Every finding on record at Life Care Center of Mount Vernon

Based on interview and record review, the facility failed to complete annual staff performance reviews as required and provide education based on the outcome of these reviews for 5 of 5 sampled staff (Staff E, F, G, H and I) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings included . Review of the facility staff list documented: - Staff E, Certified Nursing Assistant (CNA) was hired 01/17/2025, - Staff F, CNA, was hired 04/09/2024, - Staff G, CNA, was hired 02/06/2024, - Staff H, CNA, was hired 08/13/2024, and - Staff I, CNA was hired 05/07/2025, The most recent performance evaluations for Staff E, F, G, H and I were requested on 07/22/2026 and none were provided. In an interview on 07/23/2026 at 10:57 AM Staff A, Administrator, stated they were unsure if they would be able to provide proof of performance evaluations for Staff E, F, G, H, and I. In an interview on 07/23/2026 at 11:16 AM, Staff C, Regional Nurse Consultant, stated performance evaluations for Staff E, F, G, H, and I were not completed. Reference: WAC 388-97-1680(1)(2)(a-c)

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- assessment/a federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) level I were referred for a PASRR level II and followed up on for 5 of 7 residents (Residents 1, 11, 14, 16 and 60) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life. Findings included . Review of the facility policy, dated 09/26/2025, titled Pre-admission Screening and Resident Review), documented that admissions are to be screened for possible serious mental disorders. The PASRR level I is completed prior to admission and if positive an in-depth evaluation must be conducted, PASRR level II, prior to admission to a nursing facility. The level II PASRR determination and evaluation specify services to be provided by the facility and/or by the State. Recommendations from the PASRR level II are to be incorporated into the care plan. <RESIDENT 1> Resident 1 was admitted to the facility on [DATE], with diagnoses to include depression, bipolar disorder (manic and depression episodes) and anxiety. Review of Resident 1's PASRR level I, dated 03/23/2025, documented an exempted hospital discharge with instructions that a PASRR level II must be completed if a scheduled discharge did not occur in 30 days. Review of Resident 1's medical record found no documented PASRR level II follow-up. In an interview on 07/24/2026 at 10:02 AM, Staff D, Social Services Director (SSD), stated they did not locate any documented PASRR level II follow-up. <RESIDENT 14> Resident 14 was admitted to the facility on [DATE], with diagnoses to include depression and anxiety. Review of Resident 14's PASRR level I, dated 03/24/2026, documented they required a PASRR level II evaluation. Review of Resident 14's PASRR level I notice of determination, dated 03/26/2026, documented they would receive a PASRR level II evaluation. Review of Resident 14's progress note, dated 06/15/2026 at 2:25 PM, documented they had been referred for a PASRR level II evaluation. Review of Resident 14's PASRR level I, dated 07/16/2026, documented they required a PASRR level II evaluation. In an interview on 07/24/2026 at 10:02 AM, Staff D, SSD, stated they did not know if there was follow up between 03/30/2026 and 06/15/2026. Staff D stated they previously had an assistant who may have corresponded with the PASRR level II evaluator. <RESIDENT 16> Resident 16 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder and depression. Review of Resident 16's PASRR level I, dated 01/26/2026, documented an exempted hospital discharge with instructions that a PASRR level II must be completed if a scheduled discharge did not occur in 30 days. Review of Resident 1's progress note, dated 06/11/2026 at 2:30 PM, documented they had been referred for PASRR level II. In an interview on 07/24/2026 at 10:02 AM, Staff D, SSD, stated they were unable to locate or provide any documented PASRR level II follow-up. <RESIDENT 60> Resident 60 was admitted to the facility on [DATE], with diagnoses to include bipolar disorder, vascular dementia (dementia caused by reduced or blocked blood flow and the delivery of oxygen and nutrients to the brain causing memory loss, confusion, mood swings, and cognitive impairment), anxiety, and hallucinations. Review of Resident 60's PASRR level I, dated 05/02/2023, documented a PASRR level II evaluation referral required for significant change. Review of Resident 60's medical record found no PASRR level II had been completed. In an interview on 07/24/2026 at 10:02 AM, Staff D, SSD, stated they should follow up with the PASRR level II evaluator a few days or a week before the 30-day hospital exemptions were up. Staff D stated there would be progress notes documented when any communication to the PASRR level II evaluator was attempted or completed, and they should attempt follow-up with the PASRR level II evaluator every 1-2 weeks. Staff D stated they were unable to locate documented PASRR level II follow-up. <RESIDENT 11> Resident 11 was admitted to the facility on [DATE] with diagnoses to include schizophrenia (a serious mental disorder that makes it hard for a person to tell what is real, manage their emotions, and think clearly), anxiety, and depression. Resident 11 had a hospital stay on 05/31/2025 and readmitted to the facility on [DATE]. Review of Resident 11's admission level I PASRR, dated 04/28/2025, documented No level II evaluation indicated at this time due to exempted hospital discharge, Level II must be completed if scheduled discharge does not occur). A level II PASRR invalidation was documented as the individual has been discharged out of the nursing facility, on 06/30/2025. Review of Resident 11's electronic medical record did not show a follow-up for the positive level I PASRR until 06/10/2026. In a joint interview on 07/22/2026 at 11:25 AM, Staff D, SSD, and Staff DD, Regional SSD, stated that Resident 11 should have had follow-up regarding the positive level I PASRR before 06/10/2026. Staff D stated that their process was to follow-up within 30 days with the PASRR coordinator if they have not heard back and then document in the progress notes. Staff D and Staff DD did not locate any documented PASRR level I follow-up for Resident 11. Reference WAC 388-97-1915(4)

Based on observation, interview and record review, the facility failed to ensure resident food preferences were honored for 3 of 3 residents (Residents 2, 23, and 38) reviewed for food preferences and substitutes. This failure placed residents at risk for weight loss, dissatisfaction with their food and diminished quality of life. Findings included . Review of the facility policy titled, Food Preferences, reviewed 05/12/2026 documented individual food preferences are honored to enhance the resident's satisfaction with food and dining. The preferences are obtained during admission and updated quarterly and as needed.preferences are maintained by the director of food and nutrition services or designee. included are likes/dislikes, food tolerances/allergies, special requests, and specific beverage preferences. Review of the facility policy titled Menus, Substitutions, and Alternatives, revised 05/20/2026 documented residents who express a refusal of the food served or request a different meal choice are offered a substitute of similar nutritive value.menus items vary for the same days of a consecutive weeks.menus meet the nutritional needs of residents.has planned alternatives that are nutritionally equivalent, and will provide alternatives of similar nutritive value to residents. <RESIDENT 38> Resident 38 admitted to the facility on [DATE] with diagnoses to include a fracture of the left lower leg, type two diabetes and protein-calorie malnutrition. The admission Minimum Data Set (MDS – an assessment tool) dated 07/10/2026 documented the resident had intact cognition and needed set-up or clean-up assistance for meals. Review of Resident 38's nutritional assessment dated [DATE] completed by a registered dietician documented that they like to eat greek yogurt, prunes or prune juice for breakfast and that food and beverage preferences would be honored. In an observation and interview on 07/24/2026 at 9:04 AM, Resident 38 stated they like to have greek yogurt and prune juice for breakfast every morning. Resident 38 stated that the facility told them that they would have to provide their own greek yogurt and prune juice, which they have been doing. Resident 38 stated that providing their own food was a hassle and would rather have the facility provide it if possible. Resident 38 had a small can of their own prune juice opened on their bedside table. Review of Resident 38's provider progress note (Collateral Contact 1) dated 07/10/2026 at 8:21 PM, documented Resident 38 preferred daily greek yogurt and prune juice as an effective intervention for constipation and would inform the nurse. In a provider progress note on 07/20/2026 at 3:39 PM, they documented that orders were placed for diet preferences with prune juice and greek yogurt daily. In an interview on 07/24/206, Staff O, Food Service Director, stated that they have prune juice available and could order greek yogurt through their food vendor. In an interview on 07/24/2026 at 2:12 PM, Staff O, stated that Resident 38's preferences were not on their diet slip but would add them. Staff O stated that the registered dietician was supposed to communicate with them regarding resident preferences. In an interview on 07/24/2026 at 11:12 AM, Staff B, Director of Nursing, stated they had prune juice available in the facility and was unsure why Resident 38 was told to buy their own. Staff B stated that Resident 38 preferred a specific greek yogurt that they would need to continue to supply themself. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] with diagnoses that include Crohn's disease (lifelong disease of the bowel, causes inflammation and irritation of the digestive system) with a colostomy (external opening of digestive system to divert waste) and diabetes. The admission Minimum Data Set (MDS – an assessment tool) dated 07/01/2026 documented the resident had intact cognition, was independent with meals and snacks between meals were very important to them. Review of Resident 2's dietary physician order dated 06/26/2026 documented the resident needed a consistent carbohydrate diet (CCHO – diet to stabilize blood sugar levels). Review of Resident 2's nutritional assessment dated [DATE] completed by a registered dietitian documented the resident liked chicken and pizza, the resident did not consume grains/starches and avoided carbonated beverages and pastas due to output issues. In an interview on 07/21/2026 at 9:39 AM, Resident 2 stated they wished the facility provided more diabetic choices for beverages, and the breakfast was always the same thing: toast, piece of sausage or bacon, and fake eggs, there was never any other variety. In an interview on 07/22/2026 at 9:49 AM, Resident 2 reported breakfast was the same thing today, fake eggs (made a square motion with their hands), one slice of bacon and toast. They stated they don't eat toast, too many carbs and they only have one sugar free orange drink that does not taste good, it was too sugary. In an observation and interview on 07/23/2026 at 7:45 AM, Resident 2's breakfast tray was at the bedside. Resident stated the breakfast was the same as the past two days, eggs, one sausage and toast. They reported they ate a few bites of eggs and sausage; toast was observed sitting on the tray untouched. The resident's dietary card was on the tray, under preferences, likes/dislikes there was nothing listed. In an observation and interview on 07/23/2026 at 12:40 PM, Resident 2's lunch tray was in the room at the bedside, the dietary card on the tray was blank under preferences, likes/dislikes. They stated there were not a lot of diabetic friendly snacks offered, when they ask for a snack, they would bring cookies, or peanut butter and jelly sandwiches, the resident stated some cheese sticks would be nice. In an interview on 07/24/2026 at 7:53 AM, Resident 2 reported breakfast was the same fake eggs, one small sausage patty, and toast they never eat or want. In an observation on 07/24/2026 at 12:43 PM, a diabetic lunch tray was delivered for a sample tray from the kitchen. The diabetic lunch consisted of shrimp, white cream sauce and pasta, mixed vegetables and a chocolate chip cookie. No condiments were offered. The drink was an orange sugar free drink. In an interview with on 07/24/2026 at 12:48 AM, Resident 2 reported they requested the kielbasa and peppers for lunch because pasta was not something they like or eat. They reported they did get a chocolate chip cookie for dessert, which they did not eat, as it was not sugar free. <RESIDENT 23> Resident 23 admitted to the facility on [DATE] with diagnoses that include diabetes and iron deficiency. The admission MDS dated [DATE] documented has mild cognitive impairment and required set up assist for meals. Review of Resident 23's dietary physician order dated 07/15/2026 documented the resident needed a CCHO diet with foods that were easy to chew. Review of Resident 2's nutritional assessment dated [DATE] completed by a registered dietitian documented the resident liked macaroni and cheese and potato soup, and disliked salmon. In an observation on 07/22/2026 at 8:17 AM, Resident 23 had their breakfast tray at bedside. The meal was one piece of dry toast, a piece of sausage sitting on the side of the toast, milk and juice. They were asked if they were going to eat the meal, and they made a crinkle face to show dislike. In an interview and observation on 07/23/2026 at 7:40 AM, Resident 23 was lying in bed, breakfast was at the bedside covered. Resident was asked if they were going to eat and they stated they were not hungry now. On the plate were two slices of dry toast with one small sausage sitting on the side of the toast, a glass of milk and glass of red juice as provided. Dietary card read the resident disliked eggs. No preferences were listed. In an observation on 07/24/2026 at 7:50 AM, Resident 23's breakfast tray consisted of one piece of dry toast, one small sausage, and a bowl of cream-of-wheat. Dietary card preferences were blank, dislike was eggs. In an interview on 07/24/2026 at 1:51 PM, Staff O, Food Service Director stated the dietary preferences and likes/dislikes were obtained by the registered dietician (RD) when they do the nutrition assessment. Staff O stated they then provide the information to them, and they input those into the system so it will be visible on the dietary cards. Staff O stated they do not usually visit new residents and just wait for communication from the RD. Staff O was requested to provide dietary cards for Resident 2 and Resident 23. In an interview and record review on 07/24/2026 at 2:12 PM, Staff O provided dietary cards for breakfast, lunch and dinner for Resident 2. Staff O stated the RD had emailed the information to them, and they inputted it on to the dietary cards. Resident 2's dietary card read they disliked scrambled eggs, under preferred beverages was listed flavored water, under preferences it was still blank. Staff O was not aware Resident 2 preferred to not get grains or pastas and stated they would follow up. Staff O stated there were no updates provided by the RD for Resident 23, and was not aware of their likes for macaroni and cheese and potato soup, or their dislike for salmon and stated they would follow up with the RD. In an interview on 07/27/2026 at 11:30 AM, Staff A, Administrator, stated it was their expectation Staff O was out on the floor visiting with the residents to check in on how the food was, and how they can make it better. Staff A was not aware of the preferences, likes/dislikes and diabetic substitutes were not reflected or offered to the residents. Refer WAC 388-97-1100(1), 1120(3)(a)

Based on observation and interview, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 2-nourishment refrigerators. The failure to ensure the kitchen and nourishment refrigerators were free from potential contaminants left residents at risk for food contamination, food borne illnesses, and spoiled food.Findings Included .During the initial tour of the kitchen the following was observed:-On 07/21/2026 8:52 AM observed a full box of spoiling (covered in white patches consistent with mold) cucumbers in the walk-in refrigerator. Next to the box of cucumbers was another box of cucumbers that were not spoiled.-On 07/21/2026 at 9:09 AM, food debris were observed behind the stove.-On 07/21/2026 at 9:11 AM observed the floor under the meat preparation sink/counter to have a garbage can lid, wet floor sign, an oven grate and a red bucket in far back. The floor contained food debris and other matter that could not be identified.-On 07/21/2026 at 9:16 AM observed the juice refrigerator to not have a temperature gauge inside of the unit.-On 07/21/2026 at 9:17 AM observed the vent above the ice machine to contain a thick layer of dust. The ceiling tiles next to the vent and the wall adjacent had brown colored food splatters on them.In an interview on 07/21/2026 at 9:17 AM Staff O, Food Services Director stated they complete a daily walk through of the kitchen to include the refrigerator. Staff O stated they were unaware of the spoiled cucumbers and observed them dispose of the spoiled cucumbers. Staff O stated the vents were cleaned and maintained by maintenance and would place a work order to have them cleaned. Staff O stated there were weekly and monthly cleaning checklists, to include a deep cleaning process that were utilized to ensure the kitchen was clean. Staff O stated they were not aware of there not being an additional temperature gauge in the juice refrigerator and stated they would need to order one.On 07/21/2026 at 12:35 PM observed the freezer located in the juice room (area outside of the kitchen) to have light brown splatters of a sicky substance with lint and dust in it, on the inside of the door and rim.In a follow-up visit to the kitchen on 07/24/2026 at 9:01 AM observed the following:-On 07/24/2026 at 9:01 AM observed a fan located in the right corner of the dishwashing room pointing toward the clean side. The fan was observed to have a layer of dust on the fan blades and protective grate surrounding the fan.-On 07/24/2026 at 9:01 AM garbage and food debris were observed on the floor near the garbage can located next to the dirty side of the dishwashing room. Observed dried food, white ice cream paper lid stuck to the floor with brown edges, white sugar packets with brown edges, salt and pepper packages and pink alternative sweetener packages on the floor. Observed dust adhered to the back of the dishwasher wall.In an interview on 07/24/2026 at 9:01 AM Staff O stated the dishwashing room was cleaned weekly and the wall behind the dishwasher needed to be wiped down.On 07/24/2026 at 8:35 AM observed the juice room refrigerator and freezer to contain multiple sticky splatters and debris.On 07/24/2024 at 8:35 AM Staff O stated the refrigerator and freezer, located in the juice room, required cleaning and was not sure who was responsible for maintaining the cleanliness, but would ensure it would be completed. Staff O stated the juice room was a shared space. Reference WAC 388-97-1100 (3)

Based on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for 1 of 1 juice room (room located just outside the kitchen) and 1 of 3 shower rooms. This failed practice placed residents at risk for injury, a diminished quality of life, and potential illness related to unclean/unsafe conditions. Findings included . <JUICE ROOM> In observations on 07/21/2026 at 8:47 AM, 07/23/2026 at 8:45 AM and 07/24/2026 at 8:35 AM, the cabinets located under the juice machine, contained a soiled white towel on the lower shelf with black spots and brown edges on it and maroon tablecloths had an off-white fuzzy substance covering the top of the fabric. The cabinets under the sink, next to the juice machine, were observed to have a brownish/yellowish sludge under the plumbing components. There was a plastic bucket located to the left of the cabinet, not under the plumbing components, which also contained a brown/yellowish sludge. In an interview on 07/24/2026 at 8:35 AM Staff O, Dietary Manager, stated the juice room was shared space. Staff O stated they did not know who was responsible for cleaning the space and might be housekeeping. Staff O observed the condition of the cabinets under the juice machine and sink and stated they would place a work order. In an interview on 07/24/2026 at 8:41 AM Staff BB, Housekeeping Assistant, stated they cleaned the juice room by mopping, sweeping, taking out the garbage and wiping the countertop. Staff BB stated they did not clean the inside of the cupboards nor cabinets. In an interview on 07/24/2026 at 8:51 AM Staff A, Administrator, stated they were aware there was an issue with the plumbing in the juice room, but was told by the previous maintenance director it was repaired. Staff A stated they were unaware the plumbing issues continued to be an issue. <SHOWER ROOM> In an interview on 07/22/2026 at 11:00 AM, an anonymous resident stated they were concerned about the condition of the main shower room, located across from the nurse's station. anonymous resident stated they had several allergies to mold, and the shower room was in disrepair and had mold growing in the grout. On 07/24/2026 at 10:26 AM the main shower room was observed to have missing tiles on the floor where showers took place, and there was no grout in between the tiles where the showers took place. The space in-between the tiles contained a dark colored substance and was visibly wet, some of the tiles were black and discolored. There was a strong putrid and musty odor coming from the area where the showers took place. The tiles on the bottom portion of the walls to the left and right were observed to have a pink film covering them. In an interview on 07/24/2026 at 11:13 AM, Staff AA, Maintenance Director, stated they were unaware of the issues in the main shower room. Staff AA pointed out there was missing grout and tiles that needed repair. Staff AA stated there may be an issue with how the tiles were installed and repairs would need to be made. Staff AA stated there was a distinct foul odor present in the shower area and they would need to remove the tile to determine the cause of the odor and needed repairs. In an interview on 07/27/2026 at 10:31 AM, Staff A stated they were unaware of missing tiles in the bathroom, had recently asked for a remodel to shower room which was denied, and have closed the shower room until repairs could be completed. Reference WAC 388-97-3220(1)

Based on observation, interview and record review the facility failed to ensure residents were free from potential restraints for 1 of 1 resident (Resident 8) reviewed for accidents. The facility failed to identify, obtain consent for the use, assess for safety, and care plan potential restraints used on a resident. This failure placed residents at risk for potential restraints, injury, and diminished quality of life. Findings included .Resident 8 was admitted to the facility on [DATE] with diagnoses that included brain bleed, limitation of activities, and muscle weakness. The admission Minimum Data Set (MDS - an assessment tool) dated 05/28/2026 documented the resident had mildly impaired cognition, they had no impairments to their extremities, was dependent on staff for dressing, showering, personal hygiene and transfers, and had no history of falls. In observations on 07/21/2026 at 10:25 AM and 10:55 AM, Resident 8 was observed lying in their bed. The bed was in the lowest position relative to the floor, the bed controls were hooked on the side of the footboard at the end of the bed and out of reach from the resident. In an observation on 07/21/2026 at 11:40 AM, Resident 8 was observed in a tilt-n-space (a specialized mobility device that allows the entire seat, backrest, and footrests to pivot backward as a unified system) wheelchair. The chair was slightly tilted back in a recline position, the controls to release the chair from a recline position were on the handlebars of the wheelchair behind the resident. In an observation on 07/22/2026 at 7:55 AM, Resident 8 was observed lying in their bed. The bed was in the lowest position relative to the floor, the bed controls were hooked on the side of the footboard at the end of the bed and out of reach from the resident. In observations on 07/22/2026 at 1:00 PM, Resident 8 was observed tilted back in the wheelchair in a partial recline position, parked next to their bed. At 1:25 PM they began to swing their legs as they were dangling from the chair and then placed one leg on the side of the bed. At 1:50 PM the chair had been titled back further into a recline position, and they were observed fidgeting in the chair attempting to sit forward. At 2:20 PM they were still tilted back in the recline position, unable to adjust their body. Review of Resident 8's physician orders on 07/22/2026 showed no orders for any type of physical restraints. Review of Resident 8's care plan print date 07/22/2026 showed no documentation for use of physical restraints. Review of Resident 8's medical record on 07/22/2026 showed no assessment or consent for use of physical restraints. In observations on 07/23/2026 at 7:36 AM, and 12:10 PM the resident was in the tilt-n-space wheelchair with the chair slightly tilted back. In observations on 07/24/2026 at 7:45 AM, and 9:27 AM, and 11:27 AM the resident was in the tilt-n-space wheelchair with the chair slightly tilted back. In an interview on 07/24/2026 at 9:33 AM, Staff T, Nursing Assistant Certified (NAC) stated they use the care plan and/or the Kardex (condensed version of care plan for activities of daily living) to direct all care for each resident. Staff T stated Resident 8 was a fall risk, and was trying to climb out of bed, so that was why they kept the bed in a low position. Staff T stated Resident 8 was leaning forward in a regular wheelchair, so they switched them to a tilt-n-space so they would be more comfortable. In an interview on 07/24/2026 at 9:57 AM, Staff CC, Director of Rehab. (DOR) was asked if there was an evaluation or recommendation for Resident 8 to use a tilt-n-space wheelchair. Staff CC stated they thought they had discussed that, as they were slumping down in a regular upright wheelchair and there was potential for them to slide out due to their poor trunk control. Staff CC stated they would locate the information. At 10:25 AM, Staff CC stated they were unable to find an evaluation for the tilt-n-space wheelchair. Staff CC stated they were able to find a note dated 06/01/2026 from the occupational therapist (OT) who mentioned the tilt-n-space chair. Review of the OT note on 07/24/2026 at 10:32 AM, dated 06/01/2026 documented the resident had been seen sitting in the tilt-n-space wheelchair, and the resident was repositioned with a sling, and they adjusted the headrest. The OT note was not an assessment or evaluation for the tilt-n-space wheelchair. In an interview on 07/24/2026 at 11:38 AM, Staff S, Licensed Practical Nurse (LPN) stated the Resident 8 was a fall risk, and that was why they used the tilt-n-space wheelchair and had the bed low. In an interview on 07/27/2026 at 8:08 AM, Staff R, Registered Nurse (RN)/Resident Care Manager (RCM) was asked why Resident 8 was observed with the bed low, with no access to the controls, and was in a tilt-n-space wheelchair. Staff R stated they would have to investigate that as Resident 8 was transferred from another unit at the end of June. Staff R stated there should be an order, and a consent for the use of the tilt-n-space wheelchair and low bed. Staff R added any restraint used needed to be included in the care plan. Staff R stated even if the bed was kept low the controls should be within reach of Resident 8. Staff R was not aware there was no consent, order, assessment or care plan for the tilt-n-space wheelchair or the low bed. In an interview on 07/27/2026 at 10:10 AM, Staff B, Director of Nursing Services (DNS) was asked about the reason Resident 8 had a tilt-n-space wheelchair. Staff B stated they had spoken with Staff CC, DOR and stated they had entered a late entry note today into the file for the resident to show they had been evaluated for a tilt-n-space wheelchair, and they now had a consent and orders in place. Staff B stated all of that should have been completed prior to Resident 8's use of the tilt-n-space wheelchair. Staff B was notified of the observations made of the bed in lowest position with the bed controls out of reach from them. Staff B stated they were aware of the observations and stated when Resident 8 first got to the facility, they were very anxious and trying to climb out of bed. Staff B added they would be looking into that more. In an interview on 07/27/2026 at 10:20 AM, Staff A, Administrator stated they thought maybe the staff thought they were keeping Resident 8 safe by placing the bed low and did not realize they were restraining them. Staff A stated they would investigate the situation. Refer WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to honor the legal rights of 1 of 1 resident (Resident 22) guardian to be informed of changes in the financial status of the resident. The failure to provide a Notification of Medicare Non-Coverage (NOMNC - a document informing Medicare beneficiaries that their covered services will be terminated and providing information on their appeal rights) to the guardian placed the resident at risk for unmet needs and for the resident's guardian being unable to advocate for the resident. Findings included . Resident 22 admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit. Review of Resident 22's Electronic Health Record included a guardianship document dated 02/17/2023 in which they were appointed a guardian to make decisions regarding their health, financial, and personal affairs. Review of Resident 22's NOMNC, dated 04/29/2026, was signed by Resident 22. Review of Resident 22's progress notes dated 04/10/2026 through 05/01/2026 showed no documentation that the guardian had been contacted regarding the ending of their Medicare benefits. In an interview on 07/23/2026 at 9:50 AM Staff D, Social Services Director, stated Resident 22 was incapacitated and had guardians. Staff D stated guardians would be contacted for any changes in Resident 22's condition as well as financial matters. Staff D stated the social services department was responsible for explaining NOMNC's and obtaining signatures on the forms. Staff D stated the guardians for Resident 22 should have been contacted regarding the NOMNC provided to Resident 22 on 04/10/2026. Reference: WAC 388-97-0300(1)(e)(5).

Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 5) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to obtain necessary information to demonstrate adequate indication of use of antipsychotic medication including the duration of use. These failures placed the residents at risk for medication-related complications such as drowsiness, withdrawal from activities and socialization, movement disorders, falls with injury, stroke, and increased risk of death, for receiving unnecessary psychotropic medication. Findings included . Review of the pharmacy policy, provided by the facility, titled, Psychotropic Medication Use revised 03/01/2025 documented psychotropic medications should only be prescribed to treat specific conditions as diagnosed and documented in the medical record; and facility staff should involve the resident or the resident's representative(s) in the discussion of potential nonpharmacologic and medication interventions to address the management of behaviors and the involvement should be documented in the resident's medical record. Resident 5 admitted to the facility on [DATE] with diagnoses to include fracture of the right upper leg from a fall and unspecified dementia. Review of Resident 5's Medication Administration Record for July 2026 documented they were prescribed Abilify (an anti-psychotic medication) daily for anxiety and depressive disorder. Review of Resident 5's admission Minimum Data Set (MDS-an assessment tool) dated 06/24/2026 documented that they had been taking an antipsychotic medication prior to admission. Review of Resident 5's Care Area Assessment (CAA-tool used to create comprehensive person-centered care plans) dated 07/01/2026 documented they received sertraline (an anti-depressant), trazodone (an anti-depressant), and Abilify prior to admission. Resident 5 documentation stated the use of trazodone and sertraline daily were for their depression diagnosis. No information was documented for Resident 5's prior or continued use of Abilify. Review of Resident 5's care plan dated 07/01/2026 documented they were taking an antipsychotic medication for depression and anxiety. The goal was for Resident 5 to be free from any complications of taking the medication to include movement disorder, discomfort, gait disturbance or constipation. Interventions included administering Abilify as ordered, pharmacy review, discussions with providers and family regarding ongoing need for use of medication, and monitoring for tearfulness. Review of Resident 5's progress notes dated 06/21/2026 through 07/21/2026 documented no discussion with resident or their representative regarding their use of an antipsychotic, the reason for the use, and history of behaviors/symptoms. Review of Resident 5's hospital history and physical dated 06/17/2026 and Discharge summary dated [DATE] documented they were taking Abilify daily. No other information regarding the use of Abilify was found. In an interview on 07/23/2026 at 8:15 AM Staff J, Registered Nurse/Unit Care Coordinator, when asked the rationale for Resident 5 taking Abilify, stated they had a diagnosis of dementia and mood disorder. Staff J stated Resident 5's medications were recently reviewed by the pharmacy, and they had recommended a gradual dose reduction of Abilify but the provider declined given they were approaching discharge. Staff J stated Resident 5 was taking the medication for depression, and they had admitted from the hospital on Abilify. Staff J stated they had not discussed or obtained any information/history about their use of Abilify from Resident 5 as they were a poor historian. Staff J stated they had not spoken to Resident 5's representative about the use of Abilify but believed there was a conversation with them as they signed consents for the use of Abilify. Staff J stated there were weekly meetings to discuss residents taking psychoactive medications, review their behavior monitors, and any changes in mood/behavior. Staff J stated they were monitoring Resident 5 for tearfulness and self-isolation. In an interview on 07/23/2026 at 11:56 AM Staff B, Director of Nursing Services, stated they had located information in a third-party medical records system regarding Resident 5's use of Abilify. Staff B stated they have uploaded the documentation into Resident 5's clinical record and updated their care plan. Reference WAC 388-97-0620 (1)(a)(4)(a)

Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) and provide a written notice to the resident and/or their representative of a hospital transfer for 1 of 3 residents (Resident 66) reviewed for hospitalizations. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold and lack of discharge needs while in the hospital. Findings included . Resident 66 initially admitted to the facility on [DATE] with diagnoses to include high blood pressure, history of falling, and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain). Review of Resident 66's Electronic Health Record (EHR) documented they were sent to the hospital on [DATE] due to high blood pressure. Further review of the EHR documented Resident 66 had been sent to the hospital on [DATE] related to altered mental status. Review of the EHR for Resident 66 showed no documentation that a bed hold or transfer/discharge notice had been completed, nor the resident/representative had been notified on 9/28/2025 or 07/12/2026. In an interview on 07/22/2026 at 12:51 PM, Staff K, Registered Nurse (RN), stated when a resident had a change of condition and was sent to the hospital, the resident or their representative would be presented with a bed hold policy. Staff K stated the bed hold forms and policy were kept at the nurse's station. When asked about the transfer/discharge notice, Staff K stated they had no knowledge of the form. In an interview on 07/22/2026 at 1:42 PM, Staff L, RN, stated the process for residents leaving the facility to go to the hospital included providing a bed hold notice. When asked about the transfer/discharge notice, Staff L stated they had not dealt with that paperwork. In an interview on 07/22/2026 at 1:47 PM Staff B, Director of Nursing Services, stated it was the nurse's responsibility to complete the notice of transfer/discharge and bed hold with the residents and/or their representatives at the time of their discharge or transfer to the hospital. Reference WAC 388-97-0120

Based on interview and record review, the facility failed to ensure medical records were complete and accurate for 1 of 5 residents (Resident 60) reviewed for unnecessary medications and 1 of 5 residents (Resident 38) reviewed for skin. These failures placed residents at risk of inaccurate and incomplete medical records, sensitive resident information in the wrong resident's medical records, and a decreased quality of life. Findings included . <RESIDENT 38> Review of Resident 38's progress notes on 07/09/2026 at 12:10 PM, Staff J, Registered Nurse/Resident Care Manager (RN/RCM), inaccurately documented another resident's medical information that included their name, diagnoses, and their psychotropic drug (medication that changes how your brain works) use. In an interview on 07/24/2026 at 10:02 AM, Staff J, verified the progress note on 07/09/2026 in Resident 38's medical record was incorrect and in the wrong medical chart. In an interview on 07/27/2026 at 11:11 AM Staff B, Director of Nursing Services (DNS), stated that their expectation of medical records was to be documented accurately in the correct resident chart. <RESIDENT 60> Resident 60 was admitted to the facility on [DATE], with diagnoses to include bipolar disorder, vascular dementia (dementia caused by reduced or blocked blood flow and the delivery of oxygen and nutrients to the brain causing memory loss, confusion, mood swings, and cognitive impairment), anxiety, and hallucinations. Review of Resident 60's consents for psychotropic medication use, dated 02/16/2026, venlafaxine (medication used to treat depression and anxiety), quetiapine (an antipsychotic medication used to treat bipolar disorder and depression) and divalproex (a medication used to treat bipolar disorder) documented their responsible party did not consent to the use of these medications. Review of Resident 60's medication administration records for May 2026, June 2026 and July 2026 documented they received all three medications on a daily schedule. In an interview on 07/27/2026 at 10:04 AM, Staff W, RN/RCM stated the RCMs were responsible for obtaining psychotropic medication consents from residents or their responsible party. Staff W confirmed the 'do not consent' box was checked for all three medications and stated they thought the 'do not consent' box was checked in error. In a joint interview on 07/27/2026 at 2:02 PM, Staff B, DNS and Staff W, Staff B stated their expectation was a psychotropic medication consent would be completed accurately. Staff W stated the consents were for a declination of a gradual dose reduction of the psychotropic medications, and Resident 60's responsible party did not consent to an attempted gradual dose reduction. Staff B confirmed the psychotropic medication consent forms did not indicate they were used for a gradual dose reduction and stated the consent forms should not have been used. Reference WAC: 388-97-1720 (1)(a)(i-iv)

Based on interview and record review the facility failed to accurately complete Minimum Data Sets (MDS - an assessment tool) for 2 of 24 sampled residents (Residents 5 and 35) reviewed for accurate MDS assessments. This failure affected the accuracy of federal health information obtained from the MDS and placed residents at risk for inaccurate/inadequate monitoring of the residents' health status, development of accurate comprehensive care plans, unmet care needs and a diminished quality of life. Findings included . Review of the Centers for Medicare (CMS) and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 revised October 2025, showed the RAI consisted of three basic components: the Minimum Data Set (MDS), the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three components of the RAI yielded information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. <RESIDENT 35> Resident 35 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (kidneys are damaged and slowly lose their ability to filter waste and extra fluid from your blood) and dependence on renal dialysis (an artificial cleaning process for your blood when your kidneys stop working). Resident 35 was on Medicaid for payment purposes. Review of Resident 35's admission MDS, dated [DATE], had no documentation of dialysis. The admission MDS established the resident's clinical baseline, guided personalized care planning, and determined federal Medicare and Medicaid reimbursement rates. Review of Resident 35's physician orders documented that they were a dialysis resident active as of 04/17/2026. In an interview on 07/24/2026 at 12:32 PM, Staff P, Registered Nurse/MDS Nurse, stated that Resident 35 was on dialysis upon admission and while a resident at the facility. Staff P verified that the admission MDS was inaccurate. In an interview on 07/27/2026 at 11:09 AM, Staff B, Director of Nursing Services, stated the MDS nurses should be doing their own assessments and accurately completing resident's MDS. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] with diagnoses to include fracture of the right upper leg from a fall and unspecified dementia. In an interview on 07/21/2026 at 11:00 AM, Resident 5 stated they were hard of hearing, more so on one side than the other. Resident 5 stated they had hearing aides, believed they were in a drawer at home somewhere. Resident 5 stated the staff were aware they were hard of hearing and they were not sure what to do about it. When asked about their dental status, Resident 5 stated they had a cavity on the left upper side of their mouth. Resident 5 stated the cavity was painful at times and believed there was an appointment scheduled to have it fixed. Review of Resident 5's admission MDS dated [DATE], documented they had moderate hearing loss and no dental issues. Review of Resident 5's CAA dated 07/01/2026 for communication documented they were moderately hard of hearing, the goal was for them to communicate their needs daily, and to encourage them to continue sharing thoughts even if they were having difficulty. There was no information gathered from the resident or their representative. There was no CAA related to Resident 5's dental status. Review of Resident 5's admission Nursing assessment dated [DATE], documented they were moderately hard of hearing and had no dental issues. The document did not contain any detailed information regarding their hearing or dental needs, appliances used, or pending appointments. In an interview on 07/24/2026 at 10:57 AM, Staff P, Registered Nurse/MDS, stated they attended daily utilization review (DUR) meetings where the interdisciplinary team reviewed new admissions, diagnoses, special orders, history and physical and discharge hospital records. Staff P stated the resident care managers completed the initial nursing assessment, and they gathered information from that assessment and the DUR to complete the MDS. Staff P stated they met with residents at times to complete some of the sections of the MDS when needed. In an interview on 07/27/2026 at 11:30 AM, Staff B, Director of Nursing Services, stated they were aware MDS's were being completed with information gathered from nursing assessments only and lacked information from the resident and their representatives. Reference WAC 388-97-1000 (1)(a)

Based on observation, interview and record review, the facility failed to implement comprehensive person-centered care planning for 1 of 2 residents (Resident 8) reviewed for comprehensive care planning. The facility failed to ensure Resident 8 received adequate assistance with meals. This failure placed all residents at risk of not receiving needed care, a decline in their condition, and diminished quality of life Findings included .Resident 8 was admitted to the facility on [DATE] with diagnoses that included brain bleed, limitation of activities, and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS - an assessment tool) dated 05/28/2026 documented the resident had mildly impaired cognition, had a feeding tube (medical device to deliver food directly to stomach), and was dependent on staff for meals. Review of Resident 8's care plan documented a focus dated 06/08/2026, stated the resident was a one-to-one feed assist and ensure resident was upright for all meals. Review of Resident 8's discharge speech therapy summary dated 06/25/2026 documented recommendations for the resident to have appropriate redirection with them during meals, and provide verbal cueing to facilitate follow-through, eliminate background noise, and reduce stimuli. In a continuous observation on 07/21/2026 at 11:40 AM, Resident 8 was wheeled into the dining room and placed at a table. At 12:10 PM they were served lunch; an unnamed staff member placed the food in front of them and returned to passing other trays. Resident 8 took two bites of food, then placed the napkin over the food and stopped eating. Resident 8 continued to sit there and not eat their meal, they received no assistance with the meal; at 12:28 PM they were seen leaning into the plate and got food on their elbow. At 12:41 PM a friend took the resident out of the dining room; Resident 8 had only taken two bites of food and did not receive any staff assistance. In a review of Resident 8's meal intake for 07/21/2026 documentation showed lunch was 25-50% of their meal was consumed, with extensive assist at lunch on 07/21/2026. Observation of meal was 0 - 25 %, and no assistance. In an observation on 07/22/2026 at 7:55 AM, Resident 8 was observed in bed, Staff S, Licensed Practical Nurse (LPN) stated the resident had refused breakfast. In a continuous observation on 07/22/2026 at 11:59 AM, Resident 8 was observed sitting in the dining room at a table. At 12:02 PM, a Nursing Assistant Certified (NAC) delivered their lunch tray at the table. The NAC stated to Resident 8 here was their food, and Resident 8 responded it's right here and pointed to empty space, the NAC walked away. Resident 8 then picked up their spoon and took a few bites from a dessert bowl. At 12:08 PM a nurse walked by Resident 8 and stated are you not hungry then walked away. The resident then took the spoon to take more bites from dessert bowl, scooped spoon towards bowl but the spoon was empty, the resident was observed to do this several times each time there was no food on the spoon, then stuffed the napkin in the bowl. At 12:18 Resident 8 did not eat any more food and was observed to stare around the room, room was loud with over 20 residents in the room, and a television was playing music. At 12:23 PM a staff member walked to Resident 8 and asks them if they would want any more food, they responded no, and were taken out of the dining room and back to their room. Resident 8 did not receive any staff assistance with the meal. In a review of Resident 8's meal intake for 07/22/2026 documentation showed breakfast was 0 - 25% of their meal had been consumed, with extensive assist and at lunch 0 - 25 % with extensive assistance. Observation of meals was the resident refused breakfast, and at lunch they received no assistance. In an observation on 07/23/2026 from 12:10 PM - 12:45 PM, Resident 8 observed in dining room. Was observed to take a few bites of their food, no one-to-one assistance was provided to them. In an interview on 07/23/2026 at 1:16 PM, Staff X, NAC stated they relied on the care plan and the Kardex (shortened version of the care plan related to activities of daily living) on how to care for each individual resident. Staff X stated Resident 8 needed cueing for meals, and they had a hard time following directions, Staff X stated you must go slow. Staff X stated they often will grab at the air or for objects that are not there. Staff X was asked about why the meal monitor documentation was not accurate as to what was observed, and they stated they only documented what got reported to them since they are not in the dining room when Resident 8 was eating their meals. In an observation on 07/24/2026 at 7:45 AM, Resident 8 was seen in the dining room, and was not provided any assistance with their meal. In an interview on 07/24/2026 at 9:33 AM, Staff T, NAC stated if a resident required one-to-one assistance with meals, it would be found in the care plan. Staff T stated Resident 8 had previously required one-to-one assistance but now was just stand by assist with random cueing. In an interview on 07/24/2026 at 9:47 AM, Staff Y, Speech/Language Pathologist (SLP) stated they recently had re-evaluated Resident 8 for eating and swallowing on 07/17/2026. Staff Y stated they continued to recommend Resident 8 receive one-to-one assistance with meals, and staff needed to ensure they alternated between bites and drinks. Reviewed observations made while Resident 8 had been eating the last few days with Staff Y, and they stated they would not be surprised if Resident 8 was eating less than 50% of the meal and would not be surprised if they started to have weight loss. Staff Y added they had horrible peripheral vision so wearing their glasses and getting one-to-one assistance was very important. In an interview on 07/24/2026 at 11:38 AM, Staff S, LPN stated Resident 8 required one-to-one assistance with meals in the dining room. In an interview on 07/27/2026 at 8:08 AM, Staff R, Registered Nurse (RN)/Resident Care Manager (RCM) stated care plans were created by the admission assessment, then moving forward were updated quarterly and as needed. Staff R stated it was their expectation the staff would implement the care plan interventions as directed. Staff R was asked what assistance Resident 8 required, they stated they were not sure of details but knew the resident had been going to the dining room to get some assistance. Staff R was notified Resident 8 required one-to-one assistance with meals, and based on observations over the last few days, had not received any assistance. Staff R was not aware the resident was not receiving assistance, nor that the resident had not been eating more than a few bites at the meal. In an interview on 07/27/2026 at 10:10 AM, Staff B, Director of Nursing Services (DNS) stated they were not aware Resident 8 had not received adequate assistance with their meals. Refer WAC 388-97-1020(1)(2)(a)

Based on observation, interview and record review, the facility failed to ensure treatment and care was provided in accordance with profession standards of practice for 1 of 5 residents (Resident 7) reviewed for unnecessary medications and 2 of 5 residents (Residents 5 and 38) reviewed for skin. These failures placed residents at risk for unmet care needs, medical complications, and a diminished quality of life. Findings included . <RESIDENT 7> Resident 7 was initially admitted to the facility on [DATE] with diagnoses to include high blood pressure. Review of Resident 7's physician orders documented Propranolol (blood pressure medication) to be administered once a day and to hold for systolic blood pressure (top number on a blood pressure reading) less than 110 and pulse less than 60. Amlodipine (blood pressure medication) was ordered to be administered once a day for systolic blood pressure less than 110 and pulse less than 60. Review of Resident 7's June 2026 medication administration record (MAR) documented Propranolol and Amlodipine held outside of physician ordered parameters 2 times during the month. Reviewed progress notes with no documentation for reasoning of holding medication. Review of Resident 7's May 2026 MAR documented Propranolol and Amlodipine given or held outside of physician ordered parameters 6 times during the month. Reviewed progress notes with no documentation for reasoning of holding or administering medication outside of parameters. In an interview with Staff S, Registered Nurse (RN), stated that they follow physician orders, including parameters, for medications. If a medication was outside of parameters they would hold it per instructions, notify the provider and document in the progress notes. In an interview on 07/24/2026 at 1:53 PM, Staff R, RN/Resident Care Manager (RCM), stated that their expectations of the nurses would be to follow blood pressure medication parameters per physician orders. In an interview on 07/27/2026 at 11:07 AM, Staff B, Director of Nursing, stated that their expectation would be that the nurses follow orders and parameters according to physician orders. <RESIDENT 38> Resident 38 admitted to the facility on [DATE] with diagnoses to include left lower leg fracture, type two diabetes, and anxiety. Resident 38's MDS, dated [DATE], documented that they were cognitively intact. In an interview on 07/21/2026 at 9:29 AM, Resident 38 stated that they had admitted to the facility with an abdominal lesion, that staff do not regularly monitor it, and that they were concerned about it. Review of Resident 38's provider progress note (Collateral Contact 1), on 07/20/2026 at 3:29 PM, documented that Resident 38 was anxious about the worsening of their abdominal lesion and that it was now larger, redder, and with a hard nodule-like shape. The provider documented an active diagnosis of a right lower quadrant abdominal mass and lump active as of 07/15/2026. The provider documented that part of the plan for the skin concern was to continue to monitor and note if it increased further in size and/or additional lesions developed. Review of Resident 38's physician orders, as of 07/21/2026, did not have any related orders to the right abdominal lesion. Review of Resident 38's care plan documented that weekly skin checks were to occur with an initiation date of 07/05/2026. Resident 38's admission skin assessment dated [DATE] documented an area of blanchable redness 3 centimeters round on the right abdomen. Resident 38's skin assessment dated [DATE] had no documentation of the abdominal skin lesion. Resident 38's skin assessment dated [DATE] had no documentation of the abdominal skin lesion. Resident 38's skin assessment dated [DATE] documented an area on the abdomen with circular dark spots. In an interview on 07/22/2026 at 1:19 PM, Staff S, Licensed Practical Nurse, stated that they were aware of Resident 38's skin lesion but was unaware of any orders or monitoring. In an interview on 07/24/2026 at 9:07 AM, Resident 38 stated that they were still worried about the skin lesion as they were unable to see it and that it was painful and tender when touched. In an interview on 07/22/2026 at 2:24 PM, Staff R, RN/RCM, stated that they were aware of Resident 38's right abdominal skin lesion and stated a skin monitor should be in place and was unable to find information in the care plan. Staff R stated they did not know why the skin lesion was not on the other weekly skin assessments. Staff R said that the nurses were responsible for the weekly skin assessments and their expectations would be to do a full head-to-toe skin assessment and to document. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] with diagnoses to include fracture of the right upper leg from a fall and unspecified dementia. Review of Resident 5's Medication Administration Record (MAR) from 07/01-07/22/2026 documented an order for both their heels to be floated (elevation of heels to alleviate pressure) while in bed for skin integrity. The MAR contained a check mark to indicate it had been completed for the dates 07/01-07/22/2026. Review of Resident 5's Kardex (resident specific care guide for nursing assistants derived from the care plan) dated 07/23/2026 documented no directions for them to float their heels while in bed. Review of Resident 5's care plan dated 07/19/2026 documented they were at risk for pressure ulcer development. There was no intervention for floating Resident 5's heels while in bed. In observations on 07/21/2026 at 11:07 AM, 07/22/2026 at 9:40 AM, and 07/23/2026 at 7:56 AM Resident 5 was observed in their bed, and their heels were not floated. In an interview on 07/27/2026 at 8:05 AM Staff U, RN, stated if a resident had an order for heels to be floated then they would communicate that to the nursing assistants. Staff U stated they would check heels at the time of medication administration, if the resident was in bed, and would check off in the MAR. When asked if there was a separate system for the nursing assistants to know when a resident's heels were to be floated when in bed, Staff U stated they did not know. In an interview on 07/27/2026 at 8:07 AM Staff V, Nursing Assistant Certified, stated nurses remind them if a resident's heels required floating. Staff V stated they relied on the Kardex for the direction of when and how to float a resident's heels. Staff V stated they followed the Kardex for resident specific care. Reference WAC 388-97-1060 (3)(b)(k)(i)

Based on interview and record review, the facility failed to develop a trauma trigger (a psychological stimulus that prompts recall of a previous traumatic event) assessment for 1 of 2 sampled residents (Resident 2) reviewed for trauma informed care. This failure placed residents at risk for unidentified trauma triggers, behaviors, re-traumatization and a diminished quality of life. Findings included . Review of the facility policy titled, Trauma-Informed Care, revised 01/06/2026 documented on the comprehensive assessment for residents, the facility ensured residents who are diagnosed with mental disorder and psychosocial adjustment difficulty, or who have a history of trauma and/or post-traumatic stress disorder (PTSD), receive treatment and services in accordance with professional standards of practice and will have a comprehensive person-centered care plan that reflects the resident's goals to eliminate or mitigate triggers that may cause re-traumatization to the resident.procedure would include a screening and assessment using the Trauma Informed Care Assessment in the electronic medical record system, implementing a resident driven care plan, identifying triggers, referrals and evaluation.Resident 2 was admitted to the facility on [DATE] with diagnoses that include PTSD, and anxiety disorder. The admission Minimum Data Set (MDS - an assessment tool) dated 07/01/2026 documented the resident had intact cognition with active diagnoses for PTSD and anxiety.Review of Resident 2's hospital history and physical (H & P) dated 06/09/2026 documented the resident had PTSD, dissociative identity disorder (complex mental health condition defined by the presence of two or more distinct personality states, significant memory gaps, and severe trauma history) and anxiety with a history of suicidal and homicidal ideations.Review of Resident 2' care plan, print date 07/21/2026 showed no focus, goal or interventions for the residents PTSD and other mental health diagnoses. Review of Resident 2's physician orders on 07/21/2026 showed no monitors for triggers or behaviors, potentially related to the residents PTSD and other mental health diagnoses.In an interview on 07/21/2026 at 9:39 AM, Resident 2 was asked if anyone from the facility had talked with them about their trauma history, and potential triggers and interventions to deal with. Resident 2 stated no one had come to discuss with them. Resident 2 stated they have had nightmares often and talked to their spouse about their trauma when they could.Review of Resident 2's electronic medical record showed there was an overdue assessment for Trauma Informed Care which had been due on 07/03/2026 and as of 07/24/2026 had not been completed.In an interview on 07/24/2026 at 9:11 AM, Staff G, Nursing Assistant Certified (NAC) stated Resident 2 really will not ask for a lot of assistance from staff and their spouse would usually provide most care. Staff G stated Resident 2 stayed away from everyone and kept to themselves.In an interview on 07/24/2026 at 1:04 PM, Staff U, Registered Nurse (RN) stated Resident 2 mostly kept to themselves and would not ask for assistance, as the spouse would provide more care. Staff U stated they would often refuse skin checks and would not allow them to apply cream to the buttocks as they did not want anyone close to them. Staff U was not aware they had a history of PTSD. In a joint interview on 07/24/2026 at 1:51 PM with Staff D, Social Service Director (SSD) and Staff DD, Regional SSD, Staff D stated their role at the facility for residents who admitted with a diagnosis of PTSD was they would review the diagnosis, possibly get a behavioral consult, updated the care plan and completed the Trauma Informed Care assessment for the resident. Staff D was asked if they ever reviewed the H & P from the hospital when a new resident admits, Staff DD, responded they were supposed to. Staff D stated they were not familiar with Resident 2, and they were not aware they had a diagnosis of PTSD, dissociative identity disorder or anxiety. Staff D stated they were not aware they had not completed the Trauma Informed Care assessment.In an interview on 07/27/2026 at 9:02 AM, Staff W RN/Resident Care Manager (RCM) stated a PTSD diagnosis should be included in the care plan. Staff W stated it was an interdisciplinary team effort to ensure the residents' care plan was complete. Staff W stated Resident 2 should have had care planning with appropriate behavior monitoring for triggers and interventions.In an interview on 07/27/2026 at 10:10 AM, Staff B, Director of Nursing Services (DNS) stated residents who admitted with PTSD, it was their expectation the facility was completing the appropriate assessment, care planning appropriately and implementation of interventions were done. Staff B was not aware Resident 2 had been lacking assessment, care plan, and trigger interventions. Refer 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure COVID-19 (a viral illness that causes fever, difficulty breathing or possibly death) immunizations were offered, up to date and risks and benefits of the immunizations were provided to 3 of 5 residents (Residents 3, 7 and 60) reviewed for immunization and infection control. This failure placed residents at risk for illness, lack of knowledge to make medical decisions, and spread of communicable diseases. Findings included . Review of the Centers for Disease Control (CDC) guidelines, dated 11/19/2025, showed they recommended the 2025-2026 COVID-19 vaccine for people ages six months and older. CDC stated for persons age [AGE] and older that were previously vaccinated before 2024-2025 should be vaccinated and then vaccinated with a second dose six months later. Review of the facility policy, dated 11/25/2025, titled, COVID-19 Vaccination Program Policy for Resident, documented that people 65 and older are up to date when they receive two updated 2025-2026 COVID-19 vaccines six months apart. The policy documented that the resident's medical record should include that the resident or resident representative was provided education and associated with the COVID-19 vaccine, each dose of the COVID-19 vaccine administered to the resident, and if the resident did not receive the COVID-19 vaccine due to medical contraindications. <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include type two diabetes, chronic kidney disease (kidneys are slowly losing their ability to filter waste from the blood), cancer of the blood and bone marrow, and asthma. The admission Minimum Data Set (MDS - an assessment tool) dated 06/10/2026 documented the resident had severe cognitive impairment. Review of Resident 3's immunization record on 07/24/2026, documented the resident's most recent COVID-19 vaccine was educated and refused on 10/02/2024. Review of Resident 3's electronic medical record (EMR) had no documentation of offering or declining the most recent COVID-19 immunization. <RESIDENT 7> Resident 7 was admitted to the facility on [DATE] with diagnoses to include atrial fibrillation (fast irregular heartbeat), asthma, and type two diabetes. The MDS dated [DATE] documented that the resident had no cognitive impairment. Review of Resident 7's immunization record on 07/24/2026, documented the resident's most recent COVID-19 vaccine was administered on 10/28/2024. Review of Resident 7's EMR had no documentation of offering or declining the most recent COVID-19 immunization. <RESIDENT 60> Resident 60 was admitted to the facility on [DATE] with diagnoses to include dementia, atrial fibrillation, and type two diabetes. The MDS dated [DATE] documented that the resident had severe cognitive impairment. Review of Resident 60's immunization record on 07/24/2026 documented the residents most recent COVID-19 vaccine was administered on 09/25/2024. Review of Resident 60's EMR had no documentation of offering or declining the most recent COVID-19 immunization. In an interview on 07/24/2026 at 10:48 AM, Staff Q, Infection Preventionist/Registered Nurse stated that they were responsible for the tracking of resident vaccinations. Staff Q verified that the named residents (Residents 3, 7, and 60) should have been offered an updated COVID vaccine and was going to see if they could find documentation that the residents were educated or offered the vaccine. No further documentation was provided. Reference WAC 388-97-1780 (2)(b)(d)

Based on interview, and record review, the facility failed to thoroughly investigate incidents for 1 of 1 sampled resident (Resident 1) reviewed for injury during handling resulting in bruising, and failed to investigate 2 of 2 sampled residents (Resident 1 and 2) reviewed for resident to resident altercations. This failure prevented the facility from identifying the potential causes of the occurrence and contributing factors, placed residents at risk for unidentified abuse or neglect, risk for injury, and unmet care needs. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. Findings included.<INJURY DURING HANDLING INVESTIGATION>RESIDENT 1Resident 1 admitted to the facility on [DATE] with diagnoses including dementia, depression, cirrhosis of the liver ( long term inflammation of the liver), and need for assistance with personal care. According to the Significant Change Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident had moderate cognitive impairment. Resident 1 required 2-person assistance with toileting, dressing, and bed mobility. Review of the facilities State Incident Reporting log, dated April 2026 showed documentation of an incident for Resident 1 of injury during handling with bruising on 04/09/2026 at unknown time. Review of a document titled Skin Integrity update, dated 04/09/2026 at 7:08 PM documented the resident had bruising to the right side of their groin and above vaginal area. The document did not show the color, size, or how many bruises were identified. Review of a document titled Witness Interview/Statement Form, dated 04/09/2026 at 6AM, Staff C, Licensed Practical Nurse (LPN), documented Resident 1 had two bruises above the vaginal area and 1 bruise in the right side of the groin. Review of a document titled Witness Interview/Statement Form, dated 04/09/2026 at 8:40 AM, Staff D, Registered Nurse (RN), nurse manager documented Resident 1 had three red/purple marks to their pubic bone skin area. Review of an email dated 04/09/2026 at 12:40 PM, Staff A documented Resident 1 was found to have a bruise to their pelvic bone. Review of a statement dated 04/14/2026, Staff E, Acute Care Nurse Practitioner, documented they were notified of bruising found in Resident 1's vaginal area on 04/10/2026. Staff E documented that staff reported mild bruising was noted to the external vaginal labia during care. Staff E documented they inspected the area and concluded this had occurred with the prior shift's peri care. Review of an email dated 04/09/2026 at 12:40 PM, Staff A, Administrator, documented Resident 1 was found to have a bruise to their pelvic bone, Staff E looked at the resident and felt that it was from pressing down to hard while wiping the area during care. Review of Resident 1's physician orders did not show monitoring of bruising to the resident's pelvic bone area. Review of Resident 1's Treatment Administration Record April 2026 did not show documentation of monitoring of bruising to the resident's pelvic bone area. Review of Resident 1's care plan focus for activities of daily living (ADL) showed an intervention initiated on 04/14/2026, documented;-During peri care, please ensure to be gentle with Resident 1's skin. She has very fragile skin due to her current Hospice status. She is expected to decline in all aspects of care, care staff to provide the gentlest care possible. Review of Resident 1's progress notes did not show documentation of bruising to the resident's pelvic bone area after April 12th, 2026. In an interview on 04/22/2026 at 2:58 PM, Staff F, Certified Nursing Assistant, stated the Kardex (a tool used to provide directions on how to care for a resident) gives information about how to provide care for a resident. In an interview on 04/22/2026 at 3:04 PM, Staff C, Licensed Practical Nurse, (LPN), stated when a skin issue is identified the resident is placed on alert charting for three days. Staff C stated the nurse manager would update the care plan for skin issues. Staff C stated they did not think the bruising to Resident 1's pelvic area was being monitored on the TAR. In an interview and record review on 04/23/2026 at 10:30 AM, Staff G, LPN, Nurse Manager, stated if a skin issue is identified the provider would be notified and an order would be put in to monitor every shift on the TAR until resolved. Staff G reviewed Resident 1's physician orders and TAR and acknowledged there was not a physician order to monitor bruising the resident's pelvic area and the bruising was not being monitored on the TAR. Staff G reviewed Resident 1's care plan and stated the bruising to the resident's pelvic area was not on the care plan. INJURY DURING HANDLING INCIDENT INVESTIGATION Review of a facility investigation dated 04/09/2026 documented Resident 1 was found to have bruising to their pelvic bone area that occurred during peri-care. The investigation did not show statements from staff prior to the identification of the bruising and did not show observations of peri-care performed by staff who provided incontinent care for the resident prior to identification of the bruising to rule out abuse or neglect. The investigation documented the bruising to Resident 1's pelvic area occurred during peri-care and no concerns of abuse. Abuse and neglect were ruled out related to bruising to Resident 1's pelvic area occurred from staff wiping to hard when providing peri-care. In a joint interview and record review on 04/23/2026 at 12:32 PM, with Staff A, and Staff B, RN, Director of Nursing, Staff A stated they interviewed one nursing assistant from the evening shift prior to identification of the bruising to Resident 1's pelvic area but did not document the interview. Staff A stated they did not get statements from staff who provided care for Resident 1 prior to the identification of the bruising. Staff A stated the provider felt the bruising was due to care. Staff B stated demonstration/return demonstration for peri-care should be completed to ensure staff are aware of how to provide incontinent care correctly and stated there was no documentation that observations of care were completed. Staff B stated they completed verbal competencies for reporting skin issues; the verbal competencies were not documented. Staff A stated hands on education was not completed. Staff B stated residents with identified skin issues would be put on alert charting for monitoring until resolved. Staff B acknowledged there was no documentation of bruising in Resident 1's charting after 04/12/2026. Staff A stated if bruising is identified the resident is placed on alert charting, the care plan is updated, and an intervention is initiated that day. Staff A stated they did not complete demonstration/return demonstration for care and after ruling out sexual abuse and establishing the bruising was care related they did not further investigate. <RESIDENT TO RESIDENT VERBAL ALTERCATIONS>RESIDENT 1Review of a progress note dated 04/06/2026 at 12:46 AM, documented Resident 1 was verbally fighting with her roommate (Resident 2) and calling them names. Nurse had to go in and asked both ladies to be respectful with each other and if they are not getting along they should stop talking to each other, so they don't end up offending each other. No reports of further escalation of their verbal fight was reported. Review of a progress note dated 04/21/2026 at 4:40 PM, Staff C documented Resident 1 was calling their roommate names and staff asked the resident to be nice to their roommate and not to cuss at them. Staff G, Staff A, and Staff B were notified. Review of a progress note dated 04/22/2026 at 10:15 AM documented Resident 1 was changing rooms per request from Hospice. Review of Resident 1's progress notes did not show alert charting for resident to resident altercations. Review of Resident 1's care plan showed no interventions for verbal altercations toward other residents. In an interview and observation on 04/22/2026, Resident 1 was observed lying in bed and denied concerns with other residents. RESIDENT 2Resident 2 re-admitted to the facility on [DATE] with diagnoses including anxiety, cognitive communication deficit, and need for assistance with personal care. According to the Quarterly MDS dated [DATE], the resident was cognitively intact. Resident 2 was dependent on staff for transfers. Review of a progress not dated 04/19/2026 at 3:13 AM, documented Resident 2 was answering back to their roommates insults when the nurse came in and this evening and was doing rounds. AM nurse and this nurse tried to remind both ladies to be respectful of each other but her roommate was just ignoring us. Resident was more compliant with our request. Review of Resident 2's progress notes did not show alert charting for the resident to resident altercations. Review of Resident 2's care plan did not show interventions for resident to resident altercations. In an interview on 04/23/2026 at 9:56 AM, Resident 2 stated Resident 1 would call them names, called them stupid and stated they were not a woman. The resident stated Resident 1 was manic and would verbalize things but was not physically aggressive toward them. Resident 2 stated staff were aware of Resident 1's behaviors and did not do anything to stop them. In an interview on 04/23/2026 at 10:32 AM, Staff H, CNA, stated Resident 2 did not voice concerns about Resident 1 to them. Staff H stated if they there was a resident to resident altercation they would separate the residents and report the incident. In an interview on 04/22/2026 at 3:04 PM, Staff C stated Resident 1 has had altercations with Resident 2. Staff C stated on 04/21/2026, Resident 1 was calling Resident 2 a fat cow, and they talked with both residents, re-directed Resident 1 and reported the incident to Staff A and Staff B. Staff C stated Resident 2 heard Resident 1. Staff C stated when Resident 1 yelled at Resident 2 they tried to deescalate the situation. Staff C stated Resident 1 was moved to another room on 04/22/2026. In an interview and record review on 04/22/2026 at 10:52 AM, Staff G stated residents yelling and calling names at another resident would be considered a resident to resident altercation. Staff G stated if a resident to resident altercation occurred residents would be separated, an investigation would be initiated, and the residents would be placed on alert charting. Staff G reviewed progress notes for Resident 1 dated 04/06/2026 and 04/21/2026 and Resident 2 dated 04/19/2026 and stated the documentation would be considered resident to resident altercations, investigations were not completed, the residents were not placed on alert charting and there were no interventions initiated until Resident 1 was moved to another room on 04/22/2026. In an interview and record review on 04/23/2026 at 12:32 PM with Staff A and Staff B, Staff A reviewed progress notes for Resident 1 dated 04/06/2026 and 04/22/2026 and Resident 2 dated 04/19/2026 and acknowledged these were resident to resident verbal altercations and no investigations were completed. Staff B reviewed Resident 1 and Resident 2's medical records and stated there were no interventions initiated prior to Resident 1's room move on 04/22/2026. Reference WAC 388-97-0640(6)(a)

Based on observation, interview, and record review the facility failed to protect residents right to be free from physical abuse for 2 of 2 sampled residents (Residents 3 and 4) reviewed for resident-to-resident altercations. Resident 3 caused potential harm for Resident 4 when they kicked them for not responding to a question. This failure placed residents at risk for potential physical or mental abuse, feeling safe, experiencing fear, intimidation, and a decreased quality of life.Findings included.Review of the facility policy Abuse-Protection of Residents reviewed 04/01/2026 documented the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation.Review of the Nursing Home Guidelines the purple book, dated October 2015, Appendix A, Definition Diagram-Abuse, documented Physical abuse means the willful action of inflicting bodily injury or physical mistreatment. Physical abuse includes, but is not limited to, striking with or without an object, slapping, pinching, choking, kicking, shoving, or prodding. <RESIDENT TO RESIDENT ALTERCATION>RESIDENT 3Resident 3 admitted to the facility on [DATE] with diagnoses to include depression and aphasia (a language disorder caused by brain damage that impairs a person's ability to communicate). Review of a quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 02/11/2026, documented the resident was cognitively intact. Resident 3 was independent with their wheelchair (w/c) mobility and 1-person assist for longer distances.Review of a progress note dated 04/09/2026 at 10:15 AM documented that Resident 3 had kicked another resident and that the resident continued to be confused.Review of Resident 3's electronic medical record (EMR) did not show alert charting for the resident to resident altercation.In an interview on 04/22/2026 at 3:04 PM, Staff C, Licensed Practical Nurse (LPN), stated they were told that Resident 3 had kicked at Resident 4. Staff C stated Resident 3 was able to self-propel in their wheelchair.In an interview and record review on 04/23/2026 at 10:52 AM, staff G, LPN, nurse manager reviewed Resident 3's EMR and acknowledged there was no alert charting for the incident.RESIDENT 4Resident 4 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia with agitation, anxiety, and major depressive disorder. Review of a Significant Change MDS, dated [DATE], documented the resident had significant cognitive impairment. Resident 4 required assistance with wheelchair mobility.In an interview on 04/22/2026 at 2:35 PM, Resident 4 stated no when asked if they had an incident with another resident and stated no when asked if they had concerns with any residents in the facility.Review of Resident 4's EMR did not show alert charting prior to 04/11/2026.In an interview and record review on 04/23/2026 at 10:52 AM, staff G, LPN, nurse manager reviewed Resident 4's EMR and acknowledged there was no alert charting for the resident until 04/11/2026.RESIDENT TO RESIDENT INCIDENT INVESTIGATIONReview of a facility incident investigation dated 04/09/2026 documented a physical altercation was observed between Resident 3 and Resident 4. Resident 3 was in their w/c and had wheeled past resident 4 who was in their w/c at the South nurses station. Resident 3 stopped and commented fine just ignore me and kicked resident 4 in the left lower leg. Residents 3 and 4 were separated.The investigation documented Resident 3's behavior toward Resident 4 was a result of their continued confusion and delusions and they had been on alert for behaviors that had started the previous week but had not shown aggression to other residents. The investigator documented Resident 3's actions were ruled out as willful abuse.Abuse and neglect were ruled out related to Resident 3 having continued confusion and delusions.In a joint interview on 04/23/2026 at 12:32 PM, Staff A, administrator, and Staff B, Registered Nurse, Director of Nursing, were asked how physical abuse was ruled out regarding the resident-to-resident physical altercation between Resident 3 and Resident 4. Staff A stated abuse was ruled out because Resident 3 was frustrated, did not intend to cause physical harm and was having a change in condition, there was no psychosocial harm to Resident 4 and Resident 4 could not recall the incident. Staff B stated Resident 4 was placed on alert charting on 4/11/2026. Staff A stated alert charting was not in place for Resident 3. Both Staff A and Staff B stated alert charting should be initiated at the time of the incident. Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to coordinate and ensure home health services were established prior to discharge for 2 of 3 sample residents (Residents 1 and 2) reviewed for discharge planning. This failure resulted in delays of necessary clinical services, placed residents at risk for unmet care needs, psychological distress and decreased quality of life. Findings included . Review of the facility policy titled, Discharge Summary, revised date 02/17/2026, documented a post-discharge plan of care should reflect arrangements made for community care and support services as needed. <RESIDENT 1>Resident 1 was admitted to the facility on [DATE] and discharged on 03/03/2026 with diagnoses to include aftercare following joint replacement surgery. According to the Minimum Data Set (MDS-an assessment tool) assessment, dated 03/03/2026, Resident 1 was cognitively intact. In a phone interview on 03/25/2026 at 10:02 AM, conducted by another surveyor, Resident 1 stated that they were supposed to receive home health services upon discharge; however, they were not admitted to home health services until 03/13/2026 and were not seen for services until 03/18/2026 (15 days post-discharge). Resident 1 stated they were told that the home health agent did not receive a referral from the facility. In a phone interview on 03/25/2026 at 3:51 PM, conducted by another surveyor, Collateral Contact 1 (CC1), Director of Clinical Services, stated Resident 1 called them on 03/05/2026 requesting services, but the agency had no referral on file. CC 1 stated they contacted the facility on 03/05/2026 but did not receive the referral until 03/10/2026 and initiated the resident's care on 03/13/2026. CC 1 further stated the facility claimed the delay occurred because the resident had not yet selected which home health agent they preferred. Review of a progress note dated 03/03/2026 at 4:33 PM, documented Resident 1 required a wound vac (a therapeutic technique using a vacuum pump, foam dressing, and seal to enhance healing for complex wounds) and was to be discharged with Alpha Home Health. Review of a facility form titled, Discharge Plan, dated 03/03/2026, documented Resident 1 chose Alpha Home Health for services. Review of a physician order dated 03/03/2026 at 3:25 PM, documented a referral for Alpha Home Health Services to include RN (Registered Nurse), SW (Social Worker) PT (Physical Therapist)/OT (Occupational Therapist)/ST (Speech Therapist) and Bath Aid. Review of the electronic health record (EHR), there was no documentation that the facility sent the referral, that the agency received the referral, or that the resident had been accepted by the agency. In a record review and interview on 04/07/2026 at 1:29 PM, Staff C, Social Services Director, confirmed there was no documentation for a sent referral. Staff C stated the facility received an email confirmation of acceptance from Alpha Home Health on 03/10/2026 (7 days post-discharge). Staff C stated home health services should be confirmed prior to or upon discharge and were unsure why the process failed. In an interview on 04/09/2026 at 9:36 AM, CC2, Transitional Care Coordinator, stated that they were unaware Resident 1 had been discharged with their home health services until the resident called them on 03/05/2026. CC2 stated they started to contact the facility on 03/05/2026 and only accepted the resident on 03/10/2026 after receiving all the required information from the facility. <RESIDENT 2>Resident 2 was admitted to the facility on [DATE] and discharged on 04/04/2026. According to the MDS, dated [DATE], Resident 2 was cognitively intact. In a phone interview on 04/09/2026 at 9:41 AM, Resident 2 stated they had not received a visit or phone call from home health since their discharge on [DATE]. Resident 2 stated they were taking care of their own wound care. In a phone interview on 04/09/2026 at 2:02 PM, CC2 confirmed Resident 2 was not on their caseload, and they did not receive a referral for home health services from the facility. Review of the Discharge summary dated [DATE], documented Resident 2 was discharged with a right buttock wound requiring care and was to be followed by Alpha Home Health. Review of an Alpha Home Health Initial Order Form, signed by a Nurse Practitioner on 04/03/2026, documented Resident 2 needed Alpha Home Health Services to include RN evaluation and treatment, Medical Social Worker, and PT /OT/ST evaluation and treatment. Review of a facility form titled, Discharge Plan, dated 04/04/2026, documented Resident 2 chose Alpha Home Health for home health services. Review of Resident 2's EHR showed no documentation that the referral was sent or that the resident was accepted by the home health agency. In a record review and interview on 04/09/2026 at 12:34 PM, Staff D, Social Service Assistant, stated they could not locate documentation that the referral was sent to or received by Alpha Home Health or if Resident 2 was accepted by the home health agency. In an email interview initiated on 04/13/2026 at 7:30 AM, CC1 confirmed they did not receive Resident 2's referral until 04/09/2026 (5 days post-discharge). In an interview on 04/09/2026 at 2:16 PM, Staff A, Executive Director, and Staff B, Director of Nursing, stated the expectation was to establish home health and receive confirmation of acceptance before or upon discharge. Staff A stated that even for urgent weekend discharges, confirmation should be obtained no later than the following Monday. Reference WAC 388-97-0080(1)(b)(i)(2)(a)(e)(ii)(iv)(6)

Based on observation, interview and record review, the facility failed to provide adequate intervention, update and consistently implement the care plan to prevent accidents/falls for 1 of 2 residents (Resident 1) reviewed for accidents. The facility failure to provide adequate supervision and implement appropriate interventions placed residents at risk for further falls, injury, and a diminished quality of life. Findings included . Review of a facility policy titled, Fall Management, revised date 03/11/2025, documented the facility to evaluate each resident's fall risk to develop and implement care plan interventions that create a safe and secure environment where falls and injuries are minimized. The facility falls interventions include adequate supervision, development of care plan interventions to minimize fall risk, consistent with the resident's needs, goals, care plan, current professional standards of practice, and evaluation of effectiveness of fall risk interventions. Resident 1 readmitted to the facility on [DATE] with diagnoses to include Epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity), Atresia of foramina of Magendie and Luschka (a rare congenital anomaly causing obstructive brain's ventricle outlets blocked), Muscle weakness, and difficulty in walking. According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 12/22/2025, the resident had no cognitive impairment. Resident 1 required set-up assistance for toilet transfer (the ability to get on and off a toilet or commode) and required supervision and touching assistance for walking up to 50 feet using a walker.On 02/10/2026, a review of Resident 1's clinical record documented that the resident had nine falls during 12/17/2025 to 02/02/2026.Review of an incident investigation, dated 12/17/2025 at 12:00 AM, documented Resident 1 fell from using their bedside table as a walker to assist to self-transfer to the bedside commode (BSC). Review of the staff training record, under plan/intervention to prevent recurrence, documented a bedside table needed to always have one wheel locked. There was no other intervention documented. On 02/12/2026, Resident 1's current care plan was reviewed. There was no documentation to lock the bedside table all the time.On 02/12/2026, review of current nursing Kardex (a tool used to provide directions on how to care for a resident), there was no documentation directing staff to lock the bedside table all the time.Review of an incident investigation, dated 12/21/2025 at 10:30 AM, documented Resident 1 had an unwitnessed fall and stated they had fallen off the lobby bench onto the ground. The investigation documented that the resident required one person assist for transfer and walking and the resident walked without assistance. The investigation concluded that Resident 1 had walked with their walker to the front of the building and did not use their wheelchair, which resulted in a fall. There was no documentation on what interventions provided to prevent further fall.Review of an incident investigation dated 12/24/2025 at 10:45 AM, documented confusing information about whether the resident was using a front wheeled or four wheeled walkers, and whether the resident fell in the hallway or in the room, and whether the resident was found on the floor or partially caught by a staff. The conclusion was that the resident utilized an unsafe and unstable four wheeled walker. It documented that the unsafe walker was removed from their room and the action taken was that the walker was given back to the resident. There was no documentation about what risks and benefits information had been provided to the resident or family about the unsafe use of a four wheeled walker or whether any further intervention implemented regarding the unsafe walker.Review of an incident investigation, dated 12/31/2025 at 11:45 AM, documented Resident 1 stated they slipped off the BSC in their room, landed on the floor and hit the front and back of their head. The investigation documented predisposing factors included clutter, crowding and poor lighting in the room, had a balance disorder, and ambulated without assistance from staff. There was no documentation of a conclusion or any action taken to prevent further falls.Review of an incident investigation, dated 01/23/2026 at 2:50 PM, documented Resident 1 used their FWW to use their BSC, slipped and fell from the BSC. The resident stated they bumped the right side of their head uncertain of the place. The investigation documented the resident was one person assistant with transfers and used an unsafe four wheeled walker brought in by the family due to no breaks. Resident 1 wanted to use the walker regardless of being educated several times that the walker was unsafe to use. There was no documentation about what risks and benefits education was provided to the resident and family.Review of a facility incident investigation, dated 01/25/2026 at an unknown time, documented Resident 1 was found on the floor in their room when they attempted to get up on their own but fell over. There was no documentation of a conclusion about why the fall occurred or action taken to prevent further falls.Review of a facility incident investigation, dated 02/02/2026 at 1:50 PM, documented Resident 1 fell on a box fan next to their BSC with a four wheeled walker located in front them and their call light was not in reach. The environment was cluttered with a FWW, fan and a BSC. The investigation report documented Resident 1 had impulsive behaviors; did not use call light; had history of recurrent falls, had poor safety awareness and gait imbalance; needed assistance with ADLs and ambulating. There was no documentation of conclusion and action taken. There was no documentation of interventions on the cluttered room environment.Review of a physical therapy evaluation, dated 01/27/2026, documented Resident 1 required supervision or assistance on sit to stand, chair/bed to chair transfer and toilet transfer, and the resident required moderate assistance on walk 10 feet and walk 50 feet with two turns. Review of Resident 1's current fall care plan, revised date 09/0/2025, documented an intervention initiated 01/26/2026 to place their BSC close to bed for ease of transferring. An intervention initiated on 08/13/2024 documented to make sure Resident 1's FWW was within reach. An intervention initiated on 04/28/2025 documented to encourage Resident 1 to always use both hands on their FWW when ambulating. In multiple observations on 02/10/2026 at 10:18 AM, 02/10/2026 at 11:47 AM, 02/12/2026 at 10:47 AM, Resident 1's room had a bed against the wall next to the window, a recliner in the middle of the room, a four wheeled walker at the bed foot and away from the recliner, a dresser against the wall in front of the recliner, a bedside commode against the wall behind about five feet away from the recliner. The bedside commode was about 10 feet away from the bed and the recliner was in between the bed and bedside commode. The bedside table was unlocked and placed next to the recliner and between the recliner and the bedside commode. There was no FWW in their room.In an interview on 02/05/2026 at 2:49 PM, Collateral Contact 1 (CC1), Staff from Behavioral Therapy, stated Resident 1 had multiple falls and the resident had injury on the right eye lid. CC1 stated the nurse could not provide any information about the multiple falls or how Resident 1's right eye was injured, or what interventions were implemented to prevent further falls. In an interview on 02/10/2026 at 11:49 AM, Resident 1 stated they had multiple falls in the facility. They stated they had fallen last week and fell on their head with laceration and swollen on the right eye. The resident stated they had personal caregivers who usually stayed with the resident for about four to five hours daily from Monday to Friday, but not 24 hours.In an interview on 02/10/2026 at 12:12 PM, Staff D, Nurse Assistant Certified (NAC), stated Resident 1 was a fall risk, but they did not use their call light when using their BSC, and fell frequently when they transferred without assistance from staff. When asked if the resident needed more supervision, Staff D stated they always reminded Resident 1 to use their call light even though the resident knew they needed to use call light, but they did not.In an interview on 02/10/2026 at 12:50 PM, Staff E, Licensed Practical Nurse (LPN), stated Resident 1 had frequent falls due to impulsive behaviors, forgetfulness, and unsteady gait, did not use their call light, and self-transferred to the BSC. Staff E stated the resident needed to use their wheelchair instead of a walker. When asked if Resident 1 needed more supervision with their transfer, Staff E stated the resident had personal care givers who stayed with the resident. Asked if the personal care giver was with the resident for 24 hours, Staff E stated no.In an interview on 02/12/2026 at 10:57 AM, Staff F, LPN/Unit Care Coordinator, stated Resident 1 did not follow the therapists' recommendations, and the resident used a four wheeled walker which was not safe to use. Staff F stated they educated the resident and the family multiple times but there was no documentation about what risks were provided. Staff F stated Resident 1 was supposed to use call light and was constantly reminded to use the call light, but the resident did not listen and had fallen multiple times from self-transferring. When asked if Resident 1 needed more supervision, Staff F stated the personal care giver was there with the resident all the time. Asked if the personal care giver was with the resident 24 hours, Staff F said no. Staff F stated Resident 1 had so many falls and nothing else they could do about it.In an interview and record review on 02/12/2026 at 11:32 AM, Staff B, Director of Nursing Services, stated among Resident 1's nine falls from 12/17/2025 to 02/02/2026, there were multiple incidents related to the resident self-transferring to the BSC without supervision or assistance, and used the four wheeled walker with no supervision or assistance.In an observation and interview on 02/12/2026 at 11:46 AM with Staff B, observed Resident 1's four wheeled walker was at the foot of their bed, the BSC was placed behind their recliner next to the wall. Staff B stated Resident 1 was not supposed to use the four wheeled walker and the BSC was supposed to be closer to the recliner.An interview was conducted on 02/12/2026 at 11:47 AM with Staff B and Staff D, NAC. Staff D stated Resident 1's BSC was placed behind the resident's recliner next to the wall all the time.An interview was conducted on 02/12/2026 at 11:48 AM with Staff B and Staff G, Director of Rehab. Staff G stated Resident 1 was not safe to use their four wheeled walker. Staff G stated a care conference recently held with a collaborating agency staff member who stated the resident had the right to use the walker they preferred and they had the right to fall. Staff G stated they did not document the care conference.In an interview on 02/12/2026 at 11:55 AM, Staff B stated the facility provided education to Resident 1 and their family regarding the four wheeled walker was unsafe to use. Staff B was unable to find the documentation on what risks and benefits educated to the resident and their family.In an interview on 02/12/2026 at 1:36 PM, Staff B stated Resident 1's room setting needed to be rearranged to better access the resident's BSC and minimized turns to keep the resident safe. Staff B stated the BSC, which was next to the wall behind the recliner the resident slept in, needed to be moved to the other side of the room near the bed for better access for the resident to use. Staff B stated the resident used their walker to pivot and turn to get close to the BSC, and the walker needed to be placed next to their recliner instead of far away from the recliner at the foot of bed. Staff B stated they needed safety strips on the floor to remind the resident the path to get to the commode. In a joint interview on 02/12/2026 at 2:26 PM with Staff A, Executive Director, Staff B and Staff C, Regional Support Nurse. Staff B stated they expected systematic data analysis and review from IDT team and interventions provided timely to prevent further fall incidents. Staff A stated the recent staffing changes have impacted the investigation process. Staff C stated they expected every fall incident to include a conclusion and summary with interventions. Reference WAC 388-97-1060 (3)(g)

Based on interviews and record review, the facility failed to ensure assessments were completed to evaluate the need for pressure offloading preventative measures post-surgery, assess and monitor skin integrity, and to consistently implement interventions to prevent development of an avoidable pressure ulcer/pressure injury (PU/PI - injury to skin and underlying tissue resulting from prolonged pressure) for 1 of 1 sampled resident (Resident 1), reviewed for pressure ulcers. Resident 1 experienced harm when they developed an unstageable PI [a full thickness wound where the depth of damage cannot be determined because the base is covered by slough (yellow, tan, or grayish tissue) or eschar (brown or black leathery tissue)] to their right heel, an unstageable PI to their right bottom foot, and a Deep tissue pressure injury (DTPI) to the right foot on the lateral side. These failures placed residents at risk of pain, infection, medical complications, and a decreased quality of life. Findings include. Review of the facility policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention, reviewed 06/11/2025 documents that this policy follows the professional standards of the National Pressure Injury Advisory Panel (NPUAP).a comprehensive skin assessment/inspection should be completed on re-admission to the facility, then weekly, quarterly and as needed.measures to maintain and improve residents skin will be implemented into the plan of care.implement measure to prevent against adverse effects of external forces such as pressure, friction and shearing. The National Pressure Injury Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages included:- A pressure injury (PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present itself as intact skin or an open ulcer and may be painful. The injury occurred because of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and sheer may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of soft tissue.- An DTPI, is a localized area of purple or maroon discolored intact skin or a blood-filled blister due to underlying soft tissue damage from pressure or shear. The area may be painful, firm, mushy, boggy, warmer, or cooler than surrounding tissues, - An unstageable PI is an obscured full-thickness skin and tissue loss, full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it was obscured by slough or eschar (non-viable tissue covering the wound bed) (the eschar was dry, adherent, and intact without redness). NPUAP (2017), Educational and Clinical Resources and PI Prevention Points, advises to inspect the skin at least daily for signs of pressure injury, assess pressure points, reposition all individuals at risk for pressure injury based on support surfaces and individual preference. Resident 1 readmitted to the facility on [DATE] after an elective total right knee arthroplasty (replacement of the joint) (TKA) with diagnoses including atrial fibrillation (irregular heart rhythm), and peripheral vascular disease (condition that can affect blood flow to limbs). The 5-Day Minimum Data Set (MDS - an assessment tool) dated 10/28/2025 documented the resident had intact cognition, no refusal of care and was dependent on staff to assist with bed mobility. The MDS assessment documentation showed Resident 1 was at risk for PU/PI and had no PU/PI to their right leg or foot on readmission. Review of Resident 1's readmission skin assessment completed on 10/23/2025, documented no wounds to the resident's right foot, compression stockings on legs, and edema to lower extremities. Review of Resident 1's medical record reflected a document titled, Skin Integrity Update, dated 10/28/2025, there was no documentation related to any open wounds or redness to the resident's right leg/foot. Review of Resident 1's progress notes from 10/23/2025 - 11/02/2025, showed there was no documentation that any licensed staff visualized the resident's right leg with the compression stocking removed, and that no licensed staff had remove the compression stocking to the resident's right leg for a skin assessment. Review of the facility investigation dated 11/02/2025 at 1:45 PM, the licensed nurse documented that they found several new PIs:- Top of the right foot was reddish/purplish color and measured 8.5 centimeters (cm) by 3.5cm, - Right inner foot was reddish/purplish color that measured 4cm x 1cm, - Right lateral foot reddish/purplish color that measured 2.5cm x 1.5cm, - Scab on top of foot that measured 0.5cm x 0.5cm, - Right heel with black eschar that measured approximately 8.5cm x 3.5cm. Review of Resident 1's progress note dated 11/03/2025, they were transferred to the local community hospital on [DATE]. Review of Resident 1's hospital (local community) records dated 11/03/2025, the resident was transferred to another hospital (trauma - higher level of care) on the evening of 11/03/2025. Review of Resident 1's trauma hospital medical records dated 11/04/2025 at 2:00 AM, documented the following wounds on admission: - PI to the right heel, was unstageable, with black eschar dry, and fixed edges that measured length 4 cm x width 5 cm, - PI right dorsal foot (top of foot), was unstageable, with black eschar; maroon; blistered (Boggy) - peri wound (area of skin immediately surrounding a wound) area was red with irregular edges, that measured 9cm x 5 cm x unable to determine, - PI right lateral foot, was staged as a DTPI with maroon appearance, the wound base skin remaining intact at this time does not blanch that measured 2cm x 1cm x 0cm. In a phone interview on 11/06/2025 at 3:50 PM, Resident 1 stated they were still admitted to the trauma hospital. Resident 1 stated that the staff would usually put pillows under their knees, and their feet would rest on top of the mattress. Resident 1 stated the staff never removed the compression stockings to look at their right foot. In a phone interview on 11/12/2025 at 10:24 AM, Staff E, Registered Nurse (RN) stated they were familiar with Resident 1 and had provided care stated they never looked at the resident's right foot until 11/02/2025. Staff E stated they did not contact the medical provider between 10/23/2025 - 11/02/2025 (prior to discovery of right foot) that the resident had been refusing to let them remove the compression stocking to assess the residents increased pain to their right foot, and that they never documented the refusal in the residents' medical record. In an interview on 11/12/2025 at 1:54 PM, Staff G, Nursing Assistant Certified (NAC), stated they are educated to attempt to reposition a resident every two hours or according to their care plan, and would use pillows under the knees to float heels. Staff G stated if a resident was refusing care, they would notify the nurse. Staff G stated they were in Resident 1's room, and the POA was in the room as well, and they removed the compression stocking to Resident 1's right leg. Staff G stated the foot was black, so they went to go get the nurse. In an interview on 11/12/2025 at 2:15 PM, Staff H, NAC stated they attempt to reposition all residents every two hours and will use pillows only if the residents request them. In a phone interview on 11/13/2025 at 7:51 AM, Staff F, Licensed Practical Nurse (LPN) stated all residents should be care planned for positioning with interventions to prevent skin breakdown. Staff F stated they were familiar with Resident 1. Staff F stated they never removed the compression stockings and only observed the resident's right leg with the stocking on, and it appeared very tight. Staff F stated the orders for the compression stockings were not clear, they never reached out to the provider to clarify the orders. In an interview on 11/18/2025 at 12:49 PM, Staff D, LPN/Resident Care Manager (RCM) stated that the licensed nurses should remove a residents compression stocking or any device that is on their skin and assess the skin daily. Staff D stated when the licensed nurse should be completing weekly skin checks on all residents. Staff D stated they did not remove Resident 1's compression stocking to the right leg for the readmission skin assessment and never visualized the resident's skin to the right foot. In an interview on 11/18/2025 at 1:57 PM, Staff B, RN/Outgoing DNS/Incoming RCM stated all the department managers are responsible for ensuring the residents plan of care was updated appropriately. Staff B stated when a resident returns from a procedure the orders and care plan should be updated and/or revised. Staff B stated they were familiar with Resident 1, and that they were at risk for skin breakdown. Staff B confirmed that the plan of care for the residents to be risk for skin breakdown was never revised after their post-knee replacement surgery. Staff B stated there was no documentation of the refusals, and that no licensed nurse had contacted the provider. In joint interview on 11/18/2025 at 2:31 PM, Staff A, Administrator, Staff C, Incoming DNS/RN, Staff A said there had been a lack of care planning and appropriate monitoring of Resident 1's skin. Staff A and Staff C stated that PIs to Resident 1's foot were significant injuries. Reference WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to establish an appropriate plan of care, consistently provide the required assessments monitoring, and care interventions following a total knee replacement surgery for 3 of 4 residents (Residents 1, 2, and 3) reviewed for post-surgical care and hospitalization. Resident 1 experienced harm when they verbalized increased pain to the right foot that was unassessed for six days, developed a blood clot to their right foot that caused lack of blood flow to the foot that required transfer to the hospital where a surgical intervention was performed to remove the clot and the potential for right foot amputation (removal of limb). This failure placed all post-surgical residents at risk for unmet care needs, injury, and a diminished quality of life. Findings include.Review of the facility policy titled, Comprehensive Care Plan and revisions, dated 08/29/2025 documents the facility will ensure the timeliness of each resident's person-centered care plan is reviewed and revised When changes occur, the facility shall review and update the plan of care to reflect changes to care delivery, this can include additional interventions, updating goals and interventions. Review of the facility policy titled, Changes in Resident Condition or Status, dated 08/29/2025 documents the facility will notify the primary provider of changes in the resident's condition. <RESIDENT 1> Resident 1 readmitted to the facility on [DATE] after an elective total right knee arthroplasty (replacement of the joint) (TKA) with diagnoses including atrial fibrillation (irregular heart rhythm), and peripheral vascular disease (condition that can affect blood flow to limbs). The 5-Day Minimum Data Set (MDS – an assessment tool) dated 10/28/2025 documented the resident had intact cognition, no refusal of care and was dependent on staff to assist with dressing, wearing footwear, and bed mobility. Review of Resident 1's readmission physician orders related to their knee surgery, documented the following:- Dressing to right knee to remain in place until follow up with provider, if soiled can change pad. Compression stockings to hold pad in place. Two times a day for dressing change dated 10/24/2025, - Congestive heart failure (CHF) monitor for edema every shift dated 05/29/2025,- Eliquis (blood thinning medication) oral tablet, given by mouth two times a day for anticoagulant (prevention of clots). Review of Resident 1's care plan from 10/23/2025 – 11/02/2025 did not show documentation of the resident's recent surgery, no focus area of care related to post-surgical care of the right leg, no goals of care for the right leg, and did not show interventions for staff related to the resident's post-surgical care, assessment and monitoring of the resident's right leg. Review of Resident 1's medical record documented the readmission skin assessment was completed on 10/23/2025, by Staff D Licensed Practical Nurse (LPN) / Resident Care Managers (RCM)the license nurse, did not remove the compression stocking on the right leg to visualize the skin. Further review from 10/23/2025 – 11/02/2025, showed no documentation that any licensed staff visualized the resident's right leg with the compression stocking removed, and that no licensed staff had attempted to remove the compression stocking to the resident's right leg for a skin assessment. Review of the facility investigation dated 11/02/2025 at 1:45 PM, documented the licensed nurse (Staff E, Registered Nurse – RN) was called to Resident 1's room. The licensed nurse reported that the Nursing Assistant Certified (NAC) had removed the resident's compression stocking to the right leg and found the top of the right foot to be deep dark purple, non-blanchable (indicating potential compromised blood flow to the area) and that the heel was black and hard. The investigation documented that the resident was sent to the local community hospital on [DATE] at 9:00 AM. Review of local community hospital records dated 11/03/2025, documented Resident 1 had severe narrowing and some occlusion to the arteries to their right lower leg. The resident was transferred to a trauma hospital. Review of the trauma hospital records dated 11/03/2025, documented Resident 1 had experienced worsening pain over the last week and half, imaging at local community hospital showed the residents had ischemia (inadequate blood supply) and occlusion to the right foot/ankle. The documentation reflected that the resident would need an angiogram (medical procedure using X-ray imaging and a contrast dye to visualize blood vessels and diagnose the blockage) and a percutaneous thrombectomy (surgical procedure to remove blood clots using a catheter guided through blood vessels). The vascular surgeon documented that even if they were able to reestablish arterial flow to the foot, the resident would be at risk for continued wound complications and potential amputation. In a phone interview on 11/05/2025 at 3:58 PM, Collateral Contact (CC) 1, Resident 1's power of attorney (POA) stated they were concerned about Resident 1's care at facility, and that the staff had not been removing the compression stocking to Resident 1's right leg and now they were in the hospital. In a follow up phone interview on 11/06/2025 at 3:50 PM, CC1 stated they were usually in the facility at least every other day visiting and never observed or overheard the facility staff request to remove the compression stocking on their right leg. In a phone interview on 11/06/2025 at 3:50 PM, Resident 1 stated they were still admitted to the trauma hospital, and that they had a surgical procedure the day before to try and reestablish blood flow to their right foot. Resident 1 stated I tried to tell them to take that stocking off, they just looked at me like I was a crazy lady. Resident 1 stated they do not recall ever refusing to let the staff remove the compression stocking, and said, for a while there I was in so much pain and that the pain was all they could focus on. Resident 1 stated they did not recall any staff every asking to remove the compression stocking. In an interview on 11/12/2025 at 9:10 AM, Staff I, RN stated they did not work with Resident 1 after they readmitted following their right knee replacement surgery. Staff I stated they were asked to observe the resident's foot by Staff E, RN on 11/02/2025. Staff I stated the right foot was dark red/purple on the top of the foot, and their heel was completely black and real hard. Staff I stated that Staff E looked at me and then looked at the resident and stated to the resident we might have to send you to the hospital, and the resident agreed. In a phone interview on 11/12/2025 at 10:24 AM, Staff E, RN stated that facility staff utilize the care plan, and orders to guide the care that was delivered to each resident. Staff E stated that most of the updates and revisions to the care plan are done by the nurse managers, however they could if needed. Staff E stated all documentation was required to be in the resident's medical record by end of the shift, or before you leave the facility for the day. Staff E stated it was the facility process for the licensed nurses to complete weekly skin checks on all the residents. Staff E stated that if a resident was wearing compression stockings, they are supposed to remove them to look at the skin. They stated if they refuse the electronic medical record system will send a notification to the nurse managers and they will follow up with the resident, they stated if a resident refused a medication, then they contact the provider but would not contact the provider if they were refusing a skin assessment. Staff E stated that they remembered Resident 1 had a recent knee replacement and was having increased pain. Staff E stated they asked the resident if they could remove the compression stocking to assess the pain in their right foot, but that the resident refused. Staff E stated they did not communicate that to the provider and stated it was more about pain management for them. Staff E confirmed they never looked at the resident's right foot until the NAC removed the stocking on 11/02/2025 around 1:45 PM. They stated the whole top of the resident's right foot was deep purple, redness down the sides and their heel was black and hard. Staff E stated they contacted the provider to get an order for a doppler (to check for blood flow) or to send Resident 1 out to the hospital. Staff E stated the on-call provider refused to let them get a STAT (immediately) doppler or send the resident to the hospital, so they notified the on-call nurse manager, and were instructed to monitor the resident. Staff E confirmed they did not contact the doctor at any time between 10/23/2025 – 11/02/2025 (prior to discover of right foot) that the resident had been refusing to let them remove the compression stocking to assess the residents increased pain to their right foot, and that they never documented the refusal in the residents' medical record. In an interview on 11/12/2025 at 1:54 PM, Staff G, NAC, stated if a resident was refusing care, they would notify the nurse. Staff G stated they were in Resident 1's room, and the POA was in the room as well, and they removed the compression stocking to Resident 1's right leg. Staff G stated the foot was black, so I went to go get the nurse. In an interview on 11/12/2025 at 2:15 PM, Staff H, NAC, stated that they will ask residents if they would like to have their compression stockings removed at nighttime, or they remove them at night. Staff H stated some residents prefer to keep them on. Staff H stated if a resident was refusing care they would retry and then let the nurse know. In a phone interview on 11/13/2025 at 7:51 AM, Staff F, LPN stated that the nurse managers usually would be the ones to update the care plans. They are expected to have all their documentation completed prior to leaving the facility at the end of their shift. Staff F stated they were not sure who was selected for skin checks, just that they are notified in the electronic medical record which residents on their shift need a skin check. Staff F stated they are to report to the Director of Nursing Services (DNS) and provider if a resident was refusing to let them look at their skin, and they would document in the medical record. Staff F stated they cared for Resident 1 while they were at the facility. Staff F stated they remembered the resident was having a lot of pain in the right foot, and that they were wearing compression stockings. Staff F stated the report from the day shift nurses, was that the family of Resident 1 did not want staff to remove the compression stockings. Staff F stated that they never tried to remove the compression stockings, they looked at the resident's right leg with the stocking on, and it appeared very tight. Staff F stated the orders for the compression stockings were unclear, and they never reached out to the provider to clarify the orders. Staff F stated they thought the day shift nurses were dealing with the situation, and they were focused on the pain they were having in the right foot and just wanted to make the resident comfortable. In an interview on 11/18/2025 at 12:49 PM, Staff D, LPN/Resident Care Manager (RCM) stated they had just started all the licensed nurses should be able to update the care plan, anyone who is aware of a change or revision should be responsible. Staff D stated the staff should be removing any compression device that is on a resident to assess the area of the skin at least daily if not each shift. Staff D stated they remembered Resident 1, and that they were having a lot of issues with managing their pain in the right leg, they added they recalled the pain regimen was changed a lot. Staff D stated the resident had a recent total knee replacement on the right leg, and they should have been monitored as they were at risk for blood clots. Staff D confirmed they never removed the compression stocking to the right leg, never visualized the right foot that had the increased pain, never documented that the resident had refused and never notified the provider that the resident had been refusing to remove the compression stocking to the right foot. In an interview on 11/18/2025 at 1:57 PM, Staff B, RN/Outgoing DNS/Incoming RCM stated all the department managers are responsible for ensuring the residents plan of care was updated appropriately. Staff B stated skin checks are completed on all residents weekly, and if there was a concern the staff were to report to the provider, get new orders and place a referral to our contracted outside wound provider, and place the resident on monitoring. Staff B stated the standard order for compression stockings would be on in the morning and off at night, unless there was a specific order to follow. Staff B stated if the orders are not clear they should be contacting the provider to ensure we have a clear order to follow and get it updated. Staff B stated they were familiar with Resident 1 and stated they were aware the resident had been refusing to allow staff to remove the compression stockings. Staff B stated they were not sure if any licensed staff ever contacted the provider about the clarification of the compression stockings or that they were refusing to allow them to be removed. Staff B stated they knew the resident was on a blood thinner and was at risk for blood clots. Staff B confirmed that the plan of care for post-knee replacement surgery was never incorporated into Resident 1's care plan, that there was no assessment or monitoring for blood clots, no documentation of the refusals, and that no one had contacted the provider. In joint interview on 11/18/2025 at 2:31 PM, Staff A, Administrator, Staff C, Incoming DNS/RN, Staff A and Staff C were asked if there was any notification, documentation, care planning, monitoring or assessment of Resident 1's right leg, or right foot after their surgery. Staff A & Staff C both stated there was not.No further information was provided by Staff A, and Staff C. <CARE PLAN> <RESIDENT 2> Resident 2 was admitted on [DATE] with diagnoses to include left knee replacement surgery. Resident 2 had physician orders to include ted hose (compression socks) on everyday shift and staff were to monitor for edema every shift with a start date of 10/28/2025. Resident 2's care plan did not show care interventions for the ted hose or edema monitor. <RESIDENT 3> Resident 3 was admitted on [DATE] with diagnoses to include right hip fracture. Resident 3 had physician orders to include ted hose on every morning with a start date on 10/13/2025. Resident 3's care plan did not include care interventions for the ted hose. In an interview on 11/18/2025, at 12:48 PM, Staff D, LPN/RCM, stated that residents who have ted hose orders should be in the care plan. Refer to WAC 388-97-1060(1-3)

Based on interviews, observation, and record reviews, the facility failed to assess/monitor the position of a catheter tubing (a flexible tube inserted into the bladder to remove urine and attached to a drainage bag) during catheter care and bed mobility/positioning to prevent the occurrence of an avoidable pressure ulcer (PU) and provide ordered treatment for the PU for 1 of 3 residents (Resident 3) reviewed for PU's. Resident 3 experienced harm when they developed an avoidable Stage III PU (full-thickness skin loss of skin, which is when fat is visible in the ulcer and granulation tissue which is new connective tissues and microscopic blood vessels, and rolled wound edges are often present. Slough, nonviable tissue, and/or eschar, dead or devitalized tissue, may be visible. Undermining -destruction of tissue or ulceration extending under the skin edges and tunneling - a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) which caused pain and discomfort.Findings included .The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, showed a PU/Pressure Injury (PU/PI) definition and stages as:-A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear (a combination of downward pressure and friction).-Medical device related PU/PIs were a result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.- Moisture Associated Skin Damage (MASD) was superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration. Resident 3 admitted to the facility on [DATE] with diagnoses to morbid obesity and PU's to their buttocks and sacral region (at the base of the spine to the coccyx).Review of an in-service training dated 06/19/2025 showed Nursing Assistants (NA's) were educated on urinary catheter care and directed the staff to assess the securing device daily and change it when clinically indicated.Review of Resident 3's progress note, dated 07/18/2025 at 2:00 PM, showed a urinary catheter was placed by the Assistant Director of Nursing Services and the floor nurse. Resident 3 expressed pain in their groin and genital area.Review of Resident 3's wound care assessment provided by an outside wound healing company, dated 07/23/2025, showed a newly developed facility acquired 5.0 centimeter(cm) by 7.0 cm by 0.3 cm stage III PU. The documentation showed this was caused by a medical device (Foley). The resident had MSAD in multiple locations . due to incontinence and sweat. The treatment recommendations were to apply a wound gel and foam dressing every day and as needed.Review of Resident 3's progress note, dated 07/23/2025, showed the resident's catheter tubing was found under their right thigh, with no securement device, along with a stage III PU where the tubing was found.Review of Resident 3's current care plan had a focus problem of a Foley device related stage III PU on the right buttock. Interventions included: treatment as ordered by the physician and weekly skin checks (initiated on 11/29/2024), pressure redistribution mattress (initiated on 07/25/2025), and to ensure catheter securement device was in place and the Foley catheter was properly hung on the bed (initiated on 07/29/2025).Review of Resident 3's July 2025 Treatment Administration Record showed wound care to stage III right posterior thigh every day. The nurse was instructed to clean the wound, apply wound gel and a foam dressing. Wound care was to be completed every 24 hours and as needed.In an interview and observation on 07/31/2025 at 12:12 PM, Resident 3 was observed lying on their back with the head of the bed in the upright position. There was a catheter bag attached to the right-hand side of the bed. When asked by the surveyors if they had any skin breakdown, the resident stated they had skin breakdown all over their body. Resident 3 stated they recently had their indwelling catheter replaced and the staff had placed the tubing under their leg rather than over their leg. The resident was asked if the indwelling catheter tubing was now being secured. Resident 3 proceeded to remove their sheet and expose their right leg and part of their left thigh. The catheter tubing was observed to be secured in a removable device on their upper right thigh. The resident showed an open area on the right middle upper inner thigh between a skin fold. The wound was approximately five inches long, open, wound bed was pink, and the surrounding skin was intact. The resident showed the upper inner part of both thighs. There was a brief in place, the skin was red, irritated appearing, an open wound was observed on the right inner thigh located close to the bottom of, the skin was moist, and there was no evidence of an application of a cream/ointment (that was MASD related, not r/t to the PU). This area was hard to visualize completely without assistance from staff. The resident stated the area between their upper thighs caused them discomfort (MASD).In an observation on 07/31/2025, with Staff E, Registered Nurse, and Staff F, NA, Resident 3's skin was observed. Staff E and F assisted Resident 3 onto their left side with theirbuttocks and posterior (back side) right thigh exposed. Staff F positioned the resident to ensure their skin was able to be viewed. There was an open wound approximately five inches long on the posterior right upper thigh. The wound bed was pink with no signs of active drainage. The surrounding skin around the wound was red and blanchable. There was no evidence of cream, ointment or a dressing on her upper thighs or buttocks. The right and left buttock were bright red, irritated, with two quarter size shaped wounds that were not open but had fragile skin covering both wounds. The resident had multiple red non fluid filled bumps on scatted on their back and upper part of their thighs. When asked Staff E what this could be caused by, Staff E and the resident both stated they were not sure.In an interview on 07/30/2025 at 2:23 PM Staff B, Director of Nursing Services, stated Resident 3's PU were found by an outside wound care service, and the assistant director of nursing was investigating how they occurred. Staff B stated they had been off the three days after Resident 3's PU was found. No other information was provided. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to provide a thorough assessment to timely recognize a significant change in condition, take action to notify the medical provider as ordered, and to ensure required staff were certified in Cardiopulmonary Resuscitation (CPR) for 1 of 1 resident (Resident 1) reviewed for an unexpected death in the facility. Resident 1 experienced harm when they had a significant weight gain over a 24-hour period, swelling in their left arm, slurring of their speech, difficulty breathing and change in their mentation throughout the day of [DATE], until they were found unresponsive without a pulse when assessment and treatment were delayed for several hours that constituted an immediate jeopardy. An Immediate Jeopardy (IJ) was identified, and the facility was notified of the noncompliance on [DATE]. The IJ was determined to have begun on [DATE] when the facility failed to assess and timely act on a resident's significant change in condition. The IJ was removed on [DATE] when an on-site inspection validated the facility implemented their removal plan by terminating the staff that failed to assess, treat and timely notify the physician of Resident 1 regarding their significant change in condition. The facility audited the records of all residents for unidentified changes in condition, educated staff on what to do when a resident has a change in condition, and audited employee Cardiac Pulmonary Resuscitation (CPR) certifications to ensure there were an adequate number of staff working each shift with active CPR certifications. Findings Included . Review of the facility policy titled, Changes in Resident's Conditions or Status undated, documented the facility would utilize the Lippincott procedure-change in status, communication and long-term care. Review of the Lippincott procedures titled, Change in status, identifying and communicating, long-term care, revised [DATE], documented the health care team members were responsible for communicating a resident's change in condition from their baseline. A nursing assistant who noticed a change should immediately report them to a nurse and the nurse must communicate a resident's change in status, including assessment findings, to the practitioner. At a minimum, assessment should include: reviewing the resident's medical record, asking how the resident feels and what symptoms the resident has, obtaining vital signs, observing the resident's overall condition, including function and cognition, exploring the resident's complaints. Resident 1 was admitted to the facility on [DATE] with diagnoses to include congestive heart failure (CHF-condition in which the heart doesn't pump blood as well as it should) and cellulitis (bacterial skin infection) of the left and right lower limbs. Review of Resident 1's Minimum Data Set (MDS-an assessment tool) dated [DATE] showed they were administered the Brief Interview for Mental Status (BIMS-tool to screen for cognitive impairment) with a score of 13 out of 15 which indicated intact cognition. Review of Resident 1's electronic medical record (EMR) documented the resident had passed away unexpectedly in the facility on [DATE]. Review of the care conference record dated [DATE], Resident 1 was planning to return home after rehabilitation services at the facility. Review of Resident 1's care plan dated [DATE] showed they were at risk for rehospitalization due to their history of CHF with an intervention for staff to provide timely communication to the physician regarding any change of condition. The care plan also showed Resident 1 may experience weight fluctuations with interventions to include observation and report, as needed, dependent edema of legs and feet, weight gain unrelated to intake, disorientation, cool skin, and weakness and daily weight monitoring before breakfast. Review of Resident 1's EMR documented weights on [DATE] that showed they weighed 324.8 pounds (lbs.) and on [DATE] they weighed 343.5 lbs., a weight gain of 18.7 lbs. in a 24-hour period. Review of Resident 1's Medication Administration Record (MAR) dated [DATE], documented a physician order dated [DATE] to weigh the resident every day shift before breakfast and report a three lb. weight gain in a day or five lb. weight gain in a week to the physician. The weight documented on [DATE] was 324.8 lbs., and on [DATE] the resident's weight was 343.5 lbs. There was no documented weight for [DATE]. Resident 1's EMR showed no documentation of the physician being notified of Resident 1's significant weight gain. Review of Resident 1's MAR for [DATE], dated [DATE], showed a monitor for edema (swelling that occurs when fluid builds up in the body's tissues) and a documented 3+ (a moderate to severe degree of swelling). [DATE] MAR showed no refusals for Resident 1's Lasix (a medication to treat fluid retention). Review of Resident 1's EMR documented the last vitals for the resident were taken [DATE] at 8:49 AM. Review of Resident 1's progress notes dated [DATE] at 5:31 PM documented an entry by Staff B, Registered Nurse (RN), stating the resident had developed difficulty breathing at 3:20 PM and was assessed (oxygen saturations at 96 percent-a measurement of how much oxygen the blood is carrying), resident's oxygen was increased to four liters per minute(lpm-flow rate of oxygen administered to a patient) and provided a nebulizer treatment. The progress note showed Resident 1 stabilized for about an hour, then developed shortness of breath again and was given an inhaler (a device that delivers medication directly to the lungs). At 5:30 PM Resident 1's condition was noted to deteriorate and the NAC's reported they had no pulse. Emergency services were contacted and Resident 1 passed away at 6:18 PM at which time the Director of Nursing Services (DNS) was notified and the provider. Review of Resident 1's physician orders for [DATE], showed there was no order in the residents record to titrate (increase) the oxygen up to four liters a minute. Review of Resident 1's MARs dated [DATE], documented that the resident had an order for Ipratropium-Albuterol solution 3 milliliters (mL) inhaled orally via nebulizer two times daily AM and bedtime. The review showed that on [DATE], [DATE] and [DATE] at AM the resident refused this medication. Staff B documented in their progress note dated [DATE] at 5:31 PM that nebulizer was provided to the resident, however this is not reflected on the MAR. The [DATE] MAR also documented an order for continuous oxygen to be administered at two L per minute. There was no order or documentation the physician was notified with request to increase the resident's oxygen to four L as documented in Staff B's progress note on [DATE] at 5:31 PM. In an interview on [DATE] at 11:12 AM Anonymous Staff A, Nursing Assistant Certified (NAC), stated that on [DATE] they were the assigned NAC for Resident 1 and the resident was not acting themselves. The resident had slurred speech, a swollen left arm, and was not able to track with their eyes. Staff A stated they notified their nurse, Staff B, Registered Nurse (RN) at around 9:00 AM and again around 12:00 PM. Staff A stated they knew something was Really wrong with Resident 1 and they felt that Staff B was not paying attention. Staff A stated Staff B had not checked on Resident 1 during their shift. Staff A stated they did not notify any other nursing staff of Resident 1's change of condition. In an interview on [DATE] at 12:16 PM Staff B stated they were the assigned nurse to care for Resident 1 on [DATE] and had worked a double shift that day, 6:00 AM-10:00 PM. Staff B stated they recalled Resident 1 and their diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a group of chronic lung diseases) and high blood pressure. Staff B stated they were notified at approximately 3:00 PM on [DATE] of Resident 1's change of condition by an NAC. Staff B stated they assessed Resident 1's lungs and they were clear, and the oxygen saturations were at 90%. Staff B stated Resident 1 used continuous oxygen therapy, had shortness of breath and provided breathing treatment by inhaler per physician orders. Staff B stated they directed the NAC to keep a close eye on Resident 1. Staff B stated they were called back to Resident 1's room between 4:,d+[DATE]:00 PM and stated the resident had deteriorated and was pulseless. Staff B stated they checked Resident 1 for a pulse, found one, and provided them with an ordered nebulizer (physician ordered treatment which administers a fine mist of respiratory medication through a medical device to improve breathing) breathing treatment before exiting the room and calling 911. Staff B stated Resident 1 passed away in the facility after CPR was provided by the NAC's and emergency medical services (EMS). Staff B stated Resident 1 had refused medication for the last two shifts, which included Lasix and Albuterol. Staff B stated they had not called the physician during their shift regarding Resident 1 but had notified the Resident Care Manager and the Director of Nursing Services after they passed away. Staff B stated they did not perform CPR on Resident 1 and stated there were NAC's in the room to initiate it. When asked about Resident 1's swollen left arm, they stated Resident 1 their left arm was not new, and they had that for a while. In an interview on [DATE] at 2:00 PM Staff F, Administrator, stated Staff B did not have a current Cardiopulmonary Resuscitation certification. In an interview on [DATE] at 11:40 AM Anonymous Staff D, RN stated they had received a call from Staff B on [DATE] at approximately 6:19 PM. Staff D stated Staff B informed them that Resident 1 had passed away. Staff D stated Staff B was difficult to understand because they were scattered. Staff D stated Staff B reported Resident 1 had been having breathing problems and they had given them a nebulizer. Staff D stated Staff B then hung up. Staff D stated they worked the next day and attempted to gather information about what had happened with Resident 1 and the information they obtained was inconsistent with the information Staff B provided to them. Staff D stated several NAC's expressed concerns and were visibly emotional about the passing of Resident 1. Staff D stated Resident 1 was not expected to pass away and was anticipated to return home. Staff D stated they had expressed to Staff E, Director of Nursing Services (DNS), several times about the lack of clinical judgement they observed in Staff B. Staff D stated they were unaware of the weight gain Resident 1 had from ,d+[DATE]-[DATE] and stated the physician should have been notified after reweighing them. In an interview on [DATE] at 1:14 PM Staff H, NAC stated they worked with another NAC on [DATE] and took care of Resident 1. Staff H stated they assisted with a brief change on [DATE] at approximately 12:00 PM. Staff H stated Resident 1 was incoherent, was not making sense and this was unusual for them. Staff H stated the other NAC stated they were going to notify the nurse of Resident 1's change in condition. Staff H stated they did not notify anyone of Resident 1's change in presentation. In an interview on [DATE] at 1:25 PM Staff I, Licensed Practical Nurse (LPN) stated they were not familiar with Resident 1's care. Staff I stated they were notified on [DATE] by an NAC that Staff B, RN needed help with Resident 1 who had no pulse. Staff I stated they went to the nurse's station and Staff B was on the phone with 911. Staff I stated they did not assess Resident 1 and their only involvement was when Staff B handed them the phone with 911 still on. Staff I stated if a resident had no pulse and was a full code, CPR should start immediately. On [DATE] at 11:38 AM a staff list of CPR certifications was requested and there were 86 nursing staff without certifications. Staff B and I did not have current CPR certifications, and there was no documentation as to when they had prior certification or when their certifications expired. Review of facility LPN and RN job descriptions, undated, showed LPN's and RN's must have a CPR certification upon hire and remain current during employment. In an interview on [DATE] at 2:02 PM Staff C, NAC stated on [DATE] at the start of their shift at approximately 3:30 PM they attempted to get Resident 1's weight. Staff C stated Resident 1 looked terrible and was trying to say something, but they could not understand them. Staff C stated they decided to hold off on getting the resident's weight and notified the nurse. Staff C described Resident 1 as not looking well and being pale in color. Staff C stated when they notified Staff B of the resident's changes Staff B stated Resident 1 just needed their inhaler. Staff C stated they had to ask Staff B to come into Resident 1's room and assess them and Staff B did not take their concerns as urgent or serious. Staff C stated they checked on Resident 1 again at approximately 4:00 PM and they were not speaking anymore, their breathing was very slow, and their skin was waxy and yellow in color. Staff C stated they directed the NAC with them to get Staff B and Staff B returned with nebulizer treatment. Staff C stated they told Staff B something was wrong, but they proceeded with placing a nebulizer mask on the resident. Staff C described Resident 1 as having their eyes rolled back in their head, their tongue was sticking out of their mouth, and they did not appear to be breathing when Staff B placed the nebulizer mask on them. Staff C stated they told Staff B to call 911multiple times and finally told them if they did not call for EMS, they would. Staff C stated when Staff B returned to the room, another aide had asked Staff B if they should start CPR and Staff B did not respond and left the room again. Staff C stated Resident 1 was not expected to pass away, they were planning on returning home. Staff C stated they were interviewed by Staff G on the evening of [DATE] over the telephone regarding this incident. Review of the Fire Department EMS patient care record for Resident 1, dated [DATE] at 5:47 PM showed the staff present stated they had completed seven rounds of CPR and Resident 1 had been seen 40 minutes prior and had complained of shortness of breath. Resident 1 was documented to be unresponsive, pulseless, was cool to touch and pale in color, and their lower extremities revealed cellulitis (serious bacterial infection) and pitting edema (a type of swelling where a pit remains after applying pressure indicating fluid buildup in the tissues). In an interview on [DATE] at 4:50 PM Staff G stated Resident 1 had respiratory failure and then got a respiratory illness. Staff G stated NACs assisted Resident 1 with all their activities of daily living. Staff G stated they did not know Resident 1's cause of death and they were notified after they had passed away. Staff G stated Resident 1 did not have a history of refusing care or treatments and their death was not expected. Staff G stated they were unaware of any weight changes for Resident 1, changes in weight were to be reported to the provider, and the provider should have been notified of the resident's weight increase from ,d+[DATE]-[DATE]. In an interview on [DATE] at 1:00 PM Staff F, Administrator stated Resident 1 was a full code status. Staff F stated the facility staff had performed CPR and used the defibrillator on [DATE] and had no concerns. Staff F stated information had come to them about Resident 1 after they passed away. Staff F stated they did not complete an interview with Staff B and relied upon their progress note in Resident 1's EMR. Staff F stated they did not think Staff B notified the doctor, did not contact them, and lacked communication with the proper individuals regarding Resident 1's change of condition. Staff F stated they did not know why the NACs did not seek out another nurse after informing Staff B of Resident 1's change of condition and getting no response. Cross reference F600 Reference WAC [DATE](1)

Based on interview and record review the facility failed to protect the resident's right to be free from neglect when they failed to conduct a thorough assessment, communicate a change in condition timely to the physician and notify other nursing staff to respond correctly to a medical emergency for 1 of 1 resident (Resident 1) reviewed for abuse and neglect. Resident 1 experienced harm when they had a change in condition, several caregivers were aware of the change from the resident's baseline, which worsened when nursing staff failed to take timely action; the resident became unresponsive, required cardiopulmonary resuscitation (CPR), and an unexpected death occurred. These failures placed all residents at risk of unmet care needs and potential neglect. Findings Included . Review of the facility policy titled, Abuse Identification, reviewed [DATE] documented the facility would identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators. The facility defined deprivation by staff of goods or services as abuse, which included failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being. Staff had the knowledge and ability to provide care and services, but chose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s). Resident 1 admitted to the facility on [DATE] with diagnoses to include congestive heart failure (condition in which the heart doesn't pump blood as well as it should) and cellulitis (bacterial skin infection) of the left and right lower limbs. According to the Admission Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], the resident was cognitively intact. Review of Resident 1's Electronic Medical Record (EMR) documented weights on [DATE] that showed they weighed 324.8 pounds (lbs.) and on [DATE] they weighed 343.5 pounds (lbs.), a weight gain of 18.7 lbs. in a 24-hour period. Further review showed no documentation the physician had been notified of the resident's significant weight increase. Review of Resident 1's Medication Administration Record (MAR) dated [DATE], showed a physician order dated [DATE] for daily weights before breakfast and staff were to report a three-pound weight gain in a day or five-pound weight gain in a week to the physician. The weight documented on [DATE] was 324.8 lbs., and on [DATE] the weight was 343.5 lbs. There were no documented weights for [DATE]. Review of Resident 1's MAR for [DATE], dated [DATE], showed a monitor for edema (swelling that occurs when fluid builds up in the body's tissues) and a documented 3 + (a moderate to severe degree of swelling). [DATE] MAR showed no refusals for Resident 1's Lasix (a medication to treat fluid retention). Review of Resident 1's progress notes dated [DATE] at 5:31 PM showed an entry by Staff B, Registered Nurse (RN), that the resident had developed difficulty breathing at 3:20 PM and was assessed (oxygen saturations at 96 percent-a measurement of how much oxygen the blood is carrying), resident's oxygen was increased to four liters (L) per minute (lpm-flow rate of oxygen administered to a patient) and provided a nebulizer treatment. The progress note showed Resident 1 stabilized for about an hour, then developed shortness of breath again and given an inhaler (a device that delivers medication directly to the lungs). At 5:30 PM Resident 1 condition was noted to deteriorate and the NAC's reported they had no pulse. Emergency services were contacted and Resident 1 passed away at 6:18 PM at which time the Director of Nursing Services (DNS) was notified and the provider. No other interventions and assessments were found to be completed with Resident 1. There was no documentation found in the EMR that the resident's physician or any other medical professional had been notified of the change in condition. Review of Resident 1's MARs dated [DATE], documented that the resident had an order for Ipratropium-Albuterol solution 3 milliliters (mL) inhaled orally via nebulizer two times daily AM and bedtime. The review showed that on [DATE], [DATE] and [DATE] at AM the resident refused this medication. Staff B documented in their progress note dated [DATE] at 5:31 PM that nebulizer was provided to the resident, however this is not reflected on the MAR. The [DATE] MAR also documented an order for continuous oxygen to be administered at two L per minute. There was no order or documentation the physician was notified with request to increase the resident's oxygen to four L as documented in Staff B's progress note on [DATE] at 5:31 PM. In an interview on [DATE] at 11:12 AM Staff A, Nursing Assistant Certified (NAC), stated Resident 1 was not acting themselves, presented with slurred speech, a swollen left arm, and was not able to track with their eyes. Staff A stated they notified their nurse, Staff B at around 9 AM and again around 12 PM. Staff A stated they knew something was Really wrong with Resident 1 and Staff B was not paying attention. Staff A stated Staff B had not checked on Resident 1 during their shift. Staff A stated they did not notify any other nursing staff of Resident 1's change of condition. In an interview on [DATE] at 12:16 PM Staff B stated they were the assigned nurse to care for Resident 1 on [DATE] and had worked a double shift that day, 6:00 AM-10:00 PM. Staff B stated they recalled Resident 1 and their diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a group of chronic lung diseases) and high blood pressure. Staff B stated they were notified at approximately 3:00 PM on [DATE] of Resident 1's change of condition by an NAC. Staff B stated they assessed Resident 1's lungs and they were clear, and they oxygen saturations were at 90%. Staff B stated Resident 1 used continuous oxygen therapy, had shortness of breath and provided breathing treatment by inhaler per physician orders. Staff B stated they directed the NAC to keep a close eye on Resident 1. Staff B stated they were called back to Resident 1's room between ,d+[DATE] PM and stated they had deteriorated and was pulseless. Staff B stated they checked Resident 1 for a pulse, found one, and provided them with an ordered nebulizer (physician ordered treatment which administers a fine mist of respiratory medication through a medical device to improve breathing) breathing treatment before exiting the room and calling 911. Staff B stated Resident 1 passed away in the facility after CPR was provided by the NAC's and emergency medical services (EMS). Staff B stated Resident 1 had refused medication for the last two shifts, which included Lasix and Albuterol. Staff B stated they had not called the physician during their shift regarding Resident 1 but had notified the Resident Care Manager and the Director of Nursing Services after they passed away. When asked about swelling in Resident 1's limb, Staff B stated Resident 1 had swelling in their left arm for a while. In an interview on [DATE] at 2:02 PM Staff C, NAC stated on [DATE] at the start of their shift at approximately 3:30 PM they attempted to get Resident 1's weight. Staff C stated Resident 1 looked terrible and was trying to say something, but they could not understand them. Staff C stated they had to demand that Staff B go to Resident 1's room to assess them. Staff C stated an inhaler was administered to Resident 1 by Staff B. Staff C stated when they checked on Resident 1 again at approximately 4:00 PM, their color and breathing pattern had changed. Staff C stated they had to demand Staff B contact 911 or they were going to. Staff C stated they initiated CPR with other NAC's. Staff C stated Staff B did not assist and did not provide direction to the NAC's present. Staff C stated Resident 1's vitals were taken by the NAC's and no pulse was found. Staff C stated after Resident 1 passed away they spoke with Staff G Director of Nursing Services (DNS), by telephone and expressed concerns about Staff B's lack of urgency, assessment, and assistance during Resident 1's change of condition. In an interview on [DATE] at 4:50 PM Staff G stated Resident 1 had respiratory failure and then got a respiratory illness. Staff G stated NACs assisted Resident 1 with all their activities of daily living. Staff G stated Resident 1 did not have a history of refusing care or treatments and their death was not expected. Staff G stated they were unaware of any weight changes for Resident 1, changes in weight were to be reported to the provider, and the provider should have been notified of their weight increase from ,d+[DATE]-[DATE]. Staff G stated they completed an investigation related to Resident 1's death, under risk management, did not make a report to the state hotline, and the death had not been reported to the coroner's office. Staff G stated they had provided all the documents related to their investigation, however when asked about statements from staff they stated they would need to find those. When asked why the statements were not part of their investigation, Staff G stated they guessed they should have been. Review of the incident report dated [DATE] at 6:18 PM, documented CPR was started on Resident 1 by the facility licensed nurse in addition to defibrillator use. EMS services arrived and were unable to resuscitate Resident 1. The notes section of the incident report showed Resident 1 passed away unexpectedly in the facility potentially related to a respiratory illness and other comorbid conditions. There were no other documents, statements or interviews attached, referenced or included with the incident investigation report. The investigation did not document that the physician had been notified of Resident 1's unexpected death. Review of the written statement by Staff J, NAC, dated [DATE] with an event time of 5:40 PM documented they were serving dinner when they were notified Resident 1 was unresponsive and came to assist. Staff J, according to their statement, attempted to get Resident 1's vitals and could not get an oxygen reading, while Staff B returned to the room with a nebulizer treatment. Staff J indicated they were directed to start CPR by a nurse from another unit. Staff J wrote that Staff B was not in the room until EMS arrived. Review of the written statement by Staff K, NAC dated [DATE] at 5:40 PM showed they had asked the assistance of Staff C to obtain a weight for Resident 1 earlier in the day. Resident 1 was described as responsive but nonsensical in their speech. Staff K indicated later vital signs were taken of Resident 1 and there was no pulse and no oxygen. Staff K wrote that the other aides had to push Staff B to contact 911. In an interview on [DATE] at 12:45 PM Anonymous Staff E, LPN stated Staff C, NAC had come to them visibly upset over the passing of Resident 1. Staff E stated it was reported to them that Staff B had been told several times about Resident 1's deteriorating condition and they did not address it. Staff E stated they attempted to discuss the staff's concerns regarding Staff B with Staff G and they were told they needed to keep their mouth shut. In an interview on [DATE] at 1:00 PM Staff F, Administrator stated Resident 1 was a full code status. Staff F stated the facility staff had performed CPR and used the defibrillator on [DATE] and had no concerns. Staff F stated information had come to them about Resident 1 after they passed away. Staff F stated they did not complete an interview with Staff B and relied upon their progress note in Resident 1's EMR. Staff F stated they did not think Staff B notified the doctor, did not contact them, and lacked communication with the proper individuals regarding Resident 1's change of condition. Staff F stated they did not know why the NACs did not seek out another nurse after informing Staff B of Resident 1's change of condition and getting no response. Staff F stated Staff B had been terminated. Cross Reference F684 Refer to WAC [DATE](1)(3)(c)

monitor, assess, and take timely action in accordance with professional standards of practice for 17 of 32 resident's (Residents 59, 47, 5, 55, 1, 14, 23, 27, 31, 34, 40, 50, 58, 62, 63, 69 and 70) reviewed for bowel care and management, 1 of 1 resident (Resident 49) for a hospice referral and 1 of 1 resident (Resident 121) for neurological checks. These failures resulted in harm to Resident 59 when they experienced discomfort, pain, and hospitalization for a bowel impaction (the result of constant constipation when poop was stuck inside of the rectum). These failures placed the residents at risk for constipation, discomfort, a worsening of their condition, and a delay in receiving hospice care and services. Findings included . Review of the facility policy titled, Bowel Protocol, revised 09/12/2023, showed to provide interventions for signs and symptoms of constipation that are consistent with current standards of practice. The policy directed staff to record in the electronic health records (EHR), each time a resident had a bowel movement. The facility in coordination with the residents attending practitioner will implement standing orders to address a lack of bowel movement. The protocol noted the orders may vary within the facility for each attending practitioner and depend on the individual needs of the resident. <BOWEL MANAGEMENT> RESIDENT 59 Resident 59 was readmitted to the facility on [DATE] with diagnoses to include collapsed and displaced vertebrae (back bones) multiple myeloma (cancer of plasma cells that weakens bones), torticollis (condition where neck muscles contract), and emphysema (lung disease with shortness of breath). A review of the resident's Admission Minimum Data Set (MDS- an assessment tool) assessment, dated 03/05/2024, identified the resident to have moderately impaired cognition and memory, and they did not reject care. The MDS assessment showed the resident was always continent of bowel, was not on a bowel toileting program and did not have constipation present. During an interview on 04/22/2024 at 10:53 AM, Resident 59 was in bed with a pained expression (grimacing, furrowed brow, and look of displeasure) on their face. They stated they had constipation and now they thought they were headed the other way (loose stools). Resident 59 said they needed to try to have a bowel movement (BM). Review of the care plan, dated 04/22/2024, showed there had been no constipation care plan developed until 04/22/2024. The care plan showed Resident 59 was at risk for constipation related to oxycodone (narcotic) use. The care plan did not document other narcotics with a potential to increase constipation or specify the resident's usual bowel patter or goals. The care plan goal said the resident would pass soft, formed stool but did not include the resident goals and preferred frequency of BM's through the review date. The care plan was incomplete with SPECIFY FREQ (a place marker in the software that directs the staff to specify the frequency) was still in place The interventions included: follow facility bowel protocol for bowel management, observe for medication side effects of constipation, and to keep the physician informed of any problems. Additional interventions included to observe for reported as needed (PRN) signs and symptoms of complications related to constipation. Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Bradycardia (slow, low pulse), Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Diaphoresis, Abdomen: tenderness, guarding, rigidity, fecal compaction. The care plan included an incomplete intervention directing staff to teach the resident/family/caregivers the relationship between constipation and food, fiber intake, medicine, treatment regimen, disease process (SPECIFY) and psychosocial factors. Teach the resident/family/caregivers to identify and avoid causative factors (SPECIFY: lack of exercise, not enough fiber). Review of physician's orders, dated 04/22/2024, showed Resident 59 received three narcotics with a known side effect of constipation (Dilaudid every four hours PRN, Oxycodone 15 milligrams (mg) every three hours routinely and Oxycontin 20 mg two times a day routinely). Review of the bowel medications directed the licensed nurse to implement the following: - Order, dated 03/01/2024, if the resident had no BM in three days give Milk of Magnesia (MOM - a laxative) at bedtime. Administer a Dulcolax (a laxative) suppository PRN if no results from the MOM. Administer a Fleet (a laxative) enema PRN if not results from the suppository. - Dilaudid 2 mg to 4 mg every four hours PRN, dated 03/19/2024. - Oxycontin two times a day, dated 04/10/2024. - Oxycodone 10 mg to 15 mg every three hours PRN, dated 04/10/2024. - The facility received orders on 04/10/2024 to add Senna once daily. - MiraLAX (a laxative) 17 grams was ordered PRN daily for constipation on 04/23/2024 at 10:23 AM. -MiraLAX 17 grams was ordered every Wednesday, Friday, and Sunday for constipation on the day after the resident was sent out to the hospital (04-24-2024). Review of Resident 59 bowel monitor and Medication Administration Record (MAR) for March 2024, showed the following: -The resident had a BM's on ten days of the month. - There was no BM documented from admit, 03/01/2024 until 03/07/2024, a total of at least six days (review of the clinical record showed there was no information on when the residents last BM was prior to admit) documented with no BM. - On 03/16/2024, a PRN constipation medication was given three days of no BM before an intervention was taken which was effective. - On 03/20/2024, MOM was administered after four days with no BM since 03/16/2024, and the MOM was effective. - On 03/26/2024, the resident received senna after no bm for four days which was documented in the MAR to be effective, although the bowel monitor (a separate record used to document BM's) did not show the resident had a BM. - On 03/27/2024, and the resident received senna. The nurse documented the medication was ineffective. No additional medications were administered when the medication was documented as ineffective. - The resident had three days with no BM, from 03/29/2024 until 04/01/2024, and no bowel medications were given. Review of the bowel monitor and MAR for April 2024, showed no BM documented from 04/04/2024 to 04/10/2024, a PRN constipation medication was given on 04/02/2024 which was ineffective. No additional medications were administered when the medication was ineffective. On 04/07/2024, a PRN medication was given and was ineffective. On 04/08/2024 MOM was given with no results, and then on 04/10/2024 MOM was given a second time and ineffective. No additional medications were administered when the medication was ineffective. The resident then received a Dulcolax suppository on 04/10/2024 which was documented as effective in the MAR although no BM was documented as occurred. In an interview on 04/23/2024 at 9:00 AM, Resident 59 was observed in bed with a pained expression on their face (grimacing, furrowed brow, and look of displeasure), and their knees were drawn up towards their chest. The breakfast tray was observed on their over bed table untouched. There was a bath basin near their side, and they said they were too sick to eat. The resident said they were having terrible abdominal pain and nausea and were miserable. Review of a progress note, dated 04/23/2024 at 7:16 AM, showed Resident 59 was nauseated and the nurse administered Ondansetron (anti-nausea medication) for nausea. Review of a nursing progress note, dated 04/23/2024 at 2:57 PM, showed Resident 59 was complaining of constipation and abdominal pain. Their abdomen was assessed to be rigid (hard) and tender to the touch. Staff F, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), documented they were still awaiting the STAT (urgently) x-ray to be taken before proceeding with a suppository or enema. Staff F noted the provider was notified that morning and had started the resident on routine MiraLAX and senna daily. Review of nursing progress note, dated 04/23/2024 at 3:03 PM, showed Resident 59 was nauseated and the nurse administered Ondansetron. The medication was ineffective as the resident had an emesis (vomiting). Review of the progress note, dated 04/23/2024 at 7:06 PM, showed Resident 59 had an emesis (vomited) around 4:30 PM. Staff D, Registered Nurse (RN), asked the resident to roll over, the resident reported abdominal pain with turning, and the nurse observed so hard stool coming out of the resident rectum. The nurse asked the resident if it was okay to be sent out to the hospital as the x-ray was going to take a while and an enema or suppository would not be effective due to the symptoms as the LN (licensed nurse) documented a suspected impaction at this point. Review of the facility's Nursing Home to Hospital Transfer Form, dated 04/23/2024 at 6:25 PM, showed Resident 59 was transferred to the hospital for constipation and had a pain level of six (on a zero, no pain, to 10 severe pain scale) in their abdomen. The resident's last BM was on 04/22/2024. In an interview on 04/24/2023 at 7:32 AM, Staff F said Resident 59 went out to the hospital last night. Staff F said they heard the resident had a bowel impaction, but they hadn't verified that on the hospitals electronic health record (EHR) yet. Review of the nursing progress notes from 04/01/2024 to 04/21/2024, showed no documentation the physician was notified or consulted regarding Resident 59's constipation until 04/23/2024. In an interview on 04/25/2024 at 9:01 AM, Staff D said they were the nurse who sent Resident 59 out to the hospital last night. Staff D said the resident had been having small BM's every day and did not trigger on the bowel alert (an alert system within the facility's EMR to notify staff of no bowel movement in 72 hours). Staff D said the resident complained of abdominal pain, they gave them prune juice, and MiraLAX. Staff D said the resident had vomited brown emesis. Staff D said they positioned the resident on their side to see a very hard stool.: Staff D said they had orders for an enema or suppository but there was a hard BM present, so they couldn't administer these medications. Staff D said they had already received an order for the abdominal x-ray, but it had not been taken yet. Staff D said at that time, they encouraged the resident to go out to the hospital for treatment and to get the x-ray sooner and they refused. Staff D called the residents family member who talked with them, and they agreed to go. Review of the history and physical from the emergency department physician, dated 04/23/2024, showed there was mild tenderness to palpation and the fecal load (BM filled intestines) was evident on abdominal palpation. Review of Resident 59's hospital emergency department dictation, dated 04/23/2024, showed the resident was seen for abdominal pain. The present illness showed the resident was on multiple pain medications. The resident reported they were given prune juice as they had not had a bowel movement for the past week. The resident threw up the prune juice and felt the urge to vomit since. The resident complained of abdominal pain and a history of a hernia (bulging of an organ or tissue through an abnormal opening) repair. The physician noted diffuse (spread over a wide area) abdominal tenderness. Review of the hospital's abdominal Computed Tomography (CT -exam of internal images of the body) scan results, dated 04/23/2024 at 10:24 PM, showed Resident 59 had a marked amount of fecal material in the rectum with wall thickening possibly related to stercoral colitis (occurs when a resident has chronic constipation leading to stagnant fecal matter). The CT showed distension (abnormally swollen) in the small bowel. Review of the emergency department admission report, dated 04/23/2024, showed Resident 59 presented with a concern for worsening abdominal pain, lack of a bowel movement, and vomiting. The resident had been receiving significant amounts of opioids (narcotics) for discomfort. Review of Resident 59's emergency department note, dated 04/23/2024, showed the CT scan was reviewed with the surgeon who said this did not require surgical intervention and would be appropriate for medical admission with enema and bowel preparation. They attempted manual disimpaction (a procedure to remove trapped stool by breaking it up and removing it) and were able to remove a small amount of stool however the procedure was discontinued per resident request due to the degree of discomfort. The plan was for several enemas to loosen and remove stool which may require recurrent attempts at manual disimpaction, depending on success and fullness of enema. The resident diagnoses were fecal impaction and stercoral colitis. Review of a hospital note, dated 04/24/2024, showed Resident 59 had a repeat x-ray that continued to show a large fecal load (large presence of stool in the intestines). Review of a hospital noted, dated 04/25/2023 at 5:44 PM, showed Resident 59 continued passing soft stool throughout the night, requiring multiple (incontinent) brief changes. In an interview on 04/26/2024 at 9:15 AM, Staff B, Registered Nurse (RN)/Director of Nursing Services, provided Resident 59's bowel monitors beginning 03/01/2024 and said they (the bowel records) were concerning. Staff B said they reviewed the current bowel protocol and were now working on changing the order to reflect the Medical Director's standing orders for constipation. Staff B said they have reviewed every resident's chart for bowel pattern and constipation and in serviced nursing staff to review the BM monitors twice a day. <RESIDENT 47> Resident 47 was admitted on [DATE] with diagnoses to include colon cancer, protein calorie malnutrition (the body lacks enough protein and energy to function properly) and gastroesophageal reflux disease. Review of the Admission MDS assessment, dated 01/12/2024, showed the resident was cognitively intact, occasionally incontinent of bowel, was not on a toileting program, and had no constipation. Review of a nursing progress note, dated 03/28/2024 at 2:40 AM, showed communication with a physician as the nurse noticed Resident 47 had been requesting Zofran (anti-nausea medication) lately, their bowel movements were not regular, and occasionally there was no BM for three days. The note showed the resident vomited a small amount of brown emesis and complained of right abdominal pain. The nurse noted the resident was on routine Oxycontin, Oxycodone, and Tylenol which were prone to cause constipation. Resident 47 was not on any routine laxatives, and the nurse inquired about routine laxative medication and a test to rule out bowel obstruction. Review of a nursing progress note, dated 03/28/2024 at 4:12 AM, showed Resident 47 received a Dulcolax suppository which was effective. Review of a nursing progress note, dated 03/31/2024 at 10:44 PM, showed at 5:10 PM Resident 47 was experiencing an altered mental status, complained of abdominal pain, and nausea and vomiting. At 9:30 PM, the resident was experiencing involuntary movement in all extremities and weakness. The resident reported they had abdominal pain of a 10 out of 10 and felt like someone was pushing on it. The 8:00 pm and 9:00 pm medications were held for the new symptoms. The resident continued to vomit thick saliva. The on-call provider was called, and the resident went to the hospital at 10:10 PM. Review of the readmission physician orders, dated 04/03/2024, showed Resident 47 was receiving Morphine Sulfate twice a day, a narcotic with known side effect of constipation. There were orders for MOM to be given if there was no BM in three days to be administered at bedtime, then a Dulcolax suppository PRN if no results from MOM daily, and then Fleet enema a PRN if no results from the suppository. There was also an order for Senna twice a day PRN for constipation. Review of the April 2024 bowel monitors showed Resident 47 had no BM from 04/03/2024 to 04/07/2024 and no BM from 04/13/2024 to 04/17/2024. Review of the April 2024 MAR showed Resident 47 received PRN MOM on 04/06/2024 at 9:19 PM after no bowel movement for five days. The results of this intervention was documented as unknown. The MAR showed no additional bowel medications were administered when the MOM did not elicit a bowel movement. Review of Resident 47's nursing progress note, dated 04/07/2024 at 8:05 AM, showed the administration of the PRN MOM was unknown. There was no additional assessment or information documented. Review of the current care plan showed there was no constipation care plan developed for Resident 47 until 04/24/2024. In an interview on 04/30/2024 at 12:06 PM, Resident 47 said they had struggled with constipation since they admitted . The resident said their usual bowel pattern was daily and they would like to go daily. In an interview on 05/01/2024 at 11:01 AM, Resident 47 was in bed on their right side and stated they did not feel well, their stomach was upset, and they were constipated. Review of the bowel monitor on 05/01/2024, showed Resident 47's last BM was on 04/28/2024. <RESIDENT 5> Resident 5 admitted on [DATE] with diagnoses to include left sided paralysis. The annual MDS assessment, dated 02/11/2024, showed the resident was frequently incontinent of bowel and did not have constipation. The resident was nonverbal and communicated by hand gestures. Resident 5's care plan showed they were at risk for constipation related to decreased mobility and a diminished appetite. The goal was for the resident to pass soft, formed stool at the preferred frequency of every two to three days. The care plan directed staff to follow the facility bowel protocol and observe for medication side effects of constipation and inform the physician of any problems. The staff were to record the bowel pattern each day. Review of the physician's orders, dated 12/14/2023, showed Resident 5 received a Bisacodyl suppository every other day routinely for constipation and could receive an additional suppository daily PRN. The resident had an order for a Fleet enema every 72 hours PRN for constipation, MOM PRN daily if no BM in three days, and MiraLAX daily PRN. Review of the 04/01/2024 through 04/25/2024 bowel monitors, showed Resident 5 had no BM's from 04/08/2024 until 04/13/2024, five days. Review of the bowel records from 04/01/2024 to 04/25/2024 showed the resident had bowel movements on eight days. Review of the 04/01/2024 through 04/25/2024 MAR's, showed Resident 47 did not receive any PRN medications as ordered for constipation. <RESIDENT 55> Resident 55 readmitted on [DATE]. A review of the resident's Admission MDS assessment, dated 03/05/2024, identified the resident to have moderately impaired cognition and memory and they did not reject care. The MDS assessment showed the resident was occasionally incontinent of bowel, was not on a bowel toileting program and did not have constipation present. Review of the bowel monitor and MAR, dated 04/08/2024 through 04/24/2024, showed Resident 55 had no BM documented from 04/13/2024 until 04/17/2024, a total of four days with no BM. There was no BM documented from 04/18/2024 until 04/24/2024. Review of a nursing progress note dated 04/17/2024 at 5:56 PM, showed Resident 55 was offered MOM PRN they refused the offer, and reported they had a BM yesterday. Review of the bowel monitor did not include the BM on 04/16/2024 as reported by Resident 55. In an interview on 04/29/2024 at 11:55 AM, Staff B said they had not been following the current signed bowel policy. Staff B said there were batch orders (orders to automatically be put in) on admission for bowels management that included MOM, then a suppository then Fleets enema but that order was not automatically checked and needed an (physician) order. Staff B said residents on narcotics should have the bowel protocol marked and an order for Docusate in case they need it. Staff B said they did not know why the batch orders would not have been addressed for residents on narcotics or if no BM was recognized. In an interview on 04/29/2024 at 2:29 PM, Staff D said they thought Resident 55 had regular BM's and the aides were not documenting their BM's accurately. Staff D said the bowel protocol was to give MOM if there was no BM in three days. Staff D said if the resident triggered on the no BM report (report that indicated when a resident has not had a BM in 72 hours), they would go interview the resident to validate accuracy. Staff D said that they did see BM's for Resident 59, but the facility had temporary and agency staff who did not chart BM's, so the charting may be wrong. Staff D said for resident's who took narcotics, were not very active, they would obtain an order for a routine medication to treat the constipation. Staff D said they did reach out to the Resident 59's doctor and received routine bowel medication orders the morning of 04/23/2024. During Quality Assurance Performance Improvement (QAPI) interview on 05/01/2024 at 1:30 PM, Staff A, Administrator, Staff B, Staff C, RN/Assistant Director of Nursing, Staff T, Regional Director of Clinical Services and Staff U, Divisional Director of Clinical Services were present. Staff B said they had not been aware there was an issue with bowel monitoring. Staff B said they were now running the bowel report every day and would be implementing a new bowel protocol that should be reviewed and signed by the Medical Director today (05/01/2024). Staff B said the nursing staff were to review the report twice a day and this was an audit that will not go away. In an interview on 05/02/2024 at 11:34 AM, Collateral Contact 5 (CC5), Advanced Registered Nurse Practitioner (ARNP), stated their expectation for constipation notification is that the facility notifies them on day 4. CC5 said that if a resident had not had a bowel movement for three days and all interventions had been tried such as a suppository or enema they could help. CC5 stated that they had been getting notified of no BM's on day five through written communication, which did not work. In an interview on 05/02/2024 at 11:45 AM, Staff M, Registered Dietician (RD), stated they looked for nausea, vomiting, appetite and if there was any constipation or loose stools on their visits. Staff M said they would work with the provider for medications that could assist with these constipation issues. <RESIDENT 1> Review Resident 1's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 1 had no BM's from 04/18/2024 until 04/23/2024, for five days. Review of the April 2024 MAR, showed Resident 1 did not receive medications to relieve their constipation. <RESIDENT 14> Review Resident 14's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 14 had no BM's from 04/05/2024 until 04/08/2024, for four days. Review of the April 2024 MAR, showed Resident 14 did not receive medications to relieve their constipation. <RESIDENT 23> Review of Resident 23's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 23 had no BM's from 04/02/2024 until 04/06/2024, for five days. Review of the April 2024 MAR, showed Resident 23 received MOM on 04/05/2024 at 9:12 AM that was effective although there was no BM documented on the bowel monitor. <RESIDENT 27> Review of Resident 27's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 27 had no BM's from 04/20/2024 until 04/25/2024, for five days. Review of the April 2024 MAR, showed Resident 27 received constipation medications, Miralax on 04/24/2024 at 4:33 AM and Senna at12:54 AM, that were documented to be ineffective. No additional bowel medications were administered when the resident did not have results. <RESIDENT 31> Review of Resident 31's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 31 had no BM's from 04/18/2024 until 04/22/2024, for five days. Review of the April 2024 MAR, showed Resident 31 did not receive medications to relieve their constipation. <RESIDENT 34> Review of Resident 34's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 34 had no BM's from 04/06/2024 until 04/10/2024, for four days. Review of the April 2024 MAR, showed Resident 34 did not receive medications to relieve their constipation. <RESIDENT 40> Review of Resident 40's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 40 had no BM's from 04/19/2024 until 04/22/2024, for four days. Review of the April 2024 MAR, showed Resident 40 did not receive medications to relieve their constipation. <RESIDENT 50> Review of Resident 50's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 50 had no BM's from 04/13/2024 until 04/16/2024, for four days. Review of the April 2024 MAR, showed Resident 50 did not receive medications to relieve their constipation. <RESIDENT 58> Review of Resident 58's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 58 had no BM's from 04/19/2024 until 04/23/2024, for five days. Review of the April 2024 MAR, showed Resident 58 did not receive medications to relieve their constipation. <RESIDENT 62> Review of Resident 60's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 62 had no BM's from 04/12/2024 until 04/15/2024, for four days. Review of the April 2024 MAR, showed Resident 62 did not receive medications to relieve their constipation. <RESIDENT 63> Review of Resident 63's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 63 had no BM's from 04/06/2024 until 04/09/2024, four days. Resident 63 did not have a BM from 04/12/2024 to 04/16/2024, for five days. Review of the April 2024 MAR, showed Resident 63 did not receive medications to relieve their constipation on 04/08/2024. Resident 63 did receive MOM on 04/15/2024 with no BM results from the medication. No additional medications were administered when the resident did not have a BM. <RESIDENT 69> Review of Resident 69's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 69 had no BM's from 04/01/2024 until 04/04/2024, for four days. Review of the April 2024 MAR, showed Resident 69 did not receive medications to relieve their constipation. <RESIDENT 70> Review of Resident 70's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 70 had no BM's from 04/10/2024 until 04/14/2024, for four days. Review of the April 2024 MAR, showed Resident 70 did not receive medications to relieve their constipation. <HOSPICE> Resident 47 admitted on [DATE] with cancer, hip fracture and protein calorie malnutrition. Review of a nursing progress note for Resident 47 dated 04/11/2024 at 12:03 PM showed that an order to consult hospice was entered. There were no other progress notes about hospice. In an interview on 04/22/2024 at 2:27 PM, Resident 47 said they were unsure about the plans for their stay or discharge. The resident stated they had a lot going on and they never stop worrying. The resident said I am dying and that is a lot to deal with. I do not want chemo anymore. My quality of life is terrible. The resident said they had not seen any hospice staff yet but would like them to help with their grief and coping. In an interview on 04/24/2024 at 10:45 AM, Staff I, Social Services Director (SSD), stated the local hospice agency was not able to provide services until Resident 47 was on a certain type of medical insurance. In an interview on 04/25/2024 at 10:53 AM, Collateral Contact (CC) 3, Referral Center Manager for the hospice agency, said they had not heard about Resident 47 since they were at the hospital in late December 2023 or January 2024. CC3 said they had not heard from this facility, but they could accept the resident under their current pending financial/payor source as their payor source was not a barrier to utilize hospice services. In an interview on 04/26/2024 at 9:15 AM, Staff B said there was a reason Resident 47 could not go on hospice and to talk with Staff I. In an interview on 04/26/2024 at 9:28 AM, Staff A said the facility wanted Resident 47 on hospice services and they felt they would benefit from it, but they had always been told the hospice agency would not accept residents that were pending their financial/payor source. Staff A said they would look into the lack of documentation regarding the referral and follow up. Review of a progress note on 04/26/2024 at 10:32 AM, showed Staff I sent the hospice referral to the local hospice agency via fax. In an interview on 04/29/2024 at 11:30 AM, Resident 47 said they were going to go on hospice services now since it looked like they were going to be going that way. 47047 <NEUROLOGICAL CHECKS> Resident 121 admitted to the facility on [DATE] with diagnosis to include a stroke, vascular dementia, unspecified protein calorie malnutrition. Review of Resident 121 incident report dated 04/22/2024 showed that Resident 121 had an unwitnessed fall in their room. The incident report contained a form for neurological flow sheet which was dated 04/22/2024 and contained 15-minute neurological checks every 15 minutes from 2:45 AM until 3:30 AM and 30-minute neurological checks every 30 minutes from 4:00 AM until 4:30 AM. The neurological flow sheet was empty for the one hour, four hour and 3 days following the fall. In an interview on 04/24/2024 at 3:55 PM Staff C stated they did not have additional information to provide for the investigation. When asked about the neurological checks, Staff C, stated the only checks completed were on the neurological flow sheet however, there were some progress notes addressing Resident 121's overall status as they were on alert charting. This is a repeat citation from survey 12/04/2023. Refer to WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to comprehensively assess and ensure timely and appropriate services/interventions were provided to maintain, increase and/or prevent a decrease in range of motion (ROM - was the extent that a joint can move within the expected [normal] range of values) for 2 of 5 sampled residents (Resident 29 and 5) reviewed for ROM and restorative nursing services. Resident 29 experienced harm when they developed a significant, potentially avoidable, left-hand contracture (a permanent tightening of the muscles tendons, skin that causes joint to shorten and become stiff which prevents normal movement a body part affected) and placed other residents at risk for developing new contractures and/or worsening of existing contractures. Findings Included . <RESIDENT 29> Resident 29 admitted to the facility on [DATE] with diagnoses that included vascular dementia (brain damage from impaired blood flow to the brain that causes changes in reasoning, planning, memory, and judgement), muscle weakness, atrial fibrillation (irregular heartbeat), and high blood pressure. Review of Resident 29's Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 02/03/2024, showed the resident had no impairment in their functional ROM of their upper and lower extremities during the prior seven days. Review of Resident 29's care plan, dated 10/25/2022, showed the resident required Activities of Daily Living (ADL - dressing, bed mobility, transfers, toileting, personal hygiene, etc.) assistance and therapy service to maintain or attain their highest level of function with the goal of attaining their prior level of function. The care plan interventions included cueing and supervision with Resident 29's mobility and ADL's as needed, and therapy services as ordered. In an observation on 04/23/2024 at 1:58 PM and 04/25/2024 at 2:32 PM, Resident 29 was lying in bed on their left side, and their left hand was observed in a rigid (unable to bend or be forced out of shape; not flexible) fist position. In an interview and observation on 4/25/2024 at 2:32 PM, Staff Q, Physical Therapist/Director of Rehabilitation, asked Resident 29 to open their left hand fully. Staff Q extended Resident 29's thumb, pointer finger and when attempted to extend the other three fingers (middle, ring, and pinky), Resident 29 stated that it hurt. Resident 29's middle finger, ring finger and pinky finger were fixed in a seized/clutch like position. Staff Q stated Resident 29 had a contracture of their left hand. On 04/26/2024 at 10:08 AM, Resident 29 was observed walking back to their room with the use of a walker. Resident 29 held the walker with both hands, their left hand holding the handle differently than the right. Resident 29 held the walker handle with their thumb and pointer finger. Resident 29's middle finger, ring finger, and pinky finger were observed fixed in a seized clutch like position. In an interview on 04/25/2024 at 2:32 PM, Staff Q stated Resident 29 did not have any documentation of past therapy at the facility and did not have a documented contracture. Review of the Facility Assessment, dated 03/17/2024, showed the facility's workforce profile had 0.08 hours allotted per patient day (PPD) of restorative certified nursing assistant care with and emergency PPD of 0.05 hours. If the hours were not able to be staffed by an employee of the facility, agency staff was identified as the backup. In an interview on 04/26/24 9:01 AM Staff A, Administrator, stated the facility did not have a restorative program (person centered nursing care designed to improve or maintain the functional ability of residents) related to staffing challenges during the COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) pandemic. In an interview on 04/25/2024 at 2:41PM, Staff S, Nursing Assistant Certified (NAC), stated they assisted Resident 29 during the evening shift. Staff S stated Resident 29 had some arthritis (swelling and tenderness of one or more joints) and used their right hand more than their left. Staff S stated they had not provided Resident 29 with any passive range of motion (PROM when someone physically moves or stretches a part of your body) services. In an interview on 04/25/2024 at 2:50 PM, Staff R, NAC, stated they were not aware of any differences in Resident 29's right and left hand. In an interview on 04/29/2024 at 11:02 AM Staff E, Registered Nurse (RN)/MDS Coordinator, stated they collect information for the MDS assessment through nurse and nursing aide interviews, utilization review meetings, and chart reviews. When asked how a resident's ROM was determined, Staff E stated they rely on the nursing staff and therapy. Staff E stated they do not complete an in-person assessment with the resident regarding their ROM. Staff E stated they were unaware of Resident 29's left hand contracture and did not know for how long they had it. Staff E stated the facility did not have a restorative program. Review of an Occupational Therapy (OT) evaluation, dated 04/26/2024, showed Resident 29's left hand middle, ring and pinky fingers had impaired extension and a contracture which resulted in Resident 29 having a decreased ability to grasp objects with their left hand. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] with diagnoses that included intracranial injury with loss of consciousness (brain injury), unspecified convulsions (involuntary contraction of muscles), unspecified voice and resonance disorder (inability to communicate with voice), contracture of the left ankle and left upper arm. Review of the OT evaluation, dated 04/04/2022, showed Resident 5's left upper extremity (LUE) had spastic hemiplegia (muscle tightness and involuntary contractions) resulting in the shortening and tightening of their shoulder, elbow, wrist, and hand. A PROM of their LUE with daily application of a hand/wrist splint by nursing aides were recommended to prevent further contractures. Review of the OT discharge summary dated 05/27/2022, recommended Resident 5 continue with upper extremity PROM and splint applications. Review of Resident 5's medical record from 04/28/2023 through 4/22/2024, showed they had not received any additional OT services. Review of Resident 5's care plan, dated 06/30/2021, showed the resident had a focus on ADL Self-Care Deficit as they used a left-hand splint, were at risk for contractures, had limited ROM and impaired voluntary movements of all extremities left worse than right side and neck due to history of their brain injury. The goals were Resident 5 would not have worsening of their upper extremity contracture and they would actively participate in splinting program. Interventions included: -Restorative program left hand orthoses (splints). Nursing to put on at the beginning of the night shift and it is to remain on for 6 hours initiated 5/26/2022. -Application of a brace on their right hand in the morning and off at night and use of a right leg splint and neck brace when up in their wheelchair initiated 02/13/2019. -Application of a brace to left hand and neck brace in the morning (0700) and off at night (2000) when up in the wheelchair daily. Perform PROM three to six times a week for at least 15 minutes initiated 06/30/2021. -Passive ROM/gentle stretching to left upper and lower extremity with left hand splint placement, Active Assistive ROM (AAROM - a type of exercise that involves moving a joint with some help from an external force) to right upper and lower extremity three to six times a week for at least 15 minutes initiated 03/04/2019. Review of Resident 5's Treatment Administration Record (TAR) for March 2024 and April 2024, showed on order for PROM with gentle stretching to their left upper and lower extremity, apply a left-hand splint, provide AAROM to right upper and lower extremity and head with neck splint placement three to six times a week for at least 15 minutes. The order directed the unit nurse to monitor compliance and completion of the program every day shift for Functional Mobility Maintenance starting 06/11/2021. This treatment was marked as not completed for the months of March and April 2024. Review of Resident 5's medical record from 06/05/2023 through 04/22/2024, showed no documentation to indicate the resident received PROM during routine nursing care. In an interview on 04/22/2024 at 2:39 PM, Collateral Contact 1 (CC1), Resident 5's family member, stated Resident 5 had not received therapy anymore and they used to get therapy at least yearly. CC1 stated they felt Resident 5 had declined in their ROM and they used to be able to do more. In an observation on 04/22/2024 at 2:39 PM Resident 5's left, and right hands were observed without a hand splint, their left hand rested on an arm trough (a provided support needed for resident's whose arm has little or no function). In an observation on 04/30/2024 at 2:35 PM, Resident 5's left, and right hands were observed without a hand splint and their left hand rested on an arm trough. In an interview and record review on 04/29/2024 at 3:14 PM, Staff F stated the facility did not have a restorative program. Reviewed Resident 5's March and April 2024's TAR with Staff F, and they stated the licensed nurse documented a n on the TAR for the resident's PROM indicated the treatment was not done. Staff F stated they did not know how ROM was being assessed, the risk to the resident if the PROM was not provided, or the process for obtaining a referral for therapy services. Refer to WAC 388-97-1060 (3)(d)(j)(ix)

Based on observation interview, and record review the facility failed to provide timely pain management and follow pain management orders for 2 of 3 residents (Resident 8 and 4) reviewed for pain. This failed practice resulted in harm to Resident 8 when they were not provided pain medication per physician orders which resulted in unmanaged pain. This failed practice placed all residents at risk of the potential for poor pain management and diminished quality of life. Findings included . Review of facility policy titled, Pain Assessment and Management, revised 09/15/2023, showed the facility must ensure residents receive the treatment and care in accordance with professional standards of practice. <RESIDENT 8> Resident 8 admitted to the facility on [DATE] with diagnoses to include femur (upper leg bone) fracture, generalized anxiety disorder, panic disorder, and depression. Review of Resident 8's Admission Minimum Data Set (MDS- and assessment tool) assessment, dated 09/23/2023, showed, under the health conditions section, the resident received scheduled and as needed (PRN) pain medications, and had frequent pain identified. Review of Resident 8's September 2023 physician orders showed the resident had an order dated 09/22/2023 for oxycodone 5 milligrams (mg) one tablet every four hours as needed for a pain rating of a four to six, and two tablets for pain rating of seven to ten on a pain scale of one to ten (one equals mild pain and ten equals severe pain). Review of Resident 8's September 2023 Medication Administration Record (MAR), showed the resident received oxycodone 10 mg on 09/26/2023 at 2:45 AM, 9:04 AM, and 8:48 PM Review of facility nurse staffing form, dated 09/26/2023, showed Staff D, Licensed Practical Nurse (LPN), worked from 1:06 PM until 6:58 PM on the north hall, where Resident 8 resided. In an e-mail, dated 09/29/2023, Resident 8's family member wrote on 09/26/2023 Resident 8 received oxycodone at 9:00 AM, but no other doses were given until 10:00 PM. They stated the resident used their call light several times that day. They stated the resident was experiencing a lot of pain from a recent hip fracture and surgery. In an interview on an undisclosed date and time to protect identity of Anonymous Reporter (AR1), AR1 stated Staff E, LPN, gave Resident 8 oxycodone at approximately 9:00 AM on 09/26/2023. AR1 stated Resident 8 had reported extreme pain later that day and had been very upset when the assigned nurse, Staff D had not given oxycodone when they requested, and did not receive oxycodone again until 8:48 PM. On 10/02/2023 at 2:45 PM, Resident 8 stated they had been experiencing problems with pain management, especially during the previous week. They stated they specifically had a difficult time getting pain medications one afternoon last week from a staff nurse. Resident 8 stated they were in a lot of pain that afternoon and stated they had not received pain medication until bedtime from a different nurse. Resident 8's husband was present for the interview and could not recall the exact date but recalled the situation and nurse as well. Resident 8 stated their daughter would likely know the date as they had talked to them about it. Review of Resident 8's MAR for October 2023 showed on the following dates, the resident was given 5 mg instead of 10 mg oxycodone as ordered for pain levels seven to 10: - On 10/03/2023 at 4:22 AM, pain level was a nine. - On 10/06/2023 at 9:35 AM, pain level was a seven. - On 10/06/2023 at 1:32 AM, pain level was a seven. The nurse documented the pain medication administered was ineffective. - On 10/11/2023 at 10:12 PM, pain level was a seven. - On 10/12/2023 at 4:13 AM, pain level was a seven. - On 10/16/2023 at 7:11 PM, pain level was a seven. During observations on 10/06/2023 between 1:45 PM and 2:10 PM, Resident 8 was sitting in their wheelchair in their room with verbalizing they were in pain, they had a distressed look on their face, they were grimacing, their face was flushed, they were noted to reposition themselves frequently to get into a comfortable position and the resident stated they were upset about their hip pain. Resident 8 stated they had a pain pill recently (at 1:32 PM), and they had requested more pain medication earlier but Staff A, agency Registered Nurse (RN), stated it was too early and they had to wait four hours from the previous dose given at 9:35 AM. Resident 8 stated their ARNP (Advanced Registered Nurse Practitioner) had visited earlier and stated they should have been given two oxycodone tablets (10 mg) instead of one tablet (5 mg) for their pain level of seven out of 10. Resident 8 stated for the dose they had just received (1:32 PM), the nurse had not asked their pain level which they stated was again at seven out of 10. In an interview on 10/06/2023 at 2:35 PM, Staff A stated when they arrived at the facility in the morning, Resident 8 had only two oxycodone 5 mg tablets remaining, therefore, Staff A stated to extend the medication they had given just one instead of the ordered two oxycodone. Staff A stated each time they administered oxycodone 5 mg they also gave Tylenol 500 mg. Staff A stated if oxycodone did not arrive with the pharmacy delivery, due approximately at 5:00 PM today, they would get authorization to get the medication from the pyxis machine (automated medication dispensing system). Staff A stated the oxycodone had been available in the pyxis machine all day, however, did not state the reason they did not access the oxycodone. In an interview on 10/06/2023 at 2:45 PM, Staff K, Director of Nursing Services, was informed Resident 8 had reported their pain level at a seven twice on this date, 10/06/2023, and had orders to administer 10 mg of oxycodone, however had only received 5 mg each time. Staff K was informed of Resident 8's observation of pain exhibited, and replied they would investigate the resident's pain management. In an interview on 10/06/2023 at 3:35 PM, Staff K stated they had investigated Resident 8's pain concerns and stated they felt better knowing the resident was also prescribed other medications to include Tylenol, tizanidine (medication for muscle spasms), and gabapentin (medication for nerve pain). Review of facility investigation, dated 10/06/2023, showed Staff A failed to give the correct dose of oxycodone on 10/06/2023. <RESIDENT 4> Review of a progress note, dated 08/18/2023 at 4:42 PM, showed Resident 4 had admitted to the facility on [DATE] with diagnoses to include cellulitis (a bacterial infection of the skin) from right leg with incision and drainage of the great toe and depression. Review of Resident 4's Admission MDS assessment, dated 08/21/2023, showed the resident was cognitively intact. Review of the MDS, under the health conditions section, showed the resident received a PRN medication, no routine medication or non-medication intervention for pain, and they reported frequent pain impacting their sleep and activity over the past five days. Review of Resident 4's pain Care Area Assessment, dated 08/21/2023, showed they had frequent complaints of pain due to cellulitis and wounds on both feet and they took oxycodone fairly regularly. Review of Resident 4 August 2023 physician orders and MAR showed the resident had an order for oxycodone (narcotic pain medication) 10 milligrams (mg) every three hours PRN for pain. Resident 4 did not receive their first dose of oxycodone, after they admitted to the facility until the following day, 08/19/2023 at 12:05 PM. In an interview on 09/20/2023 at 3:15 PM, Resident 4 stated it had taken so long to get pain medication when they arrived at the facility. Resident 4 stated they had severe pain in their foot that moved up their leg. The resident described the pain as really bad, and stated they did not even get any pain medication until the second day they were at the facility. On an undisclosed date and time to protect the identity of AR1, AR1 stated Resident 4 had not received their ordered oxycodone for pain due to lack of supply at facility other than the pyxis machine (automated medication dispensing system). In an interview on an undisclosed date and time to protect the identity of AR3, AR3 stated every time they informed Staff D residents needed pain medication, Staff D stated I'm busy, I'll get to it. AR3 stated they would return to Staff D and inform them the resident was still waiting for their pain medication, which would upset Staff D. AR3 stated they did not know if it had been intentional or if Staff D had forgotten residents pain medication requests. AR3 stated Resident 4 had complained numerous times that Staff D had not brought pain medication or had not brought it timely. In an interview on 09/20/2023 at 3:04 PM, Staff B, RN, stated when they needed medications for a new resident or for a resident with new orders, they sent the prescription to the pharmacy and called the pharmacy to get an authorization code to get the medication from the pyxis machine. In an interview on 10/17/2023 at 1:45 PM, Staff K stated their expectation was for residents to be administered pain medications as soon as possible when they experienced acute pain and under 20 minutes for chronic pain. Staff K stated nurses were expected to administer all medications according to the provider's orders. On 10/17/2023 at 5:30 PM, the Administrator and Staff K were informed of concerns expressed by multiple anonymous staff regarding Staff D. Reference (WAC) 388-97-1060(1)

Based on interview, observation, and record review the facility failed to promote the rights of one of one residents reviewed for dignity when they removed a resident's electronic tablet against their known preference and established routine. This failure violated the residents right to a respectful and dignified existence which resulted in harm for Resident 1 who described feelings of humiliation, diminished self-worth, and overall decreased wellbeing. Findings included . Review of facility policy titled, Resident Rights, revised 06/08/2020, showed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has a right to be treated with respect and dignity. The resident has the right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. Resident 1 admitted to facility on 08/01/2018 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to her Annual Minimum Data Set (MDS) assessment on 05/28/2021, had no cognitive impairment, required supervision assistance with bed mobility, transfers, and ambulation. In a phone interview on 07/12/2021 at 12:20 PM Collateral Contact (CC), community counselor, stated the last few phone calls with the resident they were unable to engage with the resident as the resident was only focused on the iPad. The CC stated in a conversation they had with the resident, on the previous day, the first thing the resident stated was regarding the facility was taking their iPad at night. The CC stated, This is clearly very upsetting, and they are unable to focus on anything else. I have not been able to engage with the resident as they are only focused on this. The CC stated regarding Resident 1's personal iPad being removed by the facility was hindering their community enrichment progress which promotes independence and personal growth. Review of medical record on 07/14/2021, showed an order dated 07/02/2021 for the residents iPad to be removed from resident's room and kept at nurses' station at 9:00 PM. It could be returned to resident after breakfast on the following day to ensure the resident slept throughout the night with their feet elevated at bedtime and to ensure compliance with elevation of their legs and feet. On 07/14/2021 a review of the mood and behavior care plan, revised on 03/28/2021 by the Director of Nursing Services (DNS), directed staff to put the iPad/Tablet away nightly at 10:00 PM. The resident could start using the tablet at 7:00 AM. The care plan included that the resident may protest this plan, please remind them. In an interview and observation on 07/14/2021 at 10:30 AM, Resident 1 stated they would prefer to not have the iPad taken away as it made them feel the facility staff were treating them like a child. This made the resident feel bad, and humiliated. Resident 1 stated My brother told the facility to take it away, but he is not in charge of me, I am 6* years old, I can make my own decisions. Resident 1 stated they were a night owl, and not a little kid. I cannot even put it in my drawer, they take my charger. Resident 1 stated the iPad was a helpful tool for her when she had [CONDITION(S)]. In an interview on 07/14/2021 at 11:08 AM, the DNS stated the iPad was Resident 1's whole life, it's how they prefer to do, participate in an activity. The DNS stated the resident preferred to be on the iPad sitting in their chair. The facility requested the Medical Provider speak with the resident about the swelling of their legs. The DNS stated she was unaware of the care plan goal to remove iPad at 10:00 PM, although the DNS was the staff member who initiated the goal on care plan. In an interview on 07/14/2021 at 11:37 AM, Staff A, Registered Nurse (RN)/Resident Care Manager (RCM), stated the resident had very bad leg swelling to the point of weeping blisters. The Medical Provider suggested elevation of resident's legs. Staff A said the facility contacted the residents' brother to relay the suggestion and he instructed staff to take the residents iPad away at night. Staff A stated, It was his (the brothers) suggestion. Staff A stated, that this makes the resident upset but it is usually ok because it (iPad) loses power around 7 PM, so we just take it to charge. Staff A stated the iPad charger was kept at the nurse's station because the resident would pull the charger out of the wall. Staff A was unaware the resident had the right to their personal possessions, including the iPad, despites their brothers' instructions as Resident 1 were alert and oriented and able to make their needs known. In an interview on 07/14/2021 at 11:44 AM, Staff B, RN/Regional Director of Clinical Services, stated the facility had lots of iPads available for the resident's use if the resident was unable to use theirs. As of today, we will document the risks and benefits of resident having iPad and [CONDITION(S)] and update her care plan, they can have their iPad back. In an observation and interview on 07/14/2021 at 12:30 PM, Resident 1 was sitting in their chair next to their bed with their legs elevated on the bed, coloring on her iPad. Resident 1 stated they were keeping their feet up while they colored, and stated they were happy they would get their iPad back at night now. In a joint interview on 07/14/2021 at 2:10 PM, with Staff C, Regional Vice-President/ Interim Administrator, Staff B, and DNS agreed removal of residents iPad at night was against resident rights. Staff B stated they had spoken with the resident, updated the care plan, orders, and left a message with the family to discuss Resident 1's rights. Reference (WAC) 388-97-0180(1)(2)(3)(4)(b)

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect for one of three residents (#3) reviewed for falls and one of four residents (#2) reviewed for resident to resident incidents. The facility neglected to provide assessment, supervision and intervention to an at risk resident which resulted in harm to Resident #3 who suffered a preventable fall with injury. The facility further failed to effectively protect residents from abuse which resulted in harm to Resident #2, who experienced resident to resident abuse by Resident #1. Findings included . Review of a facility policy titled: Protection of Residents: Reducing the Threat of Abuse and Neglect, dated 01/21/19 showed the facility would identify, assess and care plan appropriate interventions, and monitor residents with needs and behaviors such as verbally or physically aggressive behavior or self injurious behaviors. RESIDENT NEGLECT RESIDENT #3 Resident #3 admitted [DATE] following a workplace injury to the leg and a status of non-weightbearing necessitated nursing home placement. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident was alert and oriented with no behavioral issues and was independent with all activities of daily living. She was independent with leisure activities, and was previously independent in the community including driving. Review of progress notes on 12/23/19 and 12/24/19 showed the staff were aware of instances the resident would leave the facility and go to her personal car and smoke and/or drink alcohol. The resident was offered nicotine patches and continued to be documented to be on frequent checks and 30 minute checks from the staff related to concern for smoking as she was frequently going in and out of the building to her personal vehicle. A progress note dated 12/02/19 by the Director of Nursing Services showed the resident was seen smoking and drinking alcoholic beverages in her car and was educated regarding the risk of interaction with alcohol and her pain medications, as well as concern for driving under the influence. Review of the care plan dated 11/20/19 showed the resident was a known smoker who was consistently non-compliant with the facility smoking policy, frequently going to her personal car parked on facility property and smoking. The care plan showed no interventions had been care planned related to the known history of alcoholic beverages. Record review of a facility investigation showed: On 02/04/20 at 8:00 PM, Resident #3 received [MEDICATION NAME] (an opioid pain medication) 5mg tablet as ordered routinely for pain from Staff A, Licensed Practical Nurse. On 02/04/20 at 10:30 PM Resident #3 self reported that she had fallen in her room, landed on her knee and stated her knee was painful. A fall investigation was started at that time by Staff A which included initiating neurological assessment related to the fall being unwitnessed. On 02/04/20 at 11:15 PM the resident refused neurological assessment. On 02/04/20 at 11:23 PM, the resident requested an additional [MEDICATION NAME] as needed related to complaints of pain in her knee. Staff A administered an [MEDICATION NAME] 5mg tablet. On 02/04/20 at approximately midnight, Resident #3 passed by Resident #3 in the hallway as Resident #3 was going to go outside and Staff A noted the smell of alcohol. On 02/05/20 at 1:45 AM, Staff F, Nursing Assistant found Resident #3 in the parking lot having fallen next to her car, the resident stated her sore leg gave out. Resident #3 appeared disoriented and had difficulty moving her left arm. Staff F called for assist from Staff A and paramedics were called. The resident was transported to the hospital emergency department where she was found to have a fractured left clavicle (collarbone) and a blood alcohol level of 348, which was considered significantly high. Review of the emergency department notes dated 02/05/20 stated Your alcohol level was 348 tonight. This suggests you drink regularly to be able to tolerate that level. Also, alcohol does not mix with your pain meds. In an interview and observation on 02/10/10 at 11:13 AM, Resident #3 stated she was having increased anxiety and depression due to her circumstances and she had driven to the store earlier the day of 02/04/20 and bought some hard ciders. She stated she just needed some relief from her anxiety. She stated she had fallen in the room trying to help her room mate and she thought she hurt her knee. She stated she asked for an extra pain pill and had a few ciders. She stated she messed up because she should not have mixed the ciders with the pain medications. She stated she only saw the nursing assistant who tried to take her vital signs and she wanted to be left alone so she went out to her car. She stated nobody asked her where she was going, or what she was doing and no staff came out there. She stated she had a walker with her but her sore knee gave out and she fell on her shoulder. She stated she called out for help and did not think it was very long before someone found her. She was upset that she now had a set back in her discharge planning and felt the facility was treating her like a child, refusing to give her back her car keys and forcing her to sign in and out of the building when she was only going outside and not leaving the property. Resident #3 was observed during the interview to be neatly dressed, glasses on, with her hair pulled back sitting on the edge of her bed with a laptop computer in front of her. Her clothing smelled of cigarettes with no observations of smoking materials in the room, no burn holes seen in clothing and no observed signs of alcohol in the room. She made eye contact, spoke clearly and her hands were steady as she sat and spoke. In an interview on 02/10/20 at 1:49 PM, Staff A confirmed that she was Resident #3's nurse on the night shift from 02/04/20 at 6:00 PM until 02/05/20 at 6:00 AM. She confirmed the timeline of the investigation stating that she had administered the resident's routine [MEDICATION NAME] at 8:00 PM, and then the resident requested a prn (as needed) [MEDICATION NAME] at around 11:30 PM. She stated that she had come back to the resident's room just after administering the second [MEDICATION NAME] in order to get a statement from the resident regarding the fall the resident claimed to have had in the room. She stated it was at that time she smelled what she believed was alcohol. When asked what she had done when she had a suspicion that the resident had consumed alcohol she stated I texted my boss. She stated that she texted the Director of Nursing Services who responded stating that Staff A should ask the resident about it. Staff A stated I told (the DNS), No, I was not going to ask her (Resident #3) about it, because she (Resident #3) was already upset, and I wanted to have a good night. She stated Resident #3 was upset that she had tried to come in and get her vital signs. She stated the plan was that the DNS was going to talk to the resident in the morning. Staff A stated that she began her midnight medication pass and she observed Resident #3 put on a coat and walk out of her room and go outside. She had a walker with her because of her sore knee. She stated Resident #3 was allowed to come and go as she pleased. Staff A confirmed she did no further assessment of Resident #3 or ask Resident #3 if she had been drinking alcohol, she did no notification to the physician that there was any concern for alcohol consumption in conjunction with narcotic pain medication, and did not do any safety checks of the resident after the resident left the building. Staff A stated the next time she saw resident #3 was when she was notified that the resident had fallen in the parking lot at around 2:00 AM and she said they sent her to the ER because she was confused and had injured her left arm. In an interview on 02/10/20 at 1:43 PM, the DNS acknowledged that Staff A did not do anything when she suspected the resident had consumed alcohol. She stated Staff A's response was that she just kept circling back to the fact that she was in the middle of passing medications and that Resident #3 intimidated her. The DNS stated it was concerning that Staff A did nothing and there was no assessment or monitoring of the resident, and a nursing assistant just happened to see the walker on the ground outside while on a break. The weather was cold and rainy. On 02/10/20 at 3:53 PM the DNS confirmed that Staff A had sent her a text on 02/04/20 and the expectation was that Staff A would get more information. The DNS stated Staff A texted that she would document and see if the resident had signed out. The DNS stated she did say she would follow up with the resident the following day. The DNS stated she understood that the nurse had not followed up on the suspicion the resident was drinking, knew she had a recent fall with knee pain, had refused the neurological assessments to rule out head injury, and had just been given pain medication and the nurse did no further assessment, intervention or notification of concerns to the MD. The lack of nursing assessment, supervision, notification and intervention from Staff A, who had a duty of care, constituted neglect resulting in preventable fall with significant injury to Resident #3. RESIDENT TO RESIDENT ABUSE RESIDENT #1 Resident #1 admitted [DATE] from an inpatient addiction recovery hospital. Review of the admission documentation materials from the discharging hospital dated as being received via fax on 06/06/19 at 10:00 AM showed a section of assessment data titled Behavior and showed: · Past Behaviors: Easily irritable/agitated requiring intervention; · Behavior Descripton: Client becomes irritated if he has a room mate; · Personalized interventions: Client becomes very agitated if he has a room mate. An ETR (exception) may be needed for him to have a private room in a residential setting; caregiver to monitor client's irritation and intervene as needed. Review of the Quarterly MDS assessment dated [DATE] showed the resident had an increase in depression and behavior indicators from the prior Quarterly assesssment done 10/22/19. The resident's depression score increased from 02 to 15 indicating a significant increase in self reported depressive symptoms such as little interest in doing things and feeling down, depressed and hopeless. The resident's behavior indicatiors had previously been recorded as 0, and now showed the resident had verbal behaviors directed at others daily which were impacting others, and overall behavior indicators were listed as worse. Record review showed: On 10/24/19 at 5:46 PM, verbal altercation with another resident; arguing with another resident (Resident #9) about a misunderstood conversation near the front door and heard to state we can take this outside. In an interview on 02/04/20 at 2:36 PM, Resident #9 stated Resident #1 could be a hothead but that did not bother him. On 12/10/19 at 11:26 AM, verbal name calling stated his room mate (Resident #7) was fat and lazy. The room mate was moved to another room. In an interview on 02/06/20 at 3:00 PM, Resident #7 did not recall any incidents with other residents or room mates and denied having any current concerns with other residents. On 12/12/19 at 10:34 PM, verbal agitation toward staff regarding pain medication administration times. On 12/22/19 at 4:43 PM, verbal agitation toward staff again regarding pain medication times. He physically hit the wall with his hand; verbal irritation directed in reference to a vocal resident in the hall (Resident #8) stating and now I have to listen to this[***] Resident #8 was not interviewable. On 1/23/20 at 3:00 PM, verbal abuse directed toward another resident (Resident #4) telling the resident to you need to shut up, we all have pain. In an interview on 02/05/20 at 1:30 PM, Resident #4 stated she was having pain and she called out, she said Resident #1 told her everyone had pain. She stated she knew Resident #1 got upset when residents yelled and she said there are quite a few that do. She hears him saying shut up! She stated she was not offended by it when he said it to her, but she couldn't help it that she was in pain. On 01/23/20 at 5:41 PM, Resident #1 made statement just put a gun to my head and shoot me. The resident stated no plan, and agreed to mental health support. On 01/25/20 at 2:45 PM, the resident complains of noise from other residents and odors if his room mate has a BM Record review showed care plan interventions which were added 01/13/20 stated to redirect the resident when becoming inappropriate and stated the resident would go to his room and watch television or listen to music and the addition of mental health referral. There were no care planned interventions related to the resident's room mates or how or where to redirect the resident when the triggering issue was in his room rather than a common area and did not identify the known triggers such as noise or bathroom smells. On 02/01/20 at 8:00 PM, verbal abuse directed toward room mate (Resident #2) RESIDENT #2 Resident #2 admitted [DATE] with [DIAGNOSES REDACTED]. He admitted as a room mate to Resident #1. Review of the Admission MDS dated [DATE] showed the resident was interviewable with cognitive impairment and required minimal assistance with activities of daily living and ambulated with supervision. The resident was listed as always continent of both bowel and bladder. Review of a progress note dated 02/01/20 at 10:49 PM (in the record of Resident #1) showed that on 02/01/20 at 4:00 PM, Staff C, Licensed Practical Nurse, heard Resident #1 state to his room mate (Resident #2) Hey dude, don't use the F-king toilet here. You are a grown man, go use the bathroom to[***] Resident #2 was observed to be running out of the room to go to the hallway bathroom and had soiled himself. Resident #2 was assisted in the bathroom and moved to another room. Resident #2's chart does not include the documentation of the incident. In an interview on 02/06/20 at 9:34 AM, Staff B, Nursing Assistant, stated Resident #1 liked the room to himself and had trouble with all of his room mates verbally. She stated she thought it was a tactic to get the room to himself. She stated he liked the room to smell good and was very picky about that. She stated all of his room mates have been incontinent or used the bedside commode. She stated we were worried, we thought there would be a problem with the bedside commode for Resident #2, and she stated Resident #1 wanted to have the door closed because a lot of the people down there scream and yell, like Resident #8, and Resident #2 wanted to go in and out all the time and it really bothered Resident #1. She stated they had to move Resident #2. Staff B stated Resident #1 was doing ok right now with no room mate, he could have his door closed and use his headphones and he liked that. In an interview on 02/10/20 at 2:21 PM, Staff C stated that she was witness to the incident 02/01/20. She stated she was at the nurse's station and heard Resident #1 loudly say hey dude, don't use the f'in commode- use the f'in bathroom in the hallway and then saw Resident #2 running out of the room. Staff C stated she had a nursing assistant go help him and the resident had soiled himself. She stated the resident was normally continent. Staff C stated she called the administrator who said to get him out of there. Staff C stated when she was helping Resident #2 down to the new room she wanted to talk to him privately and ask him how he was doing and Resident #2 said to her he scares me, I am afraid of him. She stated Resident #1 spent the next several days asking why his room mate was moved and wanting to know who the snitch was. She stated he went so far as tape an actual target on his back and went up and down the halls stating staff were out to get him and asking individual staff if they would tell him who snitched. She stated Resident #1 had a fixation on his pain medications and when the times changed he was very hostile, he punched the wall because of it. We were scared of him right then, what if he tried to follow me to my car? I had someone walk me out to my car that day. In an interview on 02/05/20 at 11:43 AM, Resident #2 was lying in his bed and stated he liked his room. When asked if he had been in any other rooms prior to the current one, Resident #2 stated he had been in one room down the hall. When asked him why he moved he stated, That guy down there was not very nice, he wanted to run the room, so I decided it would be better down here. When asked if he recalled any specific issue regarding the room and not being able to use the bathroom, he shrugged and said not really. In an interview on 02/05/20 at 3:38 PM, Resident #1 stated he had been talked to about his room mate, Resident #2 and stated he felt it was blown way out of proportion. He stated that Resident #2 was hard of hearing so that was why he raised his voice. He stated he did say F'in and wanted him to use the bathroom in the hallway instead of the one in the room. He said Resident #2 would put the commode in the middle of the room to use it and said I don't need that. He stated he did get frustrated with all the yelling, He stated he was trying really hard but he was surrounded by screamers. In an interview on 02/10/20 at 3:24 PM, Staff E, Social Services Director, stated she was not aware of the prior behavior information from the discharging hospital. She stated she did not realize that information about agitation with room mates was there and stated it was a different kind of admit from an addiction hospital. Staff E stated she completed the portions of the MDS related to mood and behavior and was aware that Resident #1's mood had declined. She stated Resident #1 verbalized that being in this setting was frustrating. In summary, Resident #1 admitted with assessment data indicating a past history of agitation and irritation regarding room mates. Documentation of resident behaviors demonstrated a pattern of a low level of tolerance for other resident behaviors and increased verbal aggressiveness toward other residents, with known triggers of verbal behaviors and smells. The facility failed to prevent and protect residents from verbal abuse which resulted in psychosocial harm to Resident #2 who verbalized being fearful of Resident #1 in response to Resident #1 cursing and yelling at him while useing the bedside commode in his room and resulted in Resident #2 soiling himself while attempting to leave the situation and find an alternate bathroom. This failure further placed other residents at risk for continued exposure to verbally aggressive and agitated behaviors by Resident #1. This is a repeat deficiency from a complaint investigation dated 11/26/19 Reference (WAC) 388-97-0640 (1)

Based on interview and record review the facility failed to provide care and services for one of one residents (#1) reviewed for neglect. This failure caused harm to Resident #1 who was incontinent in bed and on the way to the bathroom when the facility staff failed to answer the resident's call light in a timely manner which caused the resident to be incontinent and have feelings of frustration, humiliation and diminished self-worth. Findings included . Resident #1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. According to the discharge Minimum Data Set assessment dated [DATE], Resident #1 was alert and oriented and continent of urine. Resident #1 discharged to another skilled nursing facility on 11/17/19. Review of the admission urinary assessment dated [DATE] showed Resident #1 was continent of urine. Review of the admission orders [REDACTED]. Review of an incident report dated 11/09/19, showed Resident #1 reported that she was not getting her needs met for toileting. Resident #1 stated that the call light would be on and she would not get assistance for 30-45 minutes. The resident stated that she had an incontinent episode in her bed on the evening shift of 11/08/19 because she had to wait so long for her call light to be answered. The resident stated she had also urinated on the floor on her way to the bathroom. The report further showed on 11/11/19, in a follow up interview by the Director of Nursing Services (DNS), where Resident #1 stated that she felt Embarrassed from the incontinent incident. The incident report documented that, Neglect was substantiated based on incontinent episode and failure of staff to assist resident in a timely manner to prevent incontinence. In an interview on 11/26/19 at 3:05 PM, Resident #1 stated that she left the previous skilled nursing facility because she was scared and felt like she had been neglected. She stated that she felt like she had a hard time getting her call light answered for assistance with toileting. Resident #1 stated that she had to wait for an hour for someone to assist her to the bathroom, during which time she stated she drenched herself in urine waiting and when she got up to walk to the bathroom she had soiled the floor as well. The resident continued to state that she was so scared that she posted a comment on social media and her friends rushed to visit her and make sure she was cared for. Resident #1 stated, Being left in urine for long periods of time, not getting assistance and being left to soil myself was the most dehumanizing experience of my life and I will never forget it. (Eyes were tearing up), I was scared, embarrassed and felt neglected by the staff by leaving me in urine and not providing the needed assistance to toilet. In an interview on 11/27/19 at 11:42 AM, the DNS stated that she was informed that Resident #1 was unhappy on 11/09/19. The DNS stated Resident #1 was upset because the evening before (11/08/19), she had her call light on to go to the bathroom, no one responded, the resident was incontinent of urine in bed, and when the Nursing Assistant Certified (NAC) finally arrived, she was than incontinent on the floor on the way to the bathroom. The DNS reported Resident #1 stated she had bladder surgery in the past and when she had to go the bathroom, she had to go immediately. The DNS continued to report that Resident #1 stated the Occupational Therapist gave her an incontinent brief to wear because she had urgency issues. The DNS stated she put a commode next to the resident's bed in an attempt to prevent the same situation from happening again. When asked why that was not done upon admit, the DNS stated, Because we did not know she had that urgency issue upon admit. The DNS stated that all residents with allegations of neglect should have charting every shift for three days to rule out psychological harm. Review of the nursing progress and social service notes from 11/09/19 through 11/12/19 showed no evidence that Resident #1 was being monitored for psychological harm. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcers for 2 of 3 residents (2 and 4) reviewed for pressure ulcers (PU). The facility failed to define, follow and implement interventions consistent with the residents' clinical needs and identified goals. The facility failed to evaluate Resident 2 and 4's clinical condition and pressure ulcer risk factors. This failure caused harm to Resident 2 when the resident developed three Deep Tissue Injury's (to the right medial heel, right lateral calf and left heel) and three stage IV PU's (to the left calf, coccyx, and right elbow). Additionally, the facility caused harm to Resident 4 who developed two Deep Tissue Injury's to the right foot. Findings included: Per the Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed: -A stage IV PU was full thickness tissue loss with exposed bone, tendon or muscle. Slough (non-viable tissue) or eschar (dead or devitalized tissue) may be present on some parts of the wound bed. There may be tunneling (a passage way of tissue destruction under the skin surface that had an opening at the skin level from the edge of the wound) present. -A Deep Tissue Injury (DTI) was purple or maroon area of discolored intact skin due to damage of underlying soft tissue. Review of the facility's Skin Integrity and the Aging Process policy, not dated, showed the elderly were at great risk for skin problems and breakdown. A nursing home was not able to prevent skin breakdown, but could attempt interventions designed to minimize the probability of skin breakdown. The facility developed a care plan consistent with the resident's values, medical history, expectations and willingness to follow the plan. RESIDENT 2 Resident 2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the significant change Minimum Data Set (MDS) assessment, dated 12/18/17, the resident had no cognitive impairment, no behaviors, was at risk for PU development and had 1 stage III PU and 5 DTI's. The resident required extensive assistance of two for bed mobility and toileting and extensive assist of one for eating. Review of the Impaired Skin Integrity care plan, dated 06/30/17, showed the resident was at risk for skin breakdown due to bowel and bladder incontinence, impaired mobility, pain, behaviors that impacted skin integrity such as refusals of care and history of PU to the heels. Interventions included to float the heels and elbows when in bed on pillows, pressure reduction mattress, and weekly skin checks. Review of the Braden Scale assessment (a tool used to predict pressure ulcer risk), dated 10/24/17, 10/31/17, 12/13/17 and 01/25/18 identified the resident at high risk for PU development. Review of the PU status record, dated 10/24/17, showed the resident developed a DTI to the right elbow. The PU measured 2.8 centimeters (cm) by 3.8 cm. Review of a Weekly Skin Integrity Data Collection (WSIDC) sheet, dated 11/17/17, showed the resident had a blister on the right elbow (according to the PU status record the right elbow had a DTI not a blister) and redness on both heels. There was no further documentation assessing the heels. Review of the WSIDC, dated 12/01/17 and 12/08/17, showed the resident had a right elbow wound and redness on both heels. There was no further documentation assessing the heels. Review of a PU status record, dated 12/06/17, showed the resident had a stage III coccyx PU that measured 1.2 cm by 3.5 cm by 0.1 cm. Review of the physician orders [REDACTED]. A treatment order for the coccyx was obtained on 12/13/17, seven days later. On 12/13/17, the resident developed: - a DTI on the right medial heel measuring 1.0 cm by 2.5 cm by 0.1 cm - a DTI to the right lateral calf measuring 5.8 cm by 3.5 cm by 0.1 cm - a DTI to the left calf measuring 7.0 cm by 8.0 cm by 0.1 cm The PU care plan was updated on 12/13/17 to reflect the resident's current skin breakdown. Staff were directed to assist as needed to reposition/shift weight to relieve pressure, discuss non-compliance with resident, minimize pressure over boney prominence's, position with pillows, alternating air mattress, and provide incontinence care after incontinent episode and to turn and reposition every 1 to 2 hours. Review of an Advanced Registered Nurse Practitioner (ARNP) note, dated, 12/14/17, showed the resident was being seen due to multiple PU's. The ARNP identified the resident's overall health status had been declining, requiring increase in assistance, not getting out of bed and difficulty to move herself. On 12/17/17, the resident started hospice services. Review of the PU status record, dated 12/20/17, showed the resident developed a left heel stage I PU measuring 5 cm by 6 cm. Review of the PU status record, dated 01/17/18, showed: -the coccyx stage III PU, measuring 2 cm by 2.5 cm by 1.8 cm. The PU had 0.6 cm of tunneling at 12 o'clock and 0.8 cm between 3 and 5 o'clock -the right elbow PU was now a stage IV PU measuring 2.5 cm by 1.5 cm by 0.5 cm -the DTI on the right medial heel measuring 0.5 cm by 0.5 cm - the DTI on the right lateral calf measuring 6 cm by 2 cm -the stage I left heel PU measuring 3 cm by 3 cm - the left calf DTI was now a stage IV PU measuring 5.5 cm by 4.5 cm by 0.5 cm Review of the PU status record, dated 02/06/18, showed: -the coccyx PU deteriorated to a stage IV PU, measuring 3.0 cm by 2.0 cm by 3.0 cm. There was varying depth of tunneling at 12 o'clock, 3 o'clock and 9 o'clock. - the right elbow stage IV PU, measured 3.0 cm by 2.1 cm by 0.4 cm. There was 0.1 cm of tunneling between 11 and 12 o'clock. - the DTI on the right medial heel had resolved - the DTI on the right lateral calf measured 6 cm by 2 cm by 0.1 cm - the left heel stage I was now a DTI measuring 1.7 cm by 2.9 cm - the left calf stage IV PU measured 4.0 cm by 2.7 cm by 0.1 cm. On 02/15/18, the left calf stage IV PU resolved. Review of the (MONTH) TAR directed the LN to provide wound care to the left calf every three days and as needed. The LN changed the resident's dressing every four days on 01/14/18, 01/22/18, 01/26/18 and 01/20/18. Review of the through (MONTH) 14th TAR directed the LN to apply skin prep to the resident's bilateral heels and left big toe daily. The LN did not do this treatment 7 days in (MONTH) and 4 days in February. In an interview on 02/15/18 at 1:50 PM, Staff D, Registered Nurse (RN), stated Resident 2 did refuse care at times. Staff D stated this information should be documented in the resident's medical record. At 1:58 PM, Staff A, RN, stated the resident did refuse care at times. This information should be on the behavior sheets or in the progress notes. Staff A was informed the facility did not monitor for refusals of care on the behavioral flow sheets. Staff A stated the resident was currently on hospice care, and comfort was the resident's goal. At 2:05 PM, Staff B, RN, stated the most recent care plan was in each resident's medical record. At 2:23 PM, Staff C, Licensed Practical Nurse, stated the resident did refuse care at times. Staff C was asked what interventions were implemented to prevent the resident from acquiring PU's. Staff C stated the interventions should be documented on the care plan. When a resident refused care, this was documented in the progress notes. At 2:30 PM, the resident was observed lying in on an air mattress slightly on her right side. The resident did not respond when interviewed. At 2:45 PM, Staff E, Nursing Assistant (NA), stated when Resident 2 refused care she would report it to the LN. Staff E stated the resident would refuse care maybe once or twice a week. Staff E stated the NA did not document anywhere when a resident refused care, just alerted the LN on duty. At 2:52 PM, Staff F, NA, stated the resident did refuse care at times. When this occurred, she would alert the LN. Staff F stated it was better to reposition the resident with two staff members because it was traumatic for her because she had a lot of sores. Staff F stated recently the resident's care plan changed to reposition her every 1 to 2 hours. At 3:10 PM, Staff G, NA, stated the resident did not refuse care. Staff G stated the resident was positioned every two hours and they would ensure that she received a pain pill prior to providing care because the resident had pain issues. On 02/21/18 at 10:52 AM, the resident's PU's were observed with the Director of Nursing Services (DNS) and Staff C. The resident was lying in bed slightly facing the left. There was a strong foul odor in the room. The resident was lying on an air mattress, had a draw sheet and a chux (an incontinent pad) pad under her buttocks and several pillows were used to support her position. The following was observed: -right lateral calf measured 6 cm by 1.8 cm. There were two areas of black tissues on the top and bottom portion of the wound. The DNS stated there was some healthy tissue in the middle of the PU and did not stage the PU - left heel measured 1 cm by 2.5 cm. The DNS did not stage the PU but stated there was 70% slough covering the wound bed (indicating a stage IV) - there was no PU on the left calf or right heel - a stage IV PU on the right elbow measuring 2.8 cm by 1.8 cm by 0.3 cm Resident 2 tolerated the dressing changes to her extremities without any concerns. At 11:17 AM, the DNS and Staff C turned the resident onto her left side. The resident immediately screamed out in pain. Staff C attempted to comfort the resident. The DNS removed the resident's brief and the old dressing came off. The dressing was saturated with drainage from the PU. There was a large opening on the resident's sacrum, with another PU observed directly above. Resident 2 was calling out in pain. The DNS and Staff C stopped the dressing changed and additional pain medication was administered. At 12:34 PM, the DNS stated Resident 2's coccyx/buttocks was measured as follows: -coccyx stage IV PU measured 3.2 cm by 1.0 cm by 4.1 cm. There was 7 cm of tunneling at 12 o'clock, 3.2 cm at nine o'clock and 5 cm at 3 o'clock -a right buttock unstageable PU, measured 5.5 cm by 3.0 cm. Review of Resident 2's progress notes from 10/01/17 to 02/14/18 showed the resident infrequently refused care and services. Resident 2 was admitted to the facility without PU's and developed 3 stage IV PU's and 3 DTI's. The facility failed to assess and implement consistent skin interventions to ensure a high risk resident did not developed PU's. RESIDENT 4 Resident 4 admitted on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment, dated 12/18/17, the resident required extensive assist for bed mobility, transfers and was at risk for skin breakdown. The resident had cognitive impairment. Review of Braden scale assessment tools, dated 12/11/17, 12/18/17, 12/25/17, 12/29/17, 01/01/18, 01/10/18 and 01/15/18 showed the resident was at moderate risk for skin breakdown. The resident's risk factors included decreased bed/chair mobility, incontinent of bowel or bladder and pain impacting his movement or mood. The resident went to an orthopedic appointment on 12/19/17. New orders were sent back to the facility to continue non-weight bearing to the right lower leg, gentle range of motion to the right lower ankle, and to have a walking boot on at all times except when working with therapy, sleeping or bathing. The (MONTH) TAR showed no direction to the LN to assess the resident's skin under the right walking boot daily. Review of the nursing progress notes from (MONTH) 19 through 27th showed no documentation the LN checked under the resident's walking boot and assessed the resident's skin for potential skin breakdown. The resident admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the (MONTH) TAR showed the LN was to remove the boot, initiated 12/29/17, to the right lower extremity and check the skin every shift. Review of the impaired skin integrity care plan, dated 12/29/17, identified the resident at risk for skin breakdown due to a walking boot on the right lower leg, incontinence and cognitive impairments. The care plan was updated on 01/17/18, to reflect a blister on the resident's right heel and plantar aspect of the right foot. Interventions included to assist the resident with positional changes every two hours, elevate heels off bed surface and float heels, remove the walking boot when in bed and to use a heel protector boot when in bed. Review of the WSIDC sheet, dated 01/15/18, identified the resident had a blister to the right heel and foot. There were no measurements done. Review of a late entry nursing progress noted, dated 01/15/18, showed the LN provided foot care to the resident and applied patch to the foot blister. There was no further documentation describing where the foot blister was, the size, what type of treatment was provided or evidence the family/physician were notified of the skin breakdown. Review of the Pressure Ulcer Status Record form, dated 01/16/18, showed the resident had a right heel DTI/blister measuring 3.5 cm by 6 cm and a 3 cm by 3.5 cm DTI to the right plantar metatarsal area. Review of a fax communication request, dated 01/17/18, showed the LN requested a treatment order for the DTI's. Review of subsequent weekly PU assessments done on 01/27/18, 02/02/18, and 02/07/18 showed the right heel DTI had increased to 4.5 cm by 6 cm and the right plantar DTI had decreased to 2 cm by 2 cm. The resident discharged to the hospital on [DATE]. In an interview on 02/21/18 at 2:30 PM, the interim DNS was not able to provide any additional information regarding how Resident 4 developed two DTI's to the right foot, what interventions were implemented to prevent the PU's from developing in a resident with known risk factors and compromising health concerns. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcers for 2 of 3 residents (14 and 9) reviewed for pressure ulcers. Failure to identify, assess, treat and implement changes in Resident 14's plan of care caused harm by the development of a stage III pressure injury and [MEDICAL CONDITION]. Additionally, the facility failed to implement care-planned interventions to prevent the development of a stage III pressure injury for Resident 9. Findings include: The facility's Skin Integrity and the Aging Process policy identified risk factors for skin breakdown included: decreased activity, memory loss, inability to care for one's self and incontinence. The policy directed staff to develop a plan of care that was consistent with the resident's values, medical history, expectations and wiliness to follow the plan. Staff were to follow the facility's Skin Management Protocols, measuring the effectiveness through the Performance Improvement Program. Per the Resident Assessment Instrument (RAI) Manual defined the following: - A stage III pressure ulcer had full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle was not exposed. Slough may be present but does not obscure the depth of tissue loss. The wound may include undermining or tunneling. -Moisture Associated Skin Damage (MASD) was a result of skin damage caused by moisture rather than pressure. It was caused by sustained exposure to moisture, which can be caused by incontinence. MASD was characterized by inflammation of the skin, and occurred with or without skin erosion and/or infection. Provision of optimal skin care and early identification and treatment of [REDACTED]. -Unstageable Pressure Ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable. RESIDENT 14 Resident 14 was a long-term care resident with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessments dated 04/09/16, 07/10/16 and 10/10/16, Resident 14 required extensive assistance of two people for bed mobility, was always incontinent of bowel and bladder, was at risk for skin breakdown, had no history of healed pressure ulcers and had no evidence of MASD. Review of the Impaired Skin Integrity care plan, initiated 10/01/12, identified the resident to be at risk for skin breakdown due to immobility, incontinence, dementia and history of pressure ulcers. Interventions included completing a Braden Scale Risk Assessment quarterly, weekly skin checks, turn every 2 hours, and provide barrier cream after each incontinent episode. Additionally, the resident was to be the last to get up out of bed and the first to be placed back to bed due to the resident's risk for skin breakdown. On 11/30/16, the facility updated the resident's care plan to reflect the current stage III pressure ulcer and implemented a pressure relieving or reduction device in bed and in the wheelchair. Review of the Braden Scale assessment dated [DATE], 07/22/16 and 10/19/16 identified the resident at high risk for skin breakdown. On 11/30/16, the resident's Braden score was a 9, which indicated the resident was at a very high risk for skin breakdown. Staff I, Licensed Nurse (LN), documented the resident was dependent for positioning, skin care and had fragile skin. Staff I did not document the resident had an existing pressure ulcer. Review of the Weekly Skin Integrity Data Collection sheet revealed the following: - On 10/06/16, 10/13/16 and 10/20/16 the resident had no redness or skin breakdown to the coccyx. - On 10/27/16, the LN documented the resident had redness on the buttocks. The LN did not describe the condition of the resident's skin. - On 11/03/16, 11/10/16 and 11/17/16 the resident had no redness or skin breakdown to the coccyx. - On 11/24/16, the LN documented a 1 centimeter (cm) by 0.5 cm new open area on the resident's coccyx. Review of the Pressure Ulcer Status Record indicated the resident developed a stage III coccyx pressure ulcer on 11/30/16. The pressure ulcer measured 1.5 cm by 3.5 cm and was 0.3 cm deep. Review of the nursing progress notes revealed there was no dressing in place until 11/27/16. On 11/27/16, the LN documented a new dressing was placed on the resident. The LN did not identify what type of dressing was placed on the resident, there was no documented assessment and the treatment was not identified on the TAR. Review of the November 2016 Treatment Administration Record (TAR) revealed no documented treatment being done. On 12/08/16, the pressure ulcer declined and measured 3 cm by 3 cm and was 0.3 cm deep. There was 80% slough covering the wound bed. The next assessment was not done until 12/29/16, 3 weeks later, and the pressure ulcer had deteriorated more. The ulcer measured 3 cm by 3 cm and was 0.3 cm deep and then had tunneling: 1.2 cm at 10 o'clock, 0.7 cm at 12 o'clock and 0.3 cm at 3 o'clock. There was 90% slough covering the wound bed and evidence of [MEDICAL CONDITION] (an infection). On 01/05/17, the pressure ulcer had deteriorated further. The pressure ulcer measured 4 cm by 3 cm and was 1.5 cm deep and had the following tunneling: 0.7 cm at 9 o'clock, 2 cm at 10-11 o'clock, 1 cm at 12 o'clock and 1.2 cm at 3 o'clock. In an interview on 01/06/17 at 4:25 PM, Staff G, LN stated Resident 14 had a pressure ulcer on her coccyx that came on quickly. At 4:45 PM, Resident 14's coccyx wound was observed with Staff G and Staff H, Nursing Assistant (NA). The resident was lying on her right side. Staff G removed the wound packing. The peri-wound was intact and red. The wound was approximately the size of a half dollar, very deep and had a thick brown covering most of the wound bed. At 4:53 PM, Staff I, stated Resident 14's wound started out as MASD. Staff I stated the resident had a prior pressure ulcer in the same location, which also placed her at risk for re-developing a pressure ulcer. Staff I was not able to provide any information regarding when the resident developed MASD, what interventions were put in place or when the resident's prior pressure ulcer healed. In an interview on 01/17/17 at 10:05 AM, the Director of Nursing Services was asked to provide additional information regarding when the resident developed the MASD, when she had a prior coccyx pressure ulcer and any additional information regarding the development and deterioration of Resident 14's pressure ulcer. The facility failed to identify, treat and implement necessary care and services to prevent Resident 14 who was identified at high risk for skin breakdown from developing a stage III coccyx pressure ulcer. The facility failed to treat the resident's pressure ulcer when first discovered on 11/24/16. The resident went one week with no documented treatment. Additionally, the facility failed to assess the resident's wound for three weeks and the resident experienced a significant decline in the pressure ulcer causing harm to Resident 14. RESIDENT 9 Resident 9 was admitted to the facility in November 1, 2016 with [DIAGNOSES REDACTED]. Review of the resident's MDS dated [DATE] and 11/13/16 revealed the resident did not have any resolved pressure ulcers, was at risk of skin breakdown, required extensive assistance of 2 persons for bed mobility and toileting, with occasional incontinence of bowel and was frequently incontinence of bladder. Review of the resident's MDS dated [DATE] revealed the resident's incontinence changed to frequently incontinent of bowel and occasionally incontinent of bladder. Subsequent MDS's dated 12/25/16 and 12/27/16 revealed the resident became frequently incontinent of both bowel and bladder. In a progress note dated 11/1/16, the day of admit, the Director of Nursing (DNS) documented the resident was admitted with a pressure ulcer to the coccyx area, there was no description of the wound or measurements, but there was a treatment ordered for the pressure ulcer that included cleansing of the wound and a dressing change. The resident's Initial Interim Care Plan dated 11/01/16, revealed the resident had a break in skin integrity related to an abrasion, a surgical wound and a pressure ulcer. There was no mention of Moisture Associated Skin Damage (MASD). The resident's Electronic Care Plan dated 11/01/16, revealed the resident had impaired skin integrity with MASD to the resident's buttocks (documented in an admission note was a pressure ulcer but not documented on the Electronic Care Plan.) The two care plans, created on the same day, that did not reflect the same problems nor the same interventions. physician's orders [REDACTED].) Treatment records for November and December of 2016 showed that the [MEDICATION NAME] dressing change to the Saccrococcyx wound was changed 22 times during both months. During all 22 dressing changes there was no documentation in the progress notes of the condition of the skin. The facility was using multiple different forms to track skin issues: Non pressure Skin condition sheets / Weekly Skin integrity data collection / Pressure Ulcer Status record and excel wound tracking sheets. The documentation on the multiple forms showed: On 11/2/16, documentation showed that on two Non pressure Skin condition sheets one his buttocks there was MASD and it that measured 1.4 x 1 x .2 in depth. On a second sheet the same area was identified, but identified the area as measuring 6 x 8 and identified it also was MASD. On 11/9/16 and 11/10/16, documentation on a Non pressure Skin condition sheet showed that on his buttocks the area measured 5 x 7 and there was no depth. On 11/16/16, documented on a wound tracking sheet, indicated the area measured 5. x 7., and it was red and blanched. The treatment was: Skin prep and a thin duoderm (MD orders indicated [MEDICATION NAME] dressing) (The skin sheet dated the same day, 11/16/16, indicated the area was resolved.) On 11/25/16, documentation on a wound tracking sheet and a non-pressure skin condition sheet, indicated his buttock had a red area of 4.8 x 6.5., was red and blanched. The treatment was: Skin prep and a thin duoderm and change every 48 hours. (The skin sheet dated 11/24/16 showed the same information) On 12/1/16, documentation on a wound tracking sheet, his indicated the buttock had an area measuring 4.8 x 6.3., with a description of [MEDICATION NAME], granulated, red and blanches. The treatment remained the same: Skin prep and a thin duoderm every 48 hours. On 12/8/16, documentation on a wound tracking sheet, indicated his buttock had an area of 1.4 x 1.0 x .2 depth with a description of [MEDICATION NAME], moist, pink and now had scant, serous drainage. The treatment remained the same: Skin prep and a thin duoderm every 48 hours. (the skin sheet had the same information on this date) On 12/14/16, the skin sheet identified the area as being a Stage 3 pressure ulcer even though it had 100% necrotic / Slough, which indicates unstageable. An updated electronic care plan dated 12/14/16 revealed the resident had developed a stage III pressure ulcer to the coccyx related to the resident's immobility, incontinence, nutritional status and disease all of which had been identified on the resident's admission MDS. The goal was to exhibit signs of healing with added interventions to reposition the resident every 2 hours while in bed and every 1 hour while up in a chair, assist the resident up last for meals and first to bed after meals and now provide pressure relieving or reduction device with a pressure reduction mattress and chair cushion. Review of the resident's Pressure Ulcer Status Record sheet revealed the following: On 12/14/16, the resident had a 1.3 cm by 0.7 cm by 0.2 cm deep, stage III pressure injury with 100% slough (a wound bed with 100% slough would indicate a wound bed was unable to be visualized). On 12/19/16, the area was then described as being on his coccyx and was documented as an in house stage 3 sheet, that measured 1.0 x .3 x .1 depth and it had pink, granulation and had no drainage. The treatment had now changed and there was a pressure relieve cushion in the wheel chair, and a [MEDICATION NAME] dressing was being applied every 48 hours. By 12/27/16 the skin sheet indicated the area was measured as being 1.7 x 1.8 and no depth but was yellow in color with slough and it had deteriorated. On 1/5/17 on a weekly skin integrity report the area was described as being MASD to the coccyx and had no description or measurements. On 1/6/17 the skin sheet had the area at 1.7 x 1.8, there was no description of the wound and no LN signature. On the same day, 1/6/17 on the back of the skin sheet for the same area measured .25 x .25 with no depth or drainage and described as [MEDICATION NAME] and granular. In an interview on 01/06/17 at 12:40 pm, Staff B stated today, the resident discharged and the pressure ulcer measured .25 by .25 even though it was documented the wound was resolved. Staff B stated she did not document that, Staff M did. In an interview on 01/06/17 at 2:59 PM Staff M, LN, Residential Care Manager stated, The resident's wound care goal was for healing, the resident is going home. In an interview on 01/06/17 at 2:59 PM Staff M, LN, RCM stated, the wound was resolved A pressure relieving wheel chair cushion was initiated on 12/14/16 and an air mattress was ordered on [DATE] but it never came in. In an interview on 01/06/17 at 4:30 PM Staff L, PT stated, Therapy had changed out the resident's standard wheelchair cushion to a matrix ridged wound care cushion, but was uncertain of the exact date. The facility identified the resident to be a risk for skin breakdown, had an actual pressure ulcer on admit, failed to implement pressure reducing devices for the bed and chair prior to the development of a stage III skin injury.

Based on interview and record review, the facility failed to assess and/or monitor hydration status for 1 of 1 resident's (1) reviewed for fluid status. Failure to monitor, document, assess and care plan for hydration status resulted in harm for Resident 1 who developed severe dehydration and a decrease in kidney function. Findings include: Review of the facility's Hydration policy stated the facility had a process in place to identify residents at risk for fluid deficit and to ensure each resident received adequate assistance. The policy directed staff to offer resident's fluids three times a day. Each shift provided the resident with fresh water which was kept in a pitcher at the resident's bedside unless it was contraindicated. The policy identified clinical symptoms of dehydration included: decrease in blood pressure and an increase in blood urea nitrogen (BUN) and creatinine laboratory (lab) level. According to the State Operations Manual, Appendix PP, stated a general guideline for determining a resident's baseline daily fluids needs was to multiply the resident's body weight in kilograms times 30 cubic centimeters (cc). Resident 1 was admitted to the facility January 2016 with [DIAGNOSES REDACTED]. On 12/26/16, Resident 1 weighed 156 pounds. The estimated fluid intake was 2,130 cc's a day. There was no dehydration/hydration care plan in place. Review of a physician faxed order dated 09/17/16, directed staff to increase the resident fluids due to a low blood pressure. Review of a laboratory (lab) report dated 09/22/16, revealed the resident's BUN was 41 (normal was 7-25) and creatinine was 1.8 (normal was 0.4-1.4). Review of a physician order [REDACTED]. This was the second time the physician directed the staff to increase the resident's fluid intake. Review of the September Medication Administration Record [REDACTED]. The Licensed Nurse (LN) placed their initials on 09/22/16 indicating this was done. There was no evidence how much fluid was offered or what the resident drank. There was no further documentation on the MAR indicated [REDACTED]. Review of the October MAR indicated [REDACTED]. There was only one day out of thirty-one the resident's fluid intake was over 1,000 cc's. The resident's intake was 600 cc's to 940 cc's daily. Review of a lab report dated 11/24/16 revealed the resident's BUN was 61 and creatinine was 2.0, which had increased. Review of a telephone order dated 11/25/16, again directed staff to encourage fluids every shift. Review of a lab report dated 12/05/16, 12/08/16 and 12/16/16 revealed the resident had an elevated BUN and creatinine level. On 12/21/16, the physician documented the resident . continues to be very dehydrated . The physician stated the resident was not drinking enough fluids, wanted to know how much fluids the resident received and if the resident should be started on intravenous hydration. The LN responded to the physician that the resident would not tolerate intravenous fluids due to her dementia and .resident will drink but staff must be more consistent with offers and encouragement . The LN did not assess and report to the physician her average daily intake. On 12/27/16, the resident had an elevated BUN (57) and creatinine (1.9). The physician documented on the lab report worsening dehydration. Review of the November 1st to January 8th MAR indicated [REDACTED]. There was no additional evidence in the resident's medical record documenting the resident's fluid intake or what the facility was doing to improve the resident's hydration status. In an observation on 12/30/16 at 12:20 PM, Resident 1 was offered chocolate milk and coffee. Resident 1 was able to access the fluid independently. In multiple observations on 01/06/17 at 9:15 AM, 11:15 AM, 2:30 PM and 4:00 PM, Resident 1 was observed to by lying in bed. There were no fluids available at the resident's bedside. In an interview on 01/06/17 at 11:33 AM, Staff B, LN, stated Resident 1 drinks well when offered fluids. At 4:03 PM, Staff D, Nursing Assistant (NA), stated each hall had a hydration cart available. The NA was responsible to pass out fluids at the beginning of their shift. Staff D usually did this between 2:00 PM and 3:00 PM. At 4:10 PM, Staff E, NA, stated fluids were offered to the each resident every shift. There was a hydration cart available and staff offered resident's their choice of fluids. Staff E stated the LN directed the NA to encourage fluids with Resident 1. Staff E was made aware there were no fluids available at Resident 1's bedside. Review of a lab report dated 01/09/17 revealed the resident's BUN was 37 and creatinine was 1.5. The physician documented on the lab report Kidney function has really improved a lot! Patient is now only mildly dehydrated. Continued to encourage lots of fluids . Review of a physician order [REDACTED]. The LN was to document the amount accepted every shift. There was no evidence how much fluids the resident consumed with meals to accurately reflect the resident's total fluid intake. In multiple observations on 01/17/17 at 9:45 AM, 9:55 AM, 10:30 AM, 10:32 AM, 11:14 AM and 11:32 AM Resident 1 was observed to have no fluids offered or available to her in her room or in the dining room. At 12:32 PM, the Director of Nursing Services and facility Administrator were made aware of the above observations. Resident 1 had clinical signs of dehydration and the physician had written orders directing staff to increase her fluid intake. The facility failed to monitor, document, assess and implement interventions to prevent dehydration or correct the resident's dehydration.

Based on interview and record review the facility failed to ensure a system was in place that ensured prompt efforts to resolve resident grievances for complaints from residents concerning nursing assistant availability and delayed call light response from staff for 4 of 4 residents interviewed (7, 23, 24 & 25) and one resident who verbalized lack of care (11). Failure to resolve grievances in a timely manner diminished resident's quality of life by not having a reliable system for answering their on-going concerns and needs. This further would cause the reasonable person psychosocial harm for not having the security that there was adequate nursing staff to respond to call lights for their immediate needs Findings include: The facility policy for the Concern and Comment Program indicated residents and families feel that staff have responded timely and with respect to reported concerns. The facility received four Concern and Comment forms from Residents 7, 11, 23 and 24, related to call light response time and about the residents not receiving their care and services. One concern was verbalized during an investigation. RESIDENT 7 Review of a Concern and Comment form, dated 03/17/16, revealed Resident 7 stated he had put the call light on at 3:15 AM because he had to use the bathroom. The resident was incontinent of urine and .laid in it til 0415 ., one hour. The grievance was not investigated. In an interview on 04/07/16 at 11:10 AM, Resident 7 confirmed and able to recall the incident on 03/17/16. In an interview on 04/08/16 at 3:00 PM, the Administrator found the Concern and Comment form in the former Administrator's office. The allegation of neglect was not investigated or responded to. RESIDENT 11 Review of a facility investigation, dated 03/12/16, revealed the resident had an unwitnessed fall in the bathroom. The resident was interviewed at the time of the fall. The LN documented the resident was in the bathroom and put his call light on for assistance. The resident waited for 15 minutes and when no one came, he tried to pull his pants up and he fell . The facility did not respond to the grievance by investigating why his call light was not answered in a timely manner or respond back to the resident. RESIDENT 23 On 02/07/16 at 4:29 PM, Resident 23 emailed the former Administrator stating on 02/05/16 he was left on the commode for 45 minutes before someone responded to the call light. The resident stated the commode . seat becomes very uncomfortable and legs become cramped and fall asleep after 10 minutes . On 02/06/16, Resident 23 stated he defecated in his bed, had to lay in excrement for 15 minutes before someone had helped him. The grievance was not investigated and no one followed up with the resident. In an interview on 04/07/16 at 11:15 AM, Resident 23 was able to recall the above incident. The resident stated he was incontinent of bowel and laid in it for 15 minutes before someone had finally answered his call light. RESIDENT 24 Review of a Concern and Comment form, dated 02/03/16, revealed Resident 24 stated she turned her call light on at 5:30 PM and received help at 6:45 PM. The resident stated she was incontinent of urine. The grievance was not investigated. In an interview on 04/07/16 at 11:30 AM, the resident was observed in her room. Resident 24 confirmed the incident on 02/03/16 had occurred. RESIDENT 25 Review of a Comment and Concern form, dated 02/12/16, revealed Resident 25 reported that an NA was very rude to her and the resident did not want the NA to provide care to her. The facility had the Lead NA interview the resident. The facility's findings were, the resident did not share specifics or give a specific example. The Resident was assured the NA would not care for her. The facility's Administrator, Director of Nursing Services (DNS), Charge Nurse or Social Services did not interview the resident. The facility failed to ensure the allegation of potential verbal abuse and/or neglect was thoroughly investigated.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided in a manner which enhanced and maintained resident dignity and feelings of self-worth by ensuring 5 of 5 residents (23, 7, 24, 11 and 25) who did not have their care concerns/needs addressed in a timely manner. This caused harm to Residents 23, 7, and 24 who experienced incontinent of bowel and/or bladder episodes, Resident 11 who laid on the floor for 15 minutes and resident 25 who was spoken to rudely. All five residents experienced diminished quality of life related to the failures and placed all residents at risk for diminished self-worth and quality of life. Findings include: RESIDENT 23 Resident 23 was a long term care resident with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment, dated 03/28/16, the resident required extensive assistance of one person for transfers and toileting and had no cognitive impairment. The resident was continent of his bowel and bladder. On 02/07/16 at 4:29 PM, Resident 23 emailed the former Administrator stating on 02/05/16 he was left on the commode for 45 minutes before someone responded to the call light. The resident stated the commode . seat becomes very uncomfortable and legs become cramped and fall asleep after 10 minutes . On 02/06/16, Resident 23 stated he defecated in his bed, had to lay in excrement for 15 minutes before someone had helped him. In an interview on 04/07/16 at 11:15 AM, Resident 23 still recalled the above incident and how upset he was. The resident stated he was incontinent of bowel and laid in it for 15 minutes before someone had finally answered his call light. The resident stated he was left on the bedside commode for 45 minutes. His light was on and waited for assistance. He stated that this was very uncomfortable for him, his legs were cramped and they fell asleep. The resident also stated during this time his bed was not working. The bed would malfunction and he would lie in bed with the lower part of the bed in the upright position and the head of the bed in the downward position. His call light was left out of reach and he could not call for help. This went on for four days. RESIDENT 7 Resident 7 was a admitted in February 2016. According to the MDS assessment, dated 03/04/16, the resident required extensive assistance of one for transfer and toileting. Resident 7 was able to make his needs known and was continent of bowel and bladder. Review of a Concern and Comment form, dated 03/17/16, revealed Resident 7 stated he had put the call light on at 3:15 AM because he had to use the bathroom. The resident was incontinent of urine and .laid in it til 0415 . In an interview on 04/07/16 at 11:10 AM, Resident 7 stated a staff member had come in to help him but left and never came back. Resident 7 said he peed and laid in it for over an hour. Resident 7 felt there was not enough staff available RESIDENT 24 Resident 24 was a long term care resident with [DIAGNOSES REDACTED]. According to the MDS assessment, dated 03/24/16, the resident had no cognitive impairment and required extensive assistance of one person for transfers and toileting. The resident was frequently incontinent of urine and was not on a toileting plan. Review of a Concern and Comment form, dated 02/03/16, revealed Resident 24 had a concern that her call light was on for 1 hour and 15 minutes and she received no help. The resident stated she was incontinent of urine because she had to wait. In an interview on 04/07/16 at 8:50 AM, Resident 24 stated there were staffing issues around meal times. The resident stated the Nursing Assistants' (NA) had to be in the dining room at meal times and there was less staff on the floor to help. Resident 24 stated there was an incident recently where she had her call light on and ended up being incontinent of urine. The resident stated this was upsetting to her At 11:30 AM, the resident confirmed the above incident occurred on 02/03/16. RESIDENT 11 Resident 11 was admitted [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment, dated 03/31/16, Resident 11 was independent in decision making skills, was frequently incontinent of bladder and required limited assistance of one person for transfers and toileting needs. On 03/12/16 the resident had an unwitnessed fall in the bathroom. Review of the medical record revealed Resident 11 lost his balance trying to pull up his pants after he used the bathroom. The resident's bathroom (emergency) light was on. Resident 11 stated he laid on the floor for 15 minutes and received no response from staff. The resident transferred him off the floor and reported the fall to staff. The LN documented .(the resident) did complain of stump pain, where he said he had hit the stump on the floor was given [MEDICATION NAME] for pain . Review of the investigation conclusion, dated 04/04/16, stated after waiting for 15 minutes (on the floor) and hearing voices in the hallway the resident was inpatient and just wanted to go back to his room. The facility educated that only facility staff could help him transfer. The facility did not address the fact the resident laid on the floor for 15 minutes with the bathroom emergency light on and no one responded. RESIDENT 25 Resident 25 admitted to the facility in January 2015. According to the MDS assessment, dated 01/2016, the resident had no cognitive impairment and was able to make her needs known. Review of a Comment and Concern form, dated 02/12/16, revealed Resident 25 reported that an NA was very rude to her and the resident did not want the NA to provide care to her. The facility's Administrator, Director of Nursing Services (DNS), Charge Nurse or Social Services did not interview the resident. The facility failed to ensure the allegation of potential verbal abuse and/or neglect was thoroughly investigated. A joint interview was done on 04/08/16 at 11:37 AM with the Director of Nursing Service (DNS) and Administrator. The Administrator was not aware Residents 7, 23, 24 and 25 made grievances as he was not the facility Administrator when the grievances were made. The Administrator and DNS were not able to provide any further information.

Based on interview and record review the facility failed to ensure thorough nursing assessments were completed or analyzed to identify the severity of problems affecting 1 of 3 residents (1). This resulted in Resident 1 being sent to the hospital for critical lab values, a pressure ulcer and poor catheter care and a systemic infection. In addition, the facility failed to timely consult with the physician when Resident 1's pain was unmanageable. This failure resulted in harm of a resident being in constant pain and the development of a pressure ulcer. Findings Include: According to the American Nurses Association, Scope and Standards of Practice, 2011, A licensed nurse shall in a complete, accurate and timely manner report and document nursing assessments or observations, the care provided by the nurse to the client, and the client's response to that care. Nurses assume liability risk if they fail to monitor a patient or recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. RESIDENT 1 Resident 1 was admitted in January 20, 2016 with [DIAGNOSES REDACTED]. The Resident was care planned to be repositioned in bed every 2 hours. The Resident was identified as at risk for pressure ulcers and was placed on aggressive prevention interventions. Interviews and record review revealed the resident could not participate in care or therapies. One request to the physician dated 01/25/16 reported the resident has not been out of bed at all. Interviews with Hospital Staff revealed the resident presented with a pressure ulcer of a Deep Tissue Injury measuring 20 x 15 centimeters (cm). The physician documented the pressure ulcer was present on admit. The Social Work Manager reported she could not find paperwork from the facility identifying the wound. The medical staff had grave concerns regarding the Resident's care because she presented with a kidney infection as well as a pressure ulcer. Documents from the facility revealed the Nursing Assistants were unable to move the resident and charted she was turned twice in six days. The care plan directed staff to turn the Resident every two hours. Some progress notes stated the resident was out of bed in a chair where other documentation contradicted those statements and reported the Resident was in such pain care was difficult to provide. The Resident had a catheter and records revealed she had one bowel movement in six days. While a skin assessment was completed upon admission to the facility, there was no further documentation in the progress notes of skin assessments or monitoring, despite the identified risk for pressure ulcers due to her pain, immobility, weight and comorbidities. Refer to F 309 (CFR 483.25) Refer to F 314 (CFR 483.25(c)

Based on interview and record review, the facility failed to ensure 1 of 3 sample residents with skin at risk (1) received consistent treatment and services to prevent development of pressure ulcers. Failure to ensure consistent assessment and positioning resulted in harm for the resident due to the development of an avoidable Deep Tissue Injury (DTI) to the sacral area measuring 20 x 15 centimeters (cm) noted upon admission to the hospital. The Resident required 2 surgeries to date and remained hospitalized from complications of the DTI. Findings Include: The Facility's Pressure Ulcer Prevention Policy, dated 02/25/15, stated at the time of admission, each patient was evaluated for special needs related to skin care. Additionally, all patients receive a weekly skin integrity check performed by licensed personnel. Ulcers that are present, or which develop after admission, are treated according to medical orders. A Deep Tissue Injury is defined in the Resident Assessment Instrument (RAI) as a purple or maroon area of discolored skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent skin. Deep Tissue Injuries may sometimes indicate severe damage. Suspected Deep Tissue Injury may precede the development of a Stage 3 or 4 pressure ulcer even with optimal treatment. RESIDENT 1 Resident 1 admitted to the facility in January 20, 2016 with [DIAGNOSES REDACTED]. The Resident admitted to the facility after a hospitalization for back pain. The Resident was being followed by a Neurosurgeon. The Resident's back pain was managed with multiple medications and pain patches. A skin assessment dated [DATE] noted the only skin issues present were bruises on the resident's arms from the previous hospitalization . A Braden Scale for Predicting Pressure Sore Risk was completed on 01/21/16. It was determined with a total score of 16, the resident was at risk to develop a pressure sore. Based on this score, a Pressure Ulcer Prevention Checklist was completed on 01/22/16. Per the Checklist the resident was to be placed on aggressive prevention interventions. The checklist noted a preventative mattress was ordered on [DATE], scheduled time out of bed was as therapy progresses. Weekly skin assessments per protocol. Licensed staff did not sign the checklist. The Resident's Interim Care Plan identified the resident with Recent Intractable Back Pain, chronic pain, left shoulder pain, strain, bursitis. The goal was for the Resident's pain to be controlled to allow participation in therapies. The interventions were monitor pain intensity following medication or treatment and to reassess pain management effectiveness every shift. The care plan also identified the resident was at risk for falls related to lower extremity weakness. Interventions included assist of 2-3 for transfers and provide assistive for bed mobility, transfers or ambulation, weight bearing 1-2 person assist. The Resident's Interim Care Plan also identified the resident was at risk for break in skin integrity related to pain. Interventions were to educate resident/family on skin care and position changes. Reposition every 2 hours in bed and reposition every 2 hours in chair. Schedule time out of bed as tolerated, weekly skin checks and therapy consult. The goal being the resident will be free of skin breakdown. An Elder Mobility Scale was in the record without a date or a name for the staff member who completed it. Staff indicated the resident scored zeros and staff wrote Unable for all categories The Resident was unable to move from a lying to a sitting position, sitting to lying, sit to stand, standing, gait, timed walk and functional reach. A faxed request to the physician dated 01/25/16 stated Resident has an appointment on Thursday 28th. She is very sedated, uses lots of meds and still cries out with movement, does not get up, would have to go via stretcher and could not be transferred for exam. Could you please see her today and eval to see if this visit would truly be beneficial for resident. She is not doing therapy, not been out of bed at all. In an interview on 02/08/16 at 12:30 P.M., Staff A, Physical Therapy Assistant, stated both therapists would approach the resident together with 1 to 2 other staff and attempted to move the Resident but could not. We wanted to try e-stim but we could not turn her enough to assess skin on her back to place the patches for the treatment. It took two of us to hold her up and to move the bed controls and then we would physically move her very slowly. She did not like the bed to move because it jerked and hurt her back. Staff A stated the Resident was unable to participate in therapies because of her pain. In an interview on 02/08/16 at 1:50 PM, Staff B, Therapy Assistant, stated Resident 1 was always in a lot of pain. Therapy was attempting to use different modalities of pain interventions to assist with her pain. Staff B stated it would take three staff members, two who were skilled therapist, to perform bed mobility. The resident was in so much pain she would not want you to use the bed controller to adjust the head of the bed up. The therapist would have to physically lift the top half of the resident while in bed, hold her in that position and use the bed controller to move the head of bed up to the same position of the resident. Staff B stated they attempted to work with Licensed Nurse's (LN) on pre-medicating prior to the therapy appointment but it did not work. Staff B stated he was never able to transfer the resident out of bed, turn her onto her side, or place [MEDICATION NAME] on her lower back related to severe pain. At 1:55 PM, Staff C, Nursing Assistant (NA) stated the resident was always in a lot of pain. She would report to the LN when the resident had any complaints of pain. At 2:00 P.M., Staff D, NA, stated she worked with the resident for 4 days since her admission. I would check on her all the time because she was in so much pain. I couldn't do much for her because she was in so much pain. I would tuck a pillow underneath her trying to get her to turn just a little, but it barely moved her. I could not reposition her every two hours like other residents. I think she only had one bowel movement when she was here because of all the medications she was taking, so we did not need to change her very often. On 02/19/16 at 9:15 A.M., Staff E, LN, stated the resident would scream in pain when staff attempted to move her. It was difficult to reposition her she moved very little, not out of bed much. She would do therapy in bed like moving her arms but that was it. She came in to us in not good condition. I gave her a suppository on the 01/24/16 and did not noticed anything on her back/buttocks area. The Resident would sit up in bed at about a 45 degree angle not a complete 90 degrees. We would try to reposition her but she would not turn to take the pressure off her back completely, she was noncompliant with turning. It would take several of the staff to try to turn her. Even with pain pills her pain would continue. The aides would let me know if they saw anything on her skin and if she did not eat or drink. Resident 1 admitted to the hospital on [DATE] at 5:55 P.M. for critical labs. The physician's orders [REDACTED]. The physician's note from the Hospital dated 01/27/16 stated the resident admitted to the emergency room for severe back pain, acute [MEDICAL CONDITION] (high potassium) of 7.7 (normal values 3.5 - 5.5), and acute kidney injury. The acute [MEDICAL CONDITION] is suggestive of hypovolemia (low volume) possibly secondary to [MEDICAL CONDITION] (kidney infection). The patient is extremely thirsty and membranes are dry. A urinalysis is positive for bacteria. The note also identified the resident [MEDICAL CONDITION] (systemic infection) secondary to Urinary Tract Infection versus [MEDICAL CONDITION]- bad hygiene around foley catheter, will discontinue, clean, and place a new foley. In addition the patient had a skin ulcer on buttocks- present on admission, clean area, and turn q (every) 2 hours, wound care consulted. A hospital nursing progress note dated 01/27/16 at 4:00 A.M., stated the resident came in with catheter looking old, moderate mucous strands in tubing. Wound found on pt gluteal cleft and sacrum with skin sloughing off and moderate sanguineous drainage. Ulcer Protocol initiated. In an interview on 02/04/16 at 3:30 P.M., the hospital Social Work Manager stated when the patient arrived at the hospital the medical staff had grave concerns about her catheter care and the large wound noted in the Emergency Department. She stated no paperwork accompanied the resident from the Nursing Home in regards to this skin issue. We gave the facility a courtesy call to inform them of our concerns. We took a picture of the wound and staff felt there is just no way that was not identified prior to admission. We now have surgery involved because of the extent of the wound. In an interview on 02/05/16 at 8:20 A.M., the hospital Wound Care Nurse stated she was consulted because the hospital staff found a wound on the resident. I saw the wound and took pictures the first time I assessed the resident. She was screaming in pain and would hold onto the side rails to try to stop us from moving her on her side. In my professional opinion, due to the extent of the wound there is no possible way she did not have this issue at the Nursing Home. She was very high risk and if she was allowed to keep constant pressure by lying on her back which caused ischemia (loss of blood flow) to her sacrum/buttocks. She was not able to reposition herself or be repositioned by staff related to her pain. She did not get a wound to this extent lying in the emergency room this is much too extensive. This wound is not from Trauma of any kind. As my notes state the wound was 20 x 15 cm of dark purple skin, suspected a Deep Tissue Injury Pressure Ulcer with areas of skin sloughing. It was later noted to be nonstageable because there is now odor and leathery eschar, tissue death. This wound is progressing to the entire sacral area and extending further onto the buttocks. Surgical consults have been started to see if surgical debridement is an option. We are looking at tissue damage to the bone. This is a result of not repositioning or off loading, the weight of the patient and her comorbidities. In an interview on 02/17/16 at 8:40 A.M., the hospital Wound Care Nurse stated the resident was on her second surgery and has a large wound on her buttocks. She is not eating and has malnutrition issues which will effect healing of the wound. The Facility Investigation dated 01/29/16 stated direct care staff were interviewed and at no time was there any notation of any redness or disruption of skin. They report small shifts in position and positioning with pillows when the resident could not tolerate a full position change. Resident had one BM (bowel movement) here after receiving a suppository per facility bowel protocol. The Summary noted Resident was complaining of back pain and her pain was well managed per MD's order. Repositioned every two hours and as needed per standard of care. When up in wheelchair and was on PT/OT case load working towards regaining prior level of functioning and maintaining muscle strength. Skin check was due on 01/27/16. Resident was transported to the hospital via stretcher which could have contributed to the development of a deep tissue injury given the resident's condition was deteriorating r/t [MEDICAL CONDITIONS], and immobility, hence decreased tissue perfusion. In an interview on 02/08/16 at 2:45 PM, the Director of Nursing Services (DNS) stated the resident was sedated by the pain medications but would still scream with movement. The DNS was made aware of the lack of charting in regards to turning the resident as per the documentation. The DNS acknowledged the expectation was the staff should document the care they provided the resident and if they could not turn the resident they needed to tell the nurse on the floor. The Licensed Staff then would need to take action and assess the issue. All daily assessments of residents were expected to be charted. Interviews with both physical and occupational therapists revealed the resident was unable to participate in therapy sessions because of pain. Staff reported the resident was in constant pain and was unable to be repositioned every two hours related to pain. The resident was identified to be at risk for skin breakdown. Documentation noted the resident was not turned and skin conditions were not documented in the progress notes. The physician documented the wound was present on admit to the hospital. Refer to F 281 (CFR483.20(k)(3)(i)

Based on interview and record review, the facility failed to consistently identify, evaluate, and act timely on condition changes for 1 of 3 sample residents (1). This failure placed Resident 1 at risk for delayed evaluation and treatment with further deterioration in status. Findings inlcude: According to the facility's Pain Management Protocol, the goal was to control/manage the pain a resident may experience due to any disease process or an identified cause. The protocol included the following: - Pain assessment was done on admission, quarterly and with a change in status; - Care plan would address the resident's individualized needs for pain management; - Licensed Nurse (LN) will monitor and document the effectiveness of the pain management program in the resident's medical record. The facility's pain flow sheet directed the LN to document the date, time, location, type, and intensity of pain, aggravating factors, non-medication interventions, medication given and side effects. Furthermore, the LN was to check the resident's pain level after the medication was given at 15 minutes, 30 minutes, 1 hour and 3 hours. RESIDENT 1 Resident 1 admitted to the facility in January 20, 2016 with [DIAGNOSES REDACTED]. The Resident had a new onset of back pain in the last few weeks which resulted in difficulty walking. The Resident had a Urinary Catheter in place from the previous hospitalization . The Resident's Interim Care Plan identified Recent Intractable Back Pain, chronic pain, left shoulder pain, strain and bursisits. The goal was the Resident's pain would be controlled to allow participation in therapies. An intervention was to monitor pain intensity following medication or treatment. Another goal was to reassess pain management effectiveness every shift. In an interview on 02/08/16 at 12:30 P.M., Staff A, Physical Therapy Assistant, stated both therapists would go in together with 1 to 2 other staff and attempt to move the Resident and could not. We wanted to try e-stim but we could not turn her enough to assess skin on her back to place the patches for the treatment. It took two of us to hold her up and to move the bed controls and then we would physically move her very slowly. She did not like the bed to move because it jerked and hurt her back. One day she said she felt good because her pain was 7 out of 10 (0 to 10 pain scale). I thought that was a strange statement since most of us consider 7 to be pretty bad pain, she was always around a 9 out 10 on her pain. Staff A stated the Resident was unable to participate in therapies because of her pain. In an interview on 02/08/16 at 1:50 PM, Staff B, Therapy Assistant, stated Resident 1 was always in a lot of pain. Therapy attempted to use different modalities of pain interventions to assist with her pain. Staff B stated it would take 3 staff members, two who were skilled therapists, to perform bed mobility. The resident was in so much pain she would not want you to use the bed controller to adjust the head of the bed up. The therapist would have to physically lift the top half of the resident while in bed, hold her in that position and use the bed controller to move the head of bed up to the same position of the resident. Staff B stated the therapists attempted to work with Licensed Nurses (LN) on pre-medicating prior to the therapy appointment but it did not work. Staff B stated he was never able to transfer the resident out of bed, turn her onto her side, or place [MEDICATION NAME] on her lower back related to severe pain. Both Occupational and Physical therapists documented the Resident's inability to participate in therapies related to her pain. At 1:55 PM, Staff C, Nursing Assistant (NA), stated the resident was always in a lot of pain. She would report to the LN when the resident had any complaints of pain. At 2:00 P.M., Staff D, NA, stated she worked with the resident for 4 days since she came to the facility. She was always in pain and would beg me to be sent back to the hospital because the pain medication was not working. I would tell the nurse and she would go in and talk with the resident. I would check on her all the time because she was in so much pain. I couldn't do much for her because she was in so much pain. I would tuck a pillow underneath her trying to get her to turn just a little, but it barely moved her. I could not reposition her every two hours like other residents. She would hide her bed remote in her shirt so we could not move the bed. She felt like it jerked her and caused more pain. I think she only had one bowel movement when she was here because of all the medications she was taking, so we did not need to change her very often. We needed at least 4 people to move her because of her pain. When I came back to work I heard she was at the hospital, hopefully they can help her with her pain. On 02/19/16 at 9:15 A.M., Staff E, Licensed Nurse (LN), stated the resident would scream in pain when staff attempted to move her. It was difficult to reposition her she moved very little, not out of bed much. She would do therapy in bed like moving her arms but that was it. She came in to us in not good condition. I gave her a suppository on the 01/24/16 and did not notice anything on her back/buttocks area. The Resident would sit up in bed at about a 45 degree angle not a complete 90 degrees. We would try to resposition her but she would not turn to take the pressure off her back completely, she was noncompliant with turning. It would take several of the staff to try to turn her. Even with pain pills her pain would continue. The aides would let me know she did not eat or drink much, she needed to be encouraged to eat. The aides would also let me know if she had any skin issues. The Pain Flow Sheet dated from 01/21/16 to 01/25/16 noted back pain as aching with the current intensity as high as 8 and not lower than 6 out of 10. The precipitating factor was chronic and the non-medication intervention was positioning. The Intensity of Pain after intervention was not consistently documented for pain relief of 1 to 3 hours after medications were administered nor were side effects monitored. The form was missing initials of the Licensed Staff who gave the medication and who were to monitor the effectiveness of the pain medication. The Behavior Intervention Flowsheet was not filled out properly for all shifts to monitor the resident for the behavior of anxiety. A physician's orders [REDACTED]. She is very sedated, uses lots of meds and still cries out with movement, does not get up, would have to go via stretcher and could not be transferred for exam. Could you please see her today and eval to see if this visit would truly be beneficial for resident. She is not doing therapy, not been out of bed at all. A review of the Rita Report, Nursing Assistants documentation program, for this resident revealed the Resident had one bowel movement in 6 days. The every 2 hours turn schedule had 2 check marks, out of 6 days with 3 shifts per day. Both check marks were on night shift. A review of the progress notes revealed a note dated 01/26/16 at 1:27 P.M., In to see the resident for her care conference. Not feeling well enough to get out of bed due to the pain. Resident is on multiple pain medications and patches. She reports no pain if she is not attempting to move. However if therapy attempts to work with her during care that requires moving or turning, resident reports at least 6/10 pain. On observation, resident is very somnulent with neurological twitching noted all over her body and her fingers are busy she is fastening and unfastening her call bell, she is noted to have trouble controlling her motor movements-having her fingers and hands go where she wants them to. She attempts to cough but has difficulty getting enough effort behind the cough to make it effective. Staff E, LN, wrote a note on 01/26/16 at 2:02 P.M., that indicated the resident refused breakfast and ate only 50% of lunch, encouraged fluids. Held her [MEDICATION NAME] related to sleepiness. There was no mention of the recent change in condition. A physician's orders [REDACTED].M., stated to send the resident to the hospital as soon as possible for acute [MEDICAL CONDITIONS], and leukocytosis (elevated white blood cell count). Resident 1 was admitted to the hospital on [DATE] at 5:55 P.M. for critical labs. The physician's note from the Hospital, dated 01/27/16, stated the resident admitted to the emergency room for severe back pain, acute [MEDICAL CONDITION] (high potassium) of 7.7 (normal values 3.5 - 5.5), and acute kidney injury. The acute [MEDICAL CONDITION] is suggestive of hypovolemia (low volume) possibly secondary to [MEDICAL CONDITION] (kidney infection). The patient is extremely thirsty and membranes are dry. A urinalysis is positive for bacteria. The note also identified the resident [MEDICAL CONDITION] (systemic infection) secondary to Urinary Tract Infection versus [MEDICAL CONDITION], bad hygiene around foley catheter, will discontinue, clean, and place a new foley. In addition the patient had a skin ulcer on buttocks- present on admission, clean area, and turn q (every) 2 hours, wound care consulted. In an interview on 02/05/16 at 8:20 A.M., the Wound Care Nurse from the Hospital stated the Resident was sent to the emergency department because of three critical labs, not due to pain or because she was and confused. When I saw her she would just look at you and scream in pain but was unable to tell you where her pain was located. She would hold onto the side rails so we could not turn her on her side. I also assessed her for a large pressure ulcer on her sacrum/buttocks. No paperwork accompanied the Resident from the Nursing Home in regards to this skin issue. In my professional opinion, due to the extent of the wound there is no possible way she did not have this issue at the Nursing Home. She was very high risk and if she was allowed to keep constant pressure by lying on her back which caused ischemia (loss of blood flow) to her sacrum/buttocks. She was not able to reposition herself or be repositioned by staff related to her pain. In an interview on 02/08/16 at 2:35 PM, the facility's Director of Nursing Services (DNS) stated the resident was sedated by the pain medications but still screamed with movement. The facility added a [MEDICATION NAME] to the pain regimine, hoping that would help. The DNS was made aware of the incomplete charting by Licensed Staff to monitor the Resident's pain as per facility forms. The DNS reported the nurses should have documented the effectiveness of the pain medications consistently. The DNS was made aware of the lack of charting in regards to turning the resident as per the documentation. Again the expectation would be for staff to chart care given to the resident. Licensed Staff documented and reported the Resident continued to have pain to the point she would frequently not allow staff to reposition her. Documents from the Hospital Staff reported the resident arrived in severe pain. The lack of evaluation for effectiveness of pain medications for this individual resident resulted in the Resident experiencing continued back pain resulting in an inability to move without experiencing pain. As a consequence of the Resident's inability to move, she experienced a decline in skin condition and a decline in overall condition that required emergent hospitalization . RESIDENT 2 According to the facility's Behavioral Management policy, the LN was to assess possible causative factors for a resident's behaviors including assessing for pain. Resident 2, a former resident, admitted to the facility January 2016 with [DIAGNOSES REDACTED]. Review of the admission pain assessment revealed the resident was identified at risk for pain and had no pain present. Review of physician's orders [REDACTED]. Review of the January Medication Administration Record [REDACTED]. The resident received [MEDICATION NAME] 1 to 2 tablets 18 out of 21 days for mild to moderate pain. According to the pain flow sheet, the resident had chronic pain. The LN did not document how the resident responded to the pain medication 11 times and did not document why the pain medication was given twice (on 01/12/16 and 01/15/16). Review of nursing progress notes revealed the resident had significant behaviors. Even though the resident experienced chronic pain daily, the LN did not assess if the behaviors could have been pain related. In an interview on 02/08/16 at 2:35 PM, the DNS stated the LN was to assess the resident's pain every shift and document the results on the MAR. The DNS stated an expectation was the LN would assess a resident to ensure the behaviors were not pain related. When sked if the LN should have assessed the resident's daily pain and notified the physician for possible routine pain management, the DNS stated yes. Refer to F 281 (CFR 483.20(k)(3)(i)

Based on observations interview and record review, the facility's administration through its supervisory staff failed to ensure the facility effectively and efficiently attained, and/or maintained, each resident's optimal physical, mental and psychosocial well-being in the areas of dignity, supervision of residents who reside in a Secured Care Unit (SCU) and implemented the facility's abuse/neglect policy and procedure. This failure created the potential for harm for residents and placed all residents at risk for unmet needs and decreased quality of life. Findings include: 1. The Administration failed to ensure their abuse/neglect policy was implemented regarding the failure to identify, investigate and report potential abuse and/or neglect involving 8 residents. There was no evidence the facility had recognize abuse/neglect and implement policy and procedure as required placed all residents at increased risk for serious injury and psychological harm. Refer to CFR 483.13 ( c), F-226 - Develop/Implement Abuse/Neglect, etc. Policies 2. The Administration failed to promote care for cognitively impaired residents in a manner that was respectful and dignified for 15 of 27 residents who reside in the SCU by establishing schedules to wake residents up and provide showers and/or dressing and placed back to bed. Refer to CFR 483.15 (a), F 241 - Dignity 3. The Administration failed to ensure Nursing Assistance received 12 hour of in-servicing per year. Refer to CFR 483.75(e)(8), F-497 - Nurse Aide Perform Review - 12 Hr/Yr In-service The administrator is responsible for overall operation of the facility for compliance with regulations and to ensure residents received care and services that met their needs. The facility was at a substandard level of care that impacted quality of life for all residents. In an interview on 06/26/15 at 8:10 AM, the Administrator and Corporate Nurse discussed the concerns regarding the lack of supervision in the SCU, how concerns regarding abuse were not investigated when reported, the lack of specialized dementia training for the NA's and residents being woken up and provided showers and/or being dressed on the night shift. The Corporate Nurse was aware and looking into the concerns. The facility had taken appropriate action regarding initiating investigations and will continue to evaluate the SCU.

Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted the dignity of cognitively impaired residents residing in the secured unit (SCU). Based on the Reasonable Person concept, this failed practice caused psychosocial harm to 15 of 27 residents (21, 23, 25, 37, 44, 59, 77, 81, 82, 85, 87, 90, 93, 96 and 136), who would not have wanted to live in an environment where they were required to be awakened in the middle of the night to be showered or dressed. Additionally, failure to treat residents in a safe and respectful manner caused harm to Residents 85 and 136 when the facility administered sleep medications for [MEDICAL CONDITION], then failed to create a milieu that was conducive to healthy sleep patterns,by bathing and dressing residents with known cognitive and behavioral deficits during their hours of sleep. Additionally, the facility failed to maintain respectful staff-resident interactions for 1 of 1 sample residents (110), and to maintain dignity in dining related to excessive wait times for food to be served in the main dining room. These failures had the potential to decrease residents' quality of life and feelings of self-worth. Findings include: The facility's night shift (10:00 PM - 6:00 AM) Nursing Assistant (NA) book directed staff to give showers to Residents 136, 85, 25, 93, 44 and 77. The facility also directed the night shift NAs to dress 14 residents (21, 23, 25, 37, 44, 59, 77, 81, 82, 85, 87, 90, 93 and 95) prior to completing their shifts. SHOWERS AND DRESSING ON THE NIGHT SHIFT RESIDENT 136 Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long-term memory impairment and modified independence in decision-making skills. The resident required extensive assist of one person for bathing. Resident 136 was not able to be interviewed due to his cognitive status. Review of the care plan revealed no direction to staff that the resident preferred to be showered at night per his prior routine. Review of the Care Directive (a communication tool used by staff), updated 05/05/15, revealed the resident was to be showered at night between the hours of 5 and 6 AM. Review of a sleep evaluation assessment, dated 05/04/15, revealed Resident 136 had a [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. [MEDICATION NAME] 3 milligrams (mg) to 6 mg as needed at bed time was added 04/29/15. [MEDICATION NAME] 15 mg was changed on 04/13/15 from routine to [MEDICATION NAME] 7.5 mg as needed at bed time. Review of the behavior flow sheets revealed the Licensed Nurse (LN) was monitoring for signs of sleeplessness and restlessness at night. The intervention did not include offering a shower at night when the resident was experiencing [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. In 05/15 [MEDICATION NAME] was given twice and [MEDICATION NAME] once. In 06/15 [MEDICATION NAME] was given 7 times [MEDICATION NAME] was given 6 times. Review of the RITA (a computerized documentation system used by the NAs) shower documentation from 02/15 to 06/23/15 revealed the resident received showers on the day shift. In 06/15, an extra shower was scheduled on the night shift. In a continuous observation on 06/19/15 between 4:45 AM and 6:30 AM, Resident 136 was sitting on the side of his bed fully clothed. Review of the RITA documentation revealed the resident received a shower on 06/19/15. Review of the MAR indicated [REDACTED]. In an interview on 06/23/15 at 4:45 PM, the Director of Nursing Services (DNS) and Staff D, Resident Care Manager, were asked why Resident 136 was scheduled to have showers on the night shift. Neither of them knew. The DNS stated if the resident was awake and up, the NAs were to offer the shower. When asked why this resident with a [DIAGNOSES REDACTED]. When asked why he received a shower on 06/19/15 prior to 4:45 AM and received two medications for sleep at 1:15 AM, the DNS stated she would have to look into the situation. RESIDENT 85 Review of the MDS assessment dated [DATE] revealed Resident 85 had short-term memory impairment and required extensive assistance of one person for bathing. Resident 85 was not interviewable. Review of the care plan revealed the Resident had [MEDICAL CONDITION]. The goal was for the resident to sleep through the night constantly and feel rejuvenated after sleep. Interventions included to monitor hours of sleep on the MAR; evaluate the timing and effects of medications that could disturb sleep; engage in a relaxing activity if unable to sleep within 30 to 45 minutes; and to encourage the resident to follow consistent daily schedule for retiring and arising. The Activities of Daily Living care plan directed staff to provide an extra shower every Wednesday PM per family request. Nothing was found on the care plan indicating that Resident 85 preferred showers and/or dressing on the night shift per a prior routine. The sleep evaluation form, dated 12/17/14, revealed the resident slept late in the morning. Review of the MAR indicated [REDACTED]. Review of the RITA documentation from 03/15 to 06/23/15 revealed the resident was scheduled for weekly showers on the day shift. In May, an additional shower was added to the night shift, scheduled every week. In an observation on 06/19/15 at 4:55 AM, Resident 85 was fully dressed and being assisted back to her bed. In an interview on 06/23/15 at 5:00 PM, the DNS and Staff D were asked why Resident 85 was awakened on the night shift and given a shower weekly and dressed daily. The DNS stated the resident only received a shower if she was up. When asked to clarify why Resident 85 was scheduled to be showered, the DNS could not respond. The DNS was asked why the resident, who had a [DIAGNOSES REDACTED]. The DNS and Staff D could not provide any further information why the facility scheduled these two activities to be done on the night shift. RESIDENT 25 Review of the MDS assessment, dated 05/19/15, revealed Resident 25 had short and long-term memory deficits and required extensive assistance of one for bathing needs. Resident 25 was not interviewable. Review of the care plan revealed the resident was known to become verbally and physically aggressive towards staff. The staff were to promote a homelike environment. The care plan also directed staff to not take the resident's vital signs between 10 pm and 6 am unless she is ill. There was nothing on the care plan to indicate Resident 25 preferred showers and/or dressing at night per a prior routine. Review of the RITA shower documentation from 03/15 to 06/23/15 revealed the resident received scheduled showers on the night shift. RESIDENT 44 Review of the MDS assessment, dated 05/25/15, revealed the resident had short and long-term memory deficit and moderately impaired decision-making, and required extensive assistance of one person for bathing. Resident 44 was not interviewable. Review of the care plan revealed the resident's daughter was to come in once a week and assist with showers. There was nothing on the care plan indicating that Resident 44 preferred showers and/or dressing on the night shift per a prior routine. Review of the RITA shower documentation from March to June 23 revealed the resident received scheduled showers every Thursday on the night shift. RESIDENT 93 Review of the MDS assessment dated [DATE] revealed the resident had moderately impaired decision-making skills and required extensive assistance of one for bathing. In a screening interview on 06/26/15 at 1:55 PM, Resident 93 stated he took a shower once a week. When asked if he was woken up at night to take a shower, he replied occasionally. Review of the care plan revealed no documentation the resident preferred to be showered and/or dressed during the night per his prior routine. Review of the RITA documentation from March to June 23 revealed the resident was scheduled to be showered on the night shift. RESIDENT 77 Review of the MDS assessment, dated 04/05/15, revealed the resident had modified independence in decision making skills and required extensive assistance of one for bathing. Review of the care plan revealed no documentation the resident preferred to be showered and/or dressed during the night per a prior routine. Review of the RITA documentation from March to June 23 revealed the resident was scheduled to be showered on the night shift. In an interview on 06/19/15 at 5:20 AM, Staff N, Nursing Assistant (NA), replied yes when asked if residents received scheduled showers on the night shift. Staff N was asked if the NA was expected to have residents dressed before the night shift ended at 6:00 AM, Staff N replied yes. RESIDENTS DRESSED ON THE NIGHT SHIFT Review of resident's 21, 23, 37, 59, 81, 82, 87, 90, and 95 care plans revealed the residents did not have a specific preference to be dressed during the night shift, assisted to be up or placed back to bed. On 06/19/15 beginning at 4:45 AM to 6:30 AM the following was observed: Resident 85 was in the bathroom, dressed in regular clothing, taken back to her room and placed back in bed. Resident 95 was dressed and sleeping on the couch in the day room. Resident 77 and 93 were dressed and sleeping in the recliners in the day room. Resident 145 was dressed and walking throughout the unit going in and out of resident's rooms. At 5:25 AM, Staff I, NA, was interviewed regarding residents receiving scheduled showers on the night shift. Staff I, stated they did. Staff I was asked if NA's were expected to get residents dressed on the night shift, Staff I stated yes. When asked why, Staff I replied it is to help the day shift out. When asked if residents who reside outside this area were scheduled to be showered and/or dressed on the night shift, Staff I replied I don't think so. At 5:45 AM, the DNS was shown a list six residents scheduled to receive showers and 14 residents scheduled to be dressed on the night shift. The DNS replied this was only done if the residents were up and walking around and it was directed on the resident's care plan. When asked to clarify why it was scheduled to be done only if the resident was up and walking around, the DNS was not able to respond. In an anonymous interview, Staff CC stated there was a list in the secured memory care unit of residents who the staff were directed to wake up and shower on the night shift and/or dress prior to the day shift arrival. At 9:36 AM, Staff O, NA, replied yes when asked if residents were dressed when she came on shift at 6:00 AM. When asked who, Staff O stated there was a list. When asked if she was aware if showers were scheduled on the night shift, Staff O stated yes. At 9:42 AM, Staff M, NA, stated yes when asked if residents were dressed and/or showered on the night shift. At 10:30, the Administrator was made aware of residents who resided in the SCU being woken up, dressed and/or showered. RESIDENT - STAFF INTERACTION Resident 110 was admitted to the facility in September 2014 with [DIAGNOSES REDACTED]. According to the resident's care plan she had decision making and short term memory problems related to her dementia. In an observation on 06/18/15 at 8:47 AM, Resident 110 was observed to attempt a resident - staff interaction in the hallway outside the resident's room. Resident 110 raised her hand and started to talk to Staff A, Licensed Nurse, to ask a question. Staff A abruptly interrupted Resident 110, pointed down the hall and stated two more doors {Resident's name}, two more doors, and then walked away. In an interview on 06/19/15 at 9:45 AM, Resident 110 was asked if Staff A had ever come back to her to find out what she had wanted to ask her. Resident 110 stated No, I asked another staff member for help later in the afternoon. Resident 110 was asked what she wanted to ask Staff A. She stated she wanted to find out when she could get some clean socks from the laundry because she had an ankle infection that was draining and soiling the socks she was wearing. A review of Resident 110's care plan on 06/19/15 at 11:36 AM revealed approaches of care to include: allow time for resident to express understanding of tasks and for her to request specifics of her wishes during care, promote dignity and converse with resident, provide orientation and validation, use communication techniques to facilitate interaction, allow adequate time and do not rush or supply words, allow resident time to organize thoughts and words so she may be understood and needs may be met and questions answered. On 06/18/15 at 3:45 PM, the DNS was notified of the resident - staff interaction observation. In an interview on 06/23/15 at 3:13 PM, Staff B stated the facility had immediately suspended Staff A after being notified of the incident and had notified the state hotline. The facility then completed their investigation and had ruled out abuse/neglect. The investigation did determine there was an inappropriate approach/communication to the resident. The facility's corrective action plan included a requirement that Staff A complete an online anger management class. DINING OBSERVATION An observation of the Main Dining Room lunch meal service was conducted on 06/17/15. The posted lunch start time was 12:15 PM. The first tray of food was delivered to the first resident at 12:35 PM. The last lunch tray was delivered at 12:46 PM. On multiple observation between 12:15 and 12:35, Resident 32 was heard to yell out across the room is my lunch coming, don't forget about me, is lunch coming pretty soon, when will lunch be served, is lunch coming pretty soon, I'm hungry. A main dining room lunch meal service observation was conducted again on 06/19/15. The first tray was again delivered at 12:35 PM. In an interview on 06/22/15 at 12:30 PM, Staff C, Dietary Manager, was asked about the main dining room lunch schedule. Staff C stated the main dining room lunch wasn't scheduled to start until 12:30 PM. In a joint review of the Main Dining Room lunch schedule, dated 04/05/15, that was posted on the wall outside the main dining room, Staff C looked at the lunch scheduled start time of 12:15 PM then stated, I thought lunch was scheduled to start at 12:30.

Based on observation, interview and record review, the facility failed to implement its abuse/neglect policy and procedure for 8 of 13 sample residents (2, 23, 71, 81, 94, 110, 145 and 153) who were involved in incidents that required taking immediate action to protect residents; initiating an investigation; logging in the reporting log; and reporting to the state hotline and/or law enforcement. Failure to recognize abuse/neglect and implement the policy and procedure as required resulted in repeat occurrences, and placed all residents at increased risk for serious injury and psychological harm. Findings include: The facility's policy, Protection of Residents: Reducing the Threat of Abuse & Neglect included, Charges of abuse and/or neglect are among the most serious allegations that can occur in a nursing home. Frail elderly and disabled residents are frequently powerless to protect themselves from physical or sexual assault and may be unable to communicate to family or staff that they have suffered from abuse. It becomes paramount for nursing home providers to champion the safety and protection of each resident. The policy also stated the following: This facility does not condone resident abuse and/or neglect by anyone. All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation in in progress. REPORTED RESIDENT-TO-RESIDENT ALTERCATION NOT INVESTIGATED On 06/24/15 at 7:45 AM, the survey team was alerted to a physical abuse altercation between Resident 153 and Resident 71. The physical abuse was reported to the charge nurse on 06/17/15 at 9:30 PM. The altercation occurred in the secured unit (SCU). Review of the facility's state reporting log revealed there was no entry made regarding the physical abuse. Resident 153 was admitted to the facility March 2015 with Alzheimer's dementia and altered mental status. According to a Minimum Data Set (MDS) assessment dated [DATE], Resident 153 had short-term memory loss and was severely impaired in decision-making ability. The Resident had a language barrier, was sometimes able to make her needs known, and was not interviewable. Her documented behaviors were monitored daily by the Licensed Nurse (LN). Review of Resident 153's nursing progress notes revealed no documentation regarding the alleged resident-to-resident altercation. Resident 71 was a long-term care resident with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], the Resident had severe cognitive impairment and occasionally demonstrated physical and verbal behaviors. Resident 71 had documented behaviors that were being monitored daily by the LN. Review of Resident 71's nursing progress notes revealed the resident was placed on alert charting starting on 06/18/15 to monitor for an increase in aggressive behaviors. There was no documentation regarding the alleged resident-to-resident altercation. At 12:20 PM, when the Director of Nursing Services (DNS) was asked for the investigation regarding the above resident-to-resident altercation, the DNS replied she would look into it. The DNS was also asked why Resident 71 was suddenly placed on alert for an increase in behaviors. The DNS had no response and stated she would look into it. At 1:27 PM, the DNS and Staff D were asked for an incident report regarding the resident-to-resident altercation. The DNS replied that there was no actual physical contact made between the two residents, therefore there was no incident report/investigation. Staff D confirmed there was no physical contact made between the two residents. The facility did not initiate an investigation into the incident until 06/24/15, when the allegation was brought to the attention of the Administrator and the Corporate Nurse. On 07/02/15 at 2:10 PM, during the extended survey, the Administrator and Corporate Nurse stated that on 06/17/15, Resident 71 was witnessed to grab Resident 153 by both ankles, while she was on a couch, and aggressively attempt to pull her off the couch. The abusive physical contact was substantiated. RESIDENT 110 In an anonymous interview on 06/24/15 at 2:35 PM, Staff CC stated Resident 110 was moved out of the SCU because Resident 145 pushed her down. Review of Stop and Watch (a communication tool used to identify and follow up on any changes with residents) documentation revealed a Stop and Watch for Resident 110 dated 06/11/15 in the AM. The word Pain was circled and the following statement written on the tool: Resident c/o (complained of) pain said she was knocked down by a resident with her walker. c/o pain today. Resident 110 was admitted [DATE] after repair of a right hip dislocation due to a stumble and fall at home. The resident also had a [DIAGNOSES REDACTED]. This assessment and subsequent MDS assessments dated 12/26/15 and 03/28/15 indicated Resident 110 to be cognitively intact. On 06/26/15 at 9:45 AM Resident 110 was interviewed, and said that man tried to take her walker and she grabbed it so he couldn't take it. She had fallen trying to keep him from taking it away from her. Review of the Reporting Log Form revealed no information regarding the resident to resident altercation. Alleged violations are required to be entered on the log within 5 days of the occurrence. Review of the progress notes from April 1 - June 23 revealed, no documentation the resident fell or a resident to resident altercation occurred. An investigation of the incident was not initiated until 06/24/15, when the allegation was brought to the attention of administration. UNIDENTIFIED RESIDENT In review of the Concern and Comment log an entry, dated 05/19/15, documented a potential allegation of abuse to an unidentified resident by non-sample Resident 2. The concern stated Resident 2 had reported some nursing assistants (NA) were agitated with an unidentified resident and that Resident 2 helped to relax the unidentified resident so that she could rest. Resident 2 was unable to get names of staff and resident. Review of the Reporting Log Form revealed no entry of the potential allegation of verbal abuse by staff to the unidentified resident. On 06/26/15 at 9:47 AM Resident 2 was interviewed about the incident she had reported. She stated the NA was yelling and pulling/grabbing the resident. Resident 2 stated she told the NA to stop and quit yelling. Resident 2 had told the other resident to tell someone but she would not. Resident 2 reported to her nurse. Further information about the potential abuse was requested to administration. An investigation was not initiated until 07/07/15. RESIDENT 23 In a screening interview on 06/18/15, Resident 23 did not know where she was, the current date or time. Resident 23 was not interviewable. Review of the nursing progress notes revealed the resident was on alert for a bruise found on her right inner thigh (an area not vulnerable to trauma) on 04/03/15. The resident was not able to state how the bruise occurred. A review of the state reporting log revealed the bruise found on 04/03/15 was not logged. Review of the care plan revealed Resident 23 was at risk for bruising due to self-propelling her wheelchair (w/c) and running into obstacles, transfer skills, frail/thin skin and low dose of aspirin therapy. Resident 23 required extensive assistance of two people for all transfers. The care plan did not reflect the inner thigh bruise found on 4/03/15. In an interview on 06/23/2015 at 1:56 PM, Staff G, LN, stated when a skin injury was found of unknown origin (bruise, skin tears, abrasions, pressure ulcers, etc.) or resident to resident altercation occurred, the LN was expected to initiate an investigation, notify the physician and family, update the care plan and as a mandatory reporter potentially call the state hotline when applicable. Staff G further stated bruises were placed on the treatment sheet and monitored with the weekly skin check. At 4:00 PM, Staff H, Nursing Assistant (NA), stated she reported all changes, including bruises, in the residents skin to the LN immediately. In an interview on 06/24/15 at 10:45 AM, the DNS was asked if an investigation was done regarding the bruise found on the inner thigh of Resident 23. The DNS stated she would follow up right away. In a follow-up interview at 2:04 PM, the DNS stated Staff D did not initiate an investigation related to the resident slams herself on the wheelchair. The DNS was asked how Resident 23 could have slammed herself on the w/c when the resident required two people to assist her with transfers and the bruise was on her right inner thigh. Furthermore, the DNS was asked why the facility failed to rule out potential abuse at the time of the incident, over two months prior. The DNS was not able to provide any additional information. RESIDENT 94 Review of the progress notes revealed the following: - On 05/05/15 at 1:58 PM, the Resident had sustained superficial scratches on the right side of the forehead and nose. - On 05/06/15 at 2:51 PM, the resident exhibited No s/sx (sign and symptoms) of psychological harm. - On 05/07/15 at 3:28 PM, the resident had No ASE (adverse side effects) or psychological harm .watched closely as she can get into other's person space . Review of the Care Directive revealed an update on 05/05/15 directing staff to redirect Resident 94 if angry because other residents raisedtheir voice at her. Review of the state reporting log revealed there was no investigation done to rule out abuse and neglect to Resident 94. In a screening interview on 06/18/15, Resident 94 had unclear and mumbled speech. Resident 94 was not interviewable. An investigation of the incident was not initiated until 06/26/15, when the allegation was brought to the attention of the Administrator and the Corporate Nurse. The facility failed to investigate a skin injury to an area not usually susceptible to trauma to rule out possible abuse and neglect. RESIDENT 81 Review of Resident 81's progress note, dated 06/19/15, NAC (nursing assistant certified) noticed a small skin tear to left hand when transferred to bed. Pt (patient) non conversant and unable to tell where he got it . Review of the facility state log revealed the skin tear had not been investigated or logged. According to the most recent MDS quarterly assessment, dated 04/04/15, the resident was dependent in transfers and w/c mobility. In a screening interview on 06/19/15 at 9:15 AM, Resident 81 was asked how he was doing, the resident smiled in response. When asked how his breakfast was, the resident again would not answer but did smile. Resident 81 was not interviewable. An investigation of the incident was not initiated until 06/26/15, when the allegation was brought to the attention of the Administrator and the Corporate Nurse. The facility failed to investigate how the resident sustained [REDACTED]. RESIDENT 145 Review of the Non-Pressure Skin Condition Record, dated 03/31/15, revealed Resident 145 sustained a superficial scratch to the left side of his mouth which measured 3.2 x 0.1 centimeters. Review of the nursing progress notes, dated 03/31/15, revealed the Resident had a scratch to his face of unknown origin. There was no other documentation indicating how the resident received the scratch to his face. Review of the facility state log revealed the scratch had not been investigated or logged. In a screening interview on 06/19/15 at 11:30 AM, Resident 145 was asked how he was. Resident 145 mumbled something in response, which was not comprehensible, and walked away. Review of behavioral flow sheets revealed Resident 145 had demonstrated aggressive behaviors on the night shift of 03/30/15. The behaviors documented included: severe agitation (hitting/pushing), resisting care and striking out. Furthermore, documentation on 03/29/15 and 03/30/15 documented the resident was wandering in/or getting into other resident rooms. An investigation of the incident was not initiated until 06/26/15, when the allegation was brought to the attention of the Administrator and the Corporate Nurse. In an anonymous interview on 06/24/15 at 11:02, Staff AA stated a concern regarding the care and treatment of [REDACTED]. Staff AA stated resident concerns had been reported to the Director of Nursing Services (DNS) and Staff D. Staff AA felt the DNS and Staff D were not reporting or investigating the concerns. There was a stop and watch program in place. The DNS and Staff D told them not to fill out the stop and watch forms. When asked Staff AA why, Staff AA did not know why but was told not to fill them out. In an anonymous interview at 2:35 PM, Staff CC stated he/she was concerned regarding the treatment of [REDACTED]. Staff CC was directed not to report resident's behaviors or when residents were physically abusive towards staff. When asked why, Staff CC stated the staff were directed by the DNS to report these concerns to the lead NAC and not to the charge nurse or facility management. In review of individual staff in-service education records, 47 of 85 employees reviewed did not have the required annual abuse/neglect training. In review of the sign-in sheets which included topics covered, education materials included, there was no training which included components in conducting a thorough investigation. Refer to CFR 483.25 (h), F 323- Accidents and Supervision .

Based on observation, interview and record review, the facility failed to recognize inappropriate behavior of Resident 1 and provide supervision to protect residents on the secured dementia care unit. Resident 1 was allowed to make physical and sexual contact with two known cognitively impaired female residents, Residents 2 and 3, and at least two unidentified female residents. Iit was unknown if other instances had occurred and not been witnessed and / or documented by the facility. This was defined as harm to the residents involved, and potential harm to other residents on the unit. Findings include: Resident 1 was admitted to the facility 9/12/14 and [DIAGNOSES REDACTED]. Resident 1 was one of the 26 residents 16 were females who resided in the locked memory care unit. In a progress note dated 10/04/14 a licensed nurse (LN) documented, the "Resident was noted getting intimate with other resident and was separated and easily redirectable." It was not evident who the other resident was, or what intimate contact: meant, but staff determined it was an issue and made a plan to check on Resident 1 every 15 minutes. Documentation on the Care Plan / Care directive dated 10/4/14 directed staff to monitor the resident for being intimate with other resident. Re-direct and separate if they notice the resident was being too intimate with the other resident. On 10/05/14, a LN documented the resident was found sitting next to a female resident who was lying on a sofa in a common area, and was re-directed by staff. The document did not indicate if there was any type of contact, who the female resident was or why staff felt it was necessary to redirect Resident 1. There was no evidence of continued supervision or monitoring of the resident's overly friendly behaviors until 12/01/15 when documentation showed that Resident 1 was found with his hand down Resident 2's pants. Documentation indicated the residents were separated; Resident 2 was left unsupervised but was again put on 15 minute checks. Fifteen minutes after the first incident Resident 1, was seen with his hand down Resident 2's pants again. The resident was then placed on 1:1 staff supervision after the second incident. During a phone interview on 12/03/14 at 1:15 p.m., Resident 2's daughter said she was upset about the incident and "I don't want him (Resident 1) around her (Resident 2)." She stated she was thinking of notifying law enforcement. In a separate phone interview at 1:28 p.m., the Resident's son said the resident "can barely communicate with us" and would not be able to give consent for sexual activity. In a phone interview on 12/03/14 at 2:30 p.m., Resident 1's DPOA (durable power of attorney) stated the he was aware of two prior incidents at this facility when Resident 1 had made "'unwanted advances" towards a female resident or residents, as the facility had reported the incidents to him. During an interview on 12/03/14 at 12:00 p.m., the Director of Nursing (DON), said the facility needed "to protect other residents who might not want intimate contact with" Resident 1. Documentation on an interdisciplinary team (IDT) progress note dated 12/24/14 indicated the team discontinued the 15 minute checks of the resident for inappropriate sexual behaviors. On 12/26/14 at 9:44 a.m. indicated that a review of the resident behaviors showed no inappropriate behaviors, no seeking out female residents and no exit seeking. By 12:50 p.m. documentation showed that a housekeeper found Resident 1 and Resident 3 in a resident room. Both of the residents' outer and inner lower extremity clothing was "lowered to their thigh areas," and Resident 1 was saying, "I want sex." The housekeeper left the residents unsupervised while she went to get a nurse who came to the room and intervened. The resident was placed on 1:1 supervision from 6 a.m. to 10:00 p.m., and staff checks every 15 minutes at night. Documentation in the progress noted on 12/27/14 indicated that there were two instances of inappropriate sexual behavior that day. Resident 1 was coming out of the shower room, and attempted to touch a female resident "on the butt" staff pulled his hand back. In the dining room Resident 1 reached out and touched a female resident's blouse "in a motion to lift," and his hand was held back by a staff person. The resident remained on staff checks every 15 minutes at night, with 1:1 during the day. Documentation on a progress note dated 12/29/15: "Resident does continue to make attempts to touch other female residents, however all attempts have been intervened and redirected by the 1:1." Documentation by the IDT team on 1/7/15 indicated that the resident was aware that he was being monitored and there were no inappropriate behaviors noted. 1:1 would be reduced to 14 hours per day with 15 minute checks during the night. Documentation in the progress notes dated 1/9/15 at 9:02 a.m. indicated, even though the resident was on 15 minute checks, a licensed nurse, documented she found a female resident in Resident 1's room, "He had his hand up her gown, when caregiver told (him) that was an inappropriate behavior his response was, "She came to me." Further documentation indicated the above statement was incorrect and the female resident was patting Resident 1 on the cheek and he was reaching his hand behind her about to touch her when a nursing assistant intervened. Resident 1 was observed on 01/21/15 at 10:40 a.m., sitting in a recliner in a TV room, apparently asleep. Staf B was present and said "We just can't have him unsupervised." She said he slept at night, but had 1:1 staff supervision "during waking hours." During an interview on 01/28/15 at 1:00 p.m., Staff A and B were asked about the incident between Residents 1 and 3 on 12/26/15. Staff A said "He has been off and on the 1:1, but always on 15 minute checks." When asked what "being too friendly with other residents" meant on Resident 1's nursing assistant care guide, Staff B said "He can get near and talk to some, others we redirect away. We were noticing potential touching." Staff A said, "We made it broad. We cannot predict behavior." On 1/28/15 Staff C joined the above interview at 1:10 p.m. Staff C was asked why the every 15 minute checks were discontinued on 12/24/15. Staff C said "He had not had any inappropriate behaviors. He was still on every 15 minute checks for wandering." This was not specified in the progress note. Staff A, B and C did not explain how the facility had determined Resident 1 to be safe from initiating sexual contact with another resident while unsupervised between the every 15 minutes checks, as he had done 12/26/14. Staff B said "After (Resident 3, on 12/26/14), we decided we have too many ambulatory residents. He is too unpredictable. It only takes one time, he has a history of that." Two care plans were submitted to the Department. Neither of the care plans had an Activities care plan even though that was part of the facility's documentation for distracting the resident.

Based on observation, interview and record review, the facility failed to provide supervision in accordance with the assessed needs of Resident 2, one of four sampled residents. This resulted in Resident 2 sustaining a pelvic fracture on 10/17/14, and a partial thickness burn on 10/28/2014. Findings include: Fall with fracture Resident 2 had dementia, heart disease and a history of falling. Her most recent MDS (Minimum Data Set) assessment dated [DATE] documented she needed extensive assistance from staff for toileting. She required the use of a walker to stablize when walking. Her BIMS score for cognition was 6. The fall risk assessment dated [DATE] documented the resident had recent falls, needed assistance with toileting, ambulated with problems and with devices (gait is unsteady, slow, lurching), not steady, over age 85, had cardiac dysrhythmias and pain. The corresponding Restorative Assessment noted "Some imbalance, forgets walker," and "poor safety awareness." According to the care directives and care plan, the resident used a walker for ambulation, and needed the assistance of one staff for toileting. "Toilet use 1 person extensive assist" and "walking supervision for safety." Record review revealed that on 10/17/14, the resident fell unsupervised in a hallway bathroom on the night shift. Staff J, the nurse on duty, had watched her walk into the bathroom and did not act to assist the resident. An X -ray completed 10/17/14 indicated a fractured pelvis, which was non-operative. The provider included the instructions, "Careful attention to transfers to avoid further falls," and "pain medications as needed." Record review of the Pain Flow Sheet revealed the resident required narcotoc pain medication for left hip/pelvic pain beginning 10/17/14, for pain rated at a level 7 to 8 out of 10. During an interview on 11/03/2014 at 2:15 p.m., Staff A was asked why Staff J did not help Resident 2 when the Resident was going into the bathroom alone, and had been assessed as requiring assistance. Staff A said the resident "does her own thing, staff knows her well." During a phone interview with a family member familiar with Resident 2's care, on 11/04/2014 at 9:20 a.m., the family member discussed the resident's fall: "It's quite obvious she does not walk that great," and "Shouldn't somebody be helping?" The family member also said the resident had been missing her personal walker for about six weeks, and that the resident had told her "An old man took it." The resident was also missing her slippers, eyeglasses and hearing aid. The family member stated she had reported to the facility these items were missing, but they had not yet been replaced or recovered. The facility was notified of this by phone following this interview, and Staff A stated that the facility would start loooking for the items. During an interview with Staff J on 11/05/2014, the nurse who had observed the resident go into the bathroom before the resident fell , Staff J was asked how the resident appeared when she was ambulating. Staff J said the resident was holding her hands up to her chest, in a "prayer" pose as she walked. She said the resident was wearing socks, and Staff J had asked, "Where are your shoes?" after she found the resident on the floor in the bathroom. Burn On 10/31/2014 at 09:30 a.m., Resident 2 was observed lying in bed. Her upper chest was observed to have a partial thickness burn, and there were blisters on her right shoulder. Staff C, a licensed nurse, was asked what happened. He stated the resident had spilled coffee on herself. The most recent MDS (Minimum Data Set) assessment dated [DATE] documented the resident needed staff supervision and set-up to eat. Review of the medical record revealed on 09/20/14 the Restorative Assessment documented "Supervision--oversight, encouragement or cueing required" to eat. . Resident 2's care plan included that she had chewing and swallowing problems, and the nursing assistant was to report to the nurse any chewing or swallowing problems, pocketing of food or drooling. "Assist hands on of one staff for meals." The nursing assistant care guide did not reflect the resident's assessed needs for assistance with eating: "Meal assist: set up only, independent in room," and "head of bed 90 (degrees) when up in bed eating." The ADL care plan did not reflect the resident's assessed need: "Eating independent with setup," and did not correspond to the approach "Assist hands on of one staff" for meals, also on the ADL care plan. There was no assessment or care plan documentation that the resident was safe to eat unsupervised while sitting in bed. Record review of nursing assistant flow sheets for activities of daily living (ADLs) indicated the resident required staff assistance with eating: 10/20/2014: Limited assistance: some physical help provided. 10/21/2014: Extensive assistance and total dependence. 10/22/2014: Extensive and limited assistance. 10/23/2014: Total dependence. 10/24/2014: Total dependence and limited assistance. 10/25/2014: Supervision, encouragement, oversight. 10/26/2014: Supervision and limited assistance. 10/27/2014: Independent and supervision. 10/28/2014: Limited assistance and total dependence. Prior to her fall and hospitalization on [DATE], the resident's eating ability in the month of October, 2014 was coded as needing supervision, or occasionally as independent. The last nursing progress note describing the resident's status before the burn, dated October 22, 2014 and written by Staff A, documented "Up in wheelchair for meals and toileting." According to the incident report, the burn incident was unwitnessed. Staff F, a nursing assistant, served the coffee to the resident after breakfast on 10/28/2014 and left the room. Staff E from maintenance who was working in the resident's room heard the resident scream, saw that the coffee was spilled on the resident, and alerted staff. The report did not indicate if the resident was sitting in bed, or in a chair or wheelchair, or what factors in the resident or the environment might have contributed to the accident. During an interview on 10/31/2014 at 11:00, when asked about this incident, Staff A stated that Resident 2 "directs her own care," and the aide gave her coffee "per her usual routine." During an interview on 10/31/2014 at 11:25 p.m., Staff H from the kitchen said the facility coffee came out of the coffee machine at 155 degrees F. She stated she was aware Resident 2 had been burned with hot coffee. Staff H said the facility had not been checking and documenting temperature of the coffee served to the residents before or since this burn, but that they were starting a new plan to do this which would be implemented on this day. During an interview on 10/31/2014 at 3:30 p.m., Staffs A and B were asked to provide a safety plan to prevent further coffee scald burns at the facility. During a phone interview with a family member familiar with Resident 2's care, on 11/04/2014 at 9:20 a.m., the family member stated said she had seen Resident 2 a few days prior to her burn, and "she was pretty much out to lunch" cognitively. "Why would you leave her alone with hot coffee at all?" She also stated the resident's eyeglasses and hearing aid were missing, and that she had notified the facility about this. During a phone interview on 11/06/2014 at 11:36, Staff L, the nurse on duty when Resident 2 was burned, said the resident had been sitting in bed when she was burned, and that she was mostly bedridden and had not been eating much.

Based on interview and record review, the facility failed to assess and/or monitor hydration status for two of four residents who required monitoring of fluid status (Residents 2 and 4). Failure to monitor, document, assess and care plan for hydration status resulted in harm for Resident 2 who developed severe dehydration, acute [MEDICAL CONDITION] and urinal tract infection [MEDICAL CONDITION] that required hospitalization for treatment. Failure to monitor output placed Resident 4 at risk for inadequate fluid intake to meet hydration needs. Findings include: 1. Resident 2 was admitted in the end of October 2013 with multiple [DIAGNOSES REDACTED]. He had a history of [REDACTED]. He had a supra-pubic catheter for urine drainage and a peripherally inserted center catheter (PICC) for intravenous antibiotic therapy when admitted . admission orders [REDACTED]. Review of clinical records of Resident 2 revealed no evidence of 24 hour totals for I&O during his 4 days in the facility. The record documented weight loss of approximately 6 pounds in 72 hours between 11/01/13 to 11/04/13. On 11/04/13 Resident 2 developed a severe decrease in urine output and a decrease in level of consciousness (he could no longer speak or open his eyes). He was sent to the hospital for evaluation. Hospital records were requested on 12/03/13 and received on 12/23/13. Review of the hospital records on 12/24/13 revealed Resident 2 was admitted to the hospital with [REDACTED].= 1.8 milligrams/deciliter (mg/dL)), severe dehydration (BUN = 78 mg/dL and lactic acid - 5.3 millimoles/liter) and [MEDICAL CONDITION] with UTI. He was unable to swallow liquids at admission. On 12/02/13 at 2:45 p.m., the Director of Nursing Services (DNS) reported nursing staff were to document I&O for all newly admitted residents for 7 days from admission to establish a baseline hydration status. The night shift nurse should total I&O each 24 hours and determine whether a resident had any risk for dehydration. They should look at skin and oral membranes for moisture/dryness. She expected nursing staff to assess the data for indication of change in condition or possible dehydration. The DNS had no had no information why the nursing staff did not follow the facility standard for hydration assessment. Additionally, review of the facility investigation for possible dehydration of Resident 2 during his stay in the facility revealed on 11/05/13, Staff C wrote by noon on 11/04/13 Resident 2 had no interest in food or liquids. He drank "only 200 ml of liquids" during the morning. His urine output was approximately 100 ml of "very dark" color. Resident 2 "no longer opened his eyes spontaneously or responded to direct (verbal) questions." On 12/02/13 at 11:58 a/m., the consulting dietician reported she conducted an admission nutrition assessment for all residents on Mondays (her day to visit the facility). She included hydration status in her nutrition assessment. The consulting dietician stated she checks for dry mouth, dry skin, thirst complaints from residents and fluid intake if it is available from a resident's records. She wrote her assessment for Resident 2 on 11/04/13. Review of the nutrition assessment of Resident 2 revealed his average meal intake was <25-75% of breakfast, 25-75% of lunch, and 0-75% of dinner. She noted his oral intake was "poor". In a separate note, dated 11/04/13, the consulting dietician noted the family of Resident 2 was "concerned about his hydration." The consulting dietician documented Resident 2's weight was down 5.9% in the 4 days since admission. She calculated Resident 2 needed approximately 1960 ml/day of fluid. Review of the I&O record of Resident 2 revealed his intake totaled 1280 ml on 11/01/13. It decreased to 958 ml, 790 ml and 200 ml on the next 3 days. Review of the care plan for Resident 2 revealed no evidence of identification of hydration status as an issue or concern for him. There were no interventions or goals for monitoring, assessing or maintain hydration status for Resident 2. On 01/03/14 at 10:25 a.m., Staff A reported facility policy was all new admissions had I&O monitoring for 7 days, if they were on antibiotics, if they have a urinary catheter, and/or when in nursing judgment it was appropriate. Nursing staff was expected to review I&O data and skin assessments, skin turgor, renal laboratory test results as part of hydration assessment for residents. They could initiate I&O monitoring for a short time for any resident. Staff A stated nursing should have care planned hydration for Resident 2. 2. Resident 4 was most recently readmitted in November 2013. Her multiple [DIAGNOSES REDACTED]. She had a supra pubic urinary catheter. On 11/29/13, her physician ordered antibiotics for treatment of [REDACTED]. On 12/02/13 at 09:25 a.m., Resident 4 reported she drank lots of fluids as she had concerns for her blood pressure fluctuating. Review of the clinical record revealed she was on I&O monitoring for every shift. Night shift was instructed to total the 24 hour intake and output. There was no evidence of documentation of 24 hour totals for either intake or output. On 01/03/14 at 11:07 a.m., Staff B reported she had no information when staff were last trained on hydration monitoring and assessment prior to December 2013.

Based on interview and record review, the facility failed to acknowledge and address Resident 1's concerns for treatment in a timely manner. Failure to promptly discuss and respond to Resident 1's concerns regarding the 1:1 continuous supervision resulted in his feeling "frustrated and depressed" and physically hitting himself in front of staff in response to the lack of resolution to his perceived "punishment." Findings include: Resident 1 admitted to the facility in June 2013 for rehabilitation after a traumatic fracture of his left leg. His Minimum Data Set assessment, dated 07/21/13, identified his recall and memory as intact (15/15 points on the memory assessment tool). He exhibited no disruptive physical or verbal behaviors. On 06/21/13, Resident 1 signed a document reading he had received and understood the facility smoking policy. That policy identified the facility as a non-smoking facility. Residents and staff were allowed to smoke "off property only." On 06/27/13 Resident 1 smoked marijuana, which he stated he had a physician order [REDACTED]. On 07/14/13, Resident 1 again smoked marijuana in his room. Staff reiterated no residents were allowed to smoke marijuana on the premises. Resident 1 signed a copy of the "non-smoking policy" and was placed on 15 minutes checks for 7 days. He exhibited no attemnpts to moke during that time. On 07/31/13 staff placed Resident 1 on continuous 1:1 supervision, meaning a staff member accompanied Resident 1 at all times, 24 hours/day, wherever he went or whatever he did. Review of the clinical record of Resident 1 dated, 08/02/13, identified this action was initiated "to monitor for his smoking behavior." On 08/12/13 at 9:55 a.m., Resident 1 reported he could not go outside without a doctor's permission. Staff continued to bring up - "you smoked." At 1:43 p.m., observation found 7 staff members outside the door to Resident 1's room. Resident 1 reported, " They are paid to watch me like dogs. It makes me feel horrible ...I feel like I am more in jail than in a place to get better." On 08/21/13 at 10:20 a.m., Resident 1 reported he had 1:1 24 hour 7 day monitoring. He stated he had no space. If his leg was not broken, he would walk out. It felt "punitive - like go sit in the corner. You are a bad boy." Having someone sit outside the door to his room "seemed wrong, like jail." Resident 1 stated he told the Director of Nursing (DNS) and Administrator he did not like the 1:1 monitoring several times. No one had spoken to him about changing it. On 08/22/13 at 1:15 p.m., the DNS reported she was aware Resident 1 did not like the 1:1 supervision 24 hours a day, 7 days a week. He had told her more than once. She was present when he hit his head on 08/07/13 in his attempt to get staff to listen to him. When he was accompanied by 1:1 supervision on an outing to the grocery store on 08/14/13, Resident 1 purchased and drank a beer in front of the 1:1 accompanying staff member. She thought he did this as "retaliation" for the continuous 1:1 supervision. She was aware he had made no attempts to smoke since 07/14/13. She had no additional information why the facility did not meet with Resident 1 to address his feelings of the 24 hour continuous monitoring. On 08/23/13 at 10:29 a.m., the Divisional Nurse reported she advised the facility leadership to place Resident 1 on 1:1 supervision 24 hours/day 7days/week on 07/31/13. She did not know the resident and had not reviewed his clinical record. She was certain she would not like 1:1 supervision for herself, but her bigger focus was safety of all the residents in the building. She reported staff should hold a care conference as soon as possible after initiating 1:1 supervision and figure out what to do for a long term solution other than 1:1 supervision for any resident. Review of the clinical record of Resident 1 revealed on 08/07/13, nursing documented Resident 1 told the DNS he no longer needed 1:1 supervision. He felt "frustrated" by the 1:1 supervision and thought it was "making him feel depressed." Resident 1 began to "hit his head." He stated if he "hit his head so hard, maybe someone will listen." On 08/11/13, nursing documented Resident 1 requested to leave the premises of the facility. He was informed he may not leave. Resident 1 became "angry and argumentative, stating he "is a prisoner of the facility." On 08/14 13 Resident 1 left the premises accompanied with the 1:1 staff supervision. He went to a nearby grocery store and purchased a beer, which he drank there in front of the staff member. He told the staff he is [AGE] years old and "can do whatever he wants." There was no evidence of any documentation of any attempts to smoke after 07/14/13.

Based on observation, interview and record review the facility failed to provide consistent supervision to prevent 1 of 4 sample residents (Resident 1) from a fall. The failure to provide adequate supervision led to the resident sustaining significant injuries. Findings include: Resident 1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated she required extensive assistance of 1 person to navigate the unit while in the wheelchair. The same MDS indicated the resident experienced both long and short term memory problems. On 5/17/12 at 9:00 a.m., a review of the facility Plan of Care for Resident 1, stated the resident was at risk for falls related to the [DIAGNOSES REDACTED]. The facility goal was the resident "will remain safe from serious injury". The approach in keeping the resident safe from serious injury, while in the wheelchair, was she was to be "placed near the nursing station or in visual view". On 5/18/12 at 2:22 p.m., the licensed nurse (Staff A) stated that "visual view" meant the resident should be in "eye site" of a staff member. On 5/16/12 at 9:00 a.m., during observational rounds, Resident 1 was noted to have multiple colored purple, yellow, black and blue bruises surrounding the resident's right eye down the cheek bone. Bruising continued up to the hair line, forehead and scalp. A large raised contusion (damage to tissue under the skin) was observed in the middle of the forehead and another contusion was noted on the top of the head. Review of the facility nursing progress notes revealed that on 5/13/12, "before 8pm, the nurse noted that the resident was becoming a little anxious in wheelchair, slowly scooting herself forward". The nurse moved her close to the nurses' station. Sometime later, a nursing assistant toileted the resident and placed her in the television room. One of the nursing assistants heard the alarm going off and found Resident 1 on the floor in the television room in "almost a fetal" position with her "head almost touching the wall". The resident was bleeding from her mouth and nose and an "egg size contusion" was forming on the right side of her forehead with a lump on the top of her head. The nurse attending the resident that evening indicated she had left the unit for approximately 10 minutes and had told the nursing assistants she was leaving the floor. 911 was called with the resident being sent to the hospital emergency room . The emergency room physician ordered the resident to have a cat scan of the brain. The result was a "Total cephalohematoma (localized swelling filled with blood) without an underlying skull fracture". The emergency room team also put in "7 staples" to close the wound the resident sustained [REDACTED]. The facility investigation indicated a right shin injury was sustained from the resident's wheelchair footrests. Review of the facility investigation witness statements revealed there were no staff members present when the resident fell . The nurse had left the floor even though the resident at some time during the evening had been restless and tried to get out of the chair. On 5/17/12, at 2:30 p.m., the Director of Nurses stated she was aware that the fall had not been witnessed by the staff members working on the floor. The resident did not remain in visual view of any staff member, did not remain safe and sustained substantial injuries.

Based on observation, interview and record review, the facility failed to provide the treatment and services needed to prevent a pressure sore for 1 of 4 (Resident 8). Failure to provide the necessary treatments and care plan interventions resulted in harm for Resident 8 with the development and deterioration of a pressure sore with pain. Findings include: Resident 8 was readmitted from the hospital on [DATE]. The facility's initial data collection tool documented that the resident was alert and orientated and had no pressure sores. The nursing notes revealed that the resident would be working with skilled therapy due to her diminished strength and the resident was identified to be at risk for skin breakdown due to her medical condition. Review of the resident's clinical record revealed that the resident went to [MEDICAL TREATMENT] twice a week which involved long period of sitting in a recliner. Resident 8 stated that during her [MEDICAL TREATMENT] appointments she sits in a recliner for several hours without changing her position in the recliner and her "bottom hurts". The Minimum Data Set (MDS) assessment, dated 2/7/12, documented that the resident required assistance of one person for bed mobility and transfers, had pressure reducing devices on her bed and wheelchair. The MDS documented the resident was at risk for skin breakdown and currently had a Stage 2 pressure sore. A Stage 2 pressure sore-partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. On 3/8/12, the resident was observed seated in her wheelchair from 8:30 a.m. to 10: 40 a.m. The resident had an incontinent pad folded in layers on top of the wheelchair pad. At 10:42 a.m., the resident's pressure sore on her coccyx (bottom) area was observed with Licensed Nurse (LN) D. Her entire buttock was red. The pressure sore on the coccyx contained 100% yellow slough in the wound base and the edges of the wound rolled inward. The LN D verified that the wound contained eschar and surrounding tissue was red. (If eschar and necrotic tissue are covering and preventing adequate staging of a pressure ulcer, the assessor is to code the pressure ulcer as a Stage 4 pressure ulcer). LN D cleansed the wound with saline and then applied an " aqua " dressing over the pressure sore and then covered it with a foam dressing. The LN did not apply any protective barrier cream to the reddened area of the buttocks even though the Treatment Administrative Record (TAR) indicated that staff were to apply protective/barrier cream to perineal area redness or episodes of excoriation. On 3/9/12 at 8:50 a.m., the resident was observed seated on top of a folded incontinent pad on top of her cushion in her wheelchair. At 11:00 a.m., the resident stated she was waiting to go to her [MEDICAL TREATMENT] appointment and was waiting for transportation. When asked if she was able to lift herself and provide pressure relief on her buttock when in her wheelchair she stated, " No." She stated that she usually got up at 7:30 a.m., and when her bottom started to hurt, she would go to bed. When asked about staff assisting her to the toilet, she stated that she did not require toileting due to her surgical altered urinary and bowel revision. She stated there was "no plan for lying me down by the staff when my bottom hurts." She stated she sat in a recliner chair during [MEDICAL TREATMENT] and "butt hurt" from the prolonged time staying in the same position. On 3/12/12 at 9:10 a.m., the resident was observed outside seated in her wheelchair. The folded incontinent pad was still on top the wheelchair cushion. At 9:15 a.m., LN D was asked about how the facility had communicated with the [MEDICAL TREATMENT] facility, he stated "verbally." There was no documented evidence that the [MEDICAL TREATMENT] facility was aware Resident 8 had a pressure sore. On 3/12/12 at 12:10 p.m., the resident's buttocks and pressure sore were again observed. LN L stated that the pressure sore on the coccyx area was "unstageable" as the wound base contained slough. The tissue surrounded the wound was red and measured 2.5 centimeters (cm) by 2 cm in size. According to the resident she stated when the LN touched the pressure sore the area was "tender to touch" and stated, "It was like touching a bruised area." Review of the facility's pressure ulcer status record, dated 2/6/12, documented that the resident had a Stage 2 pressure sore on her coccyx. The wound measured 1 cm in size and had "pink" [MEDICATION NAME] tissue in the wound bed. The assessment did not indicate if the resident had pain associated with the pressure sore. No further documentation regarding the pressure sore was noted until 2/22/22, 16 days after the pressure sore was identified. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pain flow sheet revealed that the resident had back pain, however from 2/7/12 through 2/9/12 the documentation revealed the resident had complaints of "coccyx" pain which required narcotic pain medication. The "Pressure Ulcer Status Record", dated 2/22/22 indicated that the resident had coccyx pain, however there was no further evaluation regarding interventions to relieve pressure to her coccyx region even though the resident had been noted to sit in her wheelchair for prolonged periods of time in the facility and when out to her [MEDICAL TREATMENT] appointment twice a week. The Plan of Care for the Pressure ulcer on her coccyx, dated 2/6/12, listed care interventions such as encourage weight shifts while sitting up in chair, weekly evaluation of wound healing and to encourage resident to ask for assistance with repositioning to avoid skin friction/shearing. Review of the clinical record with LN L on 3/12/12 verified that there was no revision in the resident ' s plan of care after she developed the pressure sore on 2/6/12. The plan did not state how the facility would ensure that the [MEDICAL TREATMENT] facility was providing pressure relief measure. The LN stated the cushion in the wheelchair was not effective to relieve pressure and is used for Stage 1 pressure sores (Stage 1-an area of persistent redness with intact skin). She stated the facility needed to change the wheelchair cushion and develop a plan to ensure pressure relief was being provided and communicate with the outside source regarding the resident ' s pressure sore. Review of the facility's policy for End Stage [MEDICAL CONDITIONS] Cooperative Agreement documented that the facility was to "provide a program of patient/resident care and coordinate said the plan with the Kidney center such that the best interest of patient/resident are served. The facility's policy for Pressure Ulcer documented protocols for prevention of skin breakdown which included the use of anti pressure devices in bed and chair, weekly skin assessment and the evaluation to identify any areas of discomfort or pain that could be attributed to pressure damage. Even after the pressure sore was identified on 2/6/12 as a Stage 2 pressure sore, there was no thorough assessment of the wound weekly as per facility policy. In addition, even after the resident complained of pain in her coccyx area, there was no documented evidence that pressure relieving measures were evaluated or communicated with the [MEDICAL TREATMENT] facility. Not until 3/13/12, did the facility evaluate and change the resident ' s wheelchair cushion or provide education to the resident regarding the need for repositioning and notify the [MEDICAL TREATMENT] center regarding Resident 8's pressure ulcer to ensure repositioning and/or pressure relieving devices (cushions) were implemented to provide pressure reduction on her bottom.

Based on interview and record review, the facility failed to implement written abuse prevention policies and procedures and failed to take immediate action to protect residents during and after investigation of allegations of abuse and neglect. Allowing 2 employees (Staff 1 and Staff 2) alleged to have abused and/or neglected residents to continue working with vulnerable adults demonstrated that the facility abuse prevention program was ineffective. This failure represented an immediate jeopardy and impacted at least 10 residents (1, 4, 11, 13, 15, 19, 20, 72, 84 and 90) and potentially placed all residents at risk for abuse and neglect. Findings include: The facility stated they followed the state's "Nursing Home Guideline, fourth edition, dated March 2006." The "Nursing Home Guidelines" and the Federal Regulation 42 CFR 483.13, which applies to resident protection, directs facilities to: "Develop and implement policies and procedures that include the seven components to control and/or prevent neglect and abuse: Screening, training, prevention, identification, investigation, protection and reporting. Abuse includes willful action or inaction that inflicts injury to a vulnerable adult. Neglect includes failure to provide services necessary to avoid physical harm or mental anguish. 1. Staff 1 was hired in 6/05/10 as a Nursing Assistant (NA). Staff 1 had been an NA since 7/18/09. Review of Staff 1's personnel file revealed Staff 1 had a documented history of alleged abuse and neglect and was allowed to continue working with residents, on the night shift until 1/07/11 and then the evening shift, until he was terminated on 3/14/11. On 12/02/10 Staff 1 performed a treatment beyond the scope of his NA practice. Staff 1 suctioned (the process of mechanically removing mucus from a persons mouth or throat) Resident 1. The facility policy for suctioning residents indicated the procedure was only to be done by a Licensed Nurse (LN). On 3/18/11 at 2:30 p.m., the Director of Nursing services (DNS) and the facility Administrator (ADM) reported Staff 1 had been educated and trained to report the need for suctioning to an LN. Staff 1 was informed to not suction any resident again. On 12/13/10 Staff 1 allegedly informed Resident 19 to urinate "in her diaper" instead of assisting her to the bathroom. In addition to telling the resident to just "pee in your diaper" , the resident stated Staff 1 purposefully placed her call light out of reach. The facility investigated the allegation of the call light but not the allegation of being told to "pee in your diaper". The investigation summary concluded Resident 19 had "changed her story" and the call light allegation was unsubstantiated. Staff 1 was informed to work on his "customer service." On 12/15/10 Staff 1 was issued a "verbal warning" for "not coming to work prepared." On 3/18/11 at 2:30 p.m., the ADM reported Staff 1 had been observed several times sleeping during working hours. The DNS reported the facility was concerned at that time because of "the sleeping and other staff concerns." On 12/21/10, Resident 11 reported Staff 1 handled her roughly and kisses her on the forehead and the cheek. Resident 11 stated " I don't want him to work with me and I just cringe every time I see him. " Resident 11 stated Staff 1 is very rough with her and hurts her when he changes her and her roommate screams when he changes her brief." An investigation was completed. The investigation summary concluded Resident 11 had "clarified the situation" and the allegation was unsubstantiated. The clarification made by Resident 11 was that Staff 1 doesn't routinely kiss her (i.e. "kisses" her but that he "kissed" her, meaning once). The allegation for Resident 11's roommate screaming was not investigated. Staff 1 was issued a "1st. written warning". Staff 1 was suspended for two days during the investigation. The "Course of Action" for the incident on 12/21/10, included: 1. "Make sure to take your time and let the resident's know what you are doing before you do it. 2. Make sure to follow resident rights and not show affection if it is unwanted and listen to your residents. 3. Make sure to respect the wishes of your residents, this is their home and they need to do as they wish. 4. Make sure to always come to work prepared so you can take your time and give good care." The "Current Incident Description" on the Action Form for 12/21/10 read "During our investigation we found several complaints by residents and associates of you going really fast during care and not telling the residents what you are doing ahead of time." Those complaints were not investigated. Staff 1 during his employment continued to work unsupervised even though he worked out of his scope of practice by suctioning a resident, resident complained of lack of dignity, not coming to work prepared, rough handling of residents, and unwanted sexual contact. One day after the allegation made by Resident 11 on 12/20/11, a nurses note in Resident 11's clinical record, dated 12/21/11, read "Resident told an NA that another NA had fondled her breast and touched her in places they are not suppose to. She didn't like anyone pawing her. Her mood was pleasant." This incident was not investigated. The facility was informed of the note on 3/18/11. On 3/18/11 the facility called into the State Complaint Hotline and reported Resident 11 had changed her story and the allegation "did not occur" and that the LN writing the note thought it was the same incident as being kissed. Resident 11 had been admitted into the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 1/25/11, indicated Resident 11 had clear speech and always understood conversations, had no memory problems, 100% recall and no behaviors. On 3/18/11 the ADM reported she relied on Resident 11 to "tell her what is going on in the facility." Staff 1 worked with Resident 11 nine more times after the allegation was made. The DNS reported, on 3/18/11 at 2:30 p.m., Staff 1 was moved from night shift to the evening shift on 1/07/11 because "some people never get used to night shift and we thought he might do better." On 3/01/11, disregarding possible injury for a resident, Staff 1 lifted Resident 72 off the floor after a fall and placed her back in her chair. There were no other witnesses to this incident. The facility policy was for a resident to be comprehensively assessed by an LN before being moved after a fall. This was the second time Staff 1 did not follow standards of practice for a nursing assistance. The staff member was provided education dispite the fact this was a repeat incident and continued to work with out supervision. On 3/18/11 at 2:30 p.m., the DNS and the ADM reported Staff 1 had been trained to never move a resident after a fall. The DNS and the ADM reported they did not know why Staff 1 thought he could move a resident alone. Staff 1 was educated after the incident to not move any other residents after falls. On 3/08/11 at 5:00 p.m., Staff 1 was observed to be arguing and cursing in the hallway with Resident 13. The investigation summary for the incident read "Resident was in the hallway and was very confused regarding his oxygen tubing and his (electric) wheelchair being plugged in. Staff 1 was overheard in the hallway arguing with the resident and cursing. An NA reported it to her supervisor but he remained in the facility for 2 more hours. On 3/08/11 at 5:30 p.m., Staff 1 was observed assisting Resident 20 with her meal. Resident 20 was totally dependent on staff for eating. Staff 1 was observed to "use his hand to force Resident 20's mouth open and did not allow her adequate time to rest between bites. At one point she began coughing and Staff 1 told her "not to start that". Staff 1 was overly forceful and wiped Resident 20's mouth with a wash cloth which made her lips red. Abuse substantiated." On 3/18/11 at 2:30 p.m., the ADM reported she was in the dining room on the evening of 3/08/11 and that Staff 1 was suspended immediately, "around 6:00 p.m." after the incident with Resident 20. The "time-card" punch out time for Staff 1 on 3/08/11 was 7:00 p.m., 1 1/2 hours after the witnessed abuse. The DNS and the ADM reported the facility had done direct supervision with other staff but had not considered having Staff 1 work with someone because he had several "great reports from residents about the care he provided." The DNS reported each case was reviewed independently. 2. Staff 2 was hired as an NA in 2009. Review of Staff 2's personnel file revealed Staff 2 had a documented history of allegations of abuse and/or neglect and was allowed to continue working with residents until she resigned on 12/21/10. On 3/11/10 Resident 90 reported Staff 2 had treated her roughly during care. Resident 90 stated "Staff 2 makes me nervous and I don't want her working with me." The investigation summary determined Staff 2 did assist Resident 90 and Staff 2 may have been misunderstood by Resident 90. Staff 2 was to have education about "customer service and perception training." Resident 90 was upset by the incident and Staff 2 was not to be assigned to work in her area again. Staff 2 reported "It was just a personality conflict between me and Resident 90. I did not touch her at all." The "Suspension Pending Investigation Form", dated 3/12/10, had "Termination" written for the question "Next corrective step if current performance event continues." On 4/06/10 Resident 84 reported Staff 2 had treated her roughly during care. Resident 84 stated "Staff 2 was alittle rough but has been better over the past couple of weeks. About 2 weeks ago I decided to change my approach and things have gotten better." The investigation summary read "Staff 2 had received education regarding dignity and customer service on 3/16/10. Conclusion: Unable to substantiate abuse as rough handling was not intentional and no harm was caused." The "Suspension Pending Investigation Form", dated 4/06/10, had "Termination" written for the question "Next corrective step if current performance event continues." On 7/13/10 Resident 4 reported Staff 2 had "hurt her feelings" after repeated stating Resident had not urinated on the commode. Resident 4 stated "I feel she talks down to me and rushes ...I don' t want to get anyone in trouble I just don' t want that girl anymore." Another staff member witnessed the situation and reported "Staff 2 was in Resident 4's room finishing helping her with the commode. Staff 2 seemed very flustered and kept saying Resident 4 would not pee...when Staff 2 left the room, Resident 4 told me that Staff 2 was too rough and mean and she acted like she didn't want to be there." The "Suspension Pending Investigation Form", dated 7/13/11, had "1st., 2nd., final" written for the question "Next corrective step if current performance event continues." The "Corrective Action Form", dated 7/16/11, read: 1. Always talk and treat the residents with dignity and respect. 2. Make sure you don't say anything that might hurt feelings. 3. Don't talk about resident care in the resident's room. 4. Always take your time with the residents. On 12/21/10 Resident 15 reported Staff 2 " Had gotten mean and rude and was mean and rude to my roommate. " The roommate of Resident 15 stated Staff 2 was " indifferent " while providing care. Resident 15 stated she was so depressed about having Staff 2 as a caregiver and that it makes her cry when Staff 2 cared for her. Staff 2 resigned after the incident on 12/21/10. Four residents complained about rough care and attitude and the facility didn't take steps to protect residents.

Based on observation, interview and record review, the facility failed to administer services effectively and efficiently in order to attain, and/or maintain, each resident's optimal physical, mental and psychosocial well-being. This failure resulted in harm for three residents and placed the other residents at risk for abuse, neglect and a decreased quality of care. Findings include: 1. Administration failed to ensure the facility implemented written abuse prevention policies and procedures and failed to take immediate action to protect residents during and after investigation of allegations of abuse and neglect. This failure demonstrated that the facility's abuse prevention program was ineffective and represented an immediate jeopardy, impacting at least 10 residents and potentially placing all residents at risk for abuse and neglect. Refer to F226-Abuse policies and procedures-develop and implement 2. Administration failed to ensure the facility consistently provided needed oral care for 2 dependent residents. This resulted in harm for one resident, who experienced tooth decay/inflamed gums and left the other resident a risk for decline in her dental status. Refer to F312-ADL-Dependent resident receives services 3. Administration failed to ensure the facility provided adequate supervision and maintained an environment that was as free as possible from accident hazards for 2 residents. This failure resulted in harm for one resident related to repeated falls with injuries and repeated skin injuries for the other resident. Refer to F 323-Accidents and supervision 4. Administration failed to ensure the facility developed a comprehensive plan of care for unintended weight loss prevention and monitored the the meal and nutritional supplement intake for 2 residents. This resulted in harm for one resident, who experienced an avoidable significant weight loss and may have contributed to significant weight loss for the second resident. Refer to F 325-Maintain nutrition status unless unavoidable

Based on observation, interview and record review, the facility failed to provide services to maintain oral hygiene for 2 of 2 (20 and 57) residents reviewed for dental services. The failure to consistently provide, and/or monitor for the provision of, oral care for Resident's 57 resulted in harm as it led to tooth decay and inflammed gums and left Resident 20 at risk for dental issues. Findings include: 1. Resident 57 was readmitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 57 had no speech, was sometimes understood in conversations, had some memory problems, some recall and was moderately impaired in her decision making abilities. Resident 57 required extensive assistance with all of her daily care, used a wheelchair for mobility and was on an altered diet with thickened liquids, including juices. Resident 57 was [AGE] years old and per her family, she was admitted to the facility without any cavaties. On 4/12/10, Resident 57 went to the dentist. The dental report indicated "excessive plaque build up, very poor hygiene and multiple cavities noted." The recommendation was for brushing and flossing twice a day. On 11/29/10, Resident 57 went to another dentist appointment with a different dentist. The dental report indicated "..found significant amount of tooth decay both in her mouth exam and on Xray. She presented with severe inflammation of her gum tissue and heavy deposits of plaque and tartar on her teeth..It is extremely important for you, as primary caregivers, to focus on seriously improving her oral homecare. If you do not do so, it is in no uncertain terms neglect of your resident... We provided toothpaste with extra [MEDICATION NAME] and an electric toothbrush...do your best to floss. Resident 57 has had multiple teeth that have required very large restorations. As soon as her treatment is complete, maintenance and prevention become the focus." The Care Plan for Resident 57,dated 8/10/10, instructed staff to: 1. Use electric toothbrush and Prevident (special) toothpaste. 2. Be sure to brush gum line and tongue. 3. Floss teeth at least once per day. On 3/18/11 at 10:30 a.m., Nursing Assistant 1 (NA1) reported Resident 57 got her teeth brushed with the electric tooth brush and the Prevident tooth paste after every meal. When asked how she knew that, NA 1 reported the information was on the daily "Care Guide" used by NA's to direct care. The "Care Guide" for that day did not have any directions for oral care for Resident 57. NA 1 reported she knew what to do because she knew the resident so well. On 3/15/11 Resident 57 was observed from 11:55 p.m. before lunch to 3:45 p.m. and no oral care occurred. On 3/16/11 after breakfast Resident 57 was observed until 10:45 a.m. and no oral care occurred. The "Monthly Flow Report of Teeth Brushed" (RITA) for Resident 57 during the months of January, February and March of 2011, showed that out of 225 opportunities to brush her teeth, 61 times were documented as done and 164 times were blank. On 3/18/11 at 10:42 p.m., the Residential Care Manager (RCM) for Resident 57 was asked who was responsible for monitoring the RITA documentation, or the actual tooth brushing, to ensure Resident 57 received the service required, and she reported she wasn't sure, "maybe the cart nurses." On 3/18/11 at 12:20 p.m., Licensed Nurse 5 (LN 5), the "cart nurse" for Resident 57, reported she "sometimes sees Resident 57 at the sink with the NA's after breakfast" but doesn't look after lunch. When asked if Resident 57 got her teeth flossed, LN 5 replied "I don't know". LN 5 reported Resident 57 had a family member come in at night to help her with her teeth. On 3/21/11 at 4:30 p.m., Resident 57's family member reported she came every night but sometimes Resident 57 was already in bed when she got there. The family member reported "last night I came and her electric tooth brush was dry. I asked the NA if she had brushed her teeth and she said yes. I told her the tooth brush was dry and the aide responded she had "dry brushed" her teeth." The family member reported Resident 57 had no cavities when she was admitted into the facility. On 3/18/11 at 1:00 p.m., another family member reported it's "hit or miss" when asked if Resident 57 received oral care. The family member reported "we know we are the only ones who do it on some days". The family member reported Resident 57 took thickened liquids and the sugars "really stick to her teeth". When asked if the facility assisted Resident 57 in getting dental services, he reported "No. We always found her dental care services. It was very difficult but we had to." Record review of Resident 57's clinical record revealed no social service documentation regarding the arrangement of dental services. On 3/18/11 at 2:50 p.m., the Director of Nursing services reported the social services department was not involved in obtaining dental services for Resident 57 but that "her family always made the arrangements...they are on me all the time about it." 2. Resident 20 was admitted [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. A review of Resident 20 ' s minimum data set assessment (MDS), dated [DATE], revealed that the resident was severely cognitively impaired and required one person assistance for all of her activities of daily living such as eating, dressing, and grooming. In an interview with Resident 20 on 3/11/11, at 11:50 a.m. , she stated that staff brushed her teeth weekly, not daily. On 3/14/11 at 10:05 a.m., the residents spouse stated, he usually brushed the resident ' s teeth each day after breakfast and lunch because he was not sure it was getting done. " I even bought an electric brush to help." On 3/14/11, at 2:30 p.m., Staff 7 stated, she brushed the resident's teeth when she came back from the dining room. When she worked evenings, she brushed them before resident went to bed and that she documented this in the "RITA", which was the facility's electronic documentation of care provided by caregivers each shift. On 3/15/11 at 9:30 a.m., in an interveiw with resident's spouse, he stated, he did not think the resident's teeth had been brushed " today " . He further stated, " Yesterday when I brushed her teeth I got blood, I don ' t think they are brushing her teeth. " Upon asking the resident whether or not her teeth had been brushed, she stated said "yes" however, resident was noted to have a strong foul mouth odor. Review of the facility's documentation from the " RITA " regarding teeth brushing and mouth care given, found many holes in the documentation for Resident 20's oral care. For the month of February 2011, caregivers documented that Resident 20's teeth had been brushed only seven times during the day shift and nine times on the evening shift. For March 1 - 16th, 2011, documentation indicated the resident's teeth had been brushed only three times on the day shift and three times on the evening shift.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free as possible from accident hazards for 2 of 4 residents (132 and 13) reviewed for accidents. The failure to comprehensively assess accident hazards, to develop an effective care plan, to implement appropriate interventions, to evaluate and revise those interventions and to protect residents from further injury resulted in harm related to repeated falls with injuries for Resident 132 and skin injuries for Resident 13. Findings include: 1. Resident 132 was admitted on [DATE] following a fall resulting in a fractured arm and lumbar spine. Resident 132 had [DIAGNOSES REDACTED]. Resident 132 required extensive 1 person assistance with transfers, dressing and personal care. She required moderate one person assistance with bed mobility and walking. Resident 132 was not stable without one person assistance when balancing. A "Fall Risk" assessment, dated 9/27/10, indicated Resident 132 was at risk for falls. A Progress Note (PN) in Resident 132's clinical record, dated 9/15/10, the day she was admitted , indicated she had personal safety deficits with safety interventions in place at her previous residence. The interventions included a chair alarm, a bed "pressure sensitive" alarm, and a low bed placed close to the bathroom. There were multiple PN entries regarding safety concerns with Resident 132: On 9/17/10 (night shift): "Resident 132's roommate turned her call light on so Resident 132 could get help. I don't know why she's not turning her call light on.." On 9/29/10 (night shift): "Resident alert and pleasant, knows how to take off the personal alarm away from her body. Caught her attempting to use the bathroom by herself. Her gait is not very steady even if she uses a cane. Advised resident that we are concerned she is going to fall and she should use her call light for assistance." On 10/03/10 (night shift): "Prefers to do activities on her own but strongly encouraged her to call for help." Resident 132 was not using her call light for assistance, was removing her personal alarm and frequently went to the bathroom on her own, especially at night. An "Incident Follow-up & Recommendation Form" (IR), dated 10/4/10 at 3:30 a.m., read: "Resident removed her personal alarm and fell from her low bed onto her mat on the floor. She was assessed and not hurt." A PN, dated 10/04/10 (night shift), read: "It finally happened. Resident didn't have her personal alarm on. Somebody forgot it on her wheelchair. Resident had a fall and was found laying on the floor sideways...Her roommates said they heard her but didn't really see how she fell . All they heard was the resident kept saying "Help me. The floor is very cold." A PN, dated 10/05/10 (night shift), read: "Restorative placed a mat next to her bed." The IR for the fall asked staff "What immediate actions were taken to provide safety for the resident?" The IR reported "Will place a mat beside the resident bed. Make sure she uses the call light and not able to take off her personal alarm." This IR did not reflect the same information found in the PN for the night shift. The Licensed Nurse (LN) on duty documented staff had not attached the alarm, not that the resident had removed the alarm. The IR did not address the inconsistencies related to whether or not the resident had a mat in place at the time of the fall. Resident 132 had 2 more falls on 11/08/10 at 12:30 a.m. and 4:00 a.m.. On 11/07/10 at 9:00 p.m., a PN indicated Resident 132 remained "non-compliant with poor safety awareness" and continued to get up on her own without using the call light. An IR, dated 11/08/10 12:30 a.m., read: "Resident found lying on the floor next to her bed by the Nursing Assistant (NA). Lacerations to head were sustained." The facility was informed by emergency services to call again for transport to the hospital if the bleeding did not stop. A PN, dated 11/08/10 (night shift), indicated Resident 132 was holding her alarm when she was found on the floor and that it was off. The PN explained Resident 132 got up on her own again after the fall and that staff "encouraged her to use her call light." The IR did not address if the resident's alarm had been on and sounding, if Resident 132 had removed or turned off the alarm, if there had been a mat in place or if a mat was an effective intervention or possibly a trip hazard. The IR did not address the effectiveness of encouraging the resident to use the call light when the facility had determined the resident frequently didn't use the call light to get assistance. The IR summary read: "I interviewed the resident but she was unable to recall what happened. Conclusion: No abuse or neglect." The interventions that remained in place were: 1. Hi low bed in lowest position. 2. Fall mat at bedside. 3. Keep room free from clutter. 4. Keep personal belongings within reach. 5. Keep call light within reach. 6. Assist of one person for transfers. 7. Educate resident on the importance of asking for help. 8. Hip protector waiver signed. 9. Chair alarm when in wheelchair. 10. Bed alarm when in bed. 11. Glasses prior to getting out of bed. 12. Frequent safety checks to reduce falls. 13. Remind resident to use her call light. 14. Monitor and encourage use of proper footwear. Another IR, later the same night, dated 11/08/10 at 4:00 a.m., read: "Resident had a fall in her room and re-opened the laceration to her head. Pressure was applied and the resident was transferred to the hospital. She was readmitted with previous interventions in place." The IR summary for the fall indicated Resident 132 had gotten up on her own again before the second fall and staff had assisted her back to bed and given her the call light and "instructed on the importance of using it for assistance." The alarm was on and functional. Within a few minutes the LN was informed Resident 132 had fallen again and was bleeding from her head. Resident 132 was holding the alarm in her hand. The IR did not address if the fall mat was in place or if the alarm had sounded when the resident was found on the floor. No documentation was found to indicate the facility had assessed why Resident 132 was getting up so frequently at night to urinate, how physical or occupational therapies had been included in assesing her falls, or how increased supervision, including a toileting schedule, might have been an appropriate intervention. The Plan of Care and interventions did not change from the fall at 12:30 a.m.. The facility failed to implement different interventions even thought staff had the knowledge Resident 132 could remove, or turn off, her personal alarm. The "Emergency Department Discharge Record", dated 11/08/10 at 7:25 a.m., read: "Can not totally exclude a non-displaced fracture of the elbow. There is a fracture of the left cheek bone. Does not require surgery. There is blood in the underlying sinus and she requires antibiotics to prevent infection." After the falls on 11/08/10, Resident 132 continued to get up on her own and to turn off the alarm. PN's include: 11/10/10 (night shift): "Resident's mat was not placed next to her bed and was folded against the wall. Her pressure alarm was turned off. Replaced her pressure alarm and it alerted us that the resident was attempting to get up on her own." 1/05/11 (night shift):"Resident got up for toileting but her pressure alarm was off. Just happens we were in the room for her roommate. Resident has an unsteady gait and needs to be held and assisted." 1/06/11 (night shift): "Resident keeps on getting up because of her roommates emotional outbursts..she is weak and has an unsteady gait." 1/14/11 (night shift):"Resident continues to sneak out to the bathroom by herself. Alarm working good but by the time we walk to the resident's room she is already in the bathroom. On 2/13/11 at 2:00 a.m., Resident 132 attempted to use the bathroom by herself, fell and hit her head on the floor. Resident 132's alarm was sounding but the resident was already in the bathroom and on the floor before staff could reach her. Only after the fall on 2/13/11 did the facility implement a more frequent toileting schedule, every two hours, for Resident 132. On 2/24/11 at 6:50 a.m., Resident 132 fell again in the bathroom and had injuries to her head and wrist. She was found on the floor and transferred to the hospital. Resident 132 required 5 staples for her head wound. The IR for this fall recommended: "Different sensor pad for bed that does not require turning on or off". The IR did not reevaluate the effectiveness of the alarm, determine if it had sounded before the fall or if assistance every two hours was sufficient. PN's on 2/25/11 at 1:45 a.m. and 2/26/11 at 2:00 a.m., indicated Resident 132 continued to get up on her own even though she was assisted to the toilet every 2 hours. During the day time observation period between 3/10/11 and 3/22/11, Resident 132 was noted to be either in her wheelchair with her alarm in place or in bed with the alarm and fall mats in place. Six months (from 9/29/10 to 3/22/10) after the facility staff had recognized alarms were ineffectual for the resident because she either turned the alarm(s) off, the alarm(s) were not consistantly placed on her or her bed, or by the time facility staff responded to the alarm the resident had already fallen, they failed to reevaluate the interventions and to implement protective measures including appropriate supervision. On 3/18/11 at 3:30 p.m., the Director of Nursing services (DNS), the Assistant DNS and the Administrator had no further information to add when asked how abuse and/or neglect was ruled out, what interventions were put in place and revised to prevent further injury, when or if increased supervision was considered with Resident 132 or why the state hotline had not been notified about an unwitnessed fall with a significant injury. The DNS reported the interventions currently in place were every 2 hour toileting and frequent safety checks. The DNS did not offer a description of the expected timing for "frequent" observation. 2. Resident 13 was admitted [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. According to the resident's minimum data set assessment (MDS), dated [DATE], he required one person assistance for transfers and limited staff assist to provide guided maneuvering of his limbs. He had poor memory and recall. On discharge paperwork from hospital on [DATE], it was documented that resident had " prednisone skin ". Resident 13's daily medications included Prednisone 10 mg, Coumadin 2.5 mg and Aspirin 81 mg. A nurse's note, dated 3/2/11, documented the resident ran his wheelchair into meal cart and got a skin tear to his hand. The weekly care management review form, dated 3/9/11, documented that the resident had multiple skin tears on his arms from " running into things ". Preventive measures to protect the resident from injurying himself were not assessed or careplanned. On 3/10/11 at 10:37 a.m., the resident was observed wearing short sleves and had multiple areas of bruising at various stages of healing to his arms and hands and a skin tear on his hand. The resident was observed sitting in his electric wheelchair slumped over. When the resident was asked what happed to his arms and hands, he stated he was always hitting something. On 3/11/11, the resident was observed with wraps on both arms from his hands to just past the elbows. This intervention was not listed on the careplan. On 3/14, 3/15, 3/16 and 3/18/2011 Resident 13 was observed wearing short sleeved shirts and had no wraps on his arms. The resident was up in his electric wheelchair, operating it in a jerky fashion. Review of Resident 13's careplan revealed the resident was assessed as being at risk for injury due to falls and at risk for skin breakdown due to pressure. The risk for skin tears and/or other injuries related to the resident running into things was not addressed on the careplan, By not addressing this issue on the careplan, the direct caregivers did not have a plan in place to follow help prevent further injury to the resident and injuries continued to occur as noted above. On 3/14/11 at 2:30 p.m., LN 1 was asked how often a careplan was updated. She stated it was done quarterly by the nurse who did the MDS assessments, unless there was a fall or a significant change of condition. LN 1 stated, the careplan had not been updated to reflect Resident 13's current condition and precautions had not been put into place to protect the resident ' s skin on his arms and legs from trauma.