy titled Wound Management Protocol included the following statements: For facility-acquired pressure wounds: conduct an Avoidable versus Unavoidable assessment along with an investigation to rule out neglect. For prevention IDT (interdisciplinary team) is to review residents that experience a change of condition and admissions/readmissions and determine if appropriate preventative interventions are in place, such as floating heels, use of boots, pressure reducing mattress, wheelchair cushions, and nutritional interventions. Resident #35. review of the resident's medical record revealed [REDACTED]. Review of the Initial Data Collection Tool/Nursing Service form, dated 12/28/17, revealed the resident was alert and oriented and able to communicate his needs. There were no identified pressure ulcers on admission. The resident was unable to reposition himself, required one person to assist with bed mobility, and one to two staff to assist with transfers. Review of the baseline plan of care, dated 12/28/17, noted the resident was at risk for break in skin integrity due to history of skin injuries, diabetes with [MEDICAL CONDITION], immobility, and pain. Nursing interventions included weekly skin checks, and repositioning the resident every two hours in bed. Per progress notes, dated 01/02/18, the resident required maximum assist with two to three staff with transfers and repositioning. Review of a progress note documented by Staff J, Licensed Practical Nurse - Unit Care Coordinator (LPN/UCM) dated 01/18/18, noted when wound rounds were conducted a pressure ulcer to the right buttock was present with measurements of 4.5 by 3.2 centimeters (cms) with surface depth. The progress note stated the resident returned from the emergency room (ER) with the pressure ulcer (resident sent to ER three days earlier on 01/15/18 and was there for a total of four hours). New orders received on 01/18/18 for Venelex ointment (promotes wound healing) to area daily until resolved. Further, documentation showed two new suspected deep tissue injuries (SDTI) to the resident's right lateral foot, one on the malleolus (bony prominence on each side of the ankle), and another to the lateral side of his foot. Documentation stated the areas were not present prior to the ER visit on 01/15/18. When the resident returned from the ER, an abduction wedge was in place between his legs, which caused his right foot to turn outwards, creating pressure ulcers to the right foot. Pressure reduction boots were then applied to both feet. Daily [MEDICATION NAME] treatments were ordered on [DATE] to both areas on the right foot. Despite the above [MEDICATION NAME] treatments being ordered to the pressure ulcers on the resident's right foot on 01/18/18, review of the Treatment Administration Record (TAR) revealed the daily treatments were not initiated until 01/25/18 (seven days later). Per interview with Staff J on 04/03/18 at 4:20 PM, revealed she looked at the resident's skin when he returned from theER on [DATE] and noted an open area to the right buttock. However, no assessment was done and no physician's orders for treatment for [REDACTED]. Per progress note, dated 02/22/18, revealed the pressure ulcer to the right buttocks was resolved. The right malleolus unstageable pressure ulcer measured 0.8 by 0.6 cms with firm, brown, eschar (dead tissue) intact. Right lateral foot unstageable pressure ulcer measured 0.7 by 1.0 cms, light brown firm eschar intact. Documentation per progress note, dated 02/27/18, noted a new sore on the left buttock. The Resident Care Manager was notified. There was no evidence of a thorough assessment of the area and no measurements were noted. Review of the TAR noted a treatment, dated 02/27/18, to cleanse the left buttock wound with wound cleanser and apply [MEDICATION NAME] (transparent dressing used to cover and protect wounds) - change every five days and as needed. Despite the above observation and ordered treatment to the identified Stage II pressure ulcer, review of the resident's medical record noted no further assessment of the area and no further treatments were applied. Per progress note, dated 03/02/18, the previous Stage II pressure ulcer to the right buttock reopened, and treatment was again initiated to apply Venelex daily. The area healed on 03/08/18. Zinc Oxide was ordered on [DATE] to the buttocks twice daily to promote skin integrity. Additionally: Documentation in the progress note, dated 01/22/18, noted the resident refused treatment to his right buttock as he was eating. There was no evidence of documentation staff returned to perform treatments. Review of the (MONTH) TAR noted treatment to right buttocks was not done on 01/27/18 at 5:45 PM as the resident was eating with no evidence staff returned to perform the treatment. The prescribed treatment to the right buttock was also not documented as being done on 01/28/18. Review of the (MONTH) TAR noted no evidence a treatment was performed to the right buttock on 2/17,21,23/18. Review of the (MONTH) TAR revealed no evidence a treatment was performed to the right buttock on 3/5,6,7/18. Zinc Oxide treatments were not documented as being performed between 03/15-03/31/18 for seven of the possible 34 shifts. Review of the (MONTH) TAR noted no evidence a treatment was performed to resident's right lateral malleolus and right lateral foot on 2/21,22,23/18. Review of the (MONTH) TAR noted prescribed treatment to the resident's right foot - malleolus and lateral were not documented as being done on 3/5,6,7/18. Review of the resident's plan of care revealed no evidence of a problem addressing the actual pressure ulcers to the right foot and history of pressure ulcers to the right buttocks. The plan of care, dated 01/04/18, addressed the resident being at risk for pressure ulcers but no preventative measures to keep pressure from the resident's heels were initiated until the development of actual ulcers to the right foot on 01/18/18. There was no evidence staff took preventive steps to keep the pressure off the resident's heels prior to the development of pressure ulcers to his feet. In addition, despite the resident'a inability to reposition himself in his bed and wheelchair, there were no interventions to reposition the resident. Review of the Minimum Data Set (MDS - a comprehensive nursing assessment), completed on 03/03/18, noted the resident was identified as being at risk for pressure ulcers and had an identified Stage II pressure ulcer measuring 0.8 by 0.6 with no depth with eschar. Pressure reducing device for chair and bed were documented (the MDS makes no determination made about the type of mattress), and pressure ulcer care. There was no identified turning program or preventive methods to keep pressure from his heels. His bed mobility was extensive assist with two staff. During an interview on 03/28/18 at 11:37 AM with the resident, he stated he had two pressure ulcers on his right foot. He developed the pressure ulcers following his admission to the facility. Prior to the development of the pressure ulcers, staff was not keeping his feet off the mattress. He stated he was unable to turn himself in bed; staff had to push him and then he could roll to the side. He especially had difficulty turning to his left side (due to recent hip dislocation). Observation of the resident on 03/30/18 at 8:45 AM noted him to be lying in bed. Both feet were directly on the mattress. The resident stated he had asked staff to take his pressure reduction boots off both feet earlier that morning, which they did, however they did not place anything under his ankles/legs to reduce or eliminate pressure from the resident's feet/heels. Despite the resident's risk and actual pressure ulcers, an interview on 04/04/18 at 8:45 AM with Staff AQ, Maintenance Director, revealed the resident was on a regular foam bariatric mattress, which was not a pressure reduction mattress. Despite the resident's history and actual presence of pressure ulcers in conjunction with his inability to turn, an alternating air mattress was not placed on his bed until 04/05/18 as noted per progress note. The 04/06/18 progress note included the resident was able to communicate his needs and make slight extremity position changes when in bed. He required extensive assistance with significant changes in bed mobility. Staff J was observed on 04/04/18 at 11:10 AM to perform the prescribed treatment to the resident's right lateral foot. Both pressure ulcers, malleolus and lateral foot, were black in color. Per Staff J the areas had decreased in size. Prior to the treatment being performed both of the resident's feet were significantly externally rotated and the wedge cushion was not in place. Per Staff J and the resident, they both stated the feet would externally rotate with or without the wedge cushion (thus increasing the risk of pressure ulcers to the feet). In addition, it was observed the resident was unable to turn himself to the right side without the assistance of Staff J. An interview with the resident on 04/05 at 9:30 AM revealed he usually was transferred to bed by staff at approximately 8:30 PM, and they did not reposition him throughout the night. He stated he was unable to turn himself without assistance. At night he had the wedge cushion and a urinal in place between his legs. Resident #363. review of the resident's medical record revealed [REDACTED]. Review of the resident's Initial Data Collection Tool/Nursing Service form, dated 11/30/17, noted the resident required one person to assist with repositioning as she was unable to reposition herself. Review of the resident's plan of care, dated 12/05/17, noted she was at risk for developing a pressure ulcer, and had short and long term memory issues. Despite the resident's inability to turn herself, there was no identified turning program. Review of the Minimum Data Set (MDS), completed on 12/13/17, noted the resident was at risk for developing pressure ulcers. Interventions on the MDS noted a pressure reduction mattress and cushion for chair, but no turning program noted. The MDS also noted the resident was extensive assist with two staff for bed mobility. Review of the MDS, completed on 03/19/18, noted the resident required extensive assist with bed mobility. Per interview with Staff E, Registered Nurse - MDS Coordinator, on 04/03/18 at 9:35 AM, revealed there was no evidence of a turning program for the resident despite her having pressure ulcers, and was unable to turn herself. Review of the Pressure Ulcer Status Record revealed a pressure ulcer measuring 5 by 5 cms, staged as a deep tissue injury, was initially observed on 02/18/18. Four days later on 02/22/18, the pressure ulcer had increased to 6 by 7 cms. and was a Stage III (full thickness tissue loss). By 03/01/18 the area had further deteriorated as evidenced by measurements of 6 by 7.5 cms. Per progress note dated 02/19/18, noted late entry for 02/18/18, resident found with a suspected deep tissue injury to the right side of sacral area (below spine) measuring 5 by 5 cms - dark purple, mushy. The resident had been in bed for a week related to influenza. She was non-compliant with turning from side to side. Documentation stated, Will put skin prep to area and a foam dressing (Myselex), and will address with physician during wound rounds on 02/21/18 (three days later) to see if he wanted a different dressing. Despite the resident developing a suspected deep tissue injury on 02/18/18, there was no evidence the physician became aware of the skin problem until wound rounds were conducted on 02/22/18 (four days later). Per progress note, dated 02/23/18 from late entry dated 02/22/18, wound rounds with the physician revealed an unstageable area to the right buttock with yellow slough (mass of dead tissue) measuring 1 by 1 cm. Adjacent to the area was a Stage II measuring 3 by 3.5 with a depth of 0.1cm. with scant amount of drainage. The peri-site (area surrounding) with deep tissue injury measured 6 by 7 cms. with defined borders. The treatment order was changed to Venelix cream (promotes wound healing) and cover with foam dressing - change daily. Progress note dated 02/28/18 noted the Resident Care Manager was notified by Staff I, Registered Nurse, with a request for a pressure relieving mattress for the resident. On 03/01/18 (14 days following the development of the pressure ulcer, and approximately three months since her admitted when she was identified as being at risk for pressure ulcers), a pressure relieving mattress was placed on the resident's bed. A telephone interview with Staff I on 04/02/18 at 2:40 PM, revealed the resident had been on a regular mattress on 02/28/18, and that was why she had requested a pressure relieving mattress. Interview with Staff AQ at 2:45 PM on 4/2/18 revealed a regular mattress was not a pressure relieving mattress, but rather a foam mattress. A telephone interview on 04/04/18 at 3:00 PM with the resident's family member, revealed she visited the resident in the facility during the time she had influenza. She stated during that time the resident remained in bed and was always on her back. Resident #364. Review of the resident's medical record showed he was admitted to the facility on [DATE] with [MEDICAL CONDITION], obesity, and [MEDICAL CONDITION]. Review of the initial nursing assessment on the day of admit, dated 01/30/18, revealed the resident was alert and oriented, continent of bladder, able to reposition self in bed, independent with ambulation, transfers, and eating. Staff documented a pressure ulcer present to the left second toe with a scab to the right second toe. Two days later, on 02/01/18, staff measured the pressure ulcer to be 0.9 cm by 1.0 cm. Review of the resident's plan of care, dated 02/06/18, noted the resident was at risk for developing pressure ulcers with no interventions to turn the resident, float his heels, or pressure relieving devices. The plan of care did not address the resident's actual pressure ulcer to his left toe. Despite the resident having a pressure ulcer to the left second toe, there was no intervention to reduce or eliminate the pressure from the resident's heels until he developed a Stage III pressure ulcer to the right heel on 02/17/18. A progress note dated 02/18/18 by Staff K showed the resident had a Stage III pressure ulcer to his right heel. Staff K documented the resident's second, third, and fourth toes were light purple. No additional assessment was completed related to the discolored toes. The following day (02/19/18) a different Licensed Nurse (LN) assessed the same right heel pressure ulcer. She documented the area measured 1.5 by 1.8 with depth of 0.1 cm. The wound bed had 100% pale, yellow slough, scant amount of drainage, and no odor. The area was unstageable as unable to see the wound bed. There were no light purple areas to the toes. It was noted the resident sat in bed for long durations watching TV with heels directly in contact with the mattress. A new treatment order was initiated to apply Santyl (used in the debridement of wounds). Pressure reducing boots were provided. An interview with Staff J on 04/03/18 at 11:45 AM, revealed that despite Staff K noting the pressure ulcer on the right heel was a Stage III on 02/18, when she observed it the following day (02/19/18) it had 100% slough, thus was unstageable at that time. Also she did not see purple toes or a black area to the left toe. She also stated the initial wound assessment was not done until 02/01/18 (Two days following the resident's admission). A telephone interview on 04/04/18 at 1:20 PM with the resident revealed he was not instructed how avoid pressure on his heels until after he developed a pressure ulcer to his right heel. Staff wanted him to wear preventative boots, and when he refused, they began to position his heels so they were off the bed. Review of the resident's TAR for (MONTH) noted no documentation the prescribed treatment to the right heel was performed by staff for three days - 2/21-23/18. An interview on 04/04/18 at 8:40 AM with Staff C, Registered Nurse - Staff Development, identified as the LN not performing the above treatment on 02/21/18, stated she might not have had enough time to do the prescribed treatment as you are running from the time you get here on that unit .staffing is tight and sometimes not enough. Resident #47. Per medical record review, initially was admitted on [DATE] following a hospitalization with a urinary tract infection [MEDICAL CONDITIONS] (blood infection) from bacteria. She was re-hospitalized twice more with a [MEDICAL CONDITION] pneumonia and/or a UTI. Her latest re-admit to the facility was on 03/06/18. On 03/29/18 at 3:00 PM, Staff J, LPN, entered to look at the pressure ulcer on the sacral area (area below the spine). Staff J stated the physician did not do his wound rounds today, which were done every Thursday, and she wanted to see the area. She told the resident the pressure ulcer had healed, and the resident responded, How can that be? It hurts more than ever. Staff J explained there was moisture damage to her buttocks from the urine on her skin (increased potential for pressure ulcers). When asked how the pressure ulcer had started, Staff J said she thought the ulcer might have started because the resident sat a lot in the recliner without pressure reduction cushions. Also, the resident was ill with respiratory disease and in the hospital several times. Staff J also causes of the pressure ulcer were due to the resident's poor tissue perfusion (lack of oxygen to the tissues and cells). She further stated the resident had been on an intravenous antibiotic when she was admitted . Staff J stated, (The resident's) immune system was wrecked, thus, increasing the risk for pressure ulcers. On 04/02/18 at 2:25 PM, the resident was seated in her recliner, sitting upright with feet lowered. She said she thought she had gotten the pressure ulcer originally because of being in bed when she first came; she had pneumonia and then got the flu. She said she could not move herself and was dependent on the NAs to turn her. She thought they did do that when she asked. She said she was not usually in her wheelchair, mostly was in bed. Last week her friends brought her the recliner from home. When asked about the low pressure air mattress on her bed, she said she did not know when that was put on the bed. On 04/02/18 at 12:40 PM, a Physical Therapy Assistant stated there was no way to put a pressure reduction cushion in recliners residents bring into the facility. (The cushion could slip out as the chair rises, causing a fall hazard.) She stated a recliner is a very common spot for people who sit in them a lot to get pressure ulcers. We see that often. She stated if nursing asked about a cushion, the therapy department would inform them to not let the resident sit for long periods in a recliner due to the potential for pressure ulcers. On 04/04/18 at 10:30 AM, Staff T, Occupational Therapist, stated the resident was given a cushion for the wheelchair after her sore bottom complaint. He stated the type she has now is called a Matrix Intelgel and was a very good cushion to prevent wounds. On 04/05/18 at 1:00 PM, the resident's friend, a frequent visitor, stated she had brought the resident her recliner about a month ago and the resident then sat in it a lot because she was more comfortable than sitting in her wheelchair which did not support her neck. The resident had been very ill when she was first admitted and did stay in bed. The resident did not get the air mattress on the bed until a couple of weeks ago after the ulcer started. She said the resident did not like the pillows at her back to try and keep her on her side and she would often pull them out. Additionally, a review of the resident's weight log revealed she was admitted on [DATE] weighing 186 pounds. The weight documented on 03/19/18 revealed she had lost a total of twenty-two pounds since admit, or a 11.83% loss in approximately two months (increased potential for skin breakdown). The (MONTH) (YEAR) skin assessment for potential skin breakdown was completed using the Braden Scale and determined the resident was at moderate risk. The hospital History and Physical dated 01/22/18 documented the resident had been discharged to the nursing home but developed a worsening cough and was readmitted to the hospital. The resident's friend told the physician the resident remained mostly bedbound and sedentary, and physical therapy was not very frequent, mostly involving bed exercises. Weekly skin assessments were completed on a form. These included a re-admission skin assessment dated [DATE] showing no skin issues on the resident's back side. Then the weekly skin assessment dated [DATE] showed a sacral Stage II pressure ulcer. However, the weekly skin assessment dated [DATE] did not document the sacral area Stage II pressure ulcer, nor was further documentation found in the resident's record. The 03/06/18 readmission skin assessment documented a circular dry spot on the coccyx. There were no measurements and no interventions to prevent further breakdown documented in the record. The Pressure Ulcer Status Record described the resident's sacral region pressure ulcer started on 03/15/18 and was a Stage III with dimensions of 1.1 by 0.8 by 0.1 centimeters (cm). The 03/22/18 documentation revealed the Stage III had dimensions of 1.1 by 0.5 by 0.2 cm (the depth increased in the seven days before it was reassessed) and the resident experienced pain. Physician treatment orders on 03/15/18 also identified the pressure ulcer as a Stage III. Review of the medical record showed no documentation that the low pressure air mattress was placed until after the pressure ulcer occurred. A progress note on 03/22/18 identified specialty wheelchair in place; remains on air mattress. When interviewed on 04/11/18 at approximately 3:00 PM, nursing home administration was unable to determine when the air mattress had been supplied to the resident. An additional observation on 04/10/18 at approximately 11:00 AM revealed the resident had three small reddened areas on her sacrum in the same vicinity as the recent pressure ulcer. The care plan dated 01/12/18 revealed the resident was at risk for breaks in skin integrity related to incontinence and immobility. The resident was to be repositioned every two hours in bed and chair and scheduled with time out of bed as tolerated. Further, review of the (MONTH) care plan and the medical record did not show assessments and developed interventions were completed when the need for increased preventions for skin breakdown was revealed. However, no additional assessments or interventions were completed to ensure the resident did not develop skin breakdown. Resident #55. Per medical record, he was admitted on [DATE] and discharged home on[DATE]. His admit [DIAGNOSES REDACTED]. The resident was cognitively intact. The comprehensive assessment on 02/28/18 showed there were no pressure ulcers, but the resident was at risk for them. The 03/07/18 comprehensive assessment (MDS) documented the resident had one unstageable (unknown depth) pressure ulcer (the MDS did not specify where the ulcer was located). The 03/21/18 comprehensive assessment revealed the one unstageable pressure ulcer continued. The 02/21/18 initial care plan identified a break in skin integrity of the left lower leg, a non pressure ulcer site with [MEDICAL CONDITION] (tissue infection) and a surgical wound (identified on the inner left foot). Following rehabilitation therapy and wound care, the resident was discharged home with home health care. He remained in the facility for approximately 37 days. The 03/29/18 physician documentation described the resident's medical/surgical history and his healing foot wound. The resident had undergone an incision and drainage of a left foot infection by an orthopedic surgeon on 02/13/18. Purulent fluid (pus) was found and broken screws were removed. Also described was a 03/19/18 new left foot wound of 1.5 cm by 1.5 cm from the (walking) boot. Further description on 03/29/18 documented the wound from the boot had increased to 2 cm by 1.5 cm. The 03/29/18 nursing progress note described the left foot as slightly swollen, reddened, a resolving incision site and a black lesion to left inner foot due to walking boot. Therapy has previously assessed boot for fit as well as (the physician). Resident continued to bear weight. On 04/02/18 at 12:20 PM, the Interim Director of Rehabilitation Therapy stated the resident had a new boot that had come with him from the hospital. It had rubbed a pressure ulcer on his foot. She stated she knew they had discussed it in a therapy meeting and physical therapy reviewed the issue. The therapy's Daily Notes by Staff AM, Physical Therapy Assistant, showed documentation on 03/06/18 of an 8 minute assessment: Nursing reported patients left foot with new pressure area and thought boot might be the cause thus boot and dressing removed to left foot and inspected with nursing present. Patient has a black circular area below incision which is very firm and sticking out 4-6 MM. Patient stated that was a drain tube and nursing staff stated it probably was (no indication of a drain tube was located in the hospital records). Inspected inside of cam boot (walking boot) and nothing present that would cause pressure to that area. Patient educated to wear boot at all times when walking. On 04/05/18 at approximately 1:00 PM, Staff AM stated there was a meeting held and nursing was concerned about the pressure ulcer and the boot. She examined the boot, but did not observe the resident walking in the boot to determine if rubbed against the resident's skin. A 03/15/18 progress note was related to wound rounds with the physician and Staff J. The left foot surgical incision had stitches coming apart (dehiscence) without drainage. A black lesion was documented with firm intact eschar. Resident continues to refuse to ambulate with walking boot due to causing friction to left foot inner aspect region. Doctor aware. Review of the Pressure Ulcer Status Record noted the left foot inner pressure ulcer was first observed on 03/01/18. The left inner foot ulcer measured in length 1 centimeter (cm) by 2 cm and 100% of the wound was unstageble, necrotic (dead) tissue. The following descriptions were documented: 03/09/18 the ulcer remained unstageable and was 1 by 1.8 cm, black in color, with necrotic tissue covering; 03/15/18 the ulcer was sized at 1 by 2 cm, black in color, necrotic tissue covering the wound, noted as deteriorated; 03/22/18 the ulcer was sized at 1.6 by 2 cm, black in color with necrotic tissue and continuing to deteriorate. On 03/27/18 at approximately 11:00 AM, Staff G, Registered Nurse (RN), stated the resident came with an incision that extended to the lower left leg and foot. At the bottom there was an area that they determined was a pressure ulcer. On 03/30/18 at 9:30 AM, Staff J provided the treatment to the resident's left foot incision and pressure ulcer. The resident was lying in bed, fully dressed and ready to go home. The left side of the inner foot had a healing incision. Below the incision line was a black, raised scab. The pressure ulcer was measured by Staff J as 2 cm by 2 cm. Further, a 'walking boot' was sitting next to the wall. The resident stated the walking boot was given to him by the hospital after his foot surgery, but did not fit well and rubbed the pressure ulcer. When he went back to see his orthopedic doctor, who did the surgery, he took back the walking boot and gave it to him. He said he had then brought the boot he had at home since a previous foot surgery. He had broken bones at that time and had worn the boot for about a year. Staff J informed him he needed to check his feet when he was home due to his diabetes. Additionally, Staff J stated the nurses do full skin assessments of the whole body on a weekly basis, but she and the doctor do wound rounds on Thursdays. There was no left foot pressure ulcer one Thursday but it was there the next Thursday. On 04/04/18 at 3:27 PM, a phone call was placed to the resident's spouse who stated the resident was at home and under home health care. She said she had wondered why he had that ulcer/wound on his left foot. She said he thinks and says it was caused by the boot rubbing, but she had been told that it was from a drain tube after the surgery. She said she knew nothing a (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs in the areas of pressure ulcers and accurate comprehensive assessments using the Minimum Data Set. This failure resulted in the lack of provision of care consistent with professional standards of practice to prevent pressure ulcers for ten of ten residents (#35, 363, 364, 47, 55, 17, 20, 48, 24, 40) and 11 of 24 residents (#363, 364, 35, 47, 8, 4, 17, 31, 29, 12, 49) with comprehensive assessments that were not accurate. Findings included: Review of in-service records, dated 01/24/18, noted the in-service consisted of a short handout on how to chart wounds/pressure ulcers, but not how to assess or prevent pressure ulcers. In-service records noted only six licensed nurses signed as attended the in-service. On 04/04/18 at 2:30 PM, the Corporate Registered Nurse (RN), reported the facility had an orientation manual for new licensed nurses but it had not been utilized yet. He also stated the facility had an orientation booklet for agency licensed nurses but it had not been utilized yet either. On 04/05/18 at 3:44 PM, Staff Z, Agency RN, stated she last worked three shifts in (MONTH) (YEAR), had not worked since then, and was never oriented to the facility. An interview on 04/11/18 at 8:20 AM with Staff AA, Agency RN, revealed she had not received any training/orientation since working in the facility. When the Licensed Nurse (LN) was questioned specifically regarding wound care, she stated she had been assigned on occasion to do wound care. A telephone interview with Staff K, Licensed Practical Nurse (LPN), on 04/11/18 at 9:30 AM, revealed, when she was hired in (MONTH) (YEAR), she was to be the treatment nurse. She stated the facility promised to send her out of the facility for a week to receive specialized wound training; however, that never happened. She stated, Nobody working at the facility has received any wound training. The former Nursing Director was the only one who had any previous wound training. She stated the problem was she would assess the wound and then another nurse would come and assess the wound differently. Changes in the treatment would then be made based on that assessment. She said the wound care provided in the facility was very inconsistent when you don't have one person doing the assessments and treatments. On 04/11/18 at approximately 10:15 AM, Staff AU, Agency RN, was observed working as a medication/treatment nurse on the long-term care unit. He stated he was with the agency nursing and he had worked here before. He stated he had no training as an agency nurse related to nursing, such as wound care. He stated he would not do pressure ulcer staging; he had no training on that and would refer it to others to assess. On 04/11/18 at 12:20 PM, Staff C, RN/ Staff Development, stated she had not worked in long term care for approximately [AGE] years, so felt she needed training relative to wound care. She stated she had been asked to assess wounds, and at times provided wound care. She stated she was trying to set up education for the licensed nurses here to provide training in this area. She stated she did recently provide an inservice on wound care, however it was poorly attended. She reported had not started doing competency reviews for licensed nurses. The facility did not ensure competent staffing as evidenced by: * F 686 - 483.25(b)(1), Treatment /Services to Prevent/Heal Pressure Ulcers - For nurses completing assessments and treatments for pressure ulcers, the facility failed to ensure nurses received training. * F 637 - 483.20(b)(2)(ii), Comprehensive Assessment after a Significant Change - Nursing staff failed to ensure each resident who experienced a significant change in status was comprehensively assessed using the Resident Assessment Instrument (RAI) process. * F 641 - 483.20(g), Accuracy of Assessments - Nursing failed to ensure assessments were accurate. Reference: WAC 388-97-1080(1), 1090(1)

Based on interview and record review, the facility failed to timely evaluate and monitor for [MEDICAL CONDITION] for one of one resident (#35) who was experiencing an acute change of condition. This resulted in actual harm to the resident due to his significant pain level and delay in medical treatment. Despite the recent removal of the resident's [MEDICAL CONDITION] catheter, staff failed to monitor/assess urinary output and perform bladder assessments. Further, based on observation, interview, and record review, the facility failed to ensure skin integrity remained intact for two of two residents (#47, 12), reviewed for non-pressure related skin conditions. Additionally, the facility failed to ensure one of one resident's (#17) physician order [REDACTED]. Findings included: Resident #35. Review of the resident's medical record noted progress notes dated 12/28/17 at 4:00 PM, which showed he was admitted from the hospital with multiple [DIAGNOSES REDACTED]. The resident was alert and oriented. A [MEDICAL CONDITION] catheter was removed prior to the resident's discharge from the hospital. Progress notes dated 12/28/17 at 5:09 PM revealed the resident complained of pain, eight out of 10 (with zero being no pain and 10 being severe pain) to his back, right lower leg and hip, for which he received a narcotic medication with fair relief. The resident stated he had a [MEDICAL CONDITION] catheter at the hospital which had been removed at noon that day. The resident had not yet urinated. At 9:23 PM, the resident urinated a small amount in the urinal and commode. Per progress notes by Staff Z, agency Registered Nurse (RN), a suppository was given at 9:30 PM on 12/28/17 for complaints of constipation and abdominal pain. The resident stated his pain was getting worse. At 11:15 PM, the resident demanded to go back to the emergency room (ER). A narcotic medication was administered for pain at 11:45 PM. The physician was notified and orders were received to transport the resident to the ER which occurred at 12:45 AM on 12/29/17. Review of hospital records, dated 12/29/17, noted the resident's complaints in the ER were constipation, abdominal pain (pounding), [MEDICAL CONDITION], and chest pain. The resident stated he had not urinated for 12 hours since his catheter had been removed. On exam he had non-specific tenderness and abdominal distention. He was catheterized with more than 1000 milliliters of urine obtained. A telephone interview with Staff Z at 3:44 PM, revealed the resident was having quite a bit of abdominal and back pain on her shift. She did not recall doing a bladder assessment on the resident, and stated unless she obtained the information regarding the removal of his catheter during shift report, she would not have known to monitor his urinary output. Staff Y, corporate RN, acknowledged on 04/11/18 at 3:00 PM the facility had a bladder scanner (diagnostic tool that measured the amount of urine in the bladder). Despite the resident's inablility to urinate following the catheter removal, staff failed to utilize the bladder scanner. Resident #47. Per medical record review, she was admitted initally on 01/11/18 following a hospitalization with a urinary tract infection [MEDICAL CONDITIONS] (blood infection) from bacteria. She was re-hospitalized twice more with a [MEDICAL CONDITION] pneumonia and/or a UTI. Her latest re-admit to the facility was on 03/06/18. The resident's hospital physician's records dated 01/22/18 documented the resident had been discharged to the nursing home but developed a worsening cough and was readmitted to the hospital. The resident's family friend reported, while the resident was at the nursing home, she remained mostly bedbound and sedentary. The assessments and plans documented [DIAGNOSES REDACTED] (redness of skin), intertigo and [MEDICAL CONDITION] ([MEDICAL CONDITION] rashes of the skin) - incontinent with wetness from urine causing the skin issues. Plan for treating included application of Zinc Oxide ointment three times a day and Nystantin powder (for yeast) twice a day. The Weekly Skin assessment dated [DATE] evaluated a red, sore perineum (bottom), which was not a new skin problem. The care plan dated 01/12/18 directed staff regarding problems, but were not resident-centered plans individualized for Resident #47: At risk for break in skin integrity related to incontinence and immobility (no identification of the actual skin impairment related to urine leakage occurring for approximately three months). Always incontinent of bladder with interventions of disposable briefs and toileting hygiene and peri-care as needed. The 02/28/18 progress note identified Moisture Associated Skin Damage (MASD - a general term for inflammation of skin erosion caused by prolonged exposure to a source of moisture such as urine. Zinc Oxide ointment (skin protectant barrier ointment) was the treatment in progress. On 03/29/18 at approximately 2:15 PM, the resident was lying in bed on her left side. She said she had pain on her bottom. On 03/29/18 at 3:00 PM, the resident was lying in bed, positioned on her left side. Staff J, Licensed Practical Nurse/Unit Care Manager, stated she was going to look at the resident's Stage III pressure ulcer on the resident's sacrum as this was the day for wound rounds. When she observed the sacral area (area below the spine), it was healed. Staff J told the resident her pressure ulcer had healed, but the resident said, How can that be, it hurts more than ever. Throughout the observation, the resident leaked clear urine onto the large red, inflamed area of skin surrounding the rectum and extending upwards on each buttock. Staff J informed the resident she had MASD on her buttocks. Staff J stated the Nursing Assistants (NAs) usually cleaned the resident and then applied Zinc Oxide to protect the area. Staff J stated she had asked the NAs not to apply the barrier cream until after Staff J completed her observation. However, the NAs had been observed turning and positioning the resident at approximately 1:00 PM, resulting in an almost two and one-half hour period of time the resident was left without a skin protectant (Zinc Oxide)before Staff J completed the treatment at approximately 3:20 PM. She then said she would have the NAs come in and apply the Zinc Oxide. Following Staff J's treatment on 03/29/18, she contacted the physician for an order for [REDACTED]. On 04/03/18 at 9:15 AM, Staff S, NA, stated she had last changed the resident about 7:45 AM she thought; she was late getting to her. Staff S stated this was her first day caring for the resident who just moved into the hall yesterday. The NA did not know the resident's routine yet. She stated she was currently on her way to shower another resident, but she would stop and check Resident #47 so the surveyor could observe the resident's skin. On 04/03/18 at 9:30 AM, Staff S and Staff AL, NAs, assisted the resident to stand at her walker. The incontinent brief was removed and between the resident's skin folds of her buttocks and perineum, redness was observed and the white Zinc Oxide ointment covering the red area only in patches. The NAs stated the resident's incontinent brief was dry. Staff AL touched the reddened area with her gloved finger and asked if she was in pain in that area. The resident said it was painful. While standing for the incontinent care, the resident started to dribble urine. The NAs cleaned the resident with a pre-moistened disposable cloth removing more of the Zinc ointment. Staff S acknowledged they did not put on more barrier cream (Zinc Oxide) to protect the skin from the urine because that was for the nurses to apply. (The NAs returned to their resident care tasks without reporting to the licensed nurse.) On 04/09/18 at 2:10 PM, Staff L, LPN, stated she was concerned about the resident's bottom. She stated she had looked at it today and told the resident she thought her briefs were causing the reddened area. On 04/10/18 at 11:15 AM, Staff M, NA, stated the resident's incontinent brief had just been changed before she went to take care of another resident, but she would change her again. She had the resident grab the walker and assisted her to stand. Then she removed the resident's brief, which was wet with urine. The NA said, Once the resident stands up, she goes and, even though I just changed her she was pretty wet. The NA pointed out the resident's red skin in the peri area and upper, inner thighs. The resident said it hurt there. There was no sign of Zinc Oxide ointment (white in appearance and thick) on the resident's skin. The NA said the resident usually complained to the NA that it hurt. Staff M said the NAs used to be able to apply Zinc Oxide barrier cream to the residents' buttocks and perineum; it helped with skin issues. But then the facility took it away from us and residents' skin started deteriorating. She demonstrated there was a new barrier ointment which the NAs could use now, but it was thin, not thick, when it came out of the tube and did not provide the longer effects of a good barrier cream protecting the skin from moisture, like urine. The NA applied the new barrier cream to the resident's peri area and thighs. After placing the incontinent brief, the resident returned to sitting in her wheelchair. The NA described the resident needed incontinent care, six times during my shift. Further, the NA stated she was concerned because so far today, the agency nurse has not come to assess and put on the Zinc Oxide ointment. Review of the treatment record noted the Zinc Oxide treatment had OOF (out of facility) written for day shift for the reason the Zinc Oxide was not applied, although the resident had not left until after lunch. On 04/10/18 at 3:00 PM, Staff AA, Registered Nurse from an agency, when asked if she had observed the resident's skin before the resident left the facility after lunch for her doctor's appointment, she said, No. Staff AA stated she had not seen the resident's bottom today. Therefore, she had not applied the Zinc Oxide barrier cream for skin protection, assessed the area for healing, or assessed the resident's pain. Review of the resident's record did not locate assessments for the resident's bladder incontinence to determine how to prevent the frequent leaking onto the skin causing the skin breakdown and pain. (Reference F690) Resident #12. According to the resident's record, admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The resident's 01/23/18 comprehensive assessement included the resident was always incontinent. The resident's comprehensive care plan, dated 06/03/14, directed staff to Toilet upon rising, before meals, after meals . On 04/06/18 at 11:19 AM, staff took the resident to his room for care. Staff Q and Staff S, NAs, began to remove the resident's incontinent brief in order to clean his skin and apply a dry brief. The brief was heavily soiled with urine and as Staff S began to clean the resident's skin, he began to urinate. At this point both Staff Q and Staff S stated the resident was a heavy wetter. When the NAs turned the resident to his left side, Staff S saw an open red area on the resident's scrotum. She reported she did not see the area there when she last changed the resident's incontinent brief at 7:30 AM (four hours earlier). Staff Q and Staff R reported the usual check for wetness and change of brief was typically done when staff got the resident out of bed for breakfast, about 7:30 AM. If he went back to bed after breakfast, he was checked and changed then, and again before staff got him up for lunch. But if the resident wanted to attend one of the morning activities, he stayed up in his wheelchair and was not checked or changed until about 11:30 AM (four hours later). On 04/06/18 at 11:50 AM, when asked about transferring the resident into bed and changing his incontinent brief after breakfast and before the activities started, Staff Q said they would like to do that, but just did not have the time. On 04/09/18 at 10:00 AM, Staff L, LPN, checked the open area on the resident's scrotum. The incontinent brief was soiled with urine. Staff L stated the resident was a heavy wetter. Resident #17. According to record review the 01/31/18 quarterly assessment indicated the resident had diabetes and received insulin injections. The attending physician ordered a blood draw for a Hemoglobin A1c (a test that is reflective of how well diabetes is controlled) on 03/27/18 (now) and in six months. Review of the resident record on 04/09/18 revealed the last Hemoglobin A1c was drawn on 10/11/17 and considered high. On 03/28/18 at 3:40 PM, the resident stated she was on insulin and having problems with high blood sugars lately. Further review of the physician order [REDACTED]. On 04/09/18 at 12:30 PM, Staff J, Licensed Practical Nurse (LPN) stated after calling the lab the resident has not had her blood drawn for the test ordered on [DATE] and the physician will need to be notified. The physician's orders [REDACTED]. Reference: WAC 388-97-1060(1) This is a repeat deficiency from Statement of Deficiency dated 07/26/17.

Based on interview and record review, the facility failed to assess the resident's need for supervision, analyze the risks, and implement interventions for adequate supervision for one of six residents (#115) reviewed for falls in the facility. This caused harm to Resident #115 who had a fall with a significant head injury requiring hospitalization . Finding included: Resident #115. Per medical record, she was admitted on [DATE] following a hospitalization for a [MEDICAL CONDITION] (mini-stroke), dementia, difficulty walking, weakness and abnormality of gait. Also, she had a heart valve replacement and was on an anticoagulant to decrease blood clots (which increased the possiblity of bleeding especially with traumatic incidents including falls). The hospital discharge instructions was to be up with assist only. The 03/26/18 'Initial Nursing Assessment' identified the resident at risk of falls. The 03/26/18 'Baseline Care Plan' included I forget things I should remember and At Risk for falls. Other problems were the resident's memory deficits, unable to understand strategies, and new environment (facility). Interventions included walk with her when ambulating, inspect her room, contact guard assist for transfers, toileting, and ambulating. Also included was educate the resident on the call light and use of non-slip shoes and low bed. Review of the 03/26/18 admit nursing progress note revealed the resident had short and long term memory loss, and if re-oriented, it was only a short term effect. The resident ambulated with assistance. When Staff J, Licensed Practical Nurse (LPN)/Care Coordinator, questioned the resident on knowing the importance of using call light for supervised transfers, resident stated I'll try to remember. Fall precautions initiated were placing her bed in the lowest positon, placing the call light in reach, and the use of non skid shoes/socks. Staff J involved the family to reiterate the importance of calling for assistance, but the resident just smiled without verbalizing understanding. The resident wished to ambulate about the facility with family prior to their departure. A physical therapy evaluation, signed 03/27/18 at 12:43 PM by the Physical Therapist, documented the resident was oriented to self only and was evaluated for gait and balance. The evaluation revealed the resident was at a HIGH Risk of Falling. The 03/27/18 at 11:17 AM entry in the progress notes documented a nursing assistant (NA) had reported the resident will attempt to self transfer. The entry also noted the resident required a stand by assist from staff with toileting, bed mobility, and transfers. The fall precaution in place was her bed in the lowest positon while in bed. The 03/27/18 progress note documented that at 5:00 PM the resident was ambulating in hallways with staff attempting to redirect; she became extremely agitated entering other resident's rooms and refusing to leave. The family was notified and came to be with the resident. Then another 03/27/18 progress note documented the resident got out of bed and at 9:20 PM was found by the licensed nurse at the closet where she had fallen. The NAs and the nurse heard a big bang. The resident had gotten up and walked over to the closet and was laying on her back by window with her foot in the laundry basket and the (closet) pole to hang clothes with clothes on top of resident, blood seen from back of head, aide came running and put pressure on the wound with a clean bath blanket. The resident was not allowed to move and the emergency medical services arrived and transported her to the hospital. Review of the facility's fall investigation report documented the resident had been ambulating in the unit the evening of 03/27/18 with a staff member. At approximately 9:15 PM, a NA helped the resident to bed and, before leaving, she noticed the resident seemed already asleep. The NA left the room with the resident in bed and the bed in lowest position. Roughly five minutes later at 9:20 PM, a NA heard a loud bang and went to investigate finding the resident on the floor. Following interventions by staff the resident was transported by ambulance to the hospital and did not return to the facility. A 03/27/18 hospital record following her admit revealed a large left hematoma (a swelling of collected blood in the tissues) and laceration. The scan of the head also was suggestive of posttraumatic subarachnoid (bleeding in the space between the brain and the tissue covering the brain) and/or possibly parenchymal hemorrhage (bleeding within the brain). On 04/11/18 at 12:08 PM, Staff J stated she had assessed the resident upon admit and, during the assessment, the resident would only stand. She wanted to walk about the facility and her family remained with her so that she could after the assessment was completed. After 24 hours, they saw what cognitive deficits she had, but Staff J did not observe the poor gait. The rsident's room was located about half way down the hallway and not within sight of the nurses' station. Staff J acknowledged there were no further fall interventions put into place other than listed on the baseline care plan. On 04/11/18 11:30 AM an interview with Staff Y, a coorporate nurse, stated the facility did not employ fall alarms in the building, but if a person was a fall risk and need the supervision, especially due to dementia, then a one-on-one with a staff member would be put into place. He stated there were light duty staff who could provide that type of supervision but it had not been implemented. Despite the resident's continued assessments of her high fall risk and increasing impulsivity for the resident to be up and wandering, the facility failed to provide the needed supervision to prevent accidents. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure staff provided adequate pain management in a timely manner for one of five residents (#365) receiving as needed pain medication. This failed practice resulted in actual harm to the resident, who was admitted to the facility following recent knee surgery, and despite several requests for pain medication, there was a significant delay in receiving pain medication. Findings included: Resident #365. review of the resident's medical record revealed [REDACTED]. Review of the Pain Assessment form documented by Staff K, Licensed Practical Nurse (LPN), dated 02/15/18 with no time documented, showed the resident was currently in pain and at risk for pain but no pain score was given. An interview on 04/05/18 at 4:00 PM with Staff K revealed she conducted the pain and initial nursing assessment on the resident at the same time. Review of that form noted it was done at 12:30 PM on 02/15/18. Review of admission physician's orders [REDACTED]. Progress notes, dated 02/15/18 at 7:09 PM, revealed the resident was alert and oriented to self, time and place with some short-term memory loss. She required assistance with transfers, ambulation using a walker, and was continent of bowel and bladder. Progress notes dated 02/16/18 at 3:10 AM, documented by Staff AR, agency LPN, noted the resident was alert and oriented, and anxious for her medications. Staff informed the resident her medications would arrive in the morning, and she would have them all by tomorrow. A telephone interview with the resident on 03/30/18 at 11:50 AM, revealed when she was first admitted to the facility, there was no pain medication available. Staff stated they would send for her medications, which included the narcotic medication, as they would come from the pharmacy. The resident stated she was getting pain medication at the hospital as needed. When she arrived at the facility from the hospital, at approximately noon, she had not had pain medication since the night before. Her stated pain level at the time of admission was a 5 out of 10 (on a scale of zero to 10, with zero noting no pain, and 10 being severe pain). It got worse in the middle of the night, and by 1:00-2:00 AM it was an eight, and she was not sleeping. The resident described the pain as throbbing. It was so sore I could hardly get into bed. She stated the facility did not keep a supply of her pain medication at the facility. There was a delay in getting my pain medication. I requested pain medication several times. Review of hospital records revealed the resident's last dose of [MEDICATION NAME] was on 02/14/18 at 11:43 PM. Review of the facility Narcotic Log showed [MEDICATION NAME] was administered to the resident on 02/16/18 at 4:30 AM, 16 hours following her admission to the facility, and approximately 29 hours following her last dose of [MEDICATION NAME]. Reference: WAC 388-97-1060(1)

Based on record review and interviews the facility failed to identify, thoroughly assess/monitor, and provide treatments in a timely manner for 1 of 4 residents (#2) reviewed for non-pressure skin conditions. This resulted in actual harm to Resident #2, who was transferred to the hospital for a change of condition, due to an infected area to the left inner thigh. Findings include: Resident #2: Review of the resident's medical record noted a Progress Note (PN) written by Agency Staff A, Licensed Nurse (LN), dated 7/16/17 at 7:15 p.m., which stated the resident wanted to go see a physician for a boil (common, painful infection of a hair follicle and the surrounding skin) on the inner thigh of her leg. Documentation stated the resident's legal representative was called, and the decision was made to wait until the following day to make an appointment, and not go to the emergency room (ER) at that time. There was no assessment of the boil, and the physician was not consulted at that time due to a change in her condition. A telephone interview on 07/27/17 at 2:00 p.m. with the above Agency Staff A, revealed he had stated to the legal representative on 07/16/17, that in his opinion the resident did not need to be seen by a physician until the following morning (07/17/17). He stated he had worked the 6:00 a.m. to 6:00 p.m. shift on 07/16/17 and left shortly after documenting the above PN. He was unaware of any consultation with the physician regarding the resident's boil, or any treatment orders. Per Progress Note (PN), dated 07/16/17 at 10:15 p.m. by Staff B, LN, revealed the resident's legal representative was notified of a new physician's orders [REDACTED]. There was no description of the boil, with the exception of measurements. A telephone interview with Staff B on 07/26/17 at 12:00 p.m., revealed the treatment orders for hot compresses was actually ordered by the physician the evening of 07/14/17. The physician had given the orders by telephone to Staff C, a former LN, who failed to communicate the orders properly, thus causing a two day delay in treatments being performed to the resident's boil. Staff B stated that in addition to himself and Staff C, a third LN, Staff D, was also aware of the above physician's orders [REDACTED]. Despite the knowledge of three LNs on 07/14/17, regarding the treatment orders for the resident's boil and need for close monitoring, review of the Treatment Administration Record noted the treatment did not start until 12:00 a.m. on 7/17/17, and there was no thorough assessment of the area. Per PN an assessment of the boil, documented on 07/17/17 at 6:43 a.m., noted it was raised, very pink and warm. Documentation on a SBAR Communication form, dated 07/17/17 at 7:45 a.m., revealed the resident was not at baseline as evidenced by shaking, red skin, elevated body temperature of 99.8 degrees, more confused, and decreased level of consciousness. In addition, there appeared to be a boil on the left inner thigh. The physician was called at 8:00 a.m. and orders were received to transport the resident to the ER. Per review of the Vital Sign Flow Sheet between 7/3-16/17 noted the resident's body temperature ranged between 97.3 to 98.2 degrees. Review of hospital records, dated 07/24/17, noted the resident was hospitalized for [REDACTED]. The area was immediately opened, debrided, drained, and packed by the ER physician. She was treated with intravenous antibiotics for [MEDICAL CONDITION] (severe blood infection). Reference: (WAC) 388-97-1060(1)

Based on record review and interviews the facility failed to provide timely appropriate care and services for 2 of 4 residents (#'s 1,2) reviewed for a change of condition. Failure to thoroughly assess Resident #1 and notify the physician in a timely manner resulted in actual harm due to a delay in medical treatment for [REDACTED]. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, he was admitted with a [MEDICAL CONDITION] catheter and pacemaker. Review of Progress Notes (PNs) dated 02/02/17 at 7:24 a.m. revealed the resident was transferred to the emergency room (ER) for complaints of worsening left lower abdominal pain which radiated to his back, weakness, pale skin coloring, and diaphoresis. His body temperature at that time was 97.9 degrees Fahrenheit (F) degrees. He returned to the facility at 10:00 a.m. that same day with orders [MEDICATION NAME](antibiotic) to treat a urinary tract infection [MEDICAL CONDITION], [MEDICATION NAME] (medication used to improve urination in men with an enlarged prostate), and narcotic medication for pain as needed. The resident was also noted with kidney stones in his left kidney. The following nursing assessments were noted between 02/03-02/06/17: 02/03/17 at 5:00 a.m. - Body temperature of 99.0 degrees F, given extra blankets per resident request, no coughing or choking with fluids, no complaints of left lower abdominal pain, no gastrointestinal (GI) distress or other adverse effects 02/03/17 at 5:49 p.m. noted the resident was alert and able to make needs known with no complaints of pain, was up in his wheelchair, body temperature of 100.0 degrees F this morning - it decreased to 98.9 degrees F after Tylenol was given, bowel tones active in all four quadrants, no adverse side effects (ASE) from antibiotics, rested quietly this afternoon 02/04/17 at 3:08 a.m. - no ASE from antibiotics, continues routine Tylenol with no break through pain noted, continue to encourage fluids, will continue to monitor for increased signs/symptoms infection and pain 02/04/17 at 2:14 p.m. - resident alert and able to use call light, continues antibiotics for UTI, no ASE noted, administered narcotic with relief of pain, body temperature of 100.0 degrees F, no complaint of GI distress, encouraged to drink fluids that are brought to him 02/05/17 at 3:35 p.m. - resident took off clothes this morning with complaints of feeling too warm, body temperature of 99.0 degrees F, continues on routine Tylenol with relief of pain, no GI distress, no ASE from antibiotics, fluids encouraged/provided, assisted to bed where he is resting quietly 02/05/17 at 10:25 p.m. - alert and oriented, able to make needs known, complained of left hip hurting, resident stated routine Tylenol would help, body temperature of 101.1 degrees F- nurse called spouse regarding antibiotics and temperature; spouse stated resident having issues with gallstones, UTI, and his back goes out at times; spouse wanted resident to continue to be monitored and if he needed to go to the hospital that she wanted him to go; continue to push fluids, remains on thickened fluids and head of bed needs to be elevated Addendum: body temperaure at 11:00 p.m. was 101.9 degrees F - Tylenol administered; one hour later body temperature was 100.9 degrees F- resident stated he was fine at that time 02/06/17 at 1:00 a.m. - body temperature was 100.6 degrees F 02/06/17 at 5:00 a.m. - resident given Tylenol at 3:30 a.m., resting quietly, continue to encourage fluids, foley remains intact with appropriate amounts of clear, yellow drainage; last body temperature taken at 5:30 a.m. was 99.7 degrees F 02/06/17 at 10:23 p.m. - Nursing Assistant (NA) reported resident was really confused and had some purplish color to his feet; noted resident was confused - unable to answer simple questions appropriately; pale in color with circles around his eyes; body temperature was 103.4 degrees F, elevated heart rate of 100 beats per minute, respiratory rate of 19 per minute, and blood pressure of 132/26; spouse called and reported she was looking for the nurse to tell her that the resident did not look good at all when she visited; spouse wanted resident evaluated at hospital; the only information given in report on the resident had been that he did not want to get out of bed that day, resident transported to hospital 02/07/17 at 6:37 a.m. - Late Entry for 02/06/17 at 4:00 p.m. - resident alert and responsive, body temperature of 99.2 degrees F, heart rate of 80 beats per minute, respiratory rate of 22 per minute, and blood pressure of 134/94; resident refused to get out of bed for breakfast and lunch due to back pain; lying in bed comfortable watching TV, his NA did not notice any changes in his mentation or skin; no issues reported, lung sounds were clear, foley patent, no skin issues, mentation at baseline, resident was feeling better before dinner and asked to get out of bed, seemed in no distress, no confusion noted, was able to answer all questions asked Review of ER records, revealed the resident was admitted on [DATE] at 7:42 p.m. The resident was diagnosed with [REDACTED]. Physician documentation stated the UTI was likely a continuation of the infection found when the resident transferred to theER on [DATE], given the likely inadequate treatment. A urine culture done at that time (02/02/17) noted the prescribed antibiotic, Cipro, was intermediate resistant to the organism, thus another antibiotic was given in the ER. The resident remained in the hospital for eight days. Review of the resident's meal monitor records between January 24-February 06/17 revealed the following: Breakfast: January 24-February 03 - ate approximately 100% February 04 - did not eat February 05 - ate less than 25% February 06 - ate 25% Lunch: January 24 - February 03 - ate approximately 100% February 04 - ate 75% February 05 - no evidence of documentation February 06 - ate 25% Review of the resident's Medication Administration Record [REDACTED]. In addition, a narcotic containing 325 mgs of Tylenol was given at 3:25 p.m. on 02/02, 1:00 a.m. on 02/03, and 9:30 a.m. on 02/04/17. The above combined doses of Tylenol were as follows: 02/02 - 2925 mgs, 02/03,04 - 2275 mgs, 02/05,06/17 - 2600 mgs per day. A telephone interview on 03/15/17 at 2:00 p.m. with a pharmacist from the consulting pharmacy revealed that Tylenol and Aspirin were medications frequently administered to reduce body temperature/fevers. He stated that both medications would mask body temperatures, thus if not given the body temperature would actually be higher. Staff would need to figure out the source of the fevers. An interview on 03/10/17 at 3:40 p.m. with Staff A, NA, (caregiver for the resident on the evening shift of 2/6/17) stated the dayshift NA had told her on 02/06/17 to keep an eye on the resident as he was confused at times, and had not eaten lunch that day. She stated he did not want to eat dinner that evening as he was not feeling good. The resident was sleepy, takaing only sips of water, not talking that shift, and didn't look good. Normally, the resident would get up for meals, and was always smiling and talking. Progress Notes between 02/03-02/06/17 revealed the resident began having elevated body temperatures despite Tylenol and Aspirin being administered routinely, which mask actual body temperatures. Despite the resident's continuing fevers staff did not perform thorough assessments in an effort to determine the cause of the fever; such as lung assessments, color of skin, hydration status, change in appetite, complete sets of vital signs, and signs/symptoms of UTI. Additionally, there was no evidence staff was addressing the elevated body temperatures in conjunction with the Tylenol and Aspirin being administered, and a need to consult the physician for a change in treatment. Resident #2: Review of the resident's plan of care, dated 9/5/14, noted he required extensive assistance with transfers, and was at risk for falls due to decreased balance and activity tolerance, leg [MEDICAL CONDITION], poor safety awareness, and weakness. In addition he had impaired cognition. Review of the resident's Progress Notes, dated 02/10/17, at 8:40 a.m. revealed the resident was found on the floor bleeding from a [MEDICAL CONDITION] on the right side. The resident was transferred to the ER where steristrips were applied to the laceration, as the resident refused stitches. He returned to the facility at 1:20 p.m. that afternoon. Despite the resident's recent head injury and fall, there was no further nursing assessment of the resident until 02/12/17 at 7:03 a.m. (approximately 47 hours later). Review of facility policy stated a neurological assessment was to be done every four hours for the first 24 hours, and then at least every eight hours (unless changed per physician order), following a fall and/or head injury. Staff B, Director of Nursing, stated on 03/10/17 at 3:00 p.m. there was no evidence neurological assessments had not been performed on the resident.

Based on interviews and record reviews, the facility failed to provide care and services for: 1 of 8 residents (#6) reviewed for pain management. Failure to provide pain medication in a timely manner resulted in actual harm to Resident #6 due to continued, severe pain. 1 of 4 residents (#7) reviewed for a change of condition. Failure of the facility to assess, monitor, and obtain medical treatment potentially resulted in unmet care needs and avoidable discomfort to the resident. 1 of 3 residents (#8) reviewed for hospice services. Failure of the facility to communicate with hospice and follow the resident's plan of care potentially resulted in unmet care needs. Findings include: Pain Management Resident #6. Review of Progress Notes dated 07/15/16 noted she was admitted to the facility that afternoon at approximately 4:00 p.m. from the hospital following a total right knee replacement surgery. The incision was approximately 6.5 inches long with 32 staples. She was having pain with movement of her right leg. Review of physician's orders [REDACTED]. Review of a pain assessment dated [DATE] at 4:30 p.m. noted the resident was currently in pain as evidenced by her moaning and fidgeting. Despite [MEDICATION NAME] being ordered on admission review of her Medication Administration Record [REDACTED]. A telephone interview on 08/17/16 at 1:25 p.m. with Staff E, former Licensed Nurse (LN), revealed that when she initially observed the resident at 8:00 p.m. on 07/15/16 she had excruciating pain to her right knee area. She stated she was unable to obtain the ordered narcotic pain medication as she was the only LN in the facility at that time that had designated access to the narcotics, and it took two LNs with designated access. Thus, she had to wait until the night shift LN arrived to work at 10:00 p.m. to access the narcotic medication. Staff C, LN, stated during an interview on 08/17/16 at 11:50 a.m. that when she observed the resident at 9:00 p.m. she was screaming in pain .grabbing ahold of us she was in so much pain. She stated the staff working during that time did not have designated access to the narcotics, with the exception of Staff E, until 10:00 p.m. when the night shift LN arrived to work. A telephone interview on 8/17/16 at 1:09 p.m. with the resident's family member revealed she was with the resident at approximately 7:00 p.m. on 07/15/16. She stated the resident had really bad pain to her right knee at that time. Change of Condition Resident #7. Review of a SBAR form (communication form for changes in condition) dated 07/25/16 by Staff C noted the resident was experiencing a popping noise, which had started that day. The assessment noted that tilting his head made it worse, and he needed his ears checked. Staff C documented the ear problem could be due to wax or an ear infection. Despite the above change in the resident's condition there was no further assessment of the resident's ears until 08/02/16 (eight days later). Documentation at that time stated the resident had an appointment for his ears to be checked the following day (08/03/16) with another physician as his primary care physician had not responded. review of the resident's medical record revealed [REDACTED]. An interview on 08/17/16 at 11:50 a.m. with Staff C revealed she called the resident's primary care physician (PCP) on 07/25/16 and left a message relative to the resident's ear condition. She stated the PCP never saw the resident regarding his change of condition. An interview with the resident on 08/17/16 at 2:10 p.m. noted the problem with his left ear, prior to seeing a physician on 08/03/16, was very irritating as he had a popping noise. The symptoms were worse when he tilted his head to the left side. Hospice Services Resident #8. Review of the resident's medical record noted the resident was placed under hospice services on 07/16/16. Review of physician's standing orders under hospice revealed only registered nurses employed by hospice were authorized to order medications and treatments as prescribed by the hospice physician. Review of Nursing Facility Guidelines by hospice noted any gastrointestinal symptoms or changes in medications the hospice nurse was to be consulted. In addition, any medications removed from the resident's comfort pack (supplied by hospice) were to be accessed only at the direction of the hospice staff. A report documented on 07/27/16 by the hospice LN noted the following: 1) [MEDICATION NAME] (medication used to treat nausea) was ordered by Staff C without notification to hospice (as noted in the above hospice forms). The order was found upon review of the resident's medical record by the hospice LN. 2) The resident requested all of his medications to be discontinued, which was done on 7/25/16. However on 7/27/16 it was noted [MEDICATION NAME] (medication used to treat nausea and vomiting) was still being admnistered to him. Staff C stated the resident still needed it, however the change to continue it was never communicated to hospice. 3) [MEDICATION NAME] (anti-anxiety medication) was initiated from the comfort kit with no communication to hospice that it was being used 4) [MEDICATION NAME] (antinausea medication) rectal suppositories were ordered on [DATE] per request of Staff C due to need for a suppository rather than oral medication. As of 7/27/16 (nine days later) there were no [MEDICATION NAME] suppositories available for the resident, and no evidence of communication to hospice. Review of Case Conference documentation by the hospice LN dated 08/01/16 noted she had spent an hour with the administrator and Staff C going over medication issues, missing physician's orders [REDACTED]. physician's orders [REDACTED]. A telephone interview on 08/15/16 at 11:00 a.m. with the above hospice LN revealed staff was waiting for [MEDICATION NAME] suppositories to be sent from the hospice pharmacy, which hospice does not do. It had to be ordered from the facility consulting pharmacy, thus the medication was not given for a week and the problem was not discussed with hospice. [MEDICATION NAME] was then ordered by the resident's primary care physician rather than hospice, and hospice was not informed of that change. Medication orders had been faxed and refaxed to the facility, and they seemed to get lost. Staff C stated during an interview on 08/17/16 at 11:50 a.m. that faxes sent to the facility were coming to an unattended fax machine, thus it was possible the faxes sent by hospice were never accounted for. She stated she had not seen the hospice LN between 07/25-27/16, thus had not communicated to her that [MEDICATION NAME] was still being administered to the resident. She stated she had been waiting for hospice to send the [MEDICATION NAME] suppositories, and due to the resident's inability to take oral medications due to his nausea, she obtained physician's orders [REDACTED].

Based on record review and interviews the facility failed to ensure each resident's drug regime was free from unnecessary medications regarding adequate indication for use, and evidence of adverse consequences for 1 of 4 residents (#1) reviewed for unnecessary drugs. This failure resulted in harm to Resident #1 as evidenced by a significant decline in his condition. Findings include: Resident #1. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Progress Notes between ,[DATE]-[DATE] revealed the resident displayed frequent agitated behaviors as evidenced by yelling out, attempts to stand from his wheelchair and walk, and refusals to allow care by staff. On [DATE] the physician was notified regarding an increase in the resident's agitation as he was hitting and pinching staff, self transferring, and going into other residents' rooms. The physician ordered [MEDICATION NAME] (antipsychotic medication) 25 milligrams (mgs) at bedtime. [MEDICATION NAME] had adverse reactions which included dizziness, somnolence, increased cough, and difficulty breathing. Documentation on [DATE] revealed the resident became very aggressive and was swinging the wheelchair foot pedals at staff. Later, he closed the door to his room and would not let anyone inside. The physician was notified and gave orders to discontinue the Risperdone and increase the [MEDICATION NAME] to 100 mgs daily (50 mgs twice daily). On [DATE] the resident developed a moist cough with abnormal lung sounds, and lethargy. The physician decreased the [MEDICATION NAME] dosage that day from 100 mgs daily to 75 mgs (50 mgs in the morning and 25 mgs in the evening). Review of documentation between ,[DATE]-,[DATE] noted the resident was lethargic, and febrile with abnormal lung sounds. He was diagnosed with [REDACTED]. On [DATE] the resident displayed increased confusion condition has not improved. Oxygen therapy was initiated on ,[DATE] due to low oxygen levels. A nursing assessment dated [DATE] revealed the resident required extensive assistance with his care due to his dementia. He continued to receive therapy services. On [DATE] he was noted to be lethargic and shaky during the dinner meal. Documentation on [DATE] revealed the resident was very lethargic, not eating or swallowing that morning, and his oxygen saturation level was low. His condition continued to decline and he expired on [DATE]. Review of an Occupational Therapy (OT) assessment dated [DATE] (day of admission) revealed the resident could safely put on and take off upper body clothing, complete all hygiene and grooming tasks, and transfer to the toilet with minimal assistance. An assessment dated [DATE] noted a significant decline in the resident's abilities. He required maximum assistance with his clothing, moderate assistance with hygiene and grooming tasks (however required maximum assistance with tactile and verbal instructions), and required minimal assistance with toileting with verbal cues using grab bars. A telephone interview on [DATE] at 9:45 a.m. with Staff Member A, OT, revealed the resident's level of alertness impacted his function. At the beginning of his stay in the facility he was able to ambulate, which he no longer could do the last two weeks. He stated the resident was feeding himself when he was first admitted , but later he required much assistance with eating. He was very weak and lethargic. His condition declined and he required much verbal cueing. There were days where he was not able to participate. Staff Member B, Speech Therapist, stated during a telephone interview on [DATE] at 4:50 p.m., she did not start working with the resident until [DATE]. His condition did decline. He was much more fatigued, and unable to be alert. Most of the time he needed more cueing and total assistance with eating. He was somnolent at times, and unable to respond to commands. An interview on [DATE] at 3:00 p.m. with the resident's family member, revealed that for approximately two to three days the resident was knocked out .it was two to three more days before he got back to being awake, but was never the same. He was definitely less responsive after the [MEDICATION NAME] was given. Review of the resident's Behavior/Intervention Monthly Flow Record noted his targeted behaviors were increased agitation, and restlessness. Between [DATE]-,[DATE] the resident did not display any noted behaviors during that time with the exception of [DATE]. Review of the resident's Medication Administration Record [REDACTED]. During that time the resident refused three doses, five doses were circled by staff with no indication as to why the medication was not given, and there were omissions in documentation for two doses. Despite the resident's significant decline in condition as evidenced by interviews and documentation, with no display of targeted behaviors during March (exception of ,[DATE]), staff continued to administer [MEDICATION NAME] daily, and failed to evaluate the medication for adverse consequences, which may have contributed to his decline in condition.

Based on observation, interview and record review, the facility failed to have sufficient qualified staffing to provide and supervise care for 21 of 49 sampled residents (Residents #s 8, 30, 35, 36, 46, 49, 50, 51, 53, 71, 75, 83, 90, 104, 122, 125, 154, 160, 163, 165, 166). The facility failed to provide timely and needed care to residents, nor were the residents supervised consistently. Staff did not adequately assess, evaluate, report or document information needed to formulate effective and timely interventions. The harm resulted from a failure to provide care and services to attain and/or maintain the safety, health, and well-being of each resident related to: timely notification of the physician for a significant change in condition, supervision of residents to prevent accidents, provision of a renal diet for a [MEDICAL TREATMENT] resident, and a significant eye medication error. Findings include, but are not limited to: Although sufficient numbers of each of licensed nurses were scheduled daily, the licensed nurses were not consistently assigned to work with a section of residents that allowed them to become familar and gain an understanding of the residents' needs specific to each of their residents. The facility lacked a continuity of nursing staff to provide consistent and appropriate services and care for residents. This lack of continuity was evidenced by multiple observations and interviews with the Licensed Nurses working as medication nurses: - On 03/09/16 at 12:00 p.m., Staff Member N stated she was not familiar with working on the 200 hallway. - On 03/10/16 at 10:00 a.m., Staff Member AA stated she was working the 200 hallway, but was from another facility and had just come to help out. She stated she had no orientation and was frustrated trying to locate resident medication. - On 03/14/16 at 11:00 a.m., Staff Member W stated she usually worked night shift but was needed to work day shift today. - On 03/16/16 at approximately 9:45 a.m., Staff Member BB stated she was working the 100 hallway but she was not familiar with that hallway or the residents. On 03/17/16, she was observed working on the 300 hallway. The lack of sufficient and/or qualified staff contributed to the following citations in this report, including, but not limited to: The facility failed notify the physician in a timely manner resulted in a signficant delay in treatment which disallowed Resident #53 the ability to receive appropriate and timely medical care. The facility failed to consult with the physician in a timely manner regarding significant changes in the condition for Residents #50 & #125. Refer to 42CFR 483.10(b)ii; F-157 Notification. The facility failed to initiate prompt and active efforts towards resolution of resident grievances regarding timely response to call lights. Refer to 42CFR 483.10(f)(2); F-166 Grievances. The facility failed to provide care for Resident #46 when his call light was out of reach, staff failed to answer his verbal calling for help and he fell to the floor. Harm resulted in severe pain, humiliation, and a sense of feeling 'less than a man'. Refer to 42CFR 483.15(a); F-241 Dignity. The facility failed to ensure Resident #154, new to receiving insulin, received appropriate, complete education and supplies prior to discharge home, thus placing her at high risk for harm due to the medical complexities of insulin. Refer to 42CFR 483.15(g)(1); F-250 Medically Related Social Services. The facility failed to recognize, assess, monitor, and provide intervention for an acute medical condition which resulted in a significant delay of medical treatment causing actual harm to the resident #53. The facility failed to assess and provide timely and appropriate interventions which resulted in actual harm related to continued, severe pain for Resident #46. The facility failed to coordinate care with physicians' to ensure required eye medication was received accurately and failed to complete an assessment for a self-medication program to decrease the resident's anxiety which resulted in actual harm for resident #50. The facility failed to timely and accurately assess the resident's bowel status, including rectal bleeding, which resulted in Resident #35 experiencing discomfort. The facility failed to assess ongoing worsening behaviors and not providing 1-to-1 care resulted in inapropriate sexual behavior in front of a female resident placed Resident #160 and other residents at risk for harm. The facility failed to assess and then ensure residents were supervised sufficiently in order to not receive food items to which they were allergic for Residents #s 83, 122, 166. This failure placed the residents at risk for harm. The facility failed to ensure supervision for positioning at the dining table so Resident #51 could easily and safely reach her food and fluids which placed the resident at risk of continued weight loss. Refer to 42CFR 483.25; F-309 Provision of Care and Services. The facility failed to assist in obtaining a hearing evaluation for Resident #36. Refer to 42CFR 483.25(b); F-313 Treatment devices to maintain hearing and vision. The facility failed to monitor and provide constant supervision for a resident with impulsivity and repeated falls resulted in harm due to a fracture for Resident #20 and the potential choking of Resident #90. Refer to 42CFR 483.25(h)(1)(2); F-323 Free of Accident Hazards and Supervision. The facility failed to monitor and supervise to ensure that a new [MEDICAL TREATMENT] resident received the appropriate therapeutic diet for kidney failure for Resident #38. Refer to 42CFR 483.25(i)(2); F-325 Nutrition. The facility failed to ensure a significant eye drop, to lower intraocular pressure, was received by Resident #50, thus jeopardizing the resident's health and safety which would be impacted by further vision loss. Refer to 42CFR 483.25(m)(2); F-333 Significant Medication Error. The facility failed to ensure that an appropriate therapeutic diet was being provided to prevent choking, related to difficulty swallowing, for Resident #122. Refer to 42CFR 483.35(d)(3); F-365 Food in the Form to Meet Individual Needs.

Based on observation, interview and record review, the facility's administration: failed to effectively and/or efficiently use resources to attain and/or maintain the safety, health, and well- being of each resident related to: timely notification of the physician, supervision of residents, provide a renal diet for a [MEDICAL TREATMENT] resident, prevent a significant medication error, and providing care and service to support residents with a significant change in condition and unmanaged pain. Failure of administration to ensure through and effective supervision and oversight caused actual harm to multiple residents and placed other residents at risk for harm. Findings include, but are not limited to: Throughout the survey, the Administrator and Director of Nursing (DON) had issues brought to them regarding the above concerns identified by the surveyors. On 03/17/16 at approximately 1:00 p.m., the Administrator and DON had these issues discussed with them. Both the Administrator and DON stated they were without sufficient staff due to a lack of licensed nurses in the roles of Resident Care Managers, for which there should be three, (there was currently only one), and in the roles of medication/treatment nurses. The treatments were currently being completed by the DON, as evidenced by observation on multiple days of survey. The administration failed to recognize a lack of continuity of nursing staff to provide consistent and appropriate services and care for residents. This lack of continuity was evidenced by multiple observations and interviews with the Licensed Nurses working as medication nurses: - On 03/09/16 at 12:00 p.m., Staff Member N stated she was not familiar with working on the 200 hallway. - On 03/10/16 at 10:00 a.m., Staff Member AA stated she was working the 200 hallway, but was from another facility and had just come to help out. She stated she had no orientation and was frustrated trying to locate resident medication. - On 03/14/16 at 11:00 a.m., Staff Member W stated she usually worked night shift but was needed to work day shift today. - On 03/16/16 at approximately 9:45 a.m., Staff Member BB stated she was working the 100 hallway but she was not familiar with that hallway or the residents. On 03/17/16, she was observed working on the 300 hallway. The facility administration failed to provide the necessary oversight to ensure care and services were provided to residents as evidenced by the following concerns: The facility failed to ensure timely physician notification of supervision of nursing staff - Resident #53 who exhibited signs and symptoms of a stroke. The delay in treatment resulted in harm. - Resident #50 related to omission and/or discontinuation of two [MEDICAL CONDITION] eye medications. Refer to F-157, CFR 483.(10)(b)(11)(i)(B) for further details. The facility failed to ensure that residents were treated with dignity concerning Resident #46 who felt humiliated and less than a man after a fall. Refer to F 241, CFR 483.15(a) for further details. The facility failed to recognize, assess, monitor, and provide interventions for an acute medical condition for Resident #53. The Administration failed to assess and provide timely interventions for Resident #46 who was experiencing severe pain. The Administration failed to coordinate eye care with the physician for Resident #50. Refer to F 309, CFR 483.25 for further details. The facility failed to ensure supervision of Resident #20, with mulitple falls, who was left unsupervised and fractured his hip, and also Resident #90 who needed supervision to prevent choking. Refer to F 323, CFR 483.25 (h)(1)(2) for further details. The facility failed to provide an appropriate renal diet for Resident #38 resulting in severe weight loss. Refer to F 325, CFR 483.25 (i)(2) for further details. The facility failed to prevent a significant medication error related to Resident #50. Refer to F 333, CFR 483.25 (m)(2) for further details.

Based on record review and interview, the facility failed to consult with the physician in a timely manner regarding significant changes in the condition of 3 of 6 residents (#'s 53, 50, 125) reviewed for changes in condition. This failed practice resulted in actual harm to Resident #53 related to a signficant delay in treatment which disallowed the resident the ability to receive appropriate and timely medical care. Findings include: Resident #53. Interviews conducted with the resident's family member on 03/16/16 at 9:05 a.m. and Staff Member Q, a Nursing Assistant (NA), on 03/17/16 at 11:40 a.m. revealed they had observed significant changes in the resident's condition (leaning extensively to the left in her wheelchair and not verbally responding) at approximately 2:00 p.m. on 02/12/16. Despite them informing Staff Member BB, a Licensed Nurse (LN) on duty, of the changes, Staff Member BB felt the resident was just tired and needed a nap, thus she was transferred to bed. The family member left the facility at that time and when she returned later that evening (after supper) she informed Staff Member CC, the evening shift LN, to call the physician as there were additional changes in the resident's condition (no movement on one side of her body and unable to swallow). Review of documentation dated 02/12/16 at 7:45 p.m. by Staff Member CC revealed the resident's left side of her face was drooping, weakness of her arms and legs on the left side, and slurred speech. The physician was notified at 8:00 p.m. (approximately five hours and 45 minutes later from initial changes in the resident's condition). The resident was transferred to the emergency room at 8:05 p.m. where she was diagnosed with [REDACTED]. Refer to F309. Resident #125. admitted on [DATE] and discharged on [DATE] to an assisted living facility. [DIAGNOSES REDACTED]. Closed record review revealed the resident's care plan documented the resident is at risk for complications associated with high and low blood sugar. The approaches included to admininster insulin as ordered. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The resident's February 2016 Medication Administration Record (MAR) documented a blood sugar of 60 (low) on 02/21/16 and a blood sugar of 260 (high) on 02/22/16. There was no documented evidence the physician had been notified of these significant blood sugar changes on the nursing progress notes, nor the resident's MAR. On 03/15/16 at 2:50 p.m., Staff Member A, the Director of Nursing (DON), acknowledged the nurses had failed to call the physician of the resident's blood sugars. The failure to notify the physician of the significant blood sugar changes put the resident at risk for medical complications. Resident #50. admitted [DATE] with [DIAGNOSES REDACTED]. The resident had identified who her eye physician/specialist (opthamologist) was on the admission forms. The February and March 2016 MARs revealed Dorzolamide 2% (eye drop) medication was administered in the resident's left eye three times a day. When the resident returned from the opthamologist on 03/10/16, the physician had ordered another eye drop, [MEDICATION NAME] for [MEDICAL CONDITION], to be started. The physician had not discontinued the Dorzolamide. However, on 03/11/16, the Dorzolamide was discontinued on the MAR when the [MEDICATION NAME] was started. This incorrect eye drop regimen continued until the surveyor brought the medication error to the attention of Staff Member W, a LN, on 03/14/16. On 03/14/16 at 11:00 a.m., Staff Member W stated she usually worked the night shift. She reviewed the MAR and stated the Dorzolamide was discontinued but she understood that it was the same medication as the newly started [MEDICATION NAME]. However, the pharmacy consultant was nearby and confirmed Dozolamide and [MEDICATION NAME] were not the same eye medications. They all helped to lower the intraocular pressure but had different mechanisms to achieve that lowering. The MAR on 03/15/16 revealed the Dorzolamide was re-started as ordered on [DATE]; the resident received the first dose at 2:00 p.m. The resident had missed a total of seven doses. On 03/16/16 at approximately 11:00 a.m., the resident's opthamologist's office was contacted. The technician at the office reported the physician had been concerned about the resident's intraocular pressure continuing to increase since her 01/29/16 eye appointment. The technician confirmed the facility staff had not notified the opthamologist when the Dozolamide eye drop was incorrectly discontinued for seven doses.

Based on observation, interview and record review, the facility failed to provide care and services in a manner that promoted and enhanced resident dignity relative to: A) staff response to call lights for 1 of 1 resident (#46), B) urinary catheter bags for 1 of 2 residents (#26) reviewed for urinary catheter use, C) providing a dignified meal environment during 5 of 8 dining room observations, D) providing privacy during personal care for 1 of 4 residents (#8) observed during incontinent care. This failure caused actual harm to Resident #46 which, because his call light was out of reach, resulted in a fall to the floor resulting in severe pain, humiliation, and a sense of feeling less than a man. All residents were placed at risk for diminished self-esteem and decreased quality of life. Findings include: A. STAFF RESPONSE TO CALL LIGHTS Resident #46. The resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 11/09/15 and the 01/10/16 comprehensive assessments, the resident was able to make his needs known to staff. The resident required extensive assistance of two staff with a sit-to-stand lift (mechanical assistive device) for transfers. Additionally, the resident required extensive assistance of two staff to turn him in bed. On 03/09/16 at approximately 10:00 a.m., the resident stated he was still having pain from a fall on 02/27/16, approximately 11 days later, and that the pain had not been relieved on his left upper side and back. The resident stated that his call light was not in place and he had called out for some time for a nurse or nursing assistant (NA) to respond, but they did not for some time. The resident stated he sat up in bed with assistance of a side rail and called out the name of the staff again, but no response for approximately 30 minutes. Since the resident was not able to sit up for a long time, he slipped down from his bed and his left side and leg caught in the side rail on the bed as he fell down to the floor. He stated he hit the floor very hard on my butt and was in pain and (messed) my pants as soon as I hit the floor. The resident stated he continued to yell for the NA and the NA finally showed up. At one point, he described he was helpless and unable to do anything for himself; I feel (less than a man). He stated he felt extemely humilitated and could not explain in words how upset he was about the incident. The resident also stated he spoke with the Administrator about his concerns about the call light being in place at night so the people could get the help they needed. Additionally, the resident stated that the staff at night had taken away his call light in the past and said he was using his call light too much. B. URINARY CATHETER BAGS Resident #26: On 03/07/16 at 12:10 p.m., the resident was observed in his wheelchair exiting the dining room which contained 19 residents. His urinary catheter bag (used to collect urine from the bladder through a tube and into a clear collection bag) containing urine was hanging at the side of his wheelchair, and was not covered. C. MEAL ENVIRONMENT On 03/07/16 at 12:50 p.m., a housekeeper was observed cleaning the floor in the grand dining room with a broom and dustpan while nine residents were still eating their meal. She swept the general area around multiple tables and then went under 2 tables where three residents were eating. On 03/08/16, 03/09/16, 03/14/16, and 03/15/16, the housekeeper used a broom and a dustpan around residents in the dining room while residents were being served their food and eating their meals. D. PRIVACY DURING INCONTINENT CARE Resident #8. On 03/8/16 at 2:50 p.m., two NAs were observed changing the resident's incontinent brief while the resident lay in her bed. Staff did not attempt to cover the resident during the procedure. Thus she was left totally exposed in front of three individuals. Later at 3:40 p.m., the resident stated she did not like being exposed like that and staff frequently did not provide privacy when changing her.

Based on observation, interview and record review, the facility failed to provide care and services for: 1 of 2 residents (#53) reviewed for a change of condition. Failure of the facility to recognize, assess, monitor, and provide intervention for an acute medical condition resulted in a significant delay of medical treatment causing actual harm to the resident #53. 1 of 3 residents (#46) reviewed for pain management. Failure to assess and provide timely and appropriate interventions resulted in actual harm related to continued, severe pain for Resident #46. 1 of 1 resident (#50) reviewed for eye medication. The facility failed to coordinate care with physicians to ensure required eye medication was received accurately and failed to complete an assessment for a self-medication program to decrease the resident's anxiety resulted in actual harm for resident #50. 1 of 1 resident (#35) reviewed for bowel management and rectal bleeding. Failure to timely and accurately assess the resident's bowel status, including rectal bleeding, resulted in the resident experiencing discomfort. 1 of 3 residents (#160) reviewed for management of inappropriate behaviors. The facility's failure to assess ongoing worsening behaviors and not providing 1-to-1 care resulted in inapropriate sexual behavior in front of a female resident placed the resident at risk for harm. 3 of 3 residents (#83, 122, 166) reviewed for food allergies [REDACTED]. This failure placed the residents at risk for harm. 1 of 1 resident (#51) reviewed for proper positioning during meals. The facility failed to ensure one resident, who ate in the dining room, was positioned at the dining table so she could easily and safely reach her food and fluids. This failure placed the resident at risk of continued weight loss. Findings include but are not limited to: Change of Condition Resident #53. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly comprehensive nursing assessment dated [DATE] revealed the resident was able to understand simple, concrete statements. She required extensive assistance with wheelchair locomotion, transfers, toileting, and eating. Review of the resident's plan of care noted she had impaired communication related to difficulty understanding others, hearing, and memory deficits. Review of a facility investigation report revealed the resident's family voiced concerns on [DATE] to administrative staff regarding the care of the resident by Staff Member BB, a Licensed Nurse (LN), on [DATE]. The resident's family member observed the resident that day leaning to the left in her wheelchair and was not at her normal status. The family member stated the NA, who was present during the above observations, also stated the resident was not at her normal status. Staff Member BB told the family member and the NA that the resident was tired and to lay her down to allow her to rest. The investigation report stated the resident's family member then left the facility (following the resident being put to bed) and returned after supper. She noted the resident was not sleeping well, right hand was agitated, and she had some visual changes. She requested Staff Member CC (LN) to notify the physician, which she did. The resident was transferred to the hospital where she was diagnosed with [REDACTED]. A telephone interview on [DATE] at 9:05 a.m. with the above resident's family member revealed she came to the facility after lunch on [DATE]. While transporting the resident to her room Staff Member Q, a NA, called for Staff Member BB to check the resident as something was wrong. The resident tried to lift up her head, but had difficulty. She stated she visited the resident at least three times per week so was familiar with her condition. Normally, the resident was able to partially stand and assist with transfers, however, on that day staff had to drag her out of the wheelchair and place her on the bed. Staff Member BB assessed the resident and informed the family member, she's (resident) just tired and just needs a nap. Staff Member BB kept calling to the resident to get her to talk. Staff Member Q was very vocal with Staff Member BB stating, she's not right - there's something wrong with her. The LN was very adamant nothing was wrong. She stated she returned to the facility that same evening between ,[DATE]:00 p.m. Staff Member PP, a NA, informed her the resident never slept and was agitated all afternoon. She kept kicking the blankets off her legs, but was still not verbally responding. She stated there was still no movement on one side of her body, and she was unable to swallow. There was no way she could have eaten due to her condition. The family member stated Staff Member PP encouraged her to tell the LN she wanted the resident to go to the hospital. She stated at that time she went to a different LN (Staff Member CC) and told her something was definitely wrong with my mom - please call the physician, which she did. An interview with Staff Member BB, a LN, on [DATE] at 11:00 a.m., relative to the above incident, confirmed she had told the NA and resident's family member the resident was tired and needed a nap. The NA was yelling, she's never like that (referring to the resident). She stated the NA had worked at the facility for quite a while, and was familiar with the resident. Staff Member Q, a NA, stated during an interview on [DATE] at 11:40 a.m. that when the resident was attending an activity in the dining room on [DATE] the activities staff member came out of the activity and informed her the resident did not look good. She stated she immediately went to the resident and noted she was leaning extensively to the left, and would only nod as she could not speak. She told Staff Member BB to come right away as something was wrong with the resident as normally she was talkative. She stated the resident's assigned NA (Staff Member PP) came to the room and upon observing the resident stated, Oh my gosh, I'm getting her vital signs right now. A telephone interview on [DATE] at 11:25 a.m. with Staff Member CC, a LN, revealed she reported to work at 6:00 p.m. on [DATE]. She stated the resident's family member had approached her, just as she was going into the resident's room to assess her, and stated the resident did not recognize her and she was different, and wanted the physician called. She stated Staff Member BB had told her in shift report to keep an eye on her (the resident), but had not given her much detail. She called the physician immediately and the resident was transferred to the emergency room (ER). Review of hospital records dated [DATE] noted the resident was brought to the ER at 8:19 p.m., 6 hours after she had a right-sided gaze, left sided weakness, and being unresponsive around 2:30 p.m. that day. The hospital report stated stroke was suspected, but she did not meet the criteria for TPA (tissue plasminogen activator - intravenous medication that breaks up clots and improves the chance of recovery from a stroke). (TPA, the only FDA approved medication treatment, must be given within three hours of the first signs and symptoms of stroke and systolic blood pressure must be less than 185.) The resident's systolic blood pressure reading in the ER was 225. The resident was unable to speak. The resident was diagnosed with [REDACTED]. The resident was readmitted to the facility on [DATE] from the hospital on comfort measures. She expired at the facility six days later on [DATE]. Review of an incomplete assessment on [DATE] by Staff Member BB, a LN, (no indication of time) revealed the resident was very weak and leaning to the side while seated in her wheelchair (resident was transferred to her bed at approximately 2:00 p.m.). Her blood pressure at that time was ,[DATE]. There was no evidence of an assessment of her level of consciousness/neurological status. Despite the significant changes in the resident's condition as noted per family member and NA staff, there were no further assessments or vital signs taken by Staff Member BB. On [DATE], Staff Member CC, a LN, reported to work at 6:00 p.m., was informed during the 6:00 p.m. shift report of the need to keep an eye on the resident due to changes in her condition. However, Staff Member CC did not assess the resident until 7:45 p.m., an hour and 45 minutes following receiving information about the changes in condition. The assessment noted the resident's left side of her face was drooping, slurred speech, and left sided weakness to her arms and legs. Vital signs were obtained at that time with an increased blood pressure of ,[DATE]. The physician was called at 8:00 p.m. and the resident was transferred to the ER at 8:05 p.m., six hours after initial signs and symptoms of a change in her condition. Pain Resident #46. The resident was readmitted to the facility [DATE] with chronic pain. According to a resident assessment [DATE], the resident required extensive assistance of two staff for turning, transfer with a sit-to-stand (a mechanical assistive device) and toileting. The resident was incontinent of bowel and bladder. On [DATE] an investigative report revealed that the resident fell out of bed. The resident received Tylenol (pain reliever) four times a day for pain and 'as needed' every four hours. The last time the resident requested an 'as needed' Tylenol was on [DATE] at 3:00 p.m. according to the Medication Administration Record [REDACTED] On [DATE] at approximately 10:30 a.m., Staff Members P and R, NAs, were observed to change the resident's clothing and brief by rolling the resident side to side. The resident was asked to assist and grabbed the side rail with his left hand to turn to the right side. The resident moaned and cried out in pain. Staff Members P and R prepared the resident to transfer with the sit-to-stand and placed the harness around the resident's back and under the resident's arms (although the resident already expressed pain with this transfer method.) Staff Member R then worked the control and lifted the resident's upper body. The resident moaned and yelled out in pain. Staff Member P stated that since the resident fell out of bed two weeks ago, he had complained of more pain on his left side during turning in bed and use of the sit-to-stand to transfer. Staff Member P stated she had told the nurse(s) many times about the increase in pain. (However, there was no re-assessment of pain by the nurses during turning or transfer.) On [DATE] at approximately 2:50 p.m., Staff Member RR, a LN, stated she was unaware that the resident was complaining of pain in his left side. She said, I do not think the pain could be that bad since it was 10 days since his fall. On [DATE] at 4:11 p.m., the resident still complained of severe left upper chest pain. He stated the staff used the sit-to-stand mechanical lift to transfer him by placing the harness around his back and under his arms. He stated the transfer procedures hurt him badly on his left side. The resident recalled that he slid off the bed because he could not find his call light. He sat up in bed, put his legs over the side, and continuously called out for staff but no one came. He stated, I slid off and hit my side on the side rail and my knees were sore. My left side hurt after the incident .but they said it would go away .it was killing me on my left side . I rate the pain a 10. They didn't recognize I was in pain .and I was making faces and gripping the bar .and the machine (sit-to-stand) shook; I was shaking in pain. During the interview the resident continued to grimace frequently and stated, It still hurts. Further, the resident stated, I don't think Tylenol does anything. He said he took [MEDICATION NAME] (narcotic pain reliever) a while back. I am going to ask them about it again .I can't take this pain anymore. On [DATE] at 9:55 a.m., the resident stated, Night shift took my call light last night and said I used it too much. They won't give me anything but Tylenol. On [DATE] at 3:22 p.m., the resident stated his left side was still very painful and he was grimacing as he repositioned in his wheelchair. A friend who was visiting stated that the resident was alert and able to correctly state his pain and recall details of what goes on in his care. The friend also stated that the resident had asked staff for something stronger for pain and the facility won't listen. The facility failed to accurately assess the resident's pain. Thus, appropriate interventions were not developed which caused the resident to remain in significant pain. Refer to F-225 Eye Medication Resident #50. admitted on [DATE] with multiple [DIAGNOSES REDACTED]. She had some memory and decision making issues. Admission paper work noted the resident's preferred hospital, pharmacy and her eye physician. Her preferred pharmacy was not the one used by the facility. According to the February and [DATE] Medication Administration Record, [REDACTED]. [MEDICATION NAME] was not started until [DATE] (originally ordered on [DATE]) and the Dorzolamide was mistakenly discontinued. During an interview on [DATE] and 3:30 p.m. the consulting pharmacist stated the Dorzolamide, [MEDICATION NAME] and [MEDICATION NAME] all helped to lower intraocular pressure with different mechanisms. An evaluation by her eye physician on [DATE] noted, The patient did not get the new drop ([MEDICATION NAME] - ordered on [DATE]). The patient's IOP (intraocular pressure) is too high in her only good eye. She needs to start [MEDICATION NAME] in the left eye twice a day. The order included to continue the following eye drops of Dorzolamide, [MEDICATION NAME], and [MEDICATION NAME] into the left eye to lower the eye pressure. The physician documented again with direct emphasis in the evaluation that the resident's intraocular pressure was TOO HIGH IN HER ONLY GOOD EYE. SHE NEEDS TO START [MEDICATION NAME] IN THE LEFT EYE twice a day. On [DATE] at approximately 10:00 a.m., the resident had a small blue bottle of [MEDICATION NAME] eye drops on the bedside table. The resident stated it was her eye medication, but she did not know where a second bottle with an orange cap had gotten to; she proceeded to lean over to look under her bed and then on the overbed table and in her bedside table drawer. She became visibly upset as to what she was going to do without them. When asked if the licensed nurses had them, she did not know but maybe. Staff Member A, the Director of Nursing (DON) was in the room and the surveyor pointed out the eye medication at bedside. The DON was concerned as the resident was not on a self-medication program. On [DATE] at 11:00 a.m., Staff Member Z, a Licensed Nurse (LN), stated that she had been told by the DON about the eye drops at bedside and had removed the [MEDICATION NAME] bottle from the resident's room and threw it away. She re-ordered another one from the facility's pharmacy. She was unaware of any scheduled eye appointment. On [DATE] at 11:45 a.m., the resident was seated on her bed, dressing herself. She stated she was getting ready for lunch. Her cluttered bedside table was positioned close to her. She stated that her eye medications had been there and somebody took them; they're gone. She said it was both the blue bottle ([MEDICATION NAME]) and the orange lid bottle (Dorzolamide) that had been there this morning for me to use and now they're gone. She stated I bet (the DON) took them. On [DATE] at 12:00 p.m., Staff Member N, a LN, stated she was not familiar with this hallway and had been looking for the resident's eye drops. The labeled plastic bag on the medication cart is missing the bottles; she displayed the empty sack. She did not know where they were or if the resident had them. She stated she was going to re-order them as the Dorzolamide was scheduled three times a day and she did not want to miss the 2:00 p.m. dose. On [DATE] at 12:15 p.m., the DON stated both bottles of eye drops ([MEDICATION NAME] and Dorzolamide) were again on the resident's bedside table when the DON was doing the treatment on her legs that morning. The bottles were soiled and she threw the bottles away; they would need re-ordering (twice in two days). When asked about how and why nurses were leaving the bottles for the resident, she said she would have to talk to her night nurses. She did not believe the nurses were leaving the medication for her to self-medicate although the resident had indicated they were leaving them for her to give her own eye drops. On [DATE] at 2:45 p.m., Staff Member N stated she had just received the eye drops from the pharmacy. She then took the Dorzolamide into the resident who was seated on the side of her bed. When Staff Member N showed the resident the eye drop, the resident became visibly upset, stating that was her property and it had been taken from her room. Staff Member N explained to her that the nurses had to keep it. The resident adamantly said it was bureaucracy. She took the eye drop from the nurse, leaned back on her bed and correctly instilled a drop into her left eye. She said she had been giving herself eye drops for six years. Although hesitant, she allowed the nurse to remove the medication from the room. Staff Member N stated she did not work on this side of the facility but she thought the resident could easily be assessed for a self-medication program since it was upsetting to the resident. On [DATE] at approximately 10:00 a.m., Staff Member AA, a LN, stated she was working the hallway where the resident resided, but she did not know about the resident's eye drops. She was from another facility and had come to help out. She stated she had not had any orientation and was frustrated trying to locate resident medication. On [DATE] at 11:00 a.m., Staff Member W, a LN, stated she usually worked night shift but was needed to work day shift today. She stated she had found the eye medications in the resident's room that morning but did not know who had left them there. She acknowledged the resident would become upset that she could not keep the eye medications with her. The resident would even lecture the nurses on how she wanted to give herself the eye medication. On [DATE] at 11:00 a.m., Staff Member J, the Assistant Director of Nursing, called the eye physician's office, per the surveyor's request, and received confirmation the resident's last appointment was [DATE]. Staff Member J requested information including physician orders [REDACTED]. On [DATE] at 4:30 p.m., Staff Member J stated the resident usually left the facility without telling staff where she was going. The resident was independent with her appointments and could leave when she wanted. She was not aware the resident had any eye appointments. On [DATE] at approximately 10:00 a.m., the facility receptionist reviewed the log book where she documented residents' locations when they left the facility. The log revealed the resident had gone to a doctor's appointment on [DATE], [DATE] and [DATE]. This in-house log was available for staff to review should they want to locate a resident. On [DATE] at 11:00 a.m., a technician at the resident's eye center stated the resident had been evaluated by her ophthalmologist monthly. She stated the resident came by a local transportation company but without anyone with her, which the technician thought would be beneficial for the resident. The technician stated that on [DATE], paperwork had been given to the resident. She stated that, until talking with the surveyor, their office was not aware of the resident's move to a nursing home, her new address, or that she had a new pharmacy. Therefore, at the [DATE] appointment, when the new eye medication was ordered ([MEDICATION NAME]) the resident missed receiving it for a month because it would have been called to the old pharmacy (listed on the Admission paperwork at the facility). Further, the technician had stated the physician had also seen the resident on [DATE] and her pressure in her left eye was elevated. He wanted to see her in a couple of weeks before he ordered more eye drops, which he did on [DATE]. There was no documentation that staff consulted with the physician when the resident had missed 31 days of [MEDICATION NAME] between ,[DATE] and [DATE]. The technician indicated the ophthalmologist was concerned about the resident's increasing intraocular pressure and that she only had vision in one eye. On [DATE] at approximately 2:00 p.m., the resident was asked if she let staff know where she was going when she left the facility. The resident stated the staff always knew; the front office was always told when she left. She was unaware of the need to tell anyone else. Although facility staff could have had information on the resident's appointments, there was a lack of communication among facility staff, and between the facility and the resident's eye specialist. Therefore, nursing staff were not aware when the resident left the facility and/or her intended location. Four of four charge/medication nurses interviewed during the survey were not as familiar with the resident as should have been, which interfered with their knowledge of the resident and her needs. Bowel Management Resident #35. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A resident assessment dated [DATE] noted the resident was in pain and on [MEDICATION NAME] liquid, (narcotic pain medication which frequently causes constipation), every three hours as needed for pain, an anti-anxiety medication every six hours as-needed for restlessness, and a narcotic patch for pain every three days. Additionally, the resident required extensive assistance of two staff members with daily cares such as turning in bed, transfers, toileting and eating. The resident was assessed on the [DATE] Assessment for Bowel and Bladder as incontinent and her mental status was severely impaired. The [DATE] and [DATE], Pain Flow Sheet revealed that the resident experienced moderate pain and received pain medication and anti-anxiety medication at least 3 times or more daily to relieve her pain. According to the Speech Therapist Evaluation dated [DATE], the resident had difficulty swallowing and was at risk for aspiration. The recommended diet for the resident was pureed (thickened) consistency fluids and food. The resident's intake of food and fluids was poor. Between [DATE] and [DATE], the resident went from 8 to 10 days without bowel movements. Laxatives were given twice but with no evidence of documented results. The Nurses Progress Note for [DATE] noted the resident had rectal bleeding as evidenced by the resident's brief found full of small blood clots. The resident was constipated and the LN assisted the resident by manually removed feces from the rectum. On [DATE] the Nurses Progress Note documented the resident was constipated with bright red and dark clotted blood. The LN tried to assist the resident to have a bowel movement but was not successful. Eventually, the resident expelled a medium sized, hardened, round stool. The resident's need for [MEDICATION NAME] had increased in the past weeks and her bowel tones were distant. On [DATE] at 2:45 p.m., Staff Member O, a LN, stated on [DATE] the resident was not eating or drinking fluids, had an increase in pain medication, and was constipated. She helped the resident by manually removing feces from resident's rectum. The resident had evidence of constipation, potential bowel obstruction and/or gastric bleeding. She was not drinking fluids and was receiving an opioid narcotic pain medication which all potentially contributed to 10 days without a bowel movement. Additionally, she had rectal blood clots. The facility failed to assess and accurately monitor the resident for bowel changes, including rectal bleeding, which could result in a significant medical complication. Without an accurate assessment and monitoring, physician consultation could not be accurately communicated. Behaviors Resident #160. admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The hospital records dated [DATE] documented his condition was unstable and physician orders [REDACTED]. However, the facility's physician discontinued the [MEDICATION NAME] upon the resident's admission to the facility. The resident's [DATE] comprehensive assessment (7 days after admit) documented severe cognitive impairment, disorganized thinking, and inattention, extensive assist for bed mobility, transfers (2 person assist), dressing, personal hygiene, walking, and toilet use with limited assist for eating. The [DATE] comprehensive assessment (14 days after admit) documented a worsening of his signs and symtoms of inattention and disorganized thinking. In addition, the resident exhibited new symptoms of altered level of consciousness and psychomotor [MEDICAL CONDITION] ( .unusual decreased level of acitivity such as sluggishness, staring into space, staying in one position, moving slowly). The [DATE] Nursing Communication Form identified the resident with behaviors of being sexually inappropriate, yelling, and cursing. The treatment was to be on one-to-one while awake at night. On [DATE] at 5:00 p.m., Staff Member D, a LN, stated that on the 7th of March at 2:00 a.m. the resident had been sitting in his wheelchair next to the nurses' station. She added the resident had a tendency to yell so we tried to distract him by having him sit next to the nurses station. She commented while she was observing the resident she heard a commotion down the hallway. Another resident had fallen, so I left to help, leaving the resident sitting in his wheelchair. I did not think to get anyone else to watch him. When she returned to the nurses' station, the resident was no longer there. She proceeded to look for the resident and found him in another resident's room, undressed, and touching himself inappropriately. On [DATE] at 3:30 p.m., Staff Member E, a NA, stated the resident was aggressive and he tended to walk around at night. He grabs my hands and sometimes hurts my fingers. He is always looking for his wife, calling out her name. On [DATE] at 3:45 p.m., both Staff Member F, a LN, and Staff Member E, stated he was disruptive in the evening; he yelled and called out for his spouse. This has been happening since he got admitted . On [DATE] at 5:30 p.m., Staff Member B, a NA, stated she was present when the March incident happened. She added, the resident moves around in his wheelchair in the hallways at night and sometimes he shows his (private parts). She added he had exposed himself to her the morning of the incident. I know he has to be one-to-one, that I need to focus on him, but I have to care for ,[DATE] other residents. On [DATE] at 10:30 a.m., Staff Member A, the DON, stated the resident had a [DIAGNOSES REDACTED]. When he was first admitted , we discontinued the [MEDICATION NAME]. When asked how they made their determination to stop a newly admitted resident's anit-psychotic, the DON stated the doctor sometimes discontinues a newly-admitted resident's anti-psychotic medication to see how they do in the facility. She added that due to the resident's worsening behaviors, the anti-psychotic had been restarted recently in March. The Nursing Progress Notes dated [DATE] through [DATE] documented the resident was consistently confused, agitated, yelling, calling out for his spouse, using foul language, wandering, being impulsive, and attempting to self-transfer. Additionally, the progress note dated [DATE] documented the resident self-propelled himself into other residents' rooms. The resident's record revealed a Communication Form dated [DATE] revealed the resident was sexually inappropriate, yelling, cursing. Staff documented the resident had gotten worse. Staff document nothing made his symtoms better. The treatment for [REDACTED]. On [DATE] the Nurses Progress Note documented the resident was yelling .Resident kept asking and yelling at nurse when resident's hand went to this nurse's crotch Review of the February and [DATE] Behavior Monitoring Flow Sheets revealed they were incomplete; they lacked specific resident behaviors. On [DATE] at 11:45 a.m., Staff Member G, the Social Worker (SW), stated she had only become aware of the resident's behaviors on [DATE]. Therefore, she had not implemented a behavior care plan nor behavior monitoring flow sheets for the nurses to document the resident's behaviors of wandering, impulsivity, cussing at staff, yelling, calling out and sexually inappropriate. I was not aware of his behaviors. The nurses had not informed me of his ongoing behaviors and I generally do not review the nursing progress notes. She concluded by stating, There was a break in communication. These behaviors were not reported to me. On [DATE] at 12:50 p.m., Staff Member H, the Pharmacy Consultant, stated the approach to take when discontinuing an anti-psychotic medication was to taper the anti-psychotic, not to sudddenly stop it. In spite of the resident's identified unstable condition related to his dementia and behavior, the facility abruptly discontinued his antipsychotic medication and failed to provide the needed care while awake which resulted in inappropriate sexual behavior in front of a female resident. In addition, the plan of care did not identifiy behaviors or interventions for staff to utilize to prevent or minimize those behaviors, thus the resident was unable to achieve his highest level of psychosocial well-being. FOOD allergies [REDACTED].#83. admitted on [DATE] with [DIAGNOSES REDACTED]. The kitchen's allergy list identified he was allergic to strawberries, chocolate and shellfish. The [DATE] initial nursing assessment identifed the strawberry food allergy. The [DATE] nutritional assessment noted he was allergic to strawberries. On [DATE] at 3:00 p.m., the resident was in his room. He stated he was very allergic to strawberries and had experienced life threatening reactions in the past. He described the effect strawberries had on his respiratory system (anaphylatic shock). He reported food service was a concern to him as he had been served strawberries in the form of yogurt, baked goods and/or strawberry Jello on numerous occasions. He started writing down when they were served and kept copies which he displayed. He stated that morning he had made a grievance to management as he was tired of receiving strawberry products. He also said Staff Member K was very good at noticing and replacing the strawberry foods. However, she had been in another hallway and he had since moved. Staff Member K was no longer watching out for him. On [DATE] at 12:00 p.m., Staff Member K, a NA, stated she observed trays for the correct diet and the food allergies [REDACTED].#83's strawberry yogurt back to the kitchen in the morning and get another flavor. When she was off or on evening shift, there had been times strawberry food items had been put on his tray, according to the resident. She didn't know why the

Based on observation, interview and record review the facility failed to monitor and supervise 1 of 3 (#20) sampled residents reviewed for falls and 1 of 5 (#90) residents that required supervision during meals. Failure to supervise a resident that required constant supervision due to impulsivity and repeated falls resulted in harm (left hip fracture) for Resident #20. Failure to provide supervision of Resident #90 placed him at risk for choking. Findings include: Resident #20. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's medical record dated 01/13/16 revealed the resident had left sided weakness, ataxia (lack of muscle control) with left arm, and left visual field loss. He required two staff to assist with toileting and transfers. The resident's plan of care documented he was at risk for falls related to impaired balance, stroke with left sided weakness, left field visual neglect, impulsiveness with poor judgment, medications, and history of falls. Nursing approaches were to keep the resident in common areas visible to staff. Review of the resident's Care Directive (utilized by NA staff), dated 02/17/16, noted the resident was a high fall risk, toilet him before and after every meal, do not leave resident alone in his room, and resident was to be visible to staff in common areas. Review of a facility investigation report revealed on 03/7/16 at 6:45 a.m. the resident was found lying flat on his back with complaints of left hip pain. The resident stated he fell from his wheelchair (w/c). He was noted to be incontinent of urine. The physician was notified and orders were received to transfer him to the hospital. X-rays at the hospital on [DATE] revealed he sustained a left hip fracture. An interview with Staff Member MM, a Nursing Assistant, (a NA) on 03/15/16 at 12:50 p.m. revealed she had transferred the resident out of bed at 6:20 a.m. on 03/7/16 with a NA student. She then toileted the resident. She asked him if he wanted to go back to bed or taken out of the room and he stated no, so she left him alone in his room (despite above noted care directives). An interview on 03/11/16 at 11:00 a.m. with Staff Member BB a Licensed Nurse (LN) revealed she would always keep the resident with her and never leave him alone in his room due to his high risk for falls. She stated that he not only attempted to get up to use the bathroom, but also would try to transfer to his bed or w/c. Interviews on 03/10/16 at 4:45 p.m. with Staff Member U (Occupational Therapist) and Staff Member NN (Physical Therapist) revealed the resident was starting to walk in therapy prior to his fall on 03/7/16. The resident required two staff for toileting and transfers. Review of Progress Notes between 01/14/16-03/06/16 revealed the resident experienced the following falls, including but not limited to: 1) 01/14/16 - Resident found between the bed and the wall. He stated he slid out of bed. 2) 01/19/16 - Resident found by therapy staff attempting to self transfer to his bed from the w/c. 3) 01/21/16 - Therapy staff found the resident on the floor in his room on his left side. He stated was trying to go to the bathroom and fell forward in his chair. 4) 01/22/16 - Resident found in front of the toilet. He stated he was trying to get to the bathroom. Had poor impulse control and safety awareness. 5) 01/23/16 - Resident to be assisted every two hours with toileting to prevent falls. 6) 01/24/16 - Resident had difficulty keeping his position in the w/c- was found twice sliding off the w/c. Resident found later on the bathroom floor. He stated he was trying to get onto the toilet. 7) 01/25/16 - staff educated on placing the resident in visual areas following meals and not leaving him alone in his room. 8) 01/28/16 - Resident continued to be a high fall risk due to impulsiveness, and will self transfer when no one was around. 9) 02/01/16 - Resident tended to lean forward in his w/c and appeared to be close to falling out. He was self transferring into bed when left alone in his room. Staff reminded to place the resident at the nursing station and in visual sight. 10) 02/04/16 - Resident attempted to self transfer when up in his w/c. Must now be placed around the corner from his room or he would self propel and then self transfer. To be toileted when gotten up in the morning, before and after meals, and at bedtime. 11) 02/06/16 - Resident continued to attempt to self transfer if placed in room alone. He was placed at the nursing station to prevent any chance of a fall. 12) 02/08/16 - Resident now seated in high visual areas such as the nursing station during times following meals, and when staff not able to put him to bed immediately. 13) 03/04/16 - Sometimes forgets to call for help and attempts to get up by himself 14) 03/06/16 - impulsive and attempted to self transfer frequently - placed at the nursing station for visual observation Despite the resident's significant history of multiple falls, impaired balance, recent stroke with left sided weakness, left field visual neglect, cognitive impairment, impulsive behavior with poor judgment and safety awareness, difficulty standing without the use of a splint, noted above positioning issues in w/c, and frequent attempts to self transfer; staff failed to closely monitor the resident to prevent falls. Resident #90. admitted in 2014 with dementia. The 02/26/16 comprehensive assessment revealed severely impaired cognitive skills. Eating required supervision with set-up only. On 03/14/16 at 12:30 p.m., the resident was walking down the hall towards his room. A nursing assistant (NA) redirected him back towards the dining room where she stated the resident eats at 12:30 in the assisted dining. On 03/14/16 at 1:00 p.m., the resident was seated at a table, independently eating his food which was bone-in chicken, potatoes and spinach. Nearby tables had residents requiring assistance with their meals either by cueing or being fed by a NA. There was no direct supervision of Resident #90. The resident was holding a piece of chicken and had eaten it down to the bone. He was seated facing slightly away from the table. Using very slow and purposeful movements, he would chew the chicken bones and pick at them with his teeth before setting down the chicken on his pant leg. At 1:10 p.m., he continually was placing the chicken bones on his pant leg then picking them up to try and chew on them. At 1:15 p.m., Staff Member L, an NA, approached the resident and asked if he was done. She then removed the empty plate leaving him the chicken bones. By 1:20 p.m., the resident continued to pick and chew at the meat-less bones with his teeth. His glasses were smeared with a greasy type substance and specks of white flakes were also on the thick lenses which would impair his vision. (His dirty glasses were confirmed by the Registered Dietician who saw him walk out of the dining room). At 1:35 p.m., Staff Member TT, an NA, stood near the resident observing him. She said the resident liked to chew on chicken bones - a very small one was noticed protruding from his mouth. When it was mentioned to the NA, she said, He has a strong personality and we can't take it away from him. It was pointed out to the NA the bone was very small and sharp where he was chewing on the end. She said they just let him have it. She stated she had just asked for the bones but he still wanted to chew on them. The resident removed the small chicken bone from his mouth and then put it back into his mouth. The DON was immediately informed of the situation and went to the dining room. However, upon arriving, the resident had left and was walking in the hallway. The DON said it made sense to de-bone chicken so he was not in danger of swallowing a bone. She then located the consulting Registered Dietician, who was in the facility at that time, and requested the kitchen de-bone the meat. Failure to supervise the safety of the resident's food choices placed the resident at risk of choking or a health complication from eating chicken bones.

Based on observation, interview, and record review, the facility failed to ensure that a new [MEDICAL TREATMENT] resident received the appropriate therapeutic diet for kidney failure, for 1 of 2 residents (#38) reviewed for nutrition. This failure resulted in actual harm to the resident, as evidenced by the resident's rapid weight loss, a decline in protein intake and decreased energy level, all related to the facility not following an appropriate diet. Findings include: Resident #38. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a [MEDICATION NAME] (a large vein located by upper shoulder) catheter placed on right upper shoulder for [MEDICAL TREATMENT]. The Nutrition Data Collection assessment dated [DATE] and completed by Staff Member HH, the facility's Registered Dietitian (RD), revealed that the resident weighed 337 pounds. She noted the resident's diet order was Renal Mechanical Soft. The RD added large protein portions to the diet order, in order to replenish low protein stores and for healing of skin issues. The assessment also noted the resident had an elevated potassium level from a blood draw done on 01/07/16. Review of the written facility definition of a liberal renal diet, as supplied by the Dietary Manager, revealed the diet is high in protein with limited sodium, potassium, phosphorus, and fluids. The Liberal Renal diet is designed for residents who are on [MEDICAL TREATMENT]. Low salt and regular foods are modified to meet the restrictions of this diet. Salt is not used in cooking. A resident assessment dated [DATE] documented the resident was alert and oriented and able to make her needs know. It also revealed the resident was very weak and had difficulty walking. She required assistance of two staff and a hoyer lift (a mechanical device that is used to transfer a resident) to transfer to her wheelchair. The assessment also documented the resident ate in her room and required set-up assistance with her meal tray. Review of Resident #38's weights revealed: 01/09/16 weight = 337 pounds 02/17/16 weight = 306 pounds 02/26/16 weight = 281 pounds 02/29/16 weight = 279 pounds 03/04/16 weight = 277 pounds 03/17/16 weight = 272 pounds (a decrease of 65 pounds, or 19% loss of body weight in less than 10 weeks). A severe weight loss On 03/09/16 at approximately 5:11 p.m., the resident stated that the facility had not given her the correct foods to eat for some time. She stated she was a cook at the hospital and knew what foods she could eat and understood what protein foods she could eat. She explained the facility had repeatedly not given her what she needed for her diet and consistently didn't even do the basics, such as honoring her request for a salad with a boiled egg for one meal a day. I haven't gotten it yet. She stated she had also asked for chicken salad as an afternoon snack before she left to go to [MEDICAL TREATMENT] in the late afternoon, but she never got that either. During the continued interview with the resident, she stated she was on a low salt diet as well as high protein, but on 02/29/16 her food tasted salty. She stated she knew she could not eat it and notified the kitchen of the food not being on her diet. The resident also stated that she was asked to purchase protein bars to take with her to [MEDICAL TREATMENT] so she would have something to eat in the evening. The resident stated she asked the facility RD on 03/07/16 to help her get the right foods to eat. She stated she didn't always have the energy to continually talk to people about her diet and what foods she needed. She further stated she had lost her appetite at this point and the desire to eat due to the fact she did not receive the correct diet. A review of meal tray cards for 03/10/16, 03/11/16 and 03/14/16, found on her lunch trays, described the resident's diet as Liberal Renal/Cardiac diet with large protein portions and dislikes apples, bananas, ham, oranges and tomatoes. On 03/10/16 at lunch, the resident did not receive what she chose on the menu and was not offered a substitute. The resident was to receive, as part of her lunch, a salad with a boiled egg but was served what she described as very tough chicken and canned spinach with a roll and a glass of apple juice. The resident ate part of the roll and nothing else. Additionally, the resident noted she had not received a snack after her [MEDICAL TREATMENT] on 03/09/16 after she returned to the facility. On 03/11/16 at noon the resident was not able to eat her meal and again did not receive a salad with a boiled egg as per her request. There was no alternative offered to the resident by staff. On 03/14/16 at the noon meal, the resident did not receive the salad and boiled egg. She received tomatoes and oranges which are both foods that contain high amounts of potassium and had been designated as disliked food items by the resident as she knew she could not eat them. Review of a progress note dated 02/24/16 by Staff Member HH, the resident was eating approximately 2/3 of her meals and was not consuming enough to meet her caloric needs. The RD noted an 18 pound weight loss and the resident remained at nutrition risk. There were no changes made to her diet at that time. Review of a Monthly Flow Report of meals and snacks consumed from February 2016 through March 14, 2016, revealed an HS (bedtime) snack was documented as offered 16 out of 42 days (38% of the time). On 03/10/16 at approximately 1:30 p.m., Staff Member A, the Director of Nursing (DON), stated that there was a weekly weight meeting on Wednesdays and the dietician, dietary manager, director of nursing and others go over the weights. Staff Member A stated the last time they reviewed the resident's weights was sometime in February. She was not sure if any interventions were done to prevent weight loss or that there were concerns from the resident concerning her diet. The DON stated they were trying to get it together. On 03/14/16 at 1:40 p.m., Staff Member HH, the facility RD, stated she spoke to the resident on 03/12/16 concerning resident's preferences and not receiving her snack since she came back so late after [MEDICAL TREATMENT]. She stated she was unaware until then of the resident's concerns. The RD stated this resident fell through the cracks about what she wants to eat and the facility follow through. I would expect that this resident would be monitored weekly due weight fluctuation and .new [MEDICAL TREATMENT] resident. On 03/21/16 Collateral Staff II, a Registered Dietician-[MEDICAL TREATMENT], stated that the resident's diet was not being followed and not accurate. The type of diet the resident was to receive was very strict and if the facility dietary staff was not educated on these diets it could cause problems for the resident.

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (#50), reviewed for eye drops, was free of any significant medication errors. This caused the resident to be without medication to lower her intraocular eye pressure which was due to severe-stage [MEDICAL CONDITION]. The significant medication error jeopardized the resident's health and safety which would be impacted by further vision loss. Findings include: Resident #50. admitted on [DATE] at an advanced age, she was blind in her right eye with poor vision in the left eye. Review of the February and March 2016 Medication Administration Records (MAR) revealed the resident was receiving Dorzolamide (to decrease inner eye pressure) 2%, one drop in the left eye at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Eye clinic notes dated 03/10/16 revealed the resident had been examined by the opthamologist for her severe stage [MEDICAL CONDITION] of both eyes. The exam noted she had minimal progression and that the THE PATIENT'S IOP (interocular pressure) IS TOO HIGH IN HER ONLY GOOD EYE. The physician's plan and order was to continue the Dorzolamide drops three times a day into the left eye. In addition, [MEDICATION NAME] and [MEDICATION NAME] eye drops were to be given into the left eye. All three medications were being used to decrease the high interocular pressure. The physician wanted to recheck the IOP in a month. However, after returning from the eye specialist, the Dorzolamide was mistakenly discontinued by nursing staff who thought Dorzolamide and [MEDICATION NAME] were the same medication. On 03/14/16 at 11:00 a.m., Staff Member W, a Licensed Nurse (LN), reviewed the Medication Administration Record [REDACTED]. Staff Member W pointed out where, in the MAR, an unknown LN had written [MEDICATION NAME] below Dorzolomide because they are the same medication and so the unknown LN discontinued the Dorzolomide. This eye drop regimen continued without the Dorzolomide eye drops until brought to Staff Member W's attention by the surveyor on 03/14/16 that the opthamologist's order did not discontinue the Dorzolomide. Further review of the MAR indicated [REDACTED] Therefore, the resident had missed a total of seven doses of the medication used to prevent [MEDICAL CONDITION] by lowering the intraocular pressure. Please refer to F 309 for further details for Resident #50.

Based on record review and interviews the facility failed to consult with the physician in a timely manner regarding the deteriorating conditon for 1 of 3 residents (#1) reviewed for a significant change in condition. This failure prevented the physician from being aware of the change in condition for Resident #1, and the opportunity to initiate medical treatment in a timely manner. This resulted in actual harm to Resident #1, who was transported to the hospital where he later expired. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's assessment dated [DATE] noted the resident continued to slowly deteriorate. For the past 24 hours he had been achy all over. He had no fever, cough, or symptoms of urinary tract infection. He had slight nausea and was drinking fluids ok. The physician stated the resident was alert and oriented, frail, pale, in no acute distress. Lab testing was ordered for [DATE] and Tylenol Extra Strength every four hours as needed for joint pain. Review of Progress Notes dated [DATE] at 1:45 p.m. revealed the resident stated he vomited earlier that morning and did not feel good. He was afebrile and his blood pressure was ,[DATE]. At 9:21 p.m. documentation stated the resident's blood pressure that afternoon was low at ,[DATE], thus his blood pressure medications were held. Documentation stated he ate supper in his room. Review of his food monitoring records for [DATE] revealed he ate less than 25% of his meal supper meal on [DATE] - he generally ate approximately 50%. Review of Progress Notes documented by Staff A (Licensed Nurse) on [DATE] at 8:34 a.m. noted the resident was difficult to arrouse at midnight. He did finally arouse and sat at the edge of the bed. He took his medication, but it took several swallows of water. He had wheezes and crackles in all lobes, and was able to clear with coughing. His oral mucosa was very dry and he had difficulty speaking. At 5:00 a.m. he was noted to be too lethargic to swallow safely, thus his medications were held. His temperature at that time was 96.3 degrees, however his blood pressure was low at ,[DATE]. Review of previous blood pressures between ,[DATE]-,[DATE] at 7:51 a.m. revealed a range between ,[DATE] to ,[DATE]. The next entry in the Progress Notes was by Staff B (Licensed Nurse) on [DATE] at 2:01 p.m., which stated the resident's temperature was 101.9 degrees at 7:00 a.m. (significantly elevated from previous temperature of 96.3 degrees at 5:00 a.m.). The resident was lethargic and unable to speak clearly. He did not take any medications. Documentation stated the physician was notified. Review of the physician assessment dated [DATE] at 10:57 a.m. revealed the resident was critically ill, and had significantly declined that morning. He was febrile and did not respond to verbal/tactile stimuli. The physician's [DIAGNOSES REDACTED]. He ordered the resident to be transferred to the emergency room (ER) via 911, as the resident's wish was for full treatment. Review of hospital ER records revealed the resident arrived at theER on [DATE] at 11:35 a.m. with a blood pressure of ,[DATE]. He was in critical condition with [DIAGNOSES REDACTED]. He was admitted to the Intensive Care Unit and expired on [DATE]. Interviews with Staff A on [DATE] at 10:00 p.m., 6:20 p.m. on [DATE], and 3:20 p.m. on [DATE] revealed the following information regarding the resident's condition during the early morning hours of [DATE]: She worried about the resident's condition all night long as she did not like the way he looked. The resident would not wake up at 5:00 a.m. even after trying to wake him up. She stated on ,[DATE] and ,[DATE] she thought she had called the physician at approximately 5:30 a.m. on [DATE] to report she had held his medications and his low blood pressure. Staff A stated she never spoke with the physician, but had left a voice message. However, on [DATE] it was revealed Staff A sent the physician a text message at 6:52 a.m. on [DATE], which stated the resident looks awful today, medications held as he is so out of it and to take a look at him sometime today. Staff B (Licensed Nurse on the dayshift of [DATE]) stated during a telephone interview on [DATE] at 6:15 p.m., when he initially assessed the resident he wasn't doing very well, pretty much unresponsive, couldn't get him to talk. He was not able to take his medications that morning as he was not able to swallow. He was 99% unresponsive. Staff B was unable to recall how he notified the physician (as noted in his Progress Note dated [DATE]). An interview with the above physician on [DATE] at 10:10 a.m. revealed he had no knowledge of the resident's significant change in condition until approximately between 8:,[DATE]:00 a.m. on [DATE], when he arrived at the facility to begin his day. He stated he thought he had gone by the nursing station and Staff B informed him of the resident's elevated temperature, however he had not received any additional information from nursing staff relative to the resident's change in condition. He stated he attended a meeting and did not examine the resident until later that morning, at which time he immediately ordered the resident to be transferred to the ER. Despite the above significant changes in the resident's condition, staff did not consult with the physician in a timely manner, which resulted in a delay in obtaining medical treatment.

Based on record review and interviews the facility failed to identify, assess/evaluate, document, and communicate to the resident's physician and to the on-coming Licensed Nurse (LN) in a timely manner significant changes in the condition of 1 of 3 residents (#1) reviewed on anticoagulant therapy. This failure resulted in harm to Resident #1 as evidenced by the worsening of her condition, and hospitalization with subsequent death. Findings include: Resident #1: admitted to the facility from the hospital on [DATE] with dementia and newly diagnosed [MEDICAL CONDITION] of her right lower leg ([MEDICAL CONDITION] - blood clot). Review of hospital records revealed she was receiving [MEDICATION NAME] and [MEDICATION NAME] (medications used to prevent and treat [MEDICAL CONDITION] with side effects of bleeding). Review of the Initial Data Collection Tool dated [DATE] revealed the resident had some impairment of her cognition with short term memory loss. She was continent of bowel and bladder, and required staff assistance with transfers and repositioning. Review of the Pain Assessment form dated [DATE] and [DATE] noted the resident had pain due to arthritis in her knees and the right leg [MEDICAL CONDITION]. Review of a physician assessment dated [DATE] noted the [MEDICATION NAME] was discontinued that day as the resident's INR was 2.7 (normal range is 2XXX,[DATE].0) and she had displayed no signs of bleeding. The INR test provided information to determine the effectiveness of the [MEDICATION NAME] - how thick or thin the resident's blood was. The [MEDICATION NAME] was ordered to be continued at the same dosage with another INR to be drawn the morning of [DATE]. The goal of [MEDICATION NAME] therapy was to maintain a balance between preventing clots and causing excessive bleeding. Review of a facility investigation report dated [DATE] at 8:30 a.m. revealed two therapists (Staff A and B) had reported to the dayshift LN (Staff C) the resident had expelled blood from her rectal area. No vital signs were taken and the physician was not notified of the situation. There was no documented assessment of the resident by Staff C at that time nor the incident of rectal bleeding. In addition, the investigation revealed Staff C had not reported the above incident of rectal bleeding during shift change at 6:00 p.m. on [DATE] to on-coming Staff D (LN). Further review of the facility investigation revealed Staff D had attempted at approximately 2:00 a.m. on [DATE] to test the resident's INR utilizing a meter device. Initially, the meter read error 5, then a second attempt noted error 6. A third attempt read either error 5 or error 6. There were no further attempts to obtain blood for the INR test until 4:15 a.m. (approximately two hours later). The first two readings at that time revealed error 5 or 6 and the third attempt noted error 7. At that time Staff D consulted with another night shift LN who then obtained a reading of error 7. After consulting the meter device manual at 4:50 a.m. it was noted error 7 meant the INR was greater than 8. At approximately 5:00 a.m. on [DATE] the physician was called to report the high INR results. Upon the physician being informed the resident had no signs of bleeding he ordered to hold the [MEDICATION NAME] and he would see the resident that morning. Review of the manual for the INR meter device revealed that an error 6 in rare cases may equate to extremely high coagulation (clotting) times - above 10. If error 6 is displayed repeatedly, the result must be checked immediately using another method. Long clotting times (above 8) may receive an error 7 message on the meter display. At 6:45 a.m. on [DATE] the resident appeared lethargic and staff was unable to obtain a blood pressure despite several attempts. physician's orders [REDACTED]. Review of hospital records dated [DATE] revealed the resident's INR at the hospital was above 10.0. The resident was diagnosed with [REDACTED]. She expired at the hospital on [DATE]. An interview with the physician on [DATE] at 9:20 a.m. revealed he had no knowledge of the resident's incident of rectal bleeding on [DATE]. He stated had he been informed of the bleeding on [DATE] he likely would have ordered an INR to be done at that time. On [DATE] at 1:00 p.m. interviews with Staff A and B revealed they were in the process of standing the resident up at approximately ,[DATE]:30 a.m. on [DATE] when pink-red blood began spurting from the resident's rectal area. It was approximately eight by ten inches in size on her pad. There were also blood specks on the wall behind the resident. Staff A stated she immediately alerted Staff C of the situation. A telephone interview on [DATE] at 3:00 p.m. with Staff E (LN orientating with Staff C) revealed upon seeing the resident's rectal bleeding Staff C asked her what she would do in that situtation. Staff E told her to call the physician and check her INR result. Staff C noted the INR was 2.7 the previous day on [DATE]. Staff E stated the afternoon of [DATE] she had concerns relative to the amount of pain medication the resident had received in comparison to previous shifts, and the change in the location of the pain - from right lower leg to the left side of her abdomen. She stated the resident had stated to her she wanted to talk to the physician relative to her pain, upon which she informed Staff C of the resident's request. Review of the facility Narcotic Log and resident's Pain Flow Sheet revealed the resident was given pain medication twice on ,[DATE] and ,[DATE], and four times on [DATE]. In addition, the location of the resident's pain on ,[DATE] and ,[DATE] was the lower extremity and on [DATE] the location changed to the resident's left side. Review of the resident's Vital Signs form and an interview with Staff F (Nursing Assistant) on [DATE] at 1:30 p.m. revealed that despite the incident of rectal bleeding at approximately ,[DATE]:30 a.m. on [DATE] there were no further vital signs obtained until 2:06 a.m. on [DATE] (approximately 18 hours later). Review of Progress Notes for [DATE] (day of rectal bleeding) noted no documented assessment of the resident with the exception of complaints of left sided pain at 4:04 p.m. The next documented entry was on [DATE] at 2:06 a.m. which noted her left foot was cold and she would scream when it was touched. She reported pain to the left side from her ribs to her foot and would shout before staff had even touched her. She adamantly refused to allow staff to check her brief, or have her clothing changed, and she did not want to be moved. Despite significant changes in the resident's condition (rectal bleeding, new complaints of left sided pain which increased in intensity, changes in the left foot, and noted INR meter readings) staff did not identify the need for close monitoring and physician consultation as evidenced by a lack of thorough assessments and timely reporting to the physician.

Based on observation, record review and interviews, the facility failed to ensure accurate ongoing assessments were conducted and interventions were implemented to provide timely, necessary treatment and services to ensure a resident without a pressue ulcer, who was a risk for developing pressure ulcers, did not develop one; and to provide timely treatment to promote wound healing for existant pressure ulcers for 5 of 5 residents (#'s 1,2,3,4,5) reviewed for pressure ulcers. This failed practice resulted in actual harm to Resident #'s 1,2,3,4 due to worsening of their pressure ulcers. Findings include: The facility tool for weekly monitoring and documentation of pressure ulcers, Pressure Ulcer Status Record defined staging of pressure ulcers as follows: Stage 1: Intact skin with non-blanching redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hue. Stage II: Partial thicknes loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III. Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not abscure the depth of tissue loss. May include undermining or tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable: Not stageable due to non-removable dressing/device. Not stageable due to the coverage of wound bed by slough and/or eschar. Not stageable due to suspected deep tissue injury in evolution. Purple or maroon discolored area, intact skin or blood-filled blister. Area can be boggy, mushy, firm, warm, or cool. Resident #1. admitted to the facility on [DATE] from the hospital following surgery for [REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed she had impaired cognition with short and long term memory problems. The resident was unable to ambulate and required extensive assistance with two staff members for transfers, toileting, and bed mobility. She displayed decreased functional strength and activity tolerance since her hospitalization . Review of the resident's Braden Scale (assessment to determine risk of skin breakdown) dated 6/19/15 noted she was at risk for skin breakdown. Review of the Weekly Skin Integrity Data Collection form revealed on 7/13/15 a blister was noted by Staff A (Licensed Nurse) in addition to the surgical incision (from leg surgery to repair fracture). However, there was no evidence of documentation of where the blister was located. An interview on 8/31/15 at 1:55 p.m. with Staff A revealed she was unable to accurately recall where the blister was located (as noted on 7/13/15). Review of Progress Notes revealed that 10 days later on 7/23/15 a blister to the resident's right heel was inaccurately (as noted per facility policy) assessed as a Stage I pressure ulcer instead of a Stage II. The pressure ulcer measured 1 by 1.09 inches with no depth and noted redness surrounding the area. A wound treatment was ordered by the physician at that time to be done by staff on a daily basis. Review of the resident's Treatment Administration Record (TAR) for August 2015 noted the prescribed daily treatments were not performed by staff for 15 out of 18 days. On 8/19/15 the treatment order was changed to ever other day, however was not done by staff until 8/21/15. Despite the resident's identified pressure ulcer on 7/23/15 there was no evidence of a thorough assessment of the pressure ulcer until 8/24/15 (one month later), thus staff was unable to accurately determine the effectiveness of the prescribed treatment. Review of the Pressure Ulcer Status Record dated 8/24/15 revealed the area was assessed as unstageable with scant drainage and eschar (dead tissue). The area had increased in size to 0.86 by 1.37 inches with a depth of 0.08 inches. On 8/24/15 at 2:00 p.m. Staff B (Rehab Director) stated the resident spent much time in bed since being admitted to the facility. Her willingness to participate in therapy was minimal and she would stay on her back in bed as she was noncompliant with positioning. Despite the resident spending large amounts of time in her bed since her admission on 6/19/15 and identified pressure ulcer to the right heel on 7/23/15, review of her plan of care noted no plan to keep her heels off the mattress until 8/12/15. Review of the resident's Care Directive form (instructions for nursing assistants) noted no instructions relative to floating her heels or repositioning her every two hours. Observation of the resident's heel on 8/24/15 at 2:45 p.m. noted eschar on the bottom of her right heel. Due to no recent measurements of the pressure ulcer since 7/23/15 the state investigator requested a LN (Licensed Nurse) to obtain measurements. An attempt had been made to float the right heel as evidenced by the use of one pillow, however due to the weight of the resident's leg the intervention was ineffective as evident by her heel touching the mattress. Despite both heels being at risk for breakdown no positioning device was utilized under the left leg. Resident #2. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Skin Condition Report dated 7/24/15 noted on admission the resident had a Stage I pressure ulcer to the right heel which measured 1.8 by 2.34 inches and was red, and boggy (soft, mushy). Review of a comprehensive assessment dated [DATE] by Staff D (LN) revealed the resident displayed impaired cognition and memory impairments. She required assistance by staff with all activities of daily living, incontinent of bowel and bladder, and had limited range of motion to her right leg and arm due to fractures. The assessment inaccurately stated the resident had no pressure ulcers at that time. An interview with Staff D on 8/31/15 at 1:50 p.m. revealed she had not actually performed a skin assessment to determine if a pressure ulcer existed or not, however, there was no paperwork from staff in place informing her the resident had a pressure ulcer to her right heel. Review of the resident's plan of care dated 8/5/15 noted she was at risk for skin breakdown due to need for assistance with bed mobility, incontinency,use of blood thinner medication, and impaired range of motion to her right side. Interventions included to elevate (float) the resident's heels off the bed surface, and weekly skin assessments. Despite a Stage I pressure ulcer noted on 7/24/15 there was no further thorough assessments of the resident's skin condition until 8/19/15 (25 days later). Review of the Pressure Ulcer Status Record dated 8/19/15 noted the pressure ulcer to the right heel had worsened to a Stage II with measurements of 1.56 by 1.76 inches. At that time physician's orders [REDACTED]. Review of the resident's August 2015 TAR revealed the prescribed wound treatment to the right heel (ordered by the physician on 8/19/15 to be done every other day) was not done on 8/19/15, 8/21/15, 8/25/15, and 8/27/15. An interview with Staff C (LN) on 8/31/15 at 3:20 p.m. revealed she had seen the ordered treatment for [REDACTED]. She stated she just started employment on 8/5/15 and was having difficulty completing all the tasks. She stated she had not done the treatment on 8/27/15 as she had assumed management was going to do it. On 8/31/15 at 4:00 p.m. Staff E (Administrator) stated that management had only performed skin audits on 8/27/15 and there had been no plan for them to do any treatments on residents. In addition, she stated Staff A (Licensed Nurse) had been assigned to do a treatment on the resident either on 8/25/15, however she did not do it as she had to admit a new resident to the facility. Observation of the resident's pressure ulcer on 8/31/15 at 3:10 p.m. with Staff A revealed the open area to her right heel (as noted above). When the state investigator asked Staff A to also check the resident's left heel she stated it was boggy. The resident's family member, who was in the room at the time of the skin observation, stated she visited at least twice daily. She stated that prior to the blue boot staff was not elevating the resident's legs to ensure her heels were off the mattress. In addition, since the application of the blue boot to the right heel staff was doing nothing to prevent pressure ulcers to the left heel. The resident spent many hours lying in bed when she visited. She stated when the boot was first applied she asked nursing assistant (NA) staff what it was for and they were unable to tell her why. Review of the resident's Care Directive (kept in her closet) revealed no instructions for NA staff relative to the use of the blue boot, and to float her heels when in bed. Review of Progress Notes dated 9/1/15 noted continuing decline of the resident's skin as evidenced by the following assessment: the right heel had an open, draining, macerated (moist, soft) blister with a ring of light brown tissue surrounding it which measured 1.8 by 1.8 inches; and the left heel was boggy with slight delayed blanching and measured 1.0 by 1.95 inches. Resident #3. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed she was at risk for skin breakdown due to diabetes, [MEDICAL CONDITION], fraility, incontinence, and impaired mobility. Preventative interventions included to elevate her heels off the bed float, and to assist her to turn and reposition every two hours and as needed. Review of the resident's Care Directive dated 9/1/15 noted she required one staff to assist with bed mobility, transfers, and toileting with frequent incontinent episodes. The above interventions to prevent skin breakdown were not listed on the Care Directive to inform NA staff. Review of a Non-Pressure Skin Condition Record dated 7/16/15 noted the resident had been inaccurately assessed initially with a abrasion to her right outer ankle which measured 0.35 by 0.20 inches. Review of Progress Notes dated 7/22/15 (six days later) revealed the area was a Stage II with a black scab with pink delayed blanching. The area had worsened in size as evident by meaurements of 0.39 by 0.27 inches. Documentation stated the resident had been lying on that side. The physician was notified on 7/22/15 of the resident's pressure ulcer with wound treatment orders obtained to be performed by staff every three days. Review of the resident's TAR noted no above treatments were done by staff between 7/28-8/11/15. Between 8/12-8/30/15 there were only five treatments performed to the resident's right heel. Review of the Pressure Ulcer Status Record noted the pressure ulcer had deteriorated on 7/29/15. On 8/12/15 the assessment noted the area had increased in size to 0.39 by 0.39 inches. Despite the pressure ulcer worsening the physician was not notified, thus he was not given the necessary information needed to alter the treatment plan. Observation of the resident on 8/24/15 at 11:20 a.m. noted her to be seated in a wheelchair with her feet on the floor. Her right foot was very [MEDICAL CONDITION] and there were no positioning devices noted in the room to float her heels. Staff C (LN) stated at that time that pillows were not being used on the resident to elevate her feet. Resident #4. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden Scale dated 6/8/15 revealed the resident was at high risk for pressure ulcers. Review of the resident's plan of care dated 6/20/15 noted he was at risk for skin breakdown due to required assistance with bed mobility, incontinence, left sided weakness, and diabetes. Interventions included to float heels off the bed surface. Progress Notes dated 7/10/15 noted the resident sustained [REDACTED]. The skin tear was secured with steri-strips and a [MEDICATION NAME] dressing applied. The resident was discharged to the hospital on [DATE] due to [MEDICAL CONDITION] activity. Review of the hospital physician assessment dated [DATE] noted the resident had a nonhealing, trophic (changes in skin), ulcer of the left heel approximately 1.56 inches in size covered with purulent (containing pus) exudate (fluid). Exact staging was unknown. Review of a Skin Condition Report dated 7/27/15 (readmitted ) noted that despite the above physician assessment on 7/25/15 a LN still assessed the area on the resident's left heel as a skin tear. There was no further thorough assessment of the resident's left heel until 8/25/15 (29 days later) at which time the area was noted on the Pressure Ulcer Status Record as a Stage II pressure ulcer which measured 1.09 by 0.86 inches with a depth of less than 0.04 inches. The area was noted to have a slight odor, scant drainage, and 50% slough (yellow, tan dead tissue). A protective boot was ordered on [DATE] to be on the resident's left heel at all times when in bed. Despite the above noted interventions for the resident's pressure ulcer to his left heel an observation at 11:15 a.m. on 9/1/15 noted him to be lying in bed without the use of the protective boot and his heels were not floated off the bed surface. The protective boot was found in the resident's closet and there were no positioning devices found in his room to elevate his heels off the bed. A telephone interview on 9/1/15 at 10:34 a.m. with the resident's family member revealed she had visited the morning before and found the resident sleeping in bed. She stated the boot was not on the resident's foot, nor were his heels being elevated off the mattress. Interviews with Staff G (LN) and Staff H (NA) on 9/1/15 at 9:53 a.m. revealed the resident would not keep pillows under his legs or the protective boot on at times. Despite the above statements by staff there was no assessment found in the resident's medical record relative to the ineffectiveness of the current interventions, and no documentation to alter the treatment plan to promote healing of the current wound and prevent further pressure ulcers from occurring. Review of the resident's Care Directive (found in the resident's closet) revealed no instructions for NA staff relative to the prevention of pressure ulcers. Resident #5. admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of a nursing assessment dated [DATE] noted he required staff members to assist with transfers, toileting, bed mobility, and ambulation. Review of the Pressure Ulcer Status Record dated 8/1/15 revealed the resident was admitted with a Stage II pressure ulcer to the upper left buttock. The wound measured 0.39 by 0.59 inches with a depth of 0.04 inches. Review of the resident's plan of care dated 8/1/15 noted he was at risk for skin breakdown due to decreased mobility, skin tears, and an existant pressure ulcer. Nursing interventions were to reposition the resident every two hours, perform weekly skin checks, and wound care. Review of Progress Notes dated 8/8/15 the resident was transferred to the hospital due to a change in condition. Progress Notes dated 8/13/14 noted he was readmitted from the hospital following treatment for [REDACTED]. Review of the Pressure Ulcer Status Record dated 8/14/15 (following readmission) noted the pressure ulcer had worsened to a Stage III with measurements of 0.78 by 1.09 inches with a depth of 0.08 inches. Despite the worsening of the resident's pressure ulcer review of the August 2015 TAR revealed no evidence of documentation staff had performed any treatments to the resident's pressure ulcer since admission despite physician orders [REDACTED]. An interview on 8/31/15 at 1:55 p.m. with Staff A (LN) noted she was the Treatment LN for the entire facility until the end of July 2015 when she began training for a Resident Care Manager (RCM) position. Following that time medication LNs were assigned the wound care on residents on their units. She stated some LNs had never done dressing changes before thus some education was provided. Licensed Nurses had to work it (referring to wound care) in as a priority. Staff E (Administrator) stated during an interview on 8/31/15 at 2:20 p.m. the medication LNs on each unit were assigned to take over wound care on 7/26/15. Some LNs felt it was too much work for them and not a priority, while some were willing to do the additional assignments. She stated there had been many recent changes in staff and/or assignments for LNs due to staff leaving (either by termination or voluntarily). On 8/31/15 at 3:00 p.m. Staff F (Corporate LN) stated LNs were too used to having a wound nurse and some were lax on performing treatments. She stated the RCMs for each unit were to do follow-up assessments weekly on wounds and also were responsible for the more complex treatments such as [DEVICE].

Based on record review and interviews the facility failed to identify/evaluate the need to alter the resident's treatment plan and communicate to the physician in a timely manner acute changes in the condition of wounds for 1 of 2 residents (#2) reviewed for skin problems. This failure resulted in harm to Resident #2 who was admitted to the hospital with [REDACTED]. Findings include: Resident #2: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed she required staff assistance with transfers, bed mobility, toileting, personal hygiene, and bathing. She was noted to be at risk for skin problems on admission due to her cardiac history, diabetes, impaired mobility, urinary incontinence, and nutrition deficits. On 7/6/14 the resident developed [MEDICAL CONDITION] and abscesses of her legs (occurs when a skin infection affects the tissue in the leg). Review of a Non-Pressure Skin Condition Record dated 10/3/14 revealed the wound on the resident's right lower leg measured 9.6 by 2.4 inches with 0.08 depth, and the left lower leg measured 7.2 by 6.6 inches with no depth. Eight days later on 10/11/14 the assessment by Staff C (Treatment Licensed Nurse) of the right and left legs noted they had "deteriorated" as evidenced by the following: right leg measured 10.8 by 7.2 inches with 0.08 depth, and left leg was 6.8 by 5.2 inches and had developed a depth of 0.08 inches. The assessment performed by Staff C on 10/17/14 noted further decline as noted by the following: right leg measured 12.4 by 5.2 inches and left leg 5.6 by 9.2 inches with 0.08 depth. The assessments on both 10/11 and 10/17/14 noted red color, moderate drainage, and response to treatment noted "deteriorated." Despite significant changes in the wound, staff failed to identify/evaluate the need to alter the treatment plan until 10/21/14, at which time new treatment orders were prescribed by the physician. Review of hospital records dated 10/22/14 noted the resident was admitted to the hospital with [REDACTED]. An interview on 11/13/14 at 1:10 p.m. with Staff C noted when she observed the above deterioration of the resident's wounds she informed the charge nurse.

Based on record review and interviews the facility failed to provide appropriate, timely care and services to 1 of 3 sampled residents (#1) who exhibited a change of condition. The lack of monitoring/assessments, timely recognition and reporting of a significant change in condition to the physician resulted in delayed treatment and unnecessary pain for Resident #1. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed she had impaired cognition and memory, and required total staff assistance with bed mobility, toileting, and locomotion. Review of Progress Notes dated 7/27/14 revealed the resident had 4+ (significant) [MEDICAL CONDITION] of her left foot and ankle. There was no observed bruising or redness, however pain with movement of the left leg and ankle was present. The physician was notified and was to see the resident the following day (7/28). Documentation on 7/28/14 noted the physician was aware of the increased [MEDICAL CONDITION] and planned to assess the resident. An assessment by Staff A (Licensed Nurse) on 7/29/14 stated staff had noted the resident having increased pain in her left hip, ankle, and foot "over past few weeks" with increased swelling. An x-ray was obtained at 1:00 p.m. that day (7/29) per physician's orders [REDACTED]. Review of a physical therapy (PT) evaluation dated 5/28/14 revealed the resident was able to ambulate 290 feet with hand held assistance by staff. She was discharged from PT at that time and referred to the restorative nursing program, which was initiated on 6/5/14. Review of documentation by restorative staff for June 22-30/14 revealed she refused to ambulate on 6/24-26 and 6/30. She ambulated 75 feet on 6/22, 23/14, and she was not ambulated by staff between 6/27-29/14. Review of the July 2014 Restorative Flow Sheet noted she did not ambulate with staff for the entire month. The following documentation by Restorative Aides (RAs) was noted: 7/2 - resident would not participate and would not attempt to take steps 7/7 - resident would not stand or take a step 7/17 - did range of motion but avoided her left leg as the resident seemed to favor it An interview on 8/21/14 at 2:20 p.m. with Staff B (RA) revealed when she went to assist the resident with ambulation (as part of restorative services) on 7/2/14 she held up her foot like she did not want to put any weight on it. The RA stated this was unusual behavior for the resident so she reported it to the Licensed Nurse (LN). She stated approximately one week later she noted the left foot was swollen and Nursing Assistant (NA) staff stated they couldn't put her shoe on due to the swelling. The RA stated she could not understand why it took so long for treatment to be obtained for the resident. The RA twice reported the change in the resident's foot to licensed nursing staff. She stated for approximately two weeks the resident complained of left foot pain when moving her left foot. The resident's pain was noted by the expression on her face (became reddened and pale) and she would say "ouch" upon movement of the foot. Staff C (RA) was interviewed by telephone on 8/21/14 at 3:40 p.m. and stated she noticed the early part of July the resident's left ankle appeared swollen. She stated when she went to lift up the left foot onto the footrest the resident "winced" in pain, which was new for her. On 7/2/14 when RA staff went to ambulate the resident she lifted her left foot up and would not bear weight on it. The RAs then sat the resident down and reported their findings to Staff A. An interview on 8/21/14 at 2:46 p.m. with Staff D (Restorative Licensed Nurse) revealed Staff B had reported to her that the resident was "favoring" her left side when RA staff when to stand her up and was no longer ambulating. Staff D had questioned Staff B if she had reported her findings to a Licensed Nurse, at which time she stated she had reported to Staff A. Staff A stated during an interview on 8/21/14 at 12:30 p.m. that the resident expressed pain upon transfers, however when she was not moving did not appear to be in pain. She stated "seemed uncomfortable when turning, moving, or with transfers." Despite the above interviews and Progress Notes relative to the resident's pain, review of the resident's July 2014 Medication Administation Record revealed she was not given any medication for pain until 7/29/14 at approximately 4:15-5:00 p.m. Futhermore, despite the resident's change of condition relative to her left leg (swelling, pain, no longer ambulating) in conjunction with her severe dementia and inability to verbally communicate her needs, she was not assessed/monitored by licensed staff in a timely manner as evidenced by the above interviews and documentation, which resulted in a delay in physician notification and treatment.

Based on observation, interview and record review, the facility failed to notify the physician and family representative for 1 of 1 sampled resident (#1) who had a significant change in condition. This resulted in the potential for further health complications related to a delay in [DIAGNOSES REDACTED]. Findings include, but are not limited to: Resident #1. admitted [DATE] with [DIAGNOSES REDACTED]. There was no history of [MEDICAL CONDITION] in her record. A facility notice dated [DATE] for a 'transfer and discharge' to the hospital indicated the transfer was necessary for the resident's welfare due to a needed evaluation of respiratory distress. On [DATE] at approximately 04:30 a.m., the 'emergency medical services' (EMS) report documented the facility had called '911' due to possible [MEDICAL CONDITION] activity at 4:00 a.m. with "sudden onset" of breathing difficulty. Hospital medical records dated [DATE] revealed the resident was admitted to the hospital for respiratory distress, possible stroke, and was also diagnosed with [REDACTED]. Further, she had dark purple bruising from the center to the left side of her neck, and bite mark on her tongue and lip. An [DATE] orthopedic consultation documented a "2-part spiral fracture at the surgical neck of the humerus with almost 30 degrees of angulation...not significantly displaced...at the fracture site, the humeral head and shaft are rotated." Review of the resident's nursing home records and the facility's investigation into the resident's bruising and fractured shoulder revealed the following information from [DATE] at 11:30 p.m.: Staff Member B heard the resident "choking" and went into her room to find her stiff, pale with white face, purple lips, and eyes rolled back. The resident did not respond and the aide gave her two "rescue breaths" before calling another aide to get the Licensed Nurse/Staff Member A. Upon arriving in the room, Staff Member A found the resident had a "bluish tint" to her lips, was breathing and with a pulse, but had "some upper airway congestion." Staff Member A started 10 liters of oxygen/minute through a mask. Staff Member B stated she had started cardiopulmonary resuscitation (CPR) and completed 11 chest compressions before the licensed nurse and the second aide had arrived. Both Staff Member B and Staff Member C observed two red side-by-side bruises on the residents neck. After her breathing was stablized, the oxygen was removed. Also, the resident refused to be turned for toileting as she was in too much pain from her left shoulder. Staff Member A gave her pain medication. However, Staff Member A made the decision to wait until the morning to notify the physician and family member due to the late hour. Frequent visual checks were completed during the night until 4:00 a.m. ([DATE]) when the resident was provided care; she continued to complain of left arm/shoulder pain. A short time after leaving the room, the aide heard the resident choking and gurgling and entered to see her back arched off the bed, head tilted back, eyes rolled back and arms and legs stiff and convulsing. Staff Member A also entered the room and stated she observed the resident's arms and legs jerking for approximately one minute. The resident's lower lip had "fresh" bite mark with the tip of her tongue sticking out. Oxygen was reapplied and EMTs were called. On [DATE], the resident was in the hospital wearing a sling on her left arm. She stated she did not know what happened that caused her injuries and could not remember what occurred the night before her hospitalization . On [DATE] at 1:00 p.m., the resident's family and representative stated she had not been notified that the resident had CPR started at approximately 11:30 p.m. on [DATE]. She stated she should have been called. The facility failed to notify her physician when the resident had a sudden change in condition at 11:30 p.m. on [DATE]. This significant change in condition had resulted in the performance of CPR when as the resident was non-responsive and her physical appearance suggested lack of oxygen due to her skin coloring. Oxygen was administered (without a physician ordered) at a high concentration until the resident's oxygen level, mental state and skin color returned to normal. Further, immediately following the CPR, the resident complained of left shoulder pain to the point she was unable to be repositioned with staff assistance. She also had two red bruises on her neck. At 4:00 a.m., the resident was continuing to complain of left shoulder pain. Approximately four plus hours after the change in condition, the resident had [MEDICAL CONDITION] activity and respiratory distress that resulted in hospitalization .

Based on record review and interviews the facility failed to provide the necessary care and services related to pain management for 1 of 4 sampled residents (Resident #1) reviewed for pain issues. This potentially resulted in unrelieved pain for the resident. Findings include: Resident #1: admitted to the facility on [DATE] from home with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Progress Notes noted documentation on 5/27/12 stating the resident had a [DIAGNOSES REDACTED] which caused frequent headaches. The resident was noted to be easily agitated and did not respond well to increased stimuli/direction. She was able to ambulate independently and was oriented to self only, not able to clearly state her needs. Review of Progress Notes noted on 5/29/12 at 12:17 a.m. documentation stated the resident's family member brought the resident's narcotic pain medication ([MEDICATION NAME]) to the facility. Later that day (5/29/12) the physician was notified of the resident's behaviors as Tylenol was the only medication prescribed at that time. The physician ordered [MEDICATION NAME] (antianxiety medication) to be administered every six hours as needed for agitation. Progress Notes between 5/30-6/5/12 noted episodes of agitation continued as evidenced by: slapping and throwing water at staff, refusals of care and food, spitting out her medication at times, entering other residents' rooms, grabbing items off the medication cart, and restless behavior. Review of the resident's plan of care dated 5/27/12 addressed the resident's chronic hip pain and arthritis. The plan of care stated the resident had dementia and was unable to verbalize the site or intensity of her pain. Nursing approaches were to observe for increased agitation/fighting that might indicate the resident had pain or increased pain, and reassess the effectiveness of pain management every shift and as needed. Review of the May and June 2012 Medication Administration Records revealed the resident only received three doses of Tylenol and the [MEDICATION NAME] was never administered during the resident's stay between 5/27-6/5/12. No pain medication was administered between 6/1-5/12. Staff failed to provide prescribed narcotic pain medication to the agitated resident for generalized pain relief. This failure prevented the facillity from determining if some of the residents' agitated and combative behaviors may have been related to untreated pain causing her needless distress.

Based on record review and interviews the facility failed to provide the necessary care and services related to pain management for 1 of 3 sampled residents (Resident #2) reviewed. This failure resulted in unrelieved pain and anxiety for Resident #2 for a extended period of time. Findings include: Resident #2: admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the resident's plan of care revealed a problem addressing the resident's potential for pain related to her above diagnoses. Interventions included administration of the above routine narcotic medication. Review of Progress Notes dated 5/13/12 at 8:32 a.m. stated the resident was upset last night complaining she was not getting proper care and the Licensed Nurse (LN) not being able to attend to her needs relative to her joint pain. The resident had verbalized concerns of taking her pain medication in a timely manner. Documentation later that same day (5/13/12) at 3:55 p.m. referenced the resident missing a dose of her [MEDICATION NAME] at 11:00 a.m. on 5/12/12. An interview with the resident on 6/12/12 at 3:50 p.m. revealed the [MEDICATION NAME] ordered for 11:00 a.m. was given "real late ...almost time for the next dose." After waiting 30 minutes she put her call light on and informed Staff Nursing Assistant (NA) A she had not yet received her 11:00 a.m. pain medication and to let the LN know. She stated the NA informed her after checking with the LN that she had already received her pain medication. The resident had put her call light on several times with Staff NA A informing her each time she had already received her medication as that was what the LN had told her. She stated the LN was new to her and never checked with her regarding her pain medication. She stated she had "horrific" pain in her bladder, lower abdomen, and hip joints and once she got off her schedule it became very difficult to get the pain under control. Staff NA A stated in a telephone interview on 6/13/12 at 9:04 a.m. the resident had put her call light on "several times asking for something for pain." She stated several times she had informed Staff LN E the resident in Room (gave specific room number) needed pain medication and the response by LN E was that she had already received everything she could have. Staff NA A stated the resident was very upset regarding her pain medication. A telephone interview on 6/13/12 at 8:57 a.m. with Staff LN E revealed she had not administered the resident's pain medication at 11:00 a.m. on 5/12/12 as she was pulled to the other end of the hallway to attend to another resident and forgot to give the medication. She stated she understood Staff NA A to inform her that Resident #4 (resided in the room next to Resident #2 and had the same first name ) was requesting pain medication rather than Resident #2. She stated she had already given everything Resident #4 could have for pain and had gone into her room to explain that to her not realizing she had the wrong resident. Staff NA A had come to her approximately six times within 30 minutes requesting the resident needed something for pain. An interview with Staff LN F on 6/12/12 at 4:20 p.m. noted the resident was "very concerned about the situation" regarding her missed pain medication at 11:00 a.m. She stated she could not wait until 5:00 p.m. for the next scheduled dose thus it was administered at 3:30 p.m. (4.5 hours after it was ordered). Review of the Narcotic Log Book revealed the resident only received three doses of [MEDICATION NAME] on 5/12/12 (5:00 a.m., 3:30 p.m., and 10:30 p.m) rather than the prescribed four doses.

Based on record review and interviews the facility failed to ensure 1 of 9 sampled residents (Resident #1) was free from neglect. Failure to ensure prompt interventions were provided for Resident #1's condition changes resulted in harm to the resident. Findings include: Resident #1: Review of the resident's comprehensive nursing assessment dated [DATE] revealed he had no cognitive impairments and was able to make himself understood. Review of a facility investigation report noted on 9/19/10 at approximately midnight the resident began complaining of stomach pain to Nursing Assistant (NA) #1. Nursing Assistant #1 informed Licensed Nurse (LN) #2 of the resident's complaints of nausea with "dry heaves". A written statement by LN #2 revealed upon assessment at that time the resident was complaining of mild tenderness in his stomach but declined the offer made by LN #2 to go to the hospital. Shortly before 3:30 a.m. the resident put his call light on. Nursing Assistant #1 found the resident seated at the edge of his bed stating "he was hurting in his abdomen really bad, and wanted to go to the hospital". Nursing Assistant #1 went immediately to the nursing station and informed LN #2 (in front of NAs #'s 2 and 3) of the condition of the resident and his statement of wanting to go to the hospital. Licensed Nurse #2 responded by stating she was going on a cigarette break first and then she would see him. The cigarette break took approximately 15 minutes. The investigation noted approximately 20-30 minutes elapsed before LN #2 entered the resident's room to assess him. Review of the resident's medical record noted documentation on 9/19/10 by LN #2 at 4:30 a.m. stating the resident complained of pain in all abdominal regions. The resident was nauseated and had vomited yellowish-green bile. He was requesting to be sent to the hospital, thus physician's orders [REDACTED]. Review of hospital records revealed the resident had an acute onset of abdominal pain thus was admitted to the hospital. He remained in the hospital for five days. An interview on 9/22/10 at 1:20 p.m. with NA #1 revealed that upon answering the resident's call light at approximately 3:30 a.m. on 9/19/10 the resident was seated at the edge of his bed "doubled over in pain". He stated the resident "usually never has stomach pain", nor did he sit at the edge of his bed at night. During a telephone interview on 9/22/10 at 1:55 p.m. NA #2 stated NA #1 came to the nursing station the morning of 9/19/10 and reported to LN #2 the resident "had severe abdominal pain and wanted to go to the hospital". She stated that immediately following the information given to LN #2 she (LN #2) went outside to smoke for approximately 15 minutes. An interview on 9/26/10 at 11:10 a.m. with the resident noted he had informed LN #2 at 11:00 p.m. on 9/18/10 he was nauseated with dry heaves and had left sided abdominal pain. Nothing was done at that time and no one checked on him until he put his call light on later that night. He stated at that time NA #1 responded and was informed he was vomiting bile and had increased pain in his stomach. He stated he informed NA #1 to get the LN. He then waited approximately 30 minutes before LN #2 came to his room. Despite the resident's change of condition at the beginning of the above night shift there was no monitoring of the resident's condition nor documented assessment by LN #2. When the resident's condition worsened as evidenced by increased abdominal pain, vomiting, and requests by the resident to go to the hospital, LN #2 failed to respond to the resident's acute condition change in a timely manner.