Every finding on record at Lynnwood Post Acute Rehabilitation Center

Based on interview and record review, the facility failed to prevent physical abuse for 1 of 3 residents (Resident 1), reviewed for abuse investigations. Resident 2 walked over to Resident 1 and placed their hands and pushed inward around Resident 1's neck. This failure placed residents at increased risk of injury, emotional distress, and a diminished quality of life.Findings included .RESIDENT 1Review of the quarterly Minimum Data Set (MDS - a required assessment tool) dated 03/29/2026, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis list that included muscle weakness. The MDS further showed Resident 1 did not have impaired thinking or memory and required assistance for all mobility and transfers.RESIDENT 2Review of the quarterly MDS dated [DATE], showed Resident 2 was admitted to the facility on [DATE] with a diagnosis list that included anxiety (an emotion characterized by feelings of tension and worried thoughts). The MDS further showed the resident did not have impaired thinking or memory and could transfer and walk independently.Review of an incident investigation report dated 05/06/2026, showed Resident 2 shared a room with Resident 1, raised voices were heard coming from their room that escalated into a verbal exchange. The report further showed the assigned nurse entered the room and seen Resident 2 leaving Resident 1's side of the room, returning to their own side of the room. Resident 1 reported that Resident 2 placed their hands around their neck. Resident 2 stated that they did put their hands around Resident 1's neck because of the way Resident 1 treated and spoke to staff. The incident investigation report further showed the residents were placed in separate rooms and Resident 2 was monitored by staff until law enforcement removed Resident 2 from the facility. Resident 1 was assessed for pain/injury, and none were found.In an interview on 05/18/2026 at 2:13 PM, Resident 1 stated, we were just shooting the breeze, like we have done so many times before, I was laying in my bed when Resident 2 got up from their bed and ran over to my side of the room and put both of their hands around my neck, they started choking me. They pressed long enough and hard enough for me to start having trouble breathing. I think Resident 2 heard someone coming to the room, that is when they stopped and started to go back to their side of the room. The law enforcement came and talked to me about it; they took pictures of my neck and showed me the finger prints and red marks around my neck that were caused by them choking me. I did have a little bit of pain for a little while after it happened, but it went away. I could not sleep for about a week. I have no way of protecting myself, I can barely move without help. I would lay awake thinking Resident 2 would come back and finish the job. I was scared because I cannot defend myself against something like that.In an interview on 05/20/26 at 12:59 PM, Staff C, Certified Nursing Assistant (CNA), stated there were different types of abuse, and if a resident went over to another resident and put their hands around their neck and started to choke them, that would be considered physical abuse.In an interview on 05/20/2026 at 1:12 PM, Staff D, CNA, stated that if a resident hit another resident or if a resident went over to another resident and put their hands around their neck and started to choke them, that would be called abuse.In an interview on 05/20/2026 at 1:23 PM Staff E, Licensed Practical Nurse, stated, I was standing at my medication cart in the hall by Residet 1's and Resident 2's room, I heard a lot of commotion and loud voices, so I went to their room. When I entered the room, I saw Resident 2 leaving from Resident 1's side of the room. Resident 1 told me they were talking with Resident 2, then Resident 2 came over and put their hands around their neck and started to choke them. Staff E stated that Resident 2 stated that they did place their hands around Resident 1's neck. Staff E stated Resident 1 was seen in their bed when they saw Resident 2 walking away from Resident 1's side of the room. Staff E stated Resident 1 was dependent on staff for transfers and mobility and that Resident 2 could walk independently. Staff E further stated that it was physical abuse when Resident 2 went over to Resident 1 and placed their hands around their neck and started to choke them.In an interview on 05/20/2026 at 2:08 PM, Staff B, Director of Nursing Services, stated that when Resident 2 willfully went over to Resident 1 and placed their hands around Resident 1's neck and started to press down [choke them] that was physical abuse.Reference: (WAC) 388-97-0640(1).

Based on interview and record review, the facility failed to ensure the survey binder included the recertification and complaint survey results that resulted in citations for 2 of 3 years (2024 & 2025), reviewed for availability of survey reports. This failure prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of corrections.Findings included .Review of the Survey Binder, on 07/02/2025 at 2:50 PM and on 07/03/2025 at 10:48 AM, showed that the binder did not contain the recertification and complaint surveys that resulted in citations during the three preceding years. Further review showed the recertification survey results and the associated plan of corrections dated 07/22/2024 and complaint survey results and the associated plans of corrections dated 08/16/2024 and 03/19/2025 were not included in the survey binder.In an interview and joint record review on 07/03/2025 at 11:22 AM, Staff A, Administrator, stated that they were responsible for updating the Survey Binder. Staff A further stated that they had been in the facility for the last two years and that when they get a survey and complaint results, they will add them to the binder. A joint record review of the Survey Binder, showed that it did not contain the recertification survey results and associated plan of corrections dated 07/22/2024 and complaint survey results and associated plans of corrections dated 08/16/2024 and 03/19/2025. Staff A stated they should have been included in the Survey Binder.Reference: (WAC) 388-97-0480 (1) (a-c) (2) (a-b) (4).

Based on observation, interview, and record review, the facility failed to develop and/or implement care plans for 4 of 10 residents (Residents 22, 7, 2 & 5) reviewed for comprehensive care plans. The failure to develop and/or follow care plans for conducting an assessment, medication use, and splint usage placed the residents at risk of not receiving needed care, decline in condition, and a diminished quality of life. Findings included . Review of the facility’s policy titled, “Comprehensive Person-Centered Care Planning,” revised in August 2017, showed that the facility interdisciplinary team would develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a residents’ medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. ASSESSMENTRESIDENT 22Review of the comprehensive care plan printed on 07/02/2025 showed that the psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication care plan had an intervention that Resident 22 would have an Abnormal Involuntary Movement Scale (AIMS-a 12-item observer-rated scale developed to assess the severity of tardive dyskinesia [TD-a movement disorder that can develop due to use of antipsychotic [mind altering] medications, typically not reversible]) and follow its progression over time) assessment completed. Review of the electronic medical records (miscellaneous/documents and assessments tabs) from 06/05/2025 to 07/01/2025 did not show that an AIMS assessment was completed for quetiapine (an antipsychotic) medication use for Resident 22. Review of the June 2025 Medication Administration Record (MAR) showed Resident 22 had an order for quetiapine 25 milligrams (unit of measurement) tablet once a day for Lewy Body Dementia (progressive form of dementia [memory loss] that affects a person's ability to think, reason, and process information). In an interview and joint record review on 07/08/2025 at 11:45 AM, Staff C, Resident Care Manager, stated that AIMS assessments were completed upon resident’s admission to the facility or prior to resident’s starting antipsychotic medication, and then quarterly. A joint record review of the June 2025 MAR showed Resident 22 had an order for quetiapine. Staff C stated that Resident 22 started the quetiapine on 06/06/2025. A joint record review of Resident 22’s psychotropic care plan showed an AIMS assessment should be done. A joint record review of assessments tab did not show that an AIMS assessment was completed. Staff C stated that Resident 22 did not have an AIMS assessment and that there should have been one completed on admission. A joint record review and interview on 07/08/2025 at 5:13 PM with Staff B, Director of Nursing, showed that Resident 22 did not have an AIMS assessment. Staff B stated that Resident 22’s care plan had an intervention for AIMS assessment to be completed and that they should have had one completed upon admission. MEDICATION USERESIDENT 7Review of the May 2025 to July 2025 MAR showed Resident 7 had orders for a diuretic (medication that reduces fluid buildup in the body and increases urine output) and anticoagulant (medication that prevents or reduces blood clot [mass that forms when blood hardens from a liquid to a solid] daily, dated 05/22/2025. Review of the admission Minimum Data Set (MDS - an assessment tool) dated 05/28/2025 showed Resident 7 were marked for anticoagulant use in Section N0415E and diuretic use in Section N0415G. Review of the comprehensive care plan printed on 07/01/2025 did not show Resident 7 had a care plan for diuretic and anticoagulant use. During an interview and joint record review on 07/08/2025 at 11:49 AM, Staff C stated that resident’s use of diuretic and anticoagulant medications should be in care plan. A joint record review of Resident 7’s comprehensive care plan did not show a care plan for diuretic and anticoagulant use. Staff C stated that Resident 7 should have had care plans for diuretic and anticoagulant use. In an interview on 07/08/2025 at 5:15 PM, Staff B stated they expected a care plan for residents taking diuretic and anticoagulant medications. Staff B further stated that Resident 7 had no care plan for diuretic and anticoagulant use and that they should have. RESIDENT 2Review of Resident 2’s face sheet printed on 07/01/2025, showed they were admitted to the facility on [DATE] with a diagnosis that included diabetes (a condition that affects the level of sugar in the blood). Review of the physician’s orders printed on 07/01/2025, showed Resident 2 was prescribed insulin (medication that lowers the level of glucose [a type of sugar] in the blood) injection routinely since 03/26/2025. Review of the comprehensive care plan printed on 07/01/2025, showed Resident 2 had no care plan for diabetes or insulin. In an interview and joint record review on 07/07/2025 at 10:56 AM, Staff O, Licensed Practical Nurse, stated Resident 2 had a diagnosis of diabetes and received insulin injections. A joint record review of Resident 2’s comprehensive care plan showed no care plan for diabetes and insulin. Staff O stated they did not see a diabetes or insulin care plan for Resident 2 and that there should have been. In an interview and joint record review on 07/08/2025 at 3:00 PM, Staff C stated Resident 2 had diabetes and insulin injection orders. A joint record review of Resident 2’s comprehensive care plan showed a diabetes care plan was started on 07/08/2025. Staff C stated that Resident 2 should have had a diabetes care plan prior to 07/08/2025. In an interview on 07/08/2025 at 4:30 PM, Staff B stated that they expected Resident 2’s diabetes care plan to have been implemented (prior to 07/08/2025). RESIDENT 5Review of the annual MDS dated [DATE] showed Resident 5 had impairment on both sides of their upper and lower extremities. Review of the facility’s document titled, “Occupational Therapy Evaluation and Plan of Treatment,” dated 04/03/2025, showed that Resident 5 had a diagnosis of “contracture [a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff] of muscle, right upper arm.” Review of the limited physical mobility care plan printed on 06/30/2025, showed an intervention for Resident 5 for “Right elbow extension and right resting hand orthotic [splint] for 6-8 [six to eight] hours daily during the day.” Multiple observations on 06/30/2025 at 9:50 AM and at 1:39 PM, on 07/01/2025 at 9:22 AM, on 07/02/2025 at 9:23 AM and at 11:45 AM, on 07/03/2025 at 10:13 AM and at 1:53 PM, and on 07/07/2025 at 9:32 AM and at 12:09 PM, showed Resident 5 was not wearing the right hand/elbow splint. In an interview and joint record review on 07/07/2025 at 12:14 PM, Staff U, Certified Nursing Assistant (CNA), stated that aides were responsible for putting on splints for residents and “we chart when we put them on.” A joint record review of the Kardex (CNA care plan) showed an intervention for Resident 5, “Right elbow extension and right resting hand orthotic for 6-8 hours daily during the day.” A joint observation showed that Resident 5 did not have any splints on their right hand or elbow. Staff U stated they would look for the splint and put it on the resident. In an interview and joint record review on 07/07/2025 at 2:07 PM, Staff L, Registered Nurse, stated that “the morning shift, the aide usually,” was responsible for placing splints for Resident 5. A joint record review of the limited physical mobility care plan, showed an intervention for Resident 5, “Right elbow extension and right resting hand orthotic for 6-8 hours daily during the day.” Staff L stated that “I don’t [do not] see the splint on evening shift” and “I don’t see the splint in the afternoon when I start at two [2:00 PM].” Staff L stated that the care plan should have been followed. In an interview and joint record review on 07/08/2025 at 9:44 AM, Staff C stated that they expected staff to follow resident care plans. Staff C stated that “therapy” was responsible for putting a care plan in place for splint use and “nursing staff [was] responsible for carrying it [placing splints] out.” A joint record review of the limited physical mobility care plan, showed an intervention for Resident 5 for, “Right elbow extension and right resting hand orthotic for 6-8 hours daily during the day.” Staff C stated that they expected staff to be placing the splint for Resident 5. In an interview and joint record review on 07/08/2025 at 5:41 PM, Staff B stated that they expected staff to follow resident care plans. A joint record review of the limited physical mobility care plan, showed an intervention for Resident 5, “Right elbow extension and right resting hand orthotic for 6-8 hours daily during the day.” Staff B stated that they expected staff to apply splints for Resident 5 if the care plan said to do so. Reference: (WAC) 388-97-1020(1), (2)(a)(b) .

Based on observation, interview, and record review, the facility failed to ensure appropriate pharmacy services for medication administration and/or disposal for 4 of 6 residents (Residents 40, 6, 162, & 36), reviewed for medication administration and storage. The failure to follow physician's orders and disposal of controlled substances (a drug or other substance that is tightly controlled as it may be abused or cause addiction) placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings included . Review of the facility’s policy titled, “Administration Procedures for all Medications,” dated May 2022, showed the facility policy was, “To administer medications in a safe and effective manner.” The policy further showed staff should review the five rights three times; prior to removing the medication from the cart/drawer check the Medication Administration Record (MAR) for the order, and checking prior to removing the medication from the container, and after the dose has been prepared. Review of the facility’s policy titled, “Vials, Ampules, and Pens of Injectable Medications,” dated May 2022, showed, “Vials, ampules, and pens of injectable medications are used in accordance with the manufacturer’s recommendations or the provider pharmacy’s directions for storage, use, and disposal.” Review of the online manufacturer’s recommendations document titled, “Instructions for use Insulin Lispro [rapid-acting form of insulin [a hormone/medication] widely used to manage high blood sugar in individuals with diabetes (chronic disease where the body does not produce enough insulin or cannot properly use the insulin it produces, leading to high blood sugar levels)] …,” revised July 2023, showed, the insulin pen should be primed before each injection and that priming the pen meant removing air from the needle and cartridge. The document further showed if priming did not occur before each injection, the resident could receive too much or too little insulin. MEDICATION ADMINISTRATION RESIDENT 40 Review of Resident 40’s physician orders printed on 07/01/2025, showed an order for Docusate Sodium (medication for constipation [a problem with passing stool]) oral capsule 100 milligrams (mg- a unit of measurement), to give two capsules by mouth two times a day for constipation. The physician orders further showed an order for Magnesium Oxide (a mineral supplement) oral tablet 400 mg, to give two tablets by mouth one time a day for low magnesium level. Observation and interview on 07/01/2025 at 7:54 AM, showed Staff Q, Registered Nurse (RN), poured in a medication cup two Docusate Sodium 100 mg tablets (instead of thecapsules) and one Magnesium Oxide 400 mg tablet (instead of the two tablets) as ordered for Resident 40. Staff Q walked inside Resident 40’s room and stated they were ready to give these medications to Resident 40. A joint record review and interview on 07/01/2025 at 8:02 AM, with Staff Q, showed an order for two Docusate Sodium 100 mg capsules, and two Magnesium Oxide 400 mg tablets. Staff Q stated that prior to administering the medication they should check to see if they have the right medication, dose, route, and would follow the physician order. Staff Q stated that they did not have Docusate Sodium 100 mg capsules in supply and that they used tablets. Staff Q stated that if a medication was not in supply, they should notify the facility and the provider. Staff Q further stated they should have given two Magnesium Oxide 400 mg tablets instead of one. RESIDENT 6 Review of Resident 6’s physician orders printed on 07/01/2025, showed an order for Aspirin (used to lower the risk of heart attack, stroke [blockage of blood supply to the brain], or blood clot [a mass that forms when blood hardens from a liquid to a solid]) Low Strength oral tablet Chewable 81 mg. Observation and interview on 07/01/2025 at 8:56 AM, showed Staff N, RN, poured an Aspirin Enteric Coated (designed to dissolve in the small intestine, potentially reducing stomach irritation) 81 mg tablet in a medication cup (instead of the chewable form) as ordered for Resident 6. Staff N walked inside Resident 6’s room and stated they were ready to give the medication to Resident 6. A joint record review and interview on 07/01/2025 at 8:56 AM with Staff N, showed Resident 6 had a physician order for a chewable Aspirin 81 mg tablet. Staff N stated that prior to medication administration they should check to ensure they had the right resident, medication, route, dose, and time. Staff N stated that they were expected to follow the physician orders. Staff N further stated they prepared an enteric coated aspirin for Resident 6, and they should have given a chewable aspirin tablet. On 07/08/2025 at 9:44 AM, Staff C, Resident Care Manager, stated that prior to administering medication staff should check the rights of medication including right medication, resident, dose, time, and route. Staff C stated Staff Q should have rechecked the orders for Resident 40 and given two tablets instead of one [Magnesium Oxide 400 mg tablet], and that Staff Q should have obtained an order for Docusate Sodium tablets as the facility no longer had Docusate Sodium capsules. Staff C further stated Staff N should have given Resident 6 the “correct form” of the medication (Aspirin 81 mg chewable tablet). RESIDENT 162 Review of Resident 162’s physician orders printed on 07/01/2025, showed an order for Humalog Solution (a brand, Insulin Lispro) to inject per sliding scale (a method of adjusting insulin dosage based on blood glucose levels) before meals and at bedtime. Observation and interview on 07/01/2025 at 11:19 AM, showed Staff C, prepared Resident 162 four units of lispro insulin without priming the pen. Staff C walked inside Resident 162’s room and stated they were ready to give Resident 162 their insulin. Staff C stated they did not prime the insulin pen. Staff C further stated the insulin pen needed to be primed to “make sure the insulin is ready to administer,” and to “make sure I don’t [do not] allow air to go in.” In a phone interview on 07/07/2025 at 9:08 AM, Staff V, Pharmacist, stated that an insulin pen should be primed two units per prime, and that this was important to make sure the resident received the full dose, and to remove any air bubbles. On 07/08/2025 at 4:56 PM, Staff B, Director of Nursing, stated they would expect nursing staff to check all the medication rights. Staff B stated nursing staff were not supposed to make errors and that they needed to follow the physician orders. Staff B further stated they expected staff to follow their medication administration policy, and that if the policy said to follow manufacturer recommendations, they would expect their staff to do so. CONTROLLED SUBSTANCE DISPOSALRESIDENT 36Review of the facility’s policy titled, “Controlled Substance Disposal,” dated May 2022, showed that “The director of nursing, in collaboration with the consultant pharmacist, is responsible for the facility’s compliance with federal and state laws and regulations in the handling of controlled medications.” It showed that controlled medications were “destroyed in the presence of two licensed nurses” and that “Disposition is documented on the individual controlled substance accountability record/book.” It further showed that the information entered on the “individual controlled substance accountability record/book” included “signatures of witnesses.” A joint observation and interview on 07/03/2025 at 1:35 PM with Staff R, Licensed Practical Nurse (LPN), showed the controlled substance book for the Sound Medication Cart, a page for Resident 36’s oxycodone (a controlled pain medication) 5 (five) milligrams (a unit of measurement) had been discontinued, and 35 tablets of oxycodone were destroyed on 06/30/2025. It further showed one witness signature to the destruction of oxycodone. Staff R stated that there was one signature and could not tell whose signature it was, and the second witness line/space was blank. In an interview on 07/08/2025 at 9:44 AM, Staff C stated that the process to dispose of controlled substances was that either two RNs or one RN and one LPN would witness the destruction and “both of them would sign the narcotic [controlled substance] book.” Staff C further stated that the controlled medication book should “be signed by two witnesses.” In an interview on 07/08/2025 at 5:41 PM, Staff B stated that controlled substances were disposed of “always by two witnesses.” Staff B stated that they had “failed to sign that page” for the destruction of Resident 36’s oxycodone. When asked if the controlled medication log had been signed by two witnesses, Staff B stated, “no.” Reference: (WAC) 388-97- 1300 (1)(b)(i)(c)(ii)(3)(a)

Based on interview and record review, the facility failed to ensure adequate monitoring was conducted for use of insulin (medication that lowers the level of glucose [a type of sugar] in the blood) and/or diuretic (medication that reduces fluid buildup in the body and increases urine output) for 3 of 5 residents (Residents 2, 23 & 7), reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, related complications, and a diminished quality of life.Findings included . Review for the facility’s policy titled, “Administration Procedures for all Medications,” dated May 2022, showed that medications were administered in a safe and effective manner. The policy further showed, “monitor for side effects or adverse drug reactions immediately after administration and throughout each shift.” INSULIN USERESIDENT 2Review of Resident 2’s face sheet printed on 07/01/2025, showed they were admitted to the facility on [DATE] with diagnosis that included diabetes (a condition that affects the level of sugar in the blood). Review of the physician’s orders printed on 07/01/2025, showed Resident 2 was prescribed insulin injections routinely. The physician’s orders further showed no monitoring for hypoglycemia (low blood sugar) and/or hyperglycemia (high blood sugar). Review of Resident 2’s June 2025 and July 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show that Resident 2 was being monitored for hypoglycemia and/or hyperglycemia. Review of Resident 2’s comprehensive care plan printed on 07/01/2025 did not show a care plan for diabetes. In an interview and joint record review on 07/07/2025 at 10:56 AM, Staff O, Licensed Practical Nurse, stated residents who had a diagnosis of diabetes and were receiving insulin would be monitored for their blood sugar levels and would be checked for hypoglycemia and hyperglycemia. A joint record review of Resident 2’s physician’s orders and the June 2025 to July 2025 MAR/TAR showed they were receiving insulin and there was no documentation to show that Resident 2 was being monitored for hypoglycemia and hyperglycemia. Staff O stated they did not see that Resident 2 was monitored for hypoglycemia and hyperglycemia. In an interview and joint record review on 07/08/2025 at 3:00 PM, Staff C, Resident Care Manager, stated for residents who had diabetes and received insulin, would be monitored for hypoglycemia and hyperglycemia. A joint record review of Resident 2’s physician’s orders showed there was no documentation to show that Resident 2 was being monitored for hypoglycemia and hyperglycemia. Staff C stated that Resident 2 should have been monitored for hypoglycemia and hyperglycemia. In an interview on 07/08/2025 at 4:30 PM, Staff B, Director of Nursing, stated that they expected Resident 2 to have been monitored for hypoglycemia and hyperglycemia. DIURETIC USERESIDENT 23Review of the physician’s orders printed on 07/01/2025, showed Resident 23 was prescribed Torsemide (diuretic medication) 30 milligrams (mg-unit of mass) by mouth two times a day for edema (or swelling-the build-up of fluid in the body’s tissue). Review of the June 2025 to July 2025 MAR and TAR printed on 07/01/2025, did not show that Resident 23 was being monitored for adverse side effects of diuretic use and/or edema. Review of a care plan printed on 07/01/2025, showed Resident 23’s focus care plan indicated a potential for fluid deficits related to daily diuretic therapy with interventions to “Administer medications as ordered. Monitor/document for side effects and effectiveness.” In an interview and joint record review on 07/07/2025 at 10:45 AM, Staff O stated for residents who were receiving diuretic medication for edema, they would monitor their vital signs, fluid intake/output, hydration status, laboratory and edema. A joint record review of Resident 23’s physician’s orders and June 2025 to July 2025 MAR and TAR did not show Resident 23 was being monitored for adverse side effects related to diuretic use and/or edema. Staff O stated Resident 23 was not monitored for edema. In an interview and joint record review on 07/08/2025 at 3:00 PM, Staff C stated residents who were receiving diuretic medication for edema would be monitored for adverse side effects, vital signs, laboratory, and edema. A joint record review of Resident 23’s orders and care plan did not show Resident 23 was monitored for diuretic adverse side effects and/or edema. Staff C stated that Resident 23 should have been monitored for diuretic adverse side effects and/or edema. In an interview on 07/08/2025 at 4:30 PM, Staff B stated that for residents taking diuretics there would not be an order for monitoring edema or adverse side effects, and that the monitoring would be in the care plan. A joint record review of Resident 23’s comprehensive care plan showed no monitoring for edema. Staff B stated that Resident 23 was not monitored for edema in the care plan and they monitor for dehydration (a condition caused by the loss of too much fluid from the body – a diuretic adverse side effect). “I would be more worried about them [resident] becoming dehydrated.” RESIDENT 7Review of a face sheet printed on 07/01/2025 showed Resident 7 admitted to the facility on [DATE]. Review of the physician orders printed on 06/30/2025 showed Resident 7 had an order for furosemide (diuretic medication) 40 mg tablet. “Give 0.5 [half] tablet” once a day for congestive heart failure (long-term condition in which the heart is unable to pump enough blood to meet the body’s need). Review of the May 2025 through July 2025 MARs did not show Resident 7 was being monitored for adverse side effects related to their diuretic medication. Review of the comprehensive care plan printed on 07/01/2025 did not show Resident 7 had a care plan for use of their diuretic medication and/or that they were being monitored for adverse side effects related to their diuretic medication. In an interview and joint record review on 07/08/2025 at 11:51 AM, Staff C stated that residents taking diuretics were monitored for adverse side effects. A joint record review of Resident 7’s physician orders and comprehensive care plan did not show Resident 7 was being monitored for adverse side effects related to diuretic use. In an interview and joint record review on 07/08/2025 at 5:17 PM, Staff B stated that residents taking diuretics were monitored for dehydration in their care plan. A joint record review of the comprehensive care plan did not show that Resident 7 had a care plan for use of diuretic medication and/or that Resident 7 was being monitored for adverse side effects to their diuretic medication use. Staff B stated that Resident 7 should have a diuretic use care plan that included monitoring for dehydration. Reference: (WAC) 388-97-1060 (3)(k)(i) (4) .

Based on observation, interview, and record review, the facility failed to appropriately label and/or dispose expired medications in accordance with current accepted professional standards for 2 of 3 medication carts (Sound Medication Cart & [NAME] Medication Cart) and for 1 of 1 Medication Storage Room, reviewed for medication storage and labeling. In addition, the facility failed to properly store drugs or biologicals (diverse group of medicines made from natural sources) for 1 of 2 residents (Resident 50). These failures placed the residents at risk for receiving compromised and ineffective medications. Findings included . Review of the facility’s policy titled, “Medication Storage in the Facility,” dated May 2022, showed that “Medications and biologicals are stored safely, securely, and properly, following manufacturer’s recommendations or those of the supplier.” It showed that “Certain medications or package types, such as…multiple dose injectable vials, ophthalmics [medications for the eyes] …require an expiration date shorter than the manufacturer’s expiration date to insure medication purity and potency.” It further showed that “All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining.” SOUND MEDICATION [NAME] joint observation and interview on 07/03/2025 at 1:35 PM with Staff R, Licensed Practical Nurse (LPN), showed an opened bottle of atropine sulphate (an ophthalmic medication) with an opened date of 06/02/2025. When asked how long atropine sulphate was good for after opening, Staff R stated, “I’m [I am] not sure. I can check.” In a follow-up interview at 2:38 PM, Staff R stated, “It’s [it is] good for twenty-eight days once it was opened.” A joint observation showed that the atropine sulphate was opened on 06/02/2025. Staff R stated that they “should have been discarded” on 06/30/2025. In an interview on 07/08/2025 at 5:41 PM, Staff B, Director of Nursing, stated that they expected ophthalmic medications to have an “open date” and a “discard date.” When asked about the atropine sulphate that was opened on 06/02/2025, Staff B stated that it should have been discarded on 06/30/2025. BAKER MEDICATION [NAME] joint observation and interview on 07/03/2025 at 10:18 AM with Staff O, LPN, showed a blister pack (plastic packaging that holds medications) containing eight tablets of oxycodone (a medication for pain) with an expiration date of 01/07/2025. Staff O stated that the “medication must be discontinued” and “it should be disposed of.” Staff O further stated that there should not be expired medications in the medication cart. In an interview on 07/08/2025 at 5:41 PM, Staff B stated that they expected expired medications to be “destroyed” and to “get rid of them.” When asked about the expired oxycodone, Staff B stated, “[nursing] should’ve [should have] destroyed it.” MEDICATION STORAGE ROOM A joint observation and interview on 07/02/2025 at 1:10 PM with Staff D, Resident Care Manager, showed an opened multi-dose vial of Tubersol (a skin test to help diagnose Tuberculosis [a potentially serious bacterial infection that mainly affects the lungs]) that did not have an opened date on it in the refrigerator. Staff D stated that it was multi-dose vial and that “no, it does not” have an open date on it. Staff D further stated that “anything that we break a seal on or open has to be dated with a date on it.” In an interview on 07/08/2025 at 5:41 PM, Staff B stated that they expected staff to “put on an opened date” when opening a multi-dose vial. RESIDENT 50Review of Resident 50’s face sheet printed on 07/01/2025, showed they were admitted to the facility on [DATE] with a diagnosis that included asthma (a condition that affects the airways in the lungs). Review of a physician orders printed on 07/01/2025, showed Resident 50 was prescribed Albuterol Sulfate (an inhaler [portable device for administering a drug which is to be breathed in] used to open the airways to increase air flow to the lungs) inhaler as needed for shortness of breath. Further review of the physician orders showed Resident 50 was prescribed Biotene (brand name) oral spray as needed for dry mouth. Observations on 06/30/2025 at 10:03 AM and on 07/01/2025 at 9:04 AM, showed Resident 50 had one Albuterol Sulfate inhaler and one Biotene oral spray on top of their bedside table within reach. Resident 50 stated they used their inhaler for asthma and their oral spray for dry mouth as needed. In an interview and joint observation on 07/07/2025 at 11:33 AM, Staff O stated that residents who were on self-administration of medications kept their medications at bedside and needed to be kept in a locked drawer. “It [medications] should be kept safe so it can’t [cannot] be used or taken from [by] someone else.” A joint observation showed Resident 50 had one Biotene oral spray and one Albuterol Sulfate inhaler sitting on top of their bedside table. Staff O stated that the medications should be kept in a locked drawer when not in use. In an interview on 07/08/2025 at 3:00 PM, Staff C, RCM, stated that if a resident wanted to self-administer their medications and keep the medication at bedside, the medication would be locked in the bedside table and/or locked drawer/box. In an interview on 07/08/2025 at 4:30 PM, Staff B stated that Resident 50’s inhaler and oral spray should have been in a locked drawer. Reference: (WAC) 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to provide care and services in a dignified manner for 1 of 4 residents (Resident 5), reviewed for dignity. The failure to ensure staff to resident interaction occurred in a respectful and dignified manner placed the resident at risk for diminished self-worth, self-esteem, and feelings of embarrassment.Findings included .Review of the facility's policy titled, Quality of Life-Dignity, revised in August 2009, showed that Residents shall be treated with dignity and respect at all times. It further showed that Verbal staff-to-staff communication.shall be conducted outside the hearing range of residents and the public.Observation on 07/01/2025 at 8:43 AM, showed Staff N, Registered Nurse, enter Resident 5's room and when exiting, Staff N stated in the hallway, he's [he is] pooping. Further observation showed Staff N entered room [ROOM NUMBER], to tell the Certified Nursing Assistant (CNA) inside the room, that [Resident 5's name] is pooping and they said this in front of the resident in room [ROOM NUMBER].In an interview on 07/01/2025 at 9:49 AM, Staff N stated that it was not appropriate to speak about resident's bowel movements in the hallway or in front of another resident. When asked if it was appropriate to say about Resident 5, he's pooping in the hallway, Staff N stated, no. When asked if it was appropriate to say to a CNA in a room with another resident in in it, [Resident 5's name] is pooping, Staff N, stated, no.In an interview on 07/08/2025 at 9:44 AM, Staff C, Resident Care Manager, stated that they expected staff to provide dignity to residents, which included not saying things about residents in front of other residents. When asked if they expected staff to say he's pooping in the hallway or [Resident 5's name] is pooping in front of another resident, Staff C stated, no.In an interview on 07/08/2025 at 5:41 PM, Staff B, Director of Nursing, stated that they expected staff to treat residents with dignity, including not saying resident information in public. When asked if they expected staff to say he's pooping in the hallway, Staff B stated, ideally, no. When asked if they expected staff to say, [Resident 5's name] is pooping in front of another resident, Staff B stated, no.Reference: WAC 388-97-0180 (2).

Based on observation, interview, and record review, the facility failed to ensure evaluation and assessment for safe administration of medications were conducted for 1 of 2 residents (Resident 50), reviewed for self-administration of medications. This failure placed the resident at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life.Findings included .Review of the facility's policy titled, Self Administration of Medications, revised in May 2016, showed that if the resident desires to participate in self-administration, the interdisciplinary team will assess the resident's ability to self-administer medications. The residents' cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. If the interdisciplinary team determines that this resident is unable to carry out this responsibility.the interdisciplinary team may withdraw this right. The policy further showed that, if the resident is a candidate for self-administration of medications, a physician's order will be obtained.Review of a face sheet printed on 07/01/2025, showed Resident 50 admitted to the facility on [DATE] with a diagnosis that included asthma (a condition that affects the airways in the lungs).Review of the physician orders printed on 07/01/2025, showed Resident 50 was prescribed Albuterol Sulfate (medication used to open the airways to increase air flow to the lungs) inhaler (portable device for administering a drug which is to be breathed in) as needed for shortness of breath. Further review of the physician orders showed Resident 50 was prescribed Biotene (brand name) moisturizing oral spray as needed for dry mouth.Review of Resident 50's assessments from 02/25/2025 to 07/01/2025 showed no documentation that Resident 50 had an assessment for self-administration of medications.Observations on 06/30/2025 at 10:03 AM and on 07/01/2025 at 9:04 AM, showed Resident 50 had one Albuterol Sulfate inhaler and one Biotene oral spray on top of their bedside table within their reach. Resident 50 stated they used their inhaler for asthma and their oral spray for dry mouth as needed.In an interview and joint observation on 07/07/2025 at 11:33 AM, Staff O, Licensed Practical Nurse, stated that for residents who wanted to do self-administration of medications, they would do an assessment to make sure they were safe and then obtain a physician's order. A joint observation showed Resident 50 had a Biotene oral spray and an Albuterol Sulfate inhaler sitting on top of their bedside table. Staff O stated that Resident 50 should not have had medications at bedside.In an interview and joint record review on 07/08/2025 at 3:00 PM, Staff C, Resident Care Manager, stated that if a resident wanted to self-administer their medications, they would do an assessment and then get a physician's order. A joint record review of Resident 50's assessments showed Resident 50 did not have an assessment for self-administration of medications before 07/02/2025. Staff C stated that Resident 50 should have had a self-administration assessment before having their medications at bedside.In an interview on 07/08/2025 at 4:30 PM, Staff B, Director of Nursing, stated that they expected Resident 50 to have an assessment for self-administration of medications done prior to Resident 50 being able to self-administer their medications.Reference: (WAC) 388-97-0440, 1060(3)(l).

Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained for 1 of 2 residents (Resident 37), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice.Findings included .Review of the facility's policy titled, Advance Directives and Associated Documentation, revised in December 2023, showed that an advance directive was A written instruction that relates to the provision of health care when the individual is incapacitated, such as a Living Will, Durable Power of Attorney for Health Care or the Natural Death Act. These documents allow the individual to identify choices related to their medical treatment or designate someone to make treatment choices for them should they lose decision making capacity themselves.Review of the Advance Directive care plan, printed on 07/02/2025, showed that Resident 37 had an advance directive DPOA.Review of Resident 37's electronic health record under the miscellaneous tab reviewed on 07/01/2025, showed documentation that Resident 37 had a financial DPOA on file and did not show that there was a copy of Resident 37's advance directive.In an interview and joint record review on 07/02/2025 at 10:57, Staff S, Social Services Director, stated that the facility would ask residents at admission if they had an advance directive and would ask for a copy to have in the resident's medical records. When asked if a financial DPOA directed a resident's health care choices/wishes, Staff S stated, no, but some DPOA paperwork would show healthcare decisions. A joint record review of page 21 of Resident 37's DPOA paperwork on file, showed documentation that any healthcare decisions would defer to the attorney-in-fact named in my Durable Power of Attorney for Healthcare. In a follow-up interview at 12:06 PM, Staff S stated that they reached out to Resident 37's representative to see if they have a specific health care directive, and if not, I will provide them with one.In an interview and joint record review on 07/08/2025 at 12:56 PM, Staff A, Administrator, stated that there were two types of DPOAs, one is for financial, and one is for healthcare. Staff A stated that if a resident said they had an advance directive, then there should be a copy in the resident's medical record. A joint record review of Resident 37's DPOA paperwork, showed it was a financial DPOA. Staff A stated that the DPOA paperwork on file for Resident 37 was not an advance directive.Reference: (WAC) 388-97-0280 (3)(a)(d).

Based on interview and record review, the facility failed to provide a notice before transfer/discharge to the resident and their representative describing the reason for transfer in writing for 1 of 1 resident (Resident 43), reviewed for hospitalization. This failure placed the resident at risk for not having an opportunity to make an informed decision about transfers and discharge.Findings included .Review of the electronic clinical record (progress notes and miscellaneous/documents tab) showed Resident 43 was transferred to the hospital on [DATE]. Resident 43's clinical record showed a Nursing Home Transfer or Discharge Notice, dated 06/17/2025, stating the reason for resident transfer/discharge was necessary for their welfare and their needs could not be met at the facility. The notice showed it was provided to Resident 43's representative verbally stating, out of town. Verbal agreement. Further review of Resident 43's clinical record showed no documentation that Resident 43 and their representative had been provided with written notification of transfer to the hospital.A joint record review and interview on 07/08/2025 at 2:49 PM, with Staff C, Resident Care Manager, showed a Nursing Home Transfer or Discharge Notice, dated 06/17/2025, that was provided verbally to Resident 43's representative. Staff C stated that they expected to provide the notice in writing to the residents or representatives. Staff C stated their process was to fill out the Nursing Home Transfer or Discharge Notice form and send it with the resident and keep a copy. Staff C stated that they spoke with Resident 43's representative who was out of town and not in the facility to sign the notice. Staff C further stated that the notice was provided in Resident 43's discharge packet to the hospital. When asked if they had any documentation to support that the notice was provided, Staff C stated that there was not and that they normally did not document that.On 07/08/2025 at 4:56 PM, Staff B, Director of Nursing, stated their process was to provide the notice of transfer/discharge in writing by sending it with the resident and keeping a copy. When asked if they expected supporting documentation to show that the notice was provided to Resident 43 and their representative, Staff B stated, I'm [I am] telling you that's [that is] what we do, not everything needs a policy.Reference: (WAC) 388-97-0120 (2) (a-c)

Based on interview and record review the facility failed to ensure resident assessments were completed accurately for 2 of 10 residents (Residents 23 & 46), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding medication use and dialysis (a process of removing excess water and toxins from the blood in people whose kidneys [organs that filter blood, remove waste and balance fluids in the body] can no longer perform these functions) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). MEDICATION USERESIDENT 23Review of quarterly MDS dated [DATE], showed Resident 23 was marked for insulin (medication that lowers the level of glucose [a type of sugar] in the blood) injections and orders for insulin in Section N (Medications - under N0350A and N0350B). Review of the physician orders printed on 07/01/2025, showed Resident 23 was not prescribed insulin injections. Review of May 2025 Medication Administration Record (MAR) showed Resident 23 did not receive insulin injections during the look-back-period (05/02/2025 to 05/08/2025). In an interview and joint record review on 07/08/2025 at 10:47 AM, Staff E, MDS Coordinator, stated they would follow the RAI Manual for MDS accuracy. A joint record review of Resident 23's quarterly MDS dated [DATE] showed that insulin injections and orders for insulin were marked in Section N0350A and N0350B. Another joint record review of Resident 23’s May 2025 MAR and physician orders showed that Resident 23 did not receive insulin injections or was prescribed insulin injections. Staff E stated Resident 23 should not have been marked for insulin injections and orders for insulin in Section N0350A and N0350B. Staff E further stated Resident 23’s MDS was not accurate. In an interview on 7/08/2025 at 4:30 PM, Staff B, Director of Nursing, stated that they expected the MDS to be completed accurately for Resident 23. DIALYSISRESIDENT 46Review of the physician orders printed on 06/30/2025, showed that Resident 46 went for dialysis on Tuesday, Thursday, and Saturday. Review of the comprehensive care plan printed on 06/30/2025, showed that Resident 46 received dialysis for renal (kidney) failure. Review of the quarterly MDS dated [DATE], showed Resident 46 was not marked for dialysis in Section O (Special Treatments/Procedures). In an interview and joint record review on 07/07/2025 at 1:58 PM, Staff E stated that they used the RAI manual to complete the MDS and that it should be accurate. A joint record review of Resident 46’s physician orders showed that Resident 46 went for dialysis on Tuesday, Thursday, and Saturday. Staff E stated that they would expect the MDS to be marked for dialysis. Another joint record review of the quarterly MDS, dated Reference: (WAC) 388-97-1000 (1)(b) .

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 1 of 6 residents (Resident 108), reviewed for PASARR screening. These failures placed the resident at risk of not receiving the appropriate care and services for their needs and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities.Findings included .Review of the facility's policy titled, PASRR screening for Serious Mental Illness/Intellectual Disability, revised on 07/03/2025, showed that It is the policy of this facility to establish a PASRR process to.screen for possible serious mental disorders, intellectual disabilities, and related conditions through the PASRR process. It further showed that The initial pre-screening (PASRR level I) should be completed prior to admission to facility. A Negative Level I requires no further action. A positive Level I Screen (PASRR indicates that individual requires a PASRR Level II Referral) necessitates an in-depth evaluation of the individual by the state-designated authority (PASRR Level II).Review of a face sheet printed on 07/03/20205 showed Resident 108 admitted to the facility on [DATE] with diagnoses that included anxiety disorder (having excessive/persistent worry and fear).Review of Resident 108's Level I PASARR dated 06/17/2025, showed the diagnosis of anxiety disorder was not marked in Section IA (SMI). Further review showed that Section IV (4- Service Needs and Assessor Data) was marked for No level II evaluation indicated.A joint record review and interview on 07/03/2025 at 3:06 PM with Staff G, Social Services Assistant, showed Resident 108 had diagnosis of anxiety on their diagnosis list. An additional joint record review showed that anxiety disorder was not marked on Resident 108's Level I PASARR in Section IA. Staff G stated that Resident 108's Level l PASARR should have included their diagnosis of anxiety disorder. Staff G further stated that a Level II PASARR referral should have been sent to the PASARR coordinator for Resident 108.In an interview on 07/08/2025 at 12:49 PM, Staff A, Administrator, stated that they expected the PASARR form to be accurate, which included marking any SMI diagnoses that a resident had. When asked when a resident's PASRR should be referred for Level II evaluation, Staff A, stated, I'm [I am] not sure.Reference: (WAC) 388-97-1975(1).

Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 1 of 6 residents (Residents 109), reviewed for respiratory care. The failure to obtain accurate oxygen orders placed the residents at risk of respiratory related complications and a diminished quality of life.Findings included .Review of the facility's policy titled, Oxygen Administration, revised in February 2023, showed that It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. It further showed that the first step for oxygen administration was obtain appropriate physician's order.Review of Resident 109's physician orders showed an order for Oxygen via mask at 3-4 [three to four] LPM [Liters per minute-a unit of measurement] continuously.Observations on 06/30/2025 at 9:01 AM, on 07/01/2025 at 1:55 PM, and on 07/02/2025 at 8:28 AM, showed Resident 109 was receiving six LPM of oxygen via nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) that was connected to an oxygen concentrator.In an interview and joint record review on 07/02/2025 at 2:44 PM, Staff L, Registered Nurse, stated that they expected a physician order for oxygen use. Staff L stated that Resident 109 was on six liters of oxygen. A joint record review of Resident 109's physician orders showed an order for Oxygen via mask at 3-4 LPM continuously. Staff L stated, it's not updated and he had a change of condition, now it's [it is] six liters via nasal cannula. A joint observation showed Resident 109 was receiving six LPM of oxygen via nasal cannula. Staff L stated that the order should be for six liters of oxygen.In an interview on 07/08/2025 at 9:44 AM, Staff C, Resident Care Manager, stated that they expected a physician order for oxygen use. A joint record review of Resident 109's physician orders showed a new order for oxygen 3-10 liters, started on 07/02/2025. Staff C stated that prior to that it was three to four liters via mask, that was the order that he came from the hospital with. Staff C further stated that the nurse should have clarified the order if there was a change and that the order should match what the resident was receiving.In an interview on 07/08/2025 at 5:41 PM, Staff B, Director of Nursing, stated that they expected a physician's order for oxygen use and that the order should match what a resident was receiving. Staff B stated that Resident 109's order should have been changed to reflect what Resident 109 was receiving and now I changed it [the oxygen order].Reference: (WAC) 388-97-1060 (3)(j)(vi).

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than five percent (%). The failure to properly administer 3 of 25 medications for 2 of 5 residents (Residents 40 & 6), observed during medication administration resulted in a medication error rate of 12%. This failure placed the residents at risk for not receiving the correct form, dose, and/or receiving less than the intended therapeutic effects of physician ordered medications and possible adverse effects.Findings included .Review of the facility's policy titled, Administration Procedures for all Medications, dated May 2022, showed the facility policy was, To administer medications in a safe and effective manner. The policy further showed staff should review the five rights three times; prior to removing the medication from the cart/drawer check the Medication Administration Record (MAR) for the order, and checking prior to removing the medication from the container, and after the dose has been prepared.RESIDENT 40 Review of Resident 40's physician orders printed on 07/01/2025, showed an order for Docusate Sodium (medication for constipation [is a problem with passing stool]) oral capsule 100 milligrams (mg- a unit of measurement), to give two capsules by mouth two times a day for constipation. The physician orders further showed an order for Magnesium Oxide (a mineral supplement) oral tablet 400 mg, to give two tablets by mouth one time a day for low magnesium level.Observation and interview on 07/01/2025 at 7:54 AM, showed Staff Q, Registered Nurse (RN), poured in a medication cup two Docusate Sodium 100 mg tablets (instead of the capsules) and one Magnesium Oxide 400 mg tablet instead of the two tablets as ordered for Resident 40. Staff Q walked inside Resident 40's room and stated they were ready to give these medications to Resident 40.In a joint record review and interview on 07/01/2025 at 8:02 AM, with Staff Q, showed an order for two Docusate Sodium 100 mg capsules, and two Magnesium Oxide 400 mg tablets. Staff Q stated that prior to administering the medication they should check to see if they have the right medication, dose, route, and would follow the physician order. Staff Q stated that they did not have Docusate Sodium 100 mg capsules in supply and that they used tablets. Staff Q stated that if a medication was not in supply, they should notify the facility and the provider. Staff Q further stated they should have given two Magnesium Oxide 400 mg tablets instead of one.RESIDENT 6Review of Resident 6's physician orders printed on 07/01/2025, showed an order for Aspirin (used to lower the risk of heart attack, stroke [blockage of blood supply to the brain], or blood clot [a mass that forms when blood hardens from a liquid to a solid]) Low Strength oral tablet Chewable 81 mg.Observation and interview on 07/01/2025 at 8:56 AM, showed Staff N, RN, poured an Aspirin Enteric Coated (designed to dissolve in the small intestine, potentially reducing stomach irritation) 81 mg tablet in a medication cup instead of the chewable form as ordered for Resident 6. Staff N walked inside Resident 6's room and stated they were ready to give the medication to Resident 6.A joint record review and interview on 07/01/2025 at 8:56 AM with Staff N, showed Resident 6 had a physician order for a chewable Aspirin 81 mg tablet. Staff N stated that prior to medication administration they should check to ensure they had the right resident, medication, route, dose, and time. Staff N stated that they were expected to follow the physician orders. Staff N further stated they prepared an enteric coated aspirin for Resident 6, and they should have given a chewable aspirin tablet.On 07/08/2025 at 9:44 AM, Staff C, Resident Care Manager, stated that prior to administering medication staff should check the rights of medication including right medication, resident, dose, time, and route. Staff C stated Staff Q should have rechecked the orders for Resident 40 and given two tablets instead of one [Magnesium Oxide 400 mg tablet], and that Staff Q should have obtained an order for Docusate Sodium tablets as the facility no longer had Docusate Sodium capsules. Staff C further stated Staff N should have given Resident 6 the correct form of the medication (Aspirin 81 mg chewable tablet).On 07/08/2025 at 4:56 PM, Staff B, Director of Nursing, stated they would expect nursing staff to check all the medication rights. Staff B further stated nursing staff were not supposed to make errors and that they needed to follow the physician orders.Reference: (WAC) 388-97-1060 (3)(k)(ii).

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 4 residents (Resident 39) and failed to discard a laboratory sample for 1 of 1 discharged resident (Resident 164), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included .Review of the facility's policy titled, IPCP [Infection Prevention & Control Program] Standard and Transmission Based Precautions, revised in October 2022, showed EBP precautions indicated to use gown and gloves during high-contact resident care activities. The policy further showed that high-contact resident care activities included dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting. Additionally, the policy indicated that EBP was used for infection or colonization with MDROs [Multidrug Resistant Organisms) that included Extended-Spectrum Beta-Lactamase (ESBL bacteria - a type of antibiotic [medication that treats infections] resistance mechanism that allows bacteria to resist the effects of certain antibiotics that can lead to serious infections that are difficult to treat) producing bacteria.Review of the undated signage/posting titled, Enhanced Barrier Precautions, showed it instructed staff to wear gown and gloves for high-contact resident care activities that included dressing, bathing/showering, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting.EBPRESIDENT 39Review of the nursing progress notes dated 06/10/2025 showed Resident 39 was placed on EBP precautions related to history of ESBL.Review of Resident 39's physician orders printed on 07/03/2025 showed an order dated 06/10/2025 for ENHANCED BARRIER PRECAUTIONS: PPE [Personal Protective Equipment - gowns and gloves] required for high resident contact care activities. Indication: Hx [history of] ESBL.Observation on 07/03/2025 at 9:07 AM showed Staff J, Certified Nursing Assistant (CNA), and Staff K, CNA, entered Resident 39's room with a Hoyer (mechanical lifting device) lift without wearing their gowns. Further observation showed Resident 39's room had an EBP signage outside the room that instructed staff to wear gown and gloves or high-contact resident care activities that included dressing, bathing/showering, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. At 9:17 AM, Staff J and Staff K came out of the room pushing Resident 39 in their wheelchair.In an interview on 07/03/2025 at 9:30 AM, Staff J and Staff K stated that they helped Resident 39 with changing their briefs and clothes, washed their face, brushed their teeth and transferred them from bed to their wheelchair using the Hoyer lift. Staff J and Staff K stated that they were not wearing their gown when providing care [high-contact resident activities) for Resident 39. Staff J stated, no gown is needed for [Resident 39], and that a gown was needed for providing care to Resident 39's roommate. Staff J stated that Resident 39 did not have EBP precautions. Staff J further stated that they would use gown and gloves to provide care for residents on EBP precautions when assisting with dressing toileting, changing briefs, and transfers.In an interview and joint record review on 07/07/2025 at 12:15 PM, Staff L, Registered Nurse (RN), stated that residents on EBP precautions would have an EBP signage outside their room. Staff L stated that Resident 39 did not have EBP precautions and that it was Resident 39's roommate who was on EBP precautions. A joint record review of the physician orders showed Resident 39 had orders for EBP precautions. Staff L stated that Resident 39 had a history of ESBL and was not on EBP precautions. At 12:20 PM, Staff L stated that they spoke with Staff C, Infection Preventionist, and they said that Resident 39 was on EBP precautions. Staff L further stated that both staff [Staff J and Staff K] that provided care for Resident 39 should have worn their gown [during high-contact resident care activities].In an interview and joint record review on 07/07/2025 at 12:37 PM, Staff C stated that staff should follow EBP guidance/signage and CDC guidelines. A joint record review of Resident 39's physician orders showed an order for EBP precautions. Staff C stated that Resident 39 was on EBP precautions, had an order in place, and that they had EBP signage outside their room. Staff C further stated that nursing staff should have worn their gown when helping Resident 39 with dressing toileting, changing briefs, and transfers.In an interview on 07/08/2025 at 5:12 PM, Staff B, Director of Nursing, stated that they expected staff to follow EBP precautions signage. Staff B further stated that both CNAs should have worn their gown when care was provided for Resident 39.URINE LABORATORY SAMPLERESIDENT 164Review of a face sheet printed on 07/01/2025 showed Resident 164 was admitted to the facility on [DATE] and discharged on 05/26/2025.Observations on 06/30/2025 at 10:06 AM and on 07/01/2025 at 2:50 PM, showed the biohazard refrigerator in the Cascade Soiled Utility Room had a urine sample in a small container and two laboratory test tubes, dated 05/26/2025 labeled with Resident 164's name.An interview and joint observation on 07/01/2025 at 3:12 PM with Staff I, RN, stated that for urine samples, they would check the order, collect the urine from the resident, place it in the biohazard refrigerator, and call the laboratory to pick up the sample.A joint observation showed the biohazard refrigerator in the Cascade Soiled Utility Room had a urine sample for Resident 164 in a small container and two laboratory test tubes, dated 05/26/2025. Staff I stated that Resident 164's sample should not have been in the biohazard refrigerator, and that it should have been disposed of.In an interview on 07/07/2025 at 12:37 PM, Staff C stated that Resident 164's urine sample collected on 05/26/2025 should have been discarded.In an interview on 07/08/2025 at 5:09 PM, Staff B stated that Resident 164's urine sample should have been thrown away.Reference: (WAC) 388-97-1320 (1)(a)(4)(5)(b).

Based on observation, interview, and record review of room size measurement, two single resident rooms (Rooms 17 & 18) failed to meet the minimum room size requirement of at least 100 square feet (sq ft - unit of measurement) for a single resident room. The failure to ensure residents reside in rooms which met the regulatory requirements for square footage, placed them at risk for living in a physical environment too small to meet their needs.Findings included .Review of an undated and untitled facility provided document showed the following rooms square feet measurements were:-room [ROOM NUMBER]- 93.2 sq ft-room [ROOM NUMBER]- 92 sq ftReview of the facility's census dated 06/30/2025, showed rooms [ROOM NUMBERS] were occupied with residents.RESIDENT 28During an interview and observation on 06/30/2025 at 3:03 PM, Resident 28 stated that their room size did not bother them. Observation showed Resident 28 was in room [ROOM NUMBER] and was not found to be negatively impacted by their room size.RESIDENT 41During an interview and observation on 06/30/2025 at 3:04 PM, Resident 41 stated, I love my room, but I wish it was larger. Observation showed Resident 41 was in room [ROOM NUMBER] and was not found to be negatively impacted by their room size.In an interview and joint record review on 07/07/2025 at 10:59 AM, Staff F, Plan Operations Director, stated there were no changes in square footage for rooms [ROOM NUMBERS] since the last recertification survey. A joint record review showed that room [ROOM NUMBER] was 93.2 sq ft and room [ROOM NUMBER] was 92 sq ft. Staff F stated that the room sizes for rooms [ROOM NUMBERS] had not changed.In an interview on 07/07/2025 at 12:23 PM, Staff A, Administrator, stated that there were no changes in the rooms' square footage since the last recertification survey. Staff A further stated that rooms [ROOM NUMBERS] did not meet the required square footage for single resident rooms according to federal and state regulations.Reference: (WAC) 388-97-2440 (1).

Based on interview and record review, the facility failed to inform the resident and/or their representative about a high carbon dioxide (C02-a form of natural waste produced by the body and breathe out by the lungs) blood test level for 1 of 1 resident (Resident 1), reviewed for change in condition. This failure placed the resident and/or their representative at risk of not being provided adequate information to make informed decisions about their medical condition. Findings included . Review of the facility's policy titled, Best Practice in Change of Condition and Endorsement, revised in January 2025, showed, Physician, resident, and responsible party will be notified of any changes in resident status or condition. Review of the quarterly Minimum Data Set (an assessment tool) dated 01/20/2025 showed Resident 1 had intact cognition with diagnosis that included chronic respiratory failure with hypoxia (a medical condition that occurs when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Review of a laboratory test results dated 01/27/2025, showed Resident 1's C02 level was more than (>) 45 mmol/L (millimoles per liter-a unit of measurement). The laboratory test showed the normal reference range for C02 was 21 to 31 mmol/L. It further showed that a laboratory staff called the facility on 01/28/2025 and spoke with Staff B, Registered Nurse, who confirmed the CO2 result, and Staff B requested the paper copy of the result to be faxed to the facility. Review of Resident 1's nursing progress note dated 01/28/2025 did not show Staff B notified Resident 1 and/or their representative about Resident 1's high C02 blood test result. In an interview on 03/17/2025 at 1:13 PM, Resident Representative (RR1), stated that they were not notified of Resident 1's high C02 blood test result. RR1 stated that they received a voicemail message on their phone on 01/30/2025, informing them that staff would draw blood for Resident 1 but there was no mention about the test result. RR1 stated that they knew about Resident 1's C02 blood test level on 02/10/2025 when they spoke with Staff C, Resident Care Manager, who had informed them about it. RR1 further stated that Resident 1 had not been informed about their C02 blood test level result. In an interview and joint record review on 03/19/2025 at 11:33 AM, Staff B stated that they received Resident 1's C02 blood test result on 01/28/2025. Joint record review of the laboratory test dated 01/27/2025, showed Resident 1's C02 level was >45 mmol/L. It further showed that Staff B confirmed the CO2 result. When asked if they notified Resident 1 or their representative about the CO2 test result, Staff B stated that they did not notify Resident 1 of their C02 blood test result. In an interview on 03/19/2025 at 1:44 PM, Staff C stated that their process was to send critical laboratory result to the provider through Signal (an application software) if they [the provider] are not in the facility. Staff C further stated that if it the laboratory result was critically high, then the provider needs to be notified. Staff C further stated that they expected the charge nurse to notify the resident and/or their representative of the test result. In an interview on 03/19/2025 at 3:57 PM, Staff A, Director of Nursing, stated that they expected staff to inform Resident 1 of their CO2 test results. Staff A further stated, We inform the POA [power of attorney/or RR] about the test result if they [resident] are incapacitated or that they are not able to make decisions for themselves. Reference: (WAC) 388-97-0300(3)(a) .

Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 1) was free from a significant medication error. The failure to provide a medication (Apixaban - used to prevent blood clots) placed Resident 1 at risk for complications with heart disease, a decline in medical condition, and a diminished quality of life. Findings included . A review of the admission Minimum Data Set (MDS-an assessment tool) dated 07/15/2024, showed Resident 1 was admitted to the facility from a local hospital on 07/09/2024 with a diagnosis list that included Atrial Fibrillation (or A-fib, a form of an abnormal heartbeat). The MDS also showed the resident had impaired thinking. In an interview on 08/05/2024 at 9:37 AM, Resident 1's Collateral Contact stated that Resident 1 did not receive their heart medication [Apixaban] for a few weeks after admitting to the facility and that they had a heart condition that required the medication to be given twice a day to prevent problems with their heart. A review of the hospital discharge medication list dated 07/09/2024 showed Apixaban take 5 milligrams (mg - a unit of measurement) by mouth two times daily for A-fib. A review of the July 2024 Medication Administration Record (MAR) showed an order for Apixaban 5 mg give 1 tablet by mouth two times a day for A-fib dated 07/19/2024. Further review of the MAR showed Resident 1 was administered the first dose of Apixaban on 07/19/2024, 10 days after they were admitted to the facility. On 08/16/2024 at 11:59 AM, Staff C, Registered Nurse (RN), stated that residents who were discharged from the hospital and admitted to the facility with medication orders should be transcribed to the MAR and administered to the residents as ordered. On 08/16/2024 at 12:11 PM, Staff D, RN, stated that on admission, the hospital discharge medication list should be transcribed to the MAR and administered as ordered. On 08/16/2024 at 1:31 PM, Staff B, Director of Nursing Services, stated that the Apixaban was not transcribed from the hospital discharge medication list when Resident 1 was admitted to the facility on [DATE]. Staff B further stated that the Apixaban should have been transcribed when the resident was admitted to the facility, but the medication was not transcribed and administered until 07/19/2024 because it was missed. On 08/16/2024 at 1:53 PM Staff A, Administrator, stated Resident 1 should have received the medication as ordered when they admitted to the facility. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed for the number of staff worked, actual hours worked and included the census for 30 of 30 days, reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily placed the residents, family members and visitors, at risk of not being fully informed of the current staffing levels. Findings included . Observation on 07/15/2024 at 9:32 AM, showed that the Daily Nursing Staffing Information posting did not include the census and the actual hours worked. The column under Actual Hours worked were the same numbers under the column # [number] Staff. Additional observations on 07/16/2024 at 8:37 AM, 07/17/2024 at 9:08 AM, 07/18/2024 at 8:33 and 07/19/2024 at 8:59 AM, showed that the Daily Nursing Staffing Information posting did not include the actual hours worked. The column under Actual Hours worked were the same numbers under the column # [number] Staff. Record review of the Daily Nursing Staffing Information and the Daily Schedule from 06/19/2024 to 07/18/2024 showed that the actual hours worked was not accurately completed on the Daily Nursing Staffing Information posting from 06/19/2024 to 07/19/2024. It further showed that the census was not included on 06/29/2024, 06/30/2024, 07/12/2024, and 07/15/2024. Additionally, the number of staff for Certified Nursing Assistants (CNAs) were not updated when there were call outs for 06/23/2024, 07/04/2024, 07/10/2024, 07/11/2024, 07/13/2024 and 07/17/2024. In an interview and joint record review on 07/19/2024 at 12:57 PM, Staff K, Staffing Coordinator, stated that all direct contact nurses, CNAs, charge nurse, scheduled and actual hours worked were documented in the daily nursing staffing information posting. Staff K stated that when staff call outs on night shift, the staff on night shift would update the daily nursing staffing information posting to reflect the change. Staff K stated that the actual hours worked were updated and documented in another sheet. Joint record review of the Daily Nursing Staffing Information and the Daily Schedule of the above dates showed missing census, inaccurate number of actual hours worked, and number of staff. Staff K stated that the numbers under the column Actual Hours worked were not the number of actual hours worked. Staff K stated they did know the number of actual hours worked and that they just documented the number of staff scheduled in that column. Saff K further stated that the daily nursing staffing information posting should have included the census and updated with staff call outs. In an interview on 07/22/2024 at 10:26 AM, Staff L, Administrative Assistant, stated that they were in charge of updating the nurse staffing information posting and worked on them Monday to Wednesday. Staff L stated that they looked at the labor hours report where they get the staff's actual hours worked for the day. Staff L stated that when the nurse staffing posting information were updated, it was not posted as they were completed the next day or the days after. In an interview on 07/22/2024 at 11:05 AM, Staff A, Administrator, stated that they expected staff to follow the regulation. No associated WAC

Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the residents and/or representatives for 3 of 4 residents (Residents 45, 47 & 46), reviewed for hospitalization . This failure placed the residents at risk for not having an opportunity to make informed decision about transfers/discharges. Findings included . Review of the facility's policy titled, Discharge and Transfer, revised in February 2016, showed that transfer or discharge of a resident will be in writing, in language the resident understands and be given to the resident, resident's surrogate decision maker, if any, and the resident's family. RESIDENT 45 Review of the admission Minimum Data Set (MDS-an assessment tool) dated 05/19/2024, showed Resident 45 was admitted to the facility on [DATE]. Review of the nursing progress note dated 07/12/2024 showed that Resident 45 was sent to the emergency room due to bleeding. Review of the Electronic Health Record (EHR) did not show documentation that a written notice of transfer/discharge was provided to Resident 45 and/or their representative. In an interview on 07/17/2024 at 9:09 AM, Staff M, Licensed Practical Nurse, stated that they informed Resident 45's representative by phone and did not provide a written notice describing the reason for hospitalization . In an interview on 07/22/2024 at 10:25 AM, Staff D, Resident Care Manager, stated that their process to notify the resident and/or their representative was either by phone or verbally. In an interview on 07/22/2024 at 10:33 AM, Staff B, Director of Nursing, stated that they expected the written notice to be provided to the resident and/or their representative. 46912 RESIDENT 47 Review of the discharge MDS dated [DATE], showed that Resident 47 discharged to the hospital on 05/20/2024. Review of Resident 47's EHR showed the resident was transferred to the hospital for further evaluation on 05/20/2024. Further review of Resident 47's EHR showed no documentation that Resident 47 and/or their representative were provided written notification of transfer to the hospital. In an interview on 07/17/2024 at 11:16 AM, Staff D stated that when a resident transferred to the hospital, they notified residents and/or their representatives verbally, in person and/or a phone call. Staff D stated that it was not their policy to notify residents and/or their representatives in writing and as far as I know just verbally. In an interview on 07/22/2024 at 11:14 AM, Staff B stated that they expected staff to provide notification to residents and/or their representatives when transferred to the hospital by telephone, unless in the building. Staff B stated that they did not expect there to be written documentation. In an interview on 07/22/2024 at 12:59 PM, Staff A, Administrator, stated that they expected staff to follow the guidelines and regulations for notifying residents and/or their representatives when a resident was transferred to the hospital. When asked if a written notice was provided, Staff A stated, according to the guidelines, it should be. 47680 RESIDENT 46 Review of the discharge MDS dated [DATE], showed Resident 47 admitted to the facility on [DATE], and discharged to the hospital on 06/07/2024. Review of the nursing progress note dated 06/07/2024, showed that Resident 47 was sent to the emergency room for evaluation. Review of Resident 46's EHR did not show documentation that a written notice of transfer/discharge was provided to Resident 46 and/or their representative. In an interview on 07/17/2024 at 12:45 PM, Staff D stated that they do not provide the resident or their presentative a written notice of transfer/discharge. Staff D further stated that they would notify them of the transfer verbally and would not provide them with a written notice. In an interview on 07/18/2024 at 2:21 PM, Staff A stated that they expected staff to follow their policy. Reference: (WAC) 388-97-0120 (2)(a)(b)(c)

Based on interview and record review, the facility failed to implement written abuse and neglect policies and procedures related to the required resident protection, abuse reporting and investigation for 2 of 3 residents (Residents 1 and 2) reviewed for abuse and neglect. These failures caused harm to Resident 1 who experienced potential on-going abuse/neglect of care that resulted in psychosocial harm in the form of fear, embarrassment and change in mood. The facility's failure to address and investigate allegations of abuse and neglect placed the residents at risk for harm and a diminished quality of life. Findings included . A review of the undated facility policy titled, Abuse Investigation and Reporting, showed that It is the policy of this facility that reports of abuse, neglect, misappropriation of property and exploitation are promptly and thoroughly investigated. The policy directed the facility staff to: 1. When an incident or suspected incident of abuse or neglect was reported, the Administrator or designee will investigate the incident with the assistance of the appropriate personnel. 2. The investigation will consist of at least the following: a. A review of the completed complaint report. b. An interview with the person(s) reporting the incident. c. Interviews with any witnesses to the incident. d. An interview with the resident if possible. e. A review of the resident's medical records. f. An interview with staff members having contacts with the residents during the shift of the alleged of the alleged incident. g. Interview with the resident's roommate and family members if applicable. h. A review of all circumstances involving the incident. 3. Accused employees will be barred from any further contact with residents of the facility, pending the outcome of the investigation. 4. The Administrator will keep the resident and his/her representative informed of the progress of the investigation. 5. The facility will report incidents of abuse and neglect to the State and appropriate as required. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's admission Minimum Data Set (MDS) assessment dated [DATE] showed that Resident 1 had intact cognition and needed two-person assistance with bed mobility and toileting tasks. On 10/11/2022 at 11:30 AM, during a phone interview with Resident 1's family member (FM1)/ Power of Attorney, stated that she had communicated concerns and allegations of potential staff abuse and neglect to the facility staff, including to Staff B, Director of Nursing, both in-person and via electronic mail (email). According to FM1, Staff B even responded to one of her emails, but she was not sure what was done (if any) to address her concerns, and whether Resident 1 received protection and timely follow-up to minimize the risk of the alleged neglect. FM1 further stated that she was afraid of Resident 1's well-being while at the facility and that was why she almost call and visit Resident 1 on a regular/daily basis. FM1 stated Resident 1 was afraid of not receiving timely and appropriate care from staff and would sometimes just cry, be embarrassed and upset about the situation. A review of the emails between Staff B and FM1 submitted to the complaint investigator dated 08/16/2022, 08/18/2022, 08/20/2022, 08/30/2022 and 09/01/2022 showed that FM1 had shared several concerns related to the care and services including allegations of potential neglect care to Staff B. The concerns on the email included: A. Resident 1 was left by staff undressed, practically naked in the room alone and had to wait for at least 30-40 minutes to get staff assistance (sent via email on 08/16/2022). B. Long wait for call lights 30 minutes to an hour including concerns for potential staff retaliation by reporting concerns related to Resident 1's pain medication and being reported to Staff B (sent via email on 08/16/2022). Staff B responded to the email on 08/16/2022 and wrote I'm sorry this happened . Thank you for bringing this up. C. Ostomy (lifesaving procedure that allows bodily waste to pass through a surgically created stoma [opening] on the abdomen)/wound care concerns including problem of not having adequate/appropriate supplies to meet the needs of Resident 1 (sent via email on 08/18/2022). D. Concerns with catheter (medical device(s) that can be inserted in the body to treat or perform surgical procedures) care and allegations of neglect. The email showed that Resident 1 had waited for almost 4 hours to get catheter care from staff, and another allegation of neglect reported by FM1 (unknown resident) was crying and calling for help for at least 15 minutes to get help and assistance from staff (sent via email on 08/20/2022). E. Concerns with wound care, neglect of care, and concerns with anxiety/medication orders (sent via email on 08/30/2022). F. Concerns with Oxygen and not having adequate assessments that could potentially affect Resident 1's breathing sent via email on 09/01/2022). On 10/11/2022 at 11:00 AM, FM1 stated during a phone interview that she did not receive any resolution from her concerns and that Resident 1 continued to experience the same problem on a regular basis especially during the evening and nighttime hours. FM1 stated that she and Resident 1 were worried about repercussion and direct retaliation because Resident 1 experienced not getting and/or had refused by a nurse (Staff H, Registered Nurse) to receive her medication and was told not to involve FM1 on the issue. According to FM1, she had reported these concerns and the fear of retaliation to Staff B who she sent a detailed email on 08/16/2022. FM1 further stated that she also discussed the care concerns with Staff B regarding Staff D, Licensed Practical Nurse (LPN) and Staff F, Nursing Assistant Certified). On 10/11/2022 at 1:50 PM, Staff B stated she remembered receiving concerns from FM1 regarding Resident 1. However, Staff B stated she could not recall the specific date and time, including the details of the concerns and/or the allegations reported by FM1. According to Staff B, she did not follow and implement the facility's abuse and neglect policies and procedures related to the required resident protection, reporting and investigations when an allegation of abuse/neglect was reported. Staff B further stated, there was no records or documentation as to what action (if any) was taken to protect the resident and/or address the concerns reported by Resident 1 and FM1. On 10/11/2022 at 2:20 PM, Staff F stated he remembered hearing the concern about a specific nurse (could not recall who) from FM1. Staff F stated the concern was related to not getting/receiving a medication (could not recall what medication) and that both Resident 1 and FM1 were very upset about. Staff F stated he did not report or followed-up on the concern that was reported to him as needed and required. On 10/11/2022 at 2:33 PM, Staff D stated he was aware and had a conversation with FM1 about the concern related to Resident 1's pain medication. Staff D stated he could not recall the specific details of the incident, but he showed FM1 that the medication was available, and he was not sure why it was not given to Resident 1 as reported. Staff D stated he did not report and/or further investigate the concerns since he was told that Staff B was already aware of the issue. On 10/11/2022 at 2:45 PM, Staff H stated she was not aware or notified by the facility of any concerns related to Resident 1 (or any resident). Staff H stated she continued to work at the facility with no restrictions and/or supervision from anyone and did not receive any work reassignment or suspension related to any allegation or investigation. On 10/11/2022 at 4:00 PM, FM1 stated she and Resident 1 were always worried about what could happen to Resident 1 while at the facility. FM1 stated both her and Resident 1 were worried about serious care concerns, including lack of care/timely assistance not just for them but also for other residents of the facility who could not speak for themselves and had no advocate like her who could come and visit them at the facility. FM1 stated that Resident 1 would always call her and said that she was very anxious, worried and would sometimes lose sleep because of the lack of care and the feeling of not having anyone to help/respond timely when she needed help and/or during an emergency. A review of the facility's Incident Reporting Log (IRL) and Grievance log for August and September 2022 showed no evidence that the facility had investigated and/or reviewed the concerns reported by FM1 on 08/16/2022, 08/18/2022, 08/20/2022, 08/30/2022 and 09/01/2022. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 received new orders for [MEDICATION(S)] (an anti-anxiety/antihistamine [allergy] medication) and [MEDICATION(S)] 3 mg (a sleep enhancer) at bedtime as needed due to [CONDITION(S)] (difficulty/trouble sleeping) on 09/09/2022 and [MEDICATION(S)] (an anti-psychotic medication) on 09/14/2022. RESIDENT 2 Resident 2 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS assessment dated [DATE] showed Resident 2 had impaired cognition and needed one-to-two-person assistance with bed mobility and transfer. On 10/12/202 at 11:23 AM, Resident 2's family member (FM2) stated during a phone interview that when Resident 2 was at the facility, he had communicated his concerns about neglect of care and for starving Resident 2 to death. FM2 stated Resident 2 was not receiving staff assistance with eating his meals and was not being provided meal alternatives to sustain his overall health. According to FM2, he had reported his concerns not just to the caregivers but also to the charge nurse, Staff E, LPN/Resident Care Manager, but instead of listening to him, the facility staff (including Staff E) just gave him excuses and not even provide or give the food that he would bring for Resident 2. FM2 further stated that after days of inaction from the facility staff and after seeing Resident 2 declined (lost weight and energy), he called Resident 2's surgeon (not affiliated with the facility) and communicated his concerns. FM2 stated the surgeon told him to transfer the resident out to the emergency room and get the resident out of the facility as soon as possible or else he would be dead in days. Resident 2 was transferred to a local hospital on 09/24/2022. On 10/12/2022 at 3:50 PM, Staff E stated she could remember the day Resident 2 was transferred to the hospital on 09/24/2022. Staff E stated that FM2 made an allegation of neglect and stated that the facility was not providing care and assistance to Resident 2, and that the facility was starving the resident to death. Staff E also stated that Resident 2 was transferred to the local hospital on the same day at approximately 3:30 PM. According to Staff E, she documented the allegation made by FM2 to the nursing progress notes but she did not report the allegation to the DNS, Administrator, and the State agency as required. Staff E stated that there was no investigation conducted whether FM2's allegation was true or not. On 10/12/2022 at 5:00 PM, Staff B stated she was not aware of the allegations reported by FM2 to Staff E. Staff B stated that Staff E should have reported the allegation of neglect made by FM2 to her, the Administrator and to the state agency as required. Staff B also stated that a thorough investigation should have been conducted to rule out whether the allegation was true or not and to identify any potential residents that could have been experiencing the same problem. A review of Resident 2's clinical records (Nursing Progress Notes and meal monitors) from 09/19/2022 to 09/24/2022 showed that Resident 2 refused most of his meals and had very poor intake. Resident 2 refused at least 1-2 meals a day and had documented intake of less than 25-50% per day. A review of the facility's IRL and Grievance log for September 2022 showed no evidence that the facility had investigated and/or reviewed the concerns reported by FM2 on 09/24/2022. Reference: (WAC) 388-97-0640 (2)

Based on interview and record review, the facility failed to comprehensively assess, adequately monitor, and follow professional standards of practice for 1 of 3 residents (Resident 1) reviewed for change in condition and medication administration. Additionally, the facility failed to follow written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures caused harm to Resident 1 who experienced potentially serious Adverse Side Effects (ASEs) from opioid/narcotic overdose who was found unresponsive and not breathing at the facility. Findings included . According to the United States Food and Drug Administration (FDA), Respiratory depression is the chief hazard from [MEDICATION(S)]. Respiratory depression was a particular problem in elderly or debilitated patients [residents], usually following large initial doses in non-tolerant patients, or when opioids are given in conjunction with other agents (medications) that depress respiration (breathing). [MEDICATION(S)] should be used with extreme caution in patients with significant [CONDITION(S)] (chronic breathing problem) and in patients having a substantially decreased respiratory reserve, [CONDITION(S)] (low oxygen in the blood), hypercapnia (excessive carbon [MEDICATION(S)] in the blood), or pre-existing respiratory depression. In such patients, even usual therapeutic doses of [MEDICATION(S)] may decrease respiratory drive to the point of apnea (cessation of breathing). In these patients' alternative non-opioid analgesics should be considered, and opioids should be employed only under careful medical supervision at the lowest effective dose. Other side effects of [MEDICATION(S)] included nausea and vomiting [feeling or being sick], stomach discomfort, feeling sleepy or tired, feeling dizzy and [CONDITION(S)] (sensation of spinning), confusion and headaches. The FDA also issued a Drug Safety Communication on 08/31/2016 and on 09/20/2017 that showed, the growing combined use of opioid medicines with benzodiazepines [a class of psychoactive drugs (mind altering medications)] or other drugs that depress the central nervous system (CNS) has resulted in serious side effects, including slowed or difficult breathing and deaths. In an effort to decrease the use of opioids and benzodiazepines, or opioids and other CNS depressants [drugs that reduces stimulation in various areas of the brain], together, we are adding Boxed Warnings [signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects], our strongest warnings, to the drug labeling of prescription opioid pain and prescription opioid cough medicines, and benzodiazepines. Health care professionals should limit prescribing opioid pain medicines with benzodiazepines or other CNS depressants only to patients for whom alternative treatment options are inadequate. If these medicines are prescribed together, limit the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect. Warn patients and caregivers about the risks of slowed or difficult breathing and/or sedation, and the associated signs and symptoms. A review of the [MEDICATION(S)] package insert dated 11/05/2007 showed, A singled dose greater than 40 milligram (mg), or total daily doses greater than 80 mg, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids. Common side effects included nausea, vomiting and weakness. The package inserts also showed to call your doctor or get medical help right away if your breathing slows down, you feel confused and have other unusual symptoms. A review of the facility's policy titled, Medication Administration Standards and Principles dated 03/2022, showed that medications will be accurately prepared, administered and documented per physician order. The policy directed the facility staff to administer medications following the 10 rights of medication administration including right resident, right time, right medication, right dose, right route, right reasons, right response, right documentation, right history and right to refuse. A review of the facility's policy titled, PREVENTING AND DETECTING ADVERSE CONSEQUENCES AND MEDICATION ERRORS dated 2018 showed that the facility would employ a system to assure that medication usage is evaluated on an ongoing basis. The policy directed facility staff to: 1. The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication related problems on an ongoing basis. 2. When a resident receives a new medication, the medication order is evaluated for the following: a. The dose, route of administration, duration, and monitoring were in agreement with current clinical practice, guidelines, and/or manufacturer's specifications for use. b. Presence of a Boxed Warning for specific side effect(s). c. The resident was not taking any medications that would be incompatible with the prescribed medication. 3. Facility staff monitor the resident for possible medication related adverse consequences, including mental status changes and/or changes in level of consciousness when the following condition occurs: a. A significant change in condition (unexplained decline in function or cognition, worsening of an existing problems or condition, a new or worsening psychiatric manifestation or distressed behavior). b. Change in dose of the medication. Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's admission Minimum Data Set assessment dated [DATE] showed that Resident 1 had intact cognition and needed two-person assistance with bed mobility and toileting tasks. A review of the physician's progress notes dated 09/15/2022 showed that Staff X, Physician/Medical Director (MD), had visited and evaluated Resident 1 on 09/15/2022 following a recent re-hospitalization (re-admission to the facility on [DATE]) related to nausea and vomiting. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes also showed that She [Resident 1] was transferred on low dose [MEDICATION(S)] 5 mg every 8 hours as needed, likely because of side effects to the higher dose of [MEDICATION(S)] ER. We may require a happy medium which would accommodate her pain needs but keep safety in mind. Therefore, I am increasing her [MEDICATION(S)] to 5 to 10 mg every 4 hours as needed. A review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A total [MEDICATION(S)] dose of 90 mg per day. On 10/11/2022 at 1:00 PM, during a phone interview, Staff X stated that he was not aware of the discrepancies/transcription error he made related to Resident 1's [MEDICATION(S)] orders. Staff X stated that what he intended to do was to only increase Resident 1's [MEDICATION(S)] from 5 mg every 8 hours as needed to [MEDICATION(S)] 5 mg to 10 mg every 4 hours as needed for better pain management as detailed on his visit summary note on 09/15/2022. On 10/11/2022 at 1:15 PM, Staff C, Registered Nurse (RN) stated that she reviewed the [MEDICATION(S)] order for Resident 1 on 09/16/2022. Staff C stated that she was concerned about the dose of the [MEDICATION(S)] ordered by Staff X mainly due to Resident 1's recent bowel conditions/surgeries and was concerned that the resident may develop further bowel complications. According to Staff C, Staff X simply responded to her by saying that I added Senna (a stool softener) with no other comments about the [MEDICATION(S)]. Staff C further stated there was no further discussion about the [MEDICATION(S)] dose and that she was not aware that there were conflicting orders from the Physician [Staff X] related to what he intended to order versus what was transcribed into the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/11/2022 at 1:40 PM, Staff B, Director of Nursing, stated she was not aware of the discrepancies regarding Resident 1's [MEDICATION(S)] orders. Staff B also stated that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's clinical records (Nursing Assessments, Nursing Progress Notes, MAR/ Treatment Administration Record (TAR) and Narcotic Logbook records for September 2022 showed no evidence that the facility had monitored Resident 1 on how she would respond to the increased dose of the [MEDICATION(S)] including the required monitoring of any potential ASEs as directed by the facility policy. Additionally, the MAR and the Narcotic Logbook showed discrepancies on how much medication was being administered to Resident 1 versus what was documented in the MAR. A review of the September 2022 MAR/TAR and Narcotic logbook for Resident 1 showed the following discrepancies and medication error: Narcotic logbook records for 09/16/2022 09/16/2022 at 1:48 AM - [MEDICATION(S)] 10 mg dose 09/16/2022 at 8:00 AM - [MEDICATION(S)] 10 mg dose 09/16/2022 at 4:00 PM - [MEDICATION(S)] 10 mg dose 09/16/2022 at 9:51 PM - [MEDICATION(S)] 5 mg dose 09/16/2022 at 11:58 PM - [MEDICATION(S)] 10 mg dose The total [MEDICATION(S)] dose administered and received on 09/16/2022 per the narcotic book was 45 mg. However, the 09/16/2022, the MAR showed Resident 1 received [MEDICATION(S)] on the following schedule: 09/16/2022 at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM - [MEDICATION(S)] 10 mg dose was given and administered routinely. There was no [MEDICATION(S)] administered at 12:00 AM and 4:00 AM as ordered. 09/16/2022 at 2:13 AM - [MEDICATION(S)] 5 mg was given and administered as needed. 09/16/2022 at 9:52 PM - [MEDICATION(S)] 5 mg was given and administered as needed. The total [MEDICATION(S)] dose administered and received on 09/16/2022 per the MAR was 50 mg. Similar findings were reviewed and applicable on 09/17/2022. The Narcotic logbook records for 09/17/2022 showed the following: 09/17/2022 at 4:15 AM - [MEDICATION(S)] 10 mg dose 09/17/2022 at 8:30 AM - [MEDICATION(S)] 10 mg dose 09/17/2022 at 3:55 PM - [MEDICATION(S)] 10 mg dose 09/17/2022 at 8:05 PM - [MEDICATION(S)] 10 mg dose 09/17/2022 at 11:50 PM - [MEDICATION(S)] 10 mg dose Total [MEDICATION(S)] dose administered and received on 09/17/2022 per the narcotic book was 50 mg. However, the 09/17/2022 MAR showed Resident 1 received the [MEDICATION(S)] on the following schedule: 09/17/2022 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM - [MEDICATION(S)] 10 mg dose was given and administered routinely. There was no as needed [MEDICATION(S)] given or administered on 09/17/2022. The total [MEDICATION(S)] dose administered and received on 09/17/2022 per the MAR was 60 mg. Review of the September 2022 Narcotic logbook and September 2022 MAR showed that Resident 1 received a total [MEDICATION(S)] dose of at least 80 mg to 90 mg in 24-28-hour period: 09/18/2022 at 11:30 PM - [MEDICATION(S)] 10 mg dose 09/19/2022 at 4:00 AM - [MEDICATION(S)] 10 mg dose 09/19/2022 at 8:00 AM - [MEDICATION(S)] 10 mg dose 09/19/2022 at 12:00 PM - [MEDICATION(S)] 10 mg dose 09/19/2022 at 4:07 PM - [MEDICATION(S)] 10 mg dose 09/19/2022 at 8:00 PM - [MEDICATION(S)] 10 mg dose 09/19/2022 at 9:00 PM - [MEDICATION(S)] 10 mg dose 09/19/2022 at 11:55 PM - [MEDICATION(S)] 10 mg dose 09/20/2022 at 4:00 AM - [MEDICATION(S)] 10 mg dose Further review of Resident 1's clinical records (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 60 mg daily (an antidepressant medication). 2. [MEDICATION(S)] 20 mg daily at bedtime (an antipsychotic [mind altering] medication). 3. [MEDICATION(S)] 0.5 mg twice daily (an antipsychotic medication). 4. [MEDICATION(S)] 50 mg every 8 hours as needed (an antianxiety/antihistamine [allergy] medication). 5. [MEDICATION(S)] 3 mg at bedtime as needed (a sleep enhancer supplement/medication). A review of the nursing progress notes and the MAR from 09/15/2022 to 09/19/2022 showed that Resident 1 also complained of increase in abdominal discomfort/gas, including nausea and vomiting on 09/15/2022, 09/16/2022, 09/18/2022 and again on 09/19/2022, symptoms that were potentially related to the recent increase dose of [MEDICATION(S)]. Despite of Resident 1 reporting and showing signs of potential ASEs from her current medications, the facility staff continued to administer the medications without further consulting or reporting the potential ASEs to the physician and/or the Resident's responsible party. There was no documented evidence that the facility staff notified the physician and/or placed Resident 1 on alert monitoring from any of the serious potential ASEs related to the increase in [MEDICATION(S)] dose and the potential for an increase drug to drug interaction as required. On 10/11/2022 at 2:10 PM, Resident 1's family member (FM1) stated that she noticed Resident 1 to be more sleepy and more sedated than usual during her visits and regular phone calls to the Resident from 09/16/2022 to 09/19/2022. FM1 stated Resident 1 complained of being nauseated and sick, including concerns of feeling bloated with increased abdominal discomfort during these dates. Additionally, FM1 stated that Resident 1 would be so sleepy that nurses and staff had to wake her up during the day for her to take her [MEDICATION(S)] and other medications. FM1 further stated that the facility staff was aware of these concerns and that she had a conversation with Staff D, Licensed Practical Nurse (LPN) about these concerns on/or before 09/19/2022 (not able to recall the specific date or time) to where she was told by Staff D that Resident 1 was sleepy than usual and that they had to wake her up to give her pain medications. According to FM1, Staff D told her that he would inform the doctor of these concerns, specifically the concern of overmedication as soon as possible and that both her and the resident had agreed to discuss the concerns to the physician (Staff X). On 10/11/2022 at 2:33 PM, Staff D stated and confirmed the conversation he had with FM1 regarding Resident 1's potential ASEs including the concern for overmedication. Staff D confirmed and stated that he had received information about Resident 1 needing to be awakened to receive her routine [MEDICATION(S)] and that he informed FM1 about these concerns. However, Staff D stated he was not sure whether the physician was notified of these concerns and what actions were taken (if any) to monitor the resident and/or address the potential ASEs of the medication. Staff D stated he was not aware of the conflicting orders/discrepancies on the [MEDICATION(S)] order for Resident 1. A review of the nursing progress notes dated 09/20/2022 showed that on 09/20/2022 at approximately 4:30 AM, Resident 1 was found by a staff member unresponsive, with no pulse and not breathing (approximately 30 minutes after receiving the last dose of a routine [MEDICATION(S)] 10 mg at 4:00 AM that day [per the September 2022 MAR]). The progress notes also showed that the Licensed Nurse on duty had to perform suctioning because there's some brownish watery liquid coming out of her [Resident 1] mouth. However, the nursing progress notes, and the MAR showed that the Licensed Nurse on duty failed to administer the [MEDICATION(S)] as ordered for decreased responsiveness. Resident 1 was pronounced dead at approximately 5:20 AM that day. On 10/12/2022 at 9:00 AM, Staff B stated that the [MEDICATION(S)] order for Resident 1 should have been reviewed and clarified to ensure that the medication orders were accurate, appropriate, and safe for Resident 1. Staff B also stated that Resident 1 should have been placed on every shift monitoring for any ASEs or potential complications/drug to drug interactions related to the increase in [MEDICATION(S)] dose. According to Staff B, the physician should also have been notified immediately of the ASEs documented in the clinical records as required. Staff B further stated that she would review the [MEDICATION(S)] orders, including the discrepancies in the MAR and the Narcotic Logbook to determine the root cause of the incident and to determine why the narcotic logbook does not match the actual dose administered per the MAR. On 10/26/2022 at 1:00 PM, during a joint interview with Staff B and Staff X, Staff X stated he was not aware and was not notified of Resident 1 having any potential ASEs from the increase dose of the [MEDICATION(S)]. Staff X also stated he was not aware that Resident 1 had high risk medical conditions that could potentially affect her breathing (respiratory depression) including a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Staff X, he was not sure why the nurses did not administer the as needed [MEDICATION(S)] because he would have expected the nurses to administer the medication as ordered to reverse the potential ASEs of narcotic overdose including unresponsiveness and slow/stop breathing. During the same interview, Staff X stated that he intended to put Resident 1 on a routine [MEDICATION(S)] 10 mg every 4 hours including an additional order for [MEDICATION(S)] 5mg every 4 hours as needed [a total dose amount per day that could potentially cause fatal respiratory depression, and a different response from the interview on 10/11/2022 at 1:00 PM, when Staff X stated he only wanted to increase the as needed [MEDICATION(S)] and not put Resident 1 on routine order due to safety concerns.] When asked with clarifying questions, including whether he was aware of what was considered and/or established fatal dose of [MEDICATION(S)] (based on the drug manufacturer and/or package insert drug safety/boxed warning information) for residents including Resident 1 who was at high risk for experiencing serious ASEs from opioids due to underlying respiratory conditions (Obstructive Sleep Apnea, [CONDITION(S)] and Chronic Respiratory failure), and current medication regimen (currently taking other CNS depressants as listed above), Staff X was not able to provide an answer. Instead, Staff X stated that none of these factors mattered and should not be a concern because these would not affect or cause Resident 1's breathing to slow down/stop breathing. Reference: (WAC) 388-97 1060 (1)(4)

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for abuse and neglect was free from sexual abuse. The facility failed to prevent and/or protect the resident from another resident's (Resident 2) unwanted sexual advances. As a result of this failure, Resident 1 experienced psychosocial harm including difficulty and/or trouble sleeping, increased agitation and anxiety, statements of wanting to die, feeling helpless, restlessness, and with an increased episodes of paranoia (an intense, irrational, persistent instinct or thought process of fearful feelings). Findings included . The Code of Federal Regulation (CFR) define abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, Abuse is the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult. Resident 1 was a long-term care resident at the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the residents quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had impaired cognition and needed one-to-two-person physical help with locomotion (moving to one location to another) on and off the unit. Review of the facility's incident reporting log for the month of June 2022, showed that on 06/22/2022, Resident 1 (the victim of this sexual abuse incident) was involved with a resident-to-resident altercation with Resident 2. Review of Resident 2's clinical records (face sheet and current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's incident investigation report dated 06/22/2022, showed that on 06/22/2022 at 11:00 AM, Resident 2 was in the dining room when he propelled himself with his left hand and came up to a female resident's left side (Resident 1) who was sitting in her wheelchair and touched her left breast over her clothes. The incident report also showed that the incident was witnessed by a staff member [Staff C, Physical Therapy Assistant (PTA)] who immediately intervened and separated the residents. On 07/14/2022 at 9:15 AM, Resident 1 stated she could recall the incident when another male resident (could not recall the name of Resident 2) touched her breast and attempted to also touched her private area against her will. Resident 1 stated she forgot the name of the resident but knew who he was (referring to Resident 2) because she would not forget the person who violated her and sexually assaulted her. Resident 1 also stated that he was a nice guy, and she was not sure why he would do such a terrible act against her. Resident 1 became visibly upset and tearful during the interview. Resident 1 stated that she did not feel comfortable and safe in the facility because of this incident and that she would kill and murder this resident if he (Resident 2) ever gets close to her again. The resident stated she was angry about the situation and felt helpless because she cannot do anything. According to Resident 1, she recently had difficulty and trouble sleeping because she was afraid that he (Resident 2) would eventually show up in her room and touch her again. On 07/14/2022 at 9:35 AM, Staff D, Registered Nurse, stated that Resident 1 was still anxious related to the incident that happened on 06/22/2022 with Resident 2. Staff D also stated that Resident 2 was initially transferred to a different unit when the incident happened. However, Staff D stated that recently, Resident 2 was transferred back to the same unit with Resident 1 (approximately 3 to 4 rooms down the hallway), which made Resident 1 more fearful and restless because both residents would now see each other and shared mealtimes in the dining room. According to Staff D, Resident 1's concern and fear were valid because there was now a potential and increased risk for Resident 2 to get near Resident 1, and due to Resident 2's ability to easily self-propel his wheelchair to Resident 1 and/or towards other residents without any staff assistance. On 07/14/2022 at 9:45 AM, Staff F, Nursing Assistant Certified, stated that Resident 2 had recently transferred back to the unit and caused Resident 1 to be more anxious than usual especially during mealtimes. Staff F stated that Resident 2 was able to self-propel his wheelchair independently and could get near Resident 1, so staff would try to separate each resident and provide increase supervision as much as possible to keep them away from each other. On 07/14/2022 at 10:00 AM, a joint interview with Resident 1 was conducted with Staff E, Social Services, Resident 1 stated that she was anxious and angry about the situation and that she would kill him (Resident 2) if he ever gets close to her and tried to sexually assault her again. Resident 1 was visibly upset and tearful during this interview and stated that she did not feel comfortable and safe around and/or near Resident 2. A review of Resident 1's behavior monitoring sheet for July 2022 showed that on 07/11/2022 and 07/12/2022, Resident 1 had episodes of increase paranoia with thoughts of people wanting to kill me, [CONDITION(S)] (statements of wanting to die), and agitation/anxiety. On 07/14/2022 at 10:30 AM, during a phone interview with Staff C, and Staff G, Rehab Director, Staff C stated he witnessed the incident between Resident 1 and Resident 2. Staff C stated he saw Resident 2 approached Resident 1 and started touching and massaging Resident 1's breast (left breast) area. According to Staff C, Resident 2 did not even bother to stop even after seeing him, so he immediately rushed to intervene and separated both residents. On 07/14/2022 at 10:50 AM, both Staff A, Administrator, and Staff B, Director of Nursing, stated and confirmed the sexual abuse incident between Resident 1 and Resident 2 on 06/22/2022. Staff B stated that the facility investigation concluded that a staff member (Staff C) witnessed Resident 2 inappropriately touched Resident 1's breast area against her will and that the employee had to intervene to separate and stop the abuse. The facility failed to prevent and/or protect Resident 1 from Resident 2's sexual advances. The facility was aware of Resident 1's sexual allegation, yet they allowed Resident 2 to move back in the unit where Resident 1 was located, which resulted Resident 1's increased anxiety, fear, and emotional distress. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to develop and implement an effective infection control program related to the required screening of healthcare personnel (HCP) for COVID-19 (a highly communicable infection), failed to follow and implement written policies and procedures related to the needed precautions for known and/or suspected COVID-19 residents, and failed to ensure staff maintained infection control practices to prevent the spread of infection and/or disease. These failures placed all 53 residents of the facility in the likelihood of serious harm and potentially death related to COVID-19 infection. The facility's failure to ensure healthcare personnel were adequately screened for symptoms of COVID-19 prior to entering the facility and properly apply the required personal protective equipment (PPE) and the failure to follow and implement standards of practice and written policies and procedures for infection control, constituted a situation of an immediate jeopardy (IJ). On 07/01/20 at 3:00 PM, the facility was notified of the IJ related to CFR 483.80 F880, Infection Prevention and Control. Findings included . According to the Centers for Disease Control (CDC), COVID-19 is an illness caused by [MEDICAL CONDITION] (coronavirus) that can spread from person to person. The CDC also stated that a person can become infected from respiratory droplets when an infected person coughs, sneezes or talks. Symptoms of COVID-19 included: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting and Diarrhea. The CDC guidelines for COVID-19 included the following: A. Screen all Health Care Personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. B. HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. C. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Healthcare Personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). A review of the facility policy titled, EMERGING INFECTIOUS DISEASE (EID) EMERGENCY PLAN CORONAVIRUS 2019 (COVID-2019), dated 03/20/2020 and revised on 04/02/2020, directed facility staff to ensure facility policies and practices are in place to minimize exposures to respiratory pathogens including [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19. The policy also directed facility staff to: A. Implement active screening of residents and HCP for fever and respiratory symptoms. B. Take steps to ensure all persons with symptoms of COVID-19 or other respiratory infection (e.g., fever, cough) adhere to respiratory hygiene and etiquette and hand hygiene. C. Adhere to Standard and Transmission Based-Precautions. HCP who enters a room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator or face mask, gown, gloves and eye protection. FAILURE TO EFFECTIVELY SCREEN HCP FOR SYMPTOMS OF COVID-19 A review of the facility screening log Start of Shift Employee Screening Log dated 06/30/2020, showed the facility failed to completely screen four employees for symptoms of COVID-19 prior to the start of shift and prior to allowing access to the facility: Staff A, Certified Nursing Assistant/Activity Assistant (CNA/AA): COVID-19 screening questionnaire showed she had New Shortness of Breath or Difficulty Breathing at the start of her shift. Staff A was allowed entry to the facility even after identifying a new symptom of COVID-19. Staff B, Registered Nurse (RN): COVID-19 screening questionnaire showed she only answered the screening questions for temperature, cough, sore throat, and new shortness of breath or difficulty breathing. Staff B's screening questionnaire did not show answers on the rest of the COVID-19 screening questionnaire for symptoms of vomiting and/or diarrhea, chills and/or repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, and whether she was asked to go home or was denied entry to the facility. Staff C, Licensed Practical Nurse (LPN): COVID-19 screening questionnaire showed her temperature was not taken and/or recorded prior to the start of shift and prior to allowing access to the facility. Staff C was allowed entry to the facility even without being properly screened for an elevated temperature and/or fever. Staff D, LPN: COVID-19 screening questionnaire showed he did not answer the screening question for sore throat. Staff D was allowed entry to the facility even without completing the screening of symptoms for COVID-19. During an interview on 06/30/2020 at 10:45 AM, Staff E, Receptionist, stated that healthcare personnel were only performing self-screening and that no staff member was assigned to screen visitors, staff, and/or employees specifically before and after her assigned shift. Staff E stated, her shift started at 7:00 AM and ended at 4:00 PM. Staff E also stated that all morning shift staff today (06/30/2020) had to self-screen themselves for symptoms of COVID-19 (the morning shift staff started before 7 AM). Staff E further stated that the facility policy and the CDC guidelines indicated that if any staff and/or visitors answered yes to any screenings questions, they would not be allowed to enter the facility due to the increased risk of COVID-19 exposure. During a joint record review of the Start of Shift Employee Screening Log, dated 06/30/2020, Staff E stated that she was not aware of the incomplete COVID-19 screening questionnaires for Staff A, Staff B, Staff C and Staff D. According to Staff E, she was not aware of the holes on the screening form because all of these employees came in before her shift started. During an interview on 06/30/2020 at 11:59 AM, Staff A, CNA/AA, stated that she had filled out the COVID-19 screening questions at the start of her shift indicating she had a new episode of shortness of breath and difficulty of breathing, but there was no manager or any person at the front desk to give her directions on what to do. Staff A also stated that she had not reported her symptoms to anybody as this was her first day back to work. Staff A further stated that she was one of the first employees who tested positive for COVID-19 during an earlier outbreak of COVID-19 in the facility and she was experiencing the same symptoms of the infection which had started yesterday. Staff A was assigned to unit Baker (long-term care unit) and stated that she was responsible for providing care to at least ten residents living in the unit. During an interview on 06/30/2020 at 12:02 PM, Staff D, LPN, stated that he had self-screened himself upon entry to the facility, but said he was not aware that he did not completely answer all the screening questions for symptoms of COVID-19. Staff D further stated that it was very important to accurately screen HCP for symptoms of COVID-19 prior to entering the facility for safety of the residents and staff, and to minimize the risk of exposure and spread of COVID-19. According to Staff D, there was no manager or any person at the front desk to review and/or verify his responses to the screening questions. Staff D was assigned to unit Baker and stated he was responsible for medication administration, treatment administration, and direct resident care/assessment for twenty-two residents. During an interview on 06/30/2020 at 12:05 PM, Staff B, RN stated that she self-screened herself upon entry to the facility, but she was not aware that she did not completely answer all the screening questions for COVID-19. Staff B further stated that it was very important to accurately screen HCP for COVID-19 prior entering the facility for the safety of the residents and staff, and to minimize the risk of exposure and spread of COVID-19. According to Staff B, there was no manager or any person at the front desk to review and/or verify her responses to the screening questions. Staff B was assigned to unit Puget (short-term/rehabilitation unit) and stated she was responsible for medication administration, treatment administration, and direct resident care/assessment for eighteen residents. Staff C, Minimum Data Set (MDS) assessment coordinator/LPN, was responsible for all the required MDS resident assessments and care coordination, and had access to all residents of the facility. During an interview and record review with the Administrator on 06/30/2020 at 12:20 PM, the administrator stated that Staff A, CNA/AA, Staff B, RN, Staff C, LPN and Staff D, LPN had not been properly screened for COVID-19 symptoms and should have not been allowed to enter the facility per the facility policy and per the CDC guidelines, as this could have increased the risk of resident and staff exposures to COVID-19. According to the administrator, the lack of proper screening could have been due to not having a staff member to screen the HCP at the start of their shift and allowing HCP to fill out the required COVID-19 screening questions. During an interview and record review with the Director of Nursing (DNS) on 06/30/2020 at 12:30 PM, the DNS also stated that Staff A, CNA/AA, Staff B, RN, Staff C, LPN and Staff D, LPN had not been properly screened for COVID-19 symptoms and should have not been allowed to enter the facility per the facility policy and per the CDC guidelines, as this could have increased the serious risks of resident and staff exposures to COVID-19. A review of the facility's investigation report related to the COVID-19 screening process titled, LYNNWOOD PARK INVESTIGATION, dated 07/09/2020, showed the facility's COVID-19 screening process for HCP was not effective on 06/30/2020. A process that had allowed HCP to enter the facility without being properly screened for COVID-19 symptoms. During an interview on 07/17/2020 at 11:30 AM, Staff Y, Administrative Market Leader and Staff Z, Clinical Market Leader, both Staff Y and Staff Z stated that the facility's process for screening HCP prior to 06/30/2020 was not effective and they were not aware of the facility's practice of allowing HCP to enter the facility and provide direct resident care without being properly screened for COVID-19. The facility reported in April and May 2020 that there were at least 32 residents and 14 staff members tested positive for COVID-19 with 4 resident COVID-19 related deaths. FAILURE TO IMPLEMENT INFECTION CONTROL MEASURES RELATED TO PERSONAL PROTECTIVE EQUIPMENTS (PPE) AND HAND HYGIENE An observation on 06/30/2020 at 11:30 AM showed Staff A, CNA/AA standing in unit Baker (long-term care unit) hallway not wearing her surgical mask properly. Staff A's nose and mouth were not covered by the surgical mask. Staff A's surgical mask was placed and lowered to Staff A's neck area. Staff A was having difficulty breathing and signs of shortness of breath. Staff A then entered room [ROOM NUMBER] at 11:35 AM and room [ROOM NUMBER] at 11:48 AM to which she provided assistance to the residents by handing them their call lights and help set-up the residents' immediate environment. Additionally, Staff A was having episodes of non-productive coughing during these encounters with the residents in room [ROOM NUMBER] and room [ROOM NUMBER] while her surgical mask was lowered to her neck area. Staff A did not perform any form of hand hygiene (hand washing or hand sanitizer use) in-between residents. During a joint interview and observation on 06/30/2020 at 11:59 AM, Staff D, LPN approached Staff A, CNA/AA together with the surveyor about her improper use of the surgical mask. Staff D told Staff A that she was not wearing her surgical mask properly and that her nose and mouth should be covered at all times, especially when she was in the hallway and/or resident rooms. Staff A told Staff D that she was not able to wear the surgical mask because she had shortness of breath and was having difficulty of breathing. Staff A also stated that she knew the purpose of wearing the surgical mask was to protect the residents and others from COVID-19. Staff A stated that she had failed to protect the residents from her symptoms, but she had no other choice as she was not able to tolerate wearing a surgical mask. Staff A also stated that she had filled out the COVID-19 screening questions at the start of her shift indicating she had a new episode of shortness of breath and difficulty of breathing, but there was no manager or any person at the front desk to give her directions on what to do. Another observation on 06/30/2020 at 12:15 PM (after speaking with Staff D, LPN) showed Staff A CNA/AA again had her surgical mask lowered to her neck area with her nose and mouth uncovered. Staff A then entered room [ROOM NUMBER] and assisted the resident with her meal. FAILURE TO IMPLEMENT FACILITY POLICY AND CDC GUIDELINES RELATED TO THE REQUIRED TRANSMISSION BASED PRECAUTIONS FOR RESIDENTS WITH PENDING COVID-19 TEST RESULTS. A joint observation with the Administrator on 06/30/2020 at 11:03 AM, showed a sign on the doorway of room [ROOM NUMBER] indicating CONTACT PRECAUTIONS. The Administrator stated that the resident in room [ROOM NUMBER], Resident #1, was a newly admitted resident of the facility. Resident #1 was admitted to the facility on [DATE] from a hospital. According to the Administrator, Resident #1 was placed on contact precautions because the resident had a pending COVID-19 test result. The administrator stated that all new admissions were placed on contact precautions while waiting for their COVID-19 test results. However, when asked what was the facility's policy and what was the CDC's guidelines on the required transmission-based precautions for residents with suspected COVID-19/pending COVID-19 test results, the Administrator stated that residents with pending COVID-19 test results should have been placed on droplet precautions. The Administrator stated that she felt that it was ok to place the new residents on contact precautions since it's only an extra precaution. Similar findings were applicable to Resident #2, Resident #3 and Resident #4. Resident #2 was admitted to the facility on [DATE] from a hospital. Resident #2 had a pending COVID-19 test result and was placed on contact precautions instead of droplet precautions. Resident #3 was admitted to the facility on [DATE] from a hospital. Resident #3 had a pending COVID-19 test result and was placed on contact precautions instead of droplet precautions. Resident #4 was admitted to the facility on [DATE] from a hospital. Resident #4 had a pending COVID-19 test result and was placed on contact precautions instead of droplet precautions. During an interview and observation on 06/30/2020 at 11:15 AM, Staff F, NAC, stated that Resident #1 was on contact precautions. Staff F stated that staff were not required to wear gown, gloves, and face shields unless they provided direct resident care/contact. Staff F also stated that Resident #1's kardex (care directives) did not contain any information regarding the required infection control precautions that she needed to follow. Staff F then entered Resident #1's room and provided care without wearing a gown, gloves and face shield. During an interview and observation on 06/30/2020 at 12:05 PM, Staff B, RN stated that Resident #2 and Resident #3 were both on contact precaution due to their pending COVID-19 test results. However, when asked what was the facility policy and the CDC guidelines for residents with suspected or pending COVID-19 test results, Staff B stated that the precautions should have been droplet precautions and staff should have been wearing a complete set of PPE's such as face mask, gown, gloves, and face shield when entering the resident's room. Staff B also stated that the resident's plan of care did not include information related to the required precautions that the staff needed to follow. A review of Resident #1, Resident #2, Resident #3 and Resident #4's clinical records showed no evidence of a plan of care and/or care directives specific for the required infection precautions for staff to safely provide care and protect the residents and themselves from infection and/or COVID-19. FAILURE TO FOLLOW THE REQUIRED ISOLATION PRECAUTIONS An observation on 07/07/2020 at 3:00 PM showed Staff G, NAC/floor supervisor, enter room [ROOM NUMBER] wearing a surgical face mask. room [ROOM NUMBER] had a signage that showed, Droplet Precautions. During an interview at the time of the observation, Staff G stated that the room was on isolation due to the potential exposure of COVID-19 and that the resident in the room had a pending COVID-19 test. Staff F also stated that the isolation sign showed that staff entering the room should be wearing a complete set of Personal Protective Equipment (PPE) including a face mask, gown, gloves and a face shield. However, Staff F stated that since he was only delivering a bag of incontinent supplies to the resident, he did not think about wearing all of the required PPE and stated, I should have followed the precautions. During an interview on 07/07/2020 at 3:30 PM, both the DNS and Staff H, Infection Control Nurse (ICN) stated that Staff G should have followed the required precautions of wearing full PPE prior to entering a room with suspected and/or pending COVID-19 test results. This is a repeat citation related to F880 - Infection Prevention and Control from the last annual survey dated 12/20/19. See also: F835 - Administration F837 - Governing Body F842 - Resident Records - Identifiable Information Reference: (WAC) 388-97-1320 (1)(a)(b)(2)(a)(b)

Based on observation, interview and record review the facility failed to give 37 residents of 37 residents (1-37) or their representatives an advanced written notice of discharge in writing and in a language the residents understood which included: the effective date of transfer, the location of which each individual was being transferred to, a statement of appeal rights with contact information and directions of how to appeal and contact information of the State Ombudsman. In addition, the facility failed to document the plan in the resident's records. These failures caused residents distress, confusion, fear, uncertainty of their living situation, lack of understanding of why they had to move, and denied the residents the opportunity to have the representative / family / Ombudsman or case managers provide support to reduce transfer trauma. Findings Include: Review of an undated letter that was presented to residents and family members in a meeting on 12/21/16 at 6:00 pm. The letter indicated the facility was temporarily closing to repair the facility roof and make other repairs and improvements to the building. The letter went on to say the facility was in the process of transporting all of its residents to neighboring facilities. The letter was not individualized, did not include the effective date for each individual resident, when their transfer was to take place, location to which each resident was to be transferred to. It did not include a statement of appeal rights, including contact information or the name address or phone number of the State Ombudsman. In addition, the letter did not inform residents how to contact their Medicaid case managers or the Ombudsman for support. The facility arranged and transferred 5 residents the next day, 12/22/16 less than 24 hours after they were informed of the temporary closure. The residents were not provided any support from the Ombudsman or an involvement of the HCS case managers. In an interview on 12/28/16 at 9:30 am, the Ombudsman stated that she made a visit to the nursing home where residents and families complained that the facility had not given the residents or families a discharge notice. She also reported that families and residents were being pressured to accept placement that they were not agreeing to. The Ombudsman was not made aware of the discharges until 12/28/16, 6 days after residents were being discharged . In an interview on 12/29/17, the Administrator confirmed that individualized discharge notices were not sent to each individual resident. See also 483.15(c)(7)-F 204, Preparation for Safe/orderly Transfer/discharge 483.10(a)(1)-F 241, Dignity and Respect of Individuality 483.90(c)(2)(d)-F 456, Essential Equipment, Safe Operating Condition

Based on interview and record review the facility failed to provide sufficient preparation, orientation or documentation for each resident in a language the residents could understand about relocation plans or information about facilities; failed to consistently provide information and reassurance for individuals / families who needed the time and support necessary to make informed decisions about a relocation. This failure impacted 37 or 37 residents (,[DATE]) This failure created an atmosphere of confusion and uncertainty for residents and caused actual psychologic harm for 2 non-English speaking residents, (3 & 12), one who was placed in a cab and traveled alone for several hours alone with a driver who she could not communicate with (3) and another who was sent to another facility and was unable to communicate with family (12). Findings include: Resident 3 was a long term care resident that was admitted to the facility on [DATE]. The resident's family did not use English as their first language and often needed translations. On [DATE] the facility residents were given a letter that notified residents they had to move because the facility was closing to make repairs to the roof and heating system. On [DATE], the family member stated that she received a phone call from the receiving facility informing her that the resident would not eat. The family member stated that at the transferring facility family were close enough that they were able to come and bring her food of their culture. In an interview on [DATE], Resident 3's family member stated that she was told by the facility on [DATE] that she had one week to move Resident 3. She was not given any options or choices and was told there were no local places available. They were told the only available place was several hours away and included a ferry ride. The family wanted more time to find a more suitable local place for Resident 3 but was told she had to take what was offered. The second time the facility called the family member she realized it was a different building and the transferring facility had already moved Resident 3. In addition, the facility never had anyone speak to the family member or the resident in her native language so she understood why and when she was leaving. In an interview on [DATE], the Home and Community Service Case manager, stated the facility informed her that all local nursing home options have been exhausted, but a bed was available for this client in Bremerton. The family continued to acknowledge that she agreed to have client transferred to Bremerton as a last resort, but thought the transfer was something that would happen in the next week or two. Finally the family member noted she did not speak with an Emerald Hills staff member the day of transfer to authorize the transfer. The family at that time want to have Resident moved back into the area for ease of family visitations and support. In an interview on [DATE], the Ombudsman stated she was present that morning when the Director of Nursing Services (DNS), spoke with her that Resident 3 had transferred on [DATE]. During that conversation the DNS stated that they had obtained prior permission for the transfer to Bremerton, and he believed the staff member working on the resident's transfer left the granddaughter a message informing her of the transfer. The Ombudsman's concern was that the Facility discharged the to another facility without properly informing the family the transfer was set/occurring, and not giving the family any final input on the resident's transfer plan. Review of the medical and chart showed there was no documentation or care planning of how and who they contacted to fine local placement. In a document supplied by the DNS showed that no Adult Family Homes or other options were explored. On [DATE], the family member informed the department that the resident had passed away on [DATE]. Resident 12 Resident 12 was admitted to the facility on [DATE]. Her primary language was Chinese. In an interview on [DATE] at 2:30 pm, the resident's family member stated that the facility called her and stated that the facility was having an emergency meeting on [DATE]. At the meeting they were told that the residents all needed to be moved within the week. The resident was discharged 5 days later to a facility in another town. Resident 12's family member stated that each resident was assigned a person to assist with getting the resident's moved. They were in a hurry. The family member felt like there was not enough time to plan for everything that needed to be set up. They chose to send the resident to the closet out of town location, otherwise she was told the resident could end up hours away. Resident 12 had a phone at the old facility and whenever she needed something or got upset she would call her family so they could speak with her in her own language and reassure her. At the new facility the facility did not have a phone. It was intimidating for the resident and she was afraid to go out of her room. Without a phone it was tough, it was really tough. The family member stated the resident was very sad and went down hill fast. The resident expired 23 days later on [DATE] Review of resident 12's record showed that there was no discharge plan and no preferences were identified or addressed prior to the residents move. The records of all 37 resident's were reviewed and there was no documentation that showed the facility had a plan or that there was any preperation for any of the residents. The letter was given to the resident on [DATE] and 5 residents were discharged the next day on [DATE] less than 24 hours from the the time of the notification. Then on [DATE], five more residents were discharged . There was no documentation of plans for any of these residents. See also 483.15(c)(3)-(6)(8), F 203, Notice Requirements before transfer/discharge 483.10(a)(1)-F 241, Dignity and Respect of Individuality

Based on observation, interview and record review the facility failed to treat 37 of 37 residents with respect and dignity by discharging all of the resident without proper notification, not offering translators, discharging residents without all of their belongings or advocating for residents who did not want to leave the facility or area. This caused residents and resident representative's fear, anguish and transfer trauma. Resident 1 Resident 1 had lived in the facility for over 9 years, since [DATE]. In an interview Resident 1 stated that she was scared and did not want to move out of the facility to an area that was so far away. She stated the facility wanted to send her to a facility out of town to where she did not know anyone. The whole time the resident spoke, she was crying, They have no respect for my feelings. Resident 2 Resident 2 was admitted to the facility on [DATE]. In an interview on [DATE] at 8:45 am, the residents' daughter stated that she received a call from the receptionist who told her there was an emergency meeting at 6:00 pm on [DATE]. The families and residents were told the facility was closing and that everyone had to be out by the end of the year, [DATE]. There was a letter was on a table and attached to the letter were a list of facilities that belonged to the same company. The Administrator told everyone that the longer residents / families waited to make a decision on where to go, the further away they would be. After the meeting, the daughter said she immediately went to a neighboring facility and requested admission for her mom. The facility agreed to take her mom, so she told the facility to arrange it. The facility told the daughter that her mom's transportation would be at the facility at 2:00 pm, but she told them they would have to delay until 5 pm, because it was going to take her two car loads to get all of her mom's equipment and things. The daughter went on the say that the timing of the event was horrible, 2 days before Christmas. It was not right to be displaced right before Christmas. My mom was one of the lucky ones because I was able to take care of it right away, but there were families who did not speak English, who did not understand what was going on She said families and residents were all crying and upset. Her mom's best friend was placed at a different facility and her mom. My mom was devastated and said where are you taking me? She didn't understand and blamed me saying it's all your fault I have to leave. She also stated that her mom had to spend Christmas with a bunch of strangers taking care of her. Also after the resident got to the facility she realized she was missing a clock and a pair of pajamas. She called the facility and they said they would get back to her, but they didn't. Resident 3 Resident 3 was admitted to the facility on [DATE]. Resident 3 had dementia, did not speak English and had a Durable Power of Attorney (DPOA). In an interview on [DATE], the resident's DPOA stated that her concerns were with the discharge process and Resident 3's health and wellness being compromised by the transfer; as well as the facility failing to be forthcoming on all pertinent information regarding the facility closure and the residents transfer. Resident 3 spoke Korean and the facility made no attempt to communicate with resident in her language so she could understand, or to explain she was being transferred to another facility. The resident had no idea where she was going and why she was being moved. The DPOA created a language translation aid with translated English words to Korean words for everyday use and to help staff to assist the resident with activities of daily living (ADLs). This important aid did not travel with the resident, nor was the DPOA able to provide assurances and let her know where she was going. Now the resident is not eating and is suffering, which could have been avoided. On [DATE] the DPOA notified the department that the Resident died alone, without her family at her side, 20 days after discharge. The family felt it was due to her not eating, because she was alone. Resident 4 Resident 4 was admitted to the facility on [DATE]. In an interview with the family member on [DATE]. The son stated that the resident was Vietnamese and did not speak English. The son was the decision maker and was out of the country when the facility made there announcement to close. This information was presented in a meeting with families and residents. The resident's daughter attended and was confused regarding the move and the information that was provided. She was told that her mother had to move to Seattle and that she had to be out of the facility by the end of the year (10 days). This was very stressful for her as her brother was not unavailable. At no time did the facility ask her if she understood the information or required an interpreter. She told her brother that the DNS told her the resident must move to the Seattle facility on the 29th or they could not guarantee her a place to go. The daughter felt she had no choice and agreed. The son returned from overseas the following morning [DATE], and went directly to the facility and canceled the move to Seattle. He expressed that he would find a closer facility even if he had to knock on doors or take her home. The son explained that in the past 9 months the facility had moved/changed rooms on the resident 7 times, which cause confusion in the resident. No one was able to explain in a language that the resident could understand that she was moving. The son also indicated that the facility placed a wander guard on resident's ankle without giving him prior notice so the family could explain it to the resident. As a result the resident became very upset by the wander guard and was resistant to it being placed on her leg; this was then documented as a behavior without explanation. The son felt this was unfair and according to the facility that was the reason for the resident not being placed. He said that his sister had to come into the facility every shower day to help with the resident. When the family was in the facility they helped with the residents care needs. They brought the resident dinner every evening as she did not like the food at the facility. The family were very involved with the resident's care and wanted her to remain close to them so that they could continue to provide care, translation and support. The son stated the family was currently upset about the transfer and worried that they were being rushed in to making a decision without being able to do a thorough research. Resident 5 Resident 5 was admitted on [DATE]. In an interview the HCS case manager stated Resident 5 was transferred to a facility that included a ferry ride. The resident was moved to the facility with his power wheel chair, but the charger was left behind along with some of his other belongings that were not sent with him. In an interview, the family stated that they could no longer visit the resident, because they did not have the money to pay for a ferry ride. This had really upset the family because they felt they could no longer provide emotional support for the resident. They stated that the facility called them and wanted them to pick up his wheel chair charger and belongings and take his things to the resident. The family felt that since the facility were the ones that sent the resident so far away they did not feel they should pay out of their pocket to deliver the charger. There were also other belongs that were left behind, he only took enough clothing and belonging to last for two days, and it was a week to a week and one half before the new facility came and picked up his belongings. Resident 6 Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident recently had a feeding tube inserted as she was suffering from dehydration and not getting nourishment because she could not stomach the food at the facility. She could still eat soft food by mouth but for safety purposes the feeding tube was inserted. In an interview on [DATE] The resident's Daughter (DPOA) stated that she visited every other day to ensure the resident's needs were being met due to the language barrier and feeding concerns. On [DATE] at approximately 3:00 pm the daughter stated that she received a phone call at work. The facility told her she must attend a mandatory meeting at the facility that evening with other families and residents. She explained that it was not adequate notice and but what other option did she have. When she asked what it was about - she was told that they were not allowed to tell her, she had to come to the meeting to find out. The DPOA stated at the meeting attendees were told the facility was closing at the end of the year, and that they wanted to get everyone out ASAP. Each family was assigned a nurse to help with the transition. She was told that she would be contacted within 24 hours. The RCM called and asked location choices they wanted and she indicated Everett or Lynnwood area would be best. The daughter told the RCM that she was going to be out of state for Christmas. The RCM called her the day she returned and told her she had good news, that she found placement for the resident. When she asked for the address the RCM told her she could not give it to her until the transportation was arranged. Then, the following day the RCM called to tell her that the bed was no longer available. She has not heard from the RCM since. She tried to call the RCM twice. Left a message and the 2nd time was disconnected. No one from the facility had called her. The daughter was concerned that her mother would not be placed and it was mentioned at the meeting that some residents might have to go to Walla Walla. She was concerned because at the meeting the facility said they were closing at the end of the year. The Daughter stated that she received a letter at the meeting which was not helpful. She still had not received any notice written or verbal that her mother must move and she was worried. The Daughter had made calls to some facilities but was being told that they were not accepting Long Term Care residents. The Daughter was worried for the resident and fears the facility would not find a place for her, and she could not bring her home. She also could not visit the resident if she was far away, and this was very upsetting as the resident relies on the support she receives from the daughter on those visits. Resident 7 Resident 7 was admitted on [DATE] In an interview on [DATE] Resident 7 stated that she was upset, because she did not want to go where the facility wanted her to. She stated that she had a friend that picked her up every Sunday for church and now she did not know how she was going to get to church. During the whole discussion the resident was observed to be distressed and have a worried look on her face and at one point began to cry. In an interview on [DATE], the Ombusman stated that she and the state Ombudsman had a meeting at the facility. The remaining residents and family members were upset, some crying because the closure had been so unorganized and disruptive to not only the residents by the family members also. During an onsite visit on [DATE] at 2:15 pm, a tour of the facility was made with the Maintenance man. During the tour there were personal items that in the facility and not sent with residents. Resident 1 was discharged without her electric wheel chair and the respresentative was told that she had to pay to come and get it. The maintenance man stated that there was a whole room that was locked that contained personal items, and boxes of items in the basement were observed. Resident 2's family stated that she was missing a clock and some pajamas. Resident 3 had several bags of personal items that were left. Resident 5 was discharged without all of his belongings and the charger to his electric wheelchair. Resident 7 had multiple bags and boxes of items. Resident 8 was discharged without her front Wheeled Walker with brakes was left. Resident 9 had several bags of items. Resident 10 had a bag of items that was left. Resident 11 had 2 bags of items left. There was 1 bag that had items but it was not identified as to who it belonged to. The facility did not treat each of the 37 residents with respect and dignity by ensuring that their choices or families choices were honored and their concerns were listened to. This impacted every resident in the facility. See also below for additional details. 483.15(c)(3)-(6)(8), F 203, Notice Requirements before transfer/discharge 483.15(c)(7)-F 204, Preparation for Safe/orderly Transfer/discharge

Based on observation, interview and record review the facility failed to ensure the roof and heating system were maintained and consistently functioning. By not consistently inspecting and maintaining the roof, caused water leakage, which lead to structural damage in one part of the facility. The lack of inspection and maintenance of the boilers caused the loss of heat in two thirds of the building that caused 37 of 37 residents to be involuntarily moved out of their rooms and then out of the facility resulted in psychological harm for all of the residents due to transfer trauma. Findings Include: On an annual survey dated 9/16/16 the facility was cited at F 252 for Maintenance which included in Room 5 that had an area where the ceiling paint was peeling away and measured approximately 2 by 3 foot. At that time the Maintenance Director was unable to provide maintenance logs that showed there were any kind of rounds that were being done to identify structural issues. According to a report made to the department on 10/04/16, on 09/30/16 the facility maintenance department identified the ceiling in room 5 was found to be moist. The residents in room 5 were moved to other rooms in the building. On 10/03/16, the Maintenance department identified a leak in the facility roof over room 5. A contractor was hired by the facility to examine the roof and the facility began to move forward with repairs. The contractors requested the facility move 14 residents from rooms 4 to 11 for comfort and safety. The 14 residents were moved to other areas of the building. At that time the facility reported it would take approximately two weeks to repair. During observation on an Abbreviated survey on 10/21/16 temporary walls had been erected that were blocking the hallway where contractors were working in the area. On 12/7/16, the facility reported to the Department that on 12/2/16 at 6:40 p.m. the temperatures in building dropped to 70 degrees. The utility company arrived at 9 p.m. to check on boilers and found both were functioning normally. The facility decided to obtain a temporary heat source. On 12/3/16 at 8 a.m. the temperatures in the west wing was at 67 degrees. The construction crew was on site and discovered the boilers had been switched off accidently. The emergency switch was next to a light switch. After it was turned on the temperatures climbed immediately. Temporary heat was put in place as safety measure. The expected duration of the maintenance issue was to last 1-7 days due to a boiler pump needing replacement for the North Hall on 12/5/16. On 12/21/16 at 11:38 am, 19 days after initial report of an issue, the department received a phone call where the Administrator stated the facility was closing the facility due to failure of roof and the lack of heat in the building. (On 12/7/16, it was reported that the issue would last 1-7 days and there was no further report to the department of no heat) Written on a report dated 12/28/16 by the onsite contractor who was repairing the roof. -The two boilers serving these areas need replaced. -The Ajax boilers (No longer manufactured) are beyond their useful life. -They are currently leaking water. -Not as efficient as newer boilers. -Isolation valves were not exercised on a regular basis so they will not close all the way or move at all. -The piping system under the building have many leaks. Type M [MEDICATION NAME] (Thinner Walled) was used for repair in some areas. This [MEDICATION NAME] pipe is also running underground which should not be done. Type L or Type K should have been used. In an interview on 12/29/16 the Administrator stated the facility did not have maintenance logs and that she spoke to head of construction and he stated that there is no life safety code that required boiler systems to be inspected. The boiler system they had strictly ran the heat and not the domestic water system and that they do not routinely temp the boilers. During a visit on 1/9/17 observations showed that the temporary heaters were no longer being used. The maintenance man stated that he was able to get the heat running again. The baseboard heaters in the hallway were warm to the touch and the building was comfortable. At no time was there any mention of an emergency or a plan to close the building. Failure to keep the building in good repairs lead to actual psychological harm of residents, due to the urgency to displace of residents, lack of notices or preparation time to ensure there was no transfer trauma. See also 483.15(c)(3)-(6)(8), F 203, Notice Requirements before transfer/discharge 483.15(c)(7)-F 204, Preparation for Safe/orderly Transfer/discharge 483.10(a)(1), F 241, Dignity and Respect of Individuality

Based on observation, interview and record review the facility's administration failed to effectively and/or efficiently use its resources to ensure the facility was in good repair which affected 37 of 37 current residents who had to be discharged , without required discharge notices, allowed time for preparation or treated residents with respect / dignity. Failure to ensure compliance resulted in harm to 37 of 37 residents referenced in F 203, F 204 and F 241. Findings Include: The Administrator failed to ensure all resident were given 30 day notices. See 483.15(c)(3)-(6)(8), F 203, Notice Requirements before transfer/discharge The Administrator failed to ensure there was enough time and preparations for safe and orderly transfers. See 483.15(c)(7)-F 204, Preparation for Safe/orderly Transfer/discharge The Administrator failed to treat all 37 residents with respect and dignity. See 483.10(a)(1), F 241, Dignity and Respect of Individuality The Administrator failed to keep the facility in good repairs to prevent equipment and structure damage. See 483.90(c)(2)(d), F 456, Essential Equipment, Safe Operating Condition The Administrator failed to have policies for a facility closure. See 483.70(l)(1)-(3)-F 523, Facility Closure - Administrator

Based on observation, interview, and record review the governing body failed to provide oversight to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each residents' safety and well-being was not at risk, to ensure there was systems in place to close a building, to address the overall maintenance of the building, including the leaking roof above resident rooms. The facility's failure revealed a lack of oversight of major environmental systems, caused psycological harm due to poorly planned discharges, and placed residents at risk of physical harm if the roof would have colapsed or discomfort by the lack of heat to all residents. See the below requirements for futher information: The governing body failed ensure to ensure all resident were given 30 day notices. See 483.15(c)(3)-(6)(8), F 203, Notice Requirements before transfer/discharge The governing body failed to ensure there was enough time and preparations for safe and orderly transfers for each resident. See 483.15(c)(7), F 204, Preparation for Safe/orderly Transfer/discharge The governing body failed to treat all 37 residents with respect and dignity. See 483.10(a)(1), F 241, Dignity and Respect of Individuality The governing body failed to keep the facility in good repairs to prevent equipment and structure damage. See 483.90(c)(2)(d), F 456, Essential Equipment, Safe Operating Condition The governing body failed to provide oversight for the Administrator when a decision was made to close the building. See 483.70, F490, Administration The governing body failed to ensure the Administrator followed the regulation for submitting written notices to the appropriate enities with a 60 day notification and a plan for resident discharges. 483.70(l)(1)-(3), F 523, Facility Closure - Administrator The governing body failed to ensure there were policies for a facility closure. 483.70(l), F 524, Facility Closure - Policies

Based on observation interview and record reviews the facility Administrator failed to notify the Department, State LTC ombudsman, residents or resident representatives in writing, 60 prior to the closure of the building; Submit a written plan including assurances that the residents would be transferred to the most appropriate facility or other settings, taking into consideration the needs, choice, and best interests of each resident. This failure caused psychological harm by residents receiving a less than 24 hour notice of relocation, being moved without preperation, without choice of location, honoring respect / dignity or taking the preferences of the residents into consideration. The facility became aware of roofing problems in the end of September. There was some action taken to repair the roof at the beginning of October of 2016. It was determined that it was serious enough that residents were relocated to different areas of the building for safety concerns. Surveyors were in the building on November 21, 21 & 30/ 2016 and December 1, 2016 completing a post survey and at no time was there mention that the building would need to be shut down. On 12/6/16, the complaint investigator was in the building and observed temporary heaters being used, but was told that they were being used due to a boiler repair and loss of potential heat from the roof during a cold snap. There was no sense, at that time, or up until December 21, 2016 that there was any type of emergency or the building would needed to be shut down. On 12/21/16 the department was notified by the Administrator by the phone that the building would be closing due to lack of heat and the decay in the roof structure. The facility was unable to show proof that the Residents, Family or Ombudsman was notified 60 days prior to closing. In addition there were no written plans in place and residents were not given options per their own preferences. This caused distress, fear and anxiety in residents. See also for additional information 483.15(c)(3)-(6)(8), F 203, Notice Requirements before transfer/discharge 483.15(c)(7), F 204, Preparation for Safe/orderly Transfer/discharge 483.10(a)(1), F 241, Dignity and Respect of Individuality

Based on observation, interview and record review the facility Administrator failed to have policies and procedures in place to direct the administrator on how to manage the closure of the building. This impacted 37 out of 37 residents living in the facility. This failure denied the residents the opportunity to have the support and have the advocacy of the Ombudsman, or other interested parties to reduce transfer trauma. Findings include: In an interview on 12/29/17, the facility administrator stated that the facility did not have policies and procedures to follow for a facility closure that directed the Administrator on steps to use to close the building. By not having policies in place to follow caused actual phychological harm to residents that resulted in transfer trauma. See also for additional information: 483.15(c)(3)-(6)(8), F 203, Notice Requirements before transfer/discharge 483.15(c)(7), F 204, Preparation for Safe/orderly Transfer/discharge 483.10(a)(1), F 241, Dignity and Respect of Individuality 483.70(l)(1)-(3), F 523, Facility Closure - Administrator

Based on observation, interview and record review, the facility failed to provide care in a manner that promoted and enhanced dignity for 10 of 21 residents (67, 138, 75, 135, 61, 4, 35, 36, 3 and 88) reviewed for respect and dignity. Failure by staff to consistently respond and provide care to Resident 67's call light, promptly respond to Resident 138's concern, provide care and services in a dignified manner to Resident's 135, 75, 61, 36, 4, 35, 3 and 88 placed these residents at risk for frustration, feelings of diminished self-worth and psychosocial harm. Findings include: RESIDENT 67 Resident 67 was a long term care resident admitted to the facility in 2014 and lives in the north hall. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident 67 required extensive assist of 2 staff for bed mobility, personal hygiene, dressing and toilet use. The resident was incontinent of bowel and bladder. In an interview on 08/22/16 at 12:12 PM, Resident 67 stated she often sat in soiled and wet bedding all day without getting changed. I have to wait a long time up to 40-50 minutes after I put on my call light. In addition, the resident stated that staff speak in their own language when they are in my room. They talk to each other, not me there are about 4 staff that communicate with me they don't involve me in anything about my care. She stated she may go 3-4 days without staff changing her gown and she seldom gets set up for denture / oral care. (see call light system below) In an follow-up interview on 08/24/16 at 1:35 PM, Resident 67 stated when certain Nursing Assistant's (NA's) were on shift, she knew she would not receive care. The resident stated some days she did not get care at all during the day shift and had to wait until the evening shift. The resident stated she gave up on receiving care on the night shift a long time ago because they don't ever change me. On 08/25/16 at 9:02 AM, a strong urine smell was present in the resident's room. Resident 67 stated she was incontinent and the last time she was changed was the day before at 4:00 PM. Resident 67 then pulled back her sheets. The resident's briefs were visibly soaked through and the bottom sheet was wet from the middle of her back to her knees. Under the resident's left leg the sheet had a large area that was a red-pink color. The resident stated she had a boil on her left buttock and that is why the sheet was that color. Resident 67 stated Staff I, NA, was not on today and she would not be changed until the next shift (which started at 2:00 PM). During the interview and observation, Resident 67's roommate confirmed the resident had not received care since 4:00 PM the prior day. Resident 67 stated my poor roommate has to smell me. The roommate replied it was okay because she kept the window open. At 9:55 AM, the resident had not received any incontinent care. The resident stated she had the boil on her left buttock because she was incontinent and did not receive care promptly. When asked how this made her feel, the resident stated it made her feel unhappy and she felt ignored. At 10:52 AM, 1 hour and 50 minutes later, the resident was observed lying in her bed. The resident had not received any care. At 11:00 AM, Staff D, interim Director of Nursing Services (DNS), stated the resident had a boil on her left buttock. Resident 67's left buttock was observed to have an approximate 2 centimeter (cm) by 2 cm red raised area with a dark center. In an observation on 08/26/16 at 5:29 AM, there was a strong odor of urine in the west hallway. The urine odor was coming from Resident 67's room. At 11:24 AM, Resident 67 stated if the facility would train staff to provide her care without rushing or hurting her, she would never refuse. The resident stated some staff were not aware how to reposition her in bed and this would hurt. The resident stated I don't know why I would refuse care then, I just want someone who knows what they are doing. In an interview on 08/29/16 at 8:45 AM, Staff FF, Licensed Nurse (LN), stated the strong urine odor in the North hallway was a chronic thing. In an observation and interview at 9:19 AM, there was a strong odor of urine in the resident's room. The resident stated the last time she received incontinent care was 8:00 PM, the prior evening. The resident stated like I told you the other day, I pretty much know what time they are coming, it will be about 1 or 2 (PM), that's the usual time for day shift girls. In an interview 11:56 AM, Staff I, NA, stated she provided care for Resident 67 at approximately 1:00 PM daily. Staff I stated the resident's bed was usually soaked by the time she provided care. Staff I confirmed at times the resident may not receive care until the next day (24 hours later). In an interview and observation on 08/30/16 at 10:54 AM, the resident stated she had not been changed since the prior evening. Resident 67 stated when she did not get changed, she wanted to yell at someone to change her. The resident stated she was very frustrated and felt like she was not even human. In additional information about Resident 67 in F 312 RESIDENT 138 In an interview on 08/22/16 at 10:55 AM, Resident 138 stated she was not treated with respect and dignity by the facility staff. She stated last Thursday Staff D shoots into this room and at the top of her voice says you have active TB ([MEDICAL CONDITION]) and then shouts it down the hallway. Resident 138 stated she heard Staff D tell the staff down the hall that she had TB and needed to be shipped out of the facility and the whole ward needed to be in quarantine. Resident 138 stated she felt guilty and started to cry. The resident stated she felt this was all her fault and she felt horrible. The resident stated she didn't understand what was going on. The resident stated she had told the facility upon admission that she had been vaccinated against TB in the past related to where she lived and would always test positive when given a TB test. Resident 138 stated the next thing she knew staff had placed an isolation cart outside of her room and a bin inside her room. The resident then pointed to the isolation bin inside of her room (which the staff never removed). Resident 138 stated she was so emotionally distraught and kept asking staff questions but no one would answer her. Again, the resident did not understand why she was being isolated. In an interview on 08/30/16 at 10:48 AM, Staff D stated she told another LN to inform the resident of the results of the chest x-ray because Resident 138 did not want her (Staff D) back in her room. RESIDENT 75 In an observation on 08/24/16 at 8:30 AM, Resident 75 was sitting in her wheelchair (w/c) in her room. A strong smell of urine was detected. There was a bedside commode (BSC) with the bucket half way full of urine, feces and toilet paper and remained in the same position/condition at 9:30 AM and 11:00 AM. In an observation on 08/29/16 at 8:42 AM, Resident 75 was sitting in her w/c in her room. There was a urine odor in the room. The BSC bucket was full of toilet paper, urine and feces. At 1045, two hours later, the resident was observed sitting in her w/c in her room. There was a strong urine odor in the room. The BSC was observed in the same condition as noted two hours prior. Resident 75 pointed to the BSC and stated that she used it last night. Resident 75 stated the staff gets busy and can ' t always take care of the BSC after she used it. Resident 75 stated this occurred frequently. In an interview on 09/14/16 at 9:35 AM, Resident 75 stated the facility put her in a pull ups and when she went home she would go back to wearing panties. The resident stated she did not like the pull ups and the facility made her wear them because they were not able to get her to the bathroom in time. Resident 75 stated they have a lot of people to deal with here and when I have to go I have to go. Resident 75 stated she had been incontinent several times because staff did not allow her to use the bathroom on her own and they were not able to answer her call light on time. Resident 75 stated I am a grown woman and can walk. The resident did not want to be incontinent of urine. RESIDENT 135 According to the resident's Minimum Data Set assessment dated [DATE], the resident had mild cognitive impairment. On 08/25/16 beginning at 9:45 AM, Staff E, LN, and Staff B, NA, were observed providing wound care to Resident 135. As Staff B started to remove Resident 135's pants, she stated in a audible voice she (the resident) smells like she needs to be changed. Staff E did not appear to hear Staff B, so Staff B stated she smells poopy. At 10:50 AM, Staff E stated Staff B could have chosen different words to communicate Resident 135 was incontinent of bowel. At 11:36 AM Staff B stated she realized she could have informed Staff E the resident was incontinent of bowel differently. Resident 135 was not interviewable, but the reasonable person would not want to hear they were poopy when they were incontinent of bowel. RESIDENT 61 In a family interview on 08/22/16 at 1:56 PM, Resident 61's spouse stated staff did not treat her husband with respect and dignity. She stated her husband told her staff routinely came into his room at 4:00 AM to empty his catheter bag and to empty his trash and when they did this they woke him up. Resident 61's spouse stated she had spoken with her husband's next door neighbor who confirmed staff had been doing that to him also. In an interview on 08/26/16 at 10:57 AM, Resident 61's next door neighbor, Resident 141, confirmed staff had also been coming into his room to empty his trash early in the morning, which was waking him up. But staff had stopped because he told them they had plenty of staff during the day to do that. In observations on 08/26/16 between 4:57 AM - 5:08 AM, 3 different NA's were observed entering resident rooms emptying trash cans. In an interview at 4:57 AM, Staff H, NA, stated it was part of his job to empty resident trash cans on his last rounds between 4:00 AM - 6:00 AM. RESIDENT 4 In an interview on 08/22/16 at 2:21 PM, Resident 4 stated not all staff treated her with respect and dignity. The resident stated there was a housekeeper who would remove her fan without asking her permission and put it in the hallway. Resident 4 stated the administrator nurse was rude to me and my mom. The resident stated she felt uncomfortable when the administrator nurse told her she could not leave the facility. The resident did not understand why she would say that to her. Additionally, the resident stated there was a night shift NA who argues with me and tells me I do not need help. The resident stated the staff member was rude. During the interview, staff came into the resident's room. The resident stated it was weird the NA's were being nice today. RESIDENT 35 In an interview on 08/23/16 at 9:48 AM, Resident 35 stated staff did not treat her with respect and dignity. The resident stated Staff EE, NA, was throwing spitwads at me a couple months ago. He harassed me and was very rude and disrespectful. I will not let him take care of me anymore. She said she was in bed, he opened her door and threw a spit wad at me. I told the staff and they don't let him work with me anymore. RESIDENT 36 In an interview on 08/23/16 at 8:24 AM, Resident 36 stated staff were disrespectful. The resident stated one of the aides told me I spoke too loud, I told her if she would listen I wouldn't have to speak loud. Another time I told them they were paid to do the work I am not able to do. OBSERVATIONS OF STAFF ENTERING RESIDENT ROOMS WITHOUT KNOCKING In an observation on 08/23/16 at 9:15 AM, Resident 3 was being interviewed behind a closed door. Staff HH, NA, opened the resident's door without knocking or asking permission to enter. At 9:46 AM, Resident 35 was being interviewed behind a closed door. Staff M, NA, opened the resident's door without knocking or asking permission to enter the room. At 2:38 PM, Resident 88 was being interviewed in her room behind a drawn curtain. Staff R, NA, entered the resident's room without knocking, walked around the curtain and then said knock, knock. CALL LIGHT SYSTEMS In an interview on 08/30/16 at 12:23 PM, Staff T, Receptionist, was asked if she could hear an audible signal for call lights. Staff T stated she could see the lights blinking, but could not hear it. In an interview at 12:22 PM, Staff F, Licensed Nurse, was sitting at the computer at the front nursing station. She stated No, when asked if she could hear any audible signal coming from the call light panel. Staff F stated call light signals were only audible in this building at the west nursing station. She said they could not be seen or heard at the north nursing station and could not be heard at the front nursing station. Staff F confirmed no call light could be heard in the staff earpieces that staff were observed wearing. In an observation at approximately 12:30 PM, there was no call light system at the north nursing station. The call light in room [ROOM NUMBER] on the north unit was activated. There was a light outside the room, but no audible signal could be heard. Upon walking into the Oak Harbor Dining Room, an audible signal could be heard, but it was not audible out on the north unit. In an observation on 08/31/16 at 8:51 AM, a faint audible sound could be heard coming from the panel at the receptionist's desk. In an interview at 8:57 AM, Staff T stated today she could hear a faint audible signal, she said it must not be as noisy here today. In a joint observation at 9:29 AM, Staff U, Housekeeping Supervisor, confirmed the call light signal was not visible outside the door to the north unit bathtub room door and she would let maintenance know. Refer to F353, CFR 483.30 Nursing Services .

Based on observation, interview and record review, the facility failed to ensure 5 of 6 residents (32, 45, 36, 40 and 75) were free of significant medication errors. Failure to manage Resident 32's treatment with [MEDICATION NAME] resulted in harm when she required emergency treatment for [REDACTED]. Failure to administer the correct dose of [MEDICATION NAME] (a blood thinning medication) resulted in actual harm to Resident 45 who was hospitalized due to [MEDICAL CONDITIONS]. The facility failed to administer the correct dose of medications to Residents 75, 36, 32 and 40 placed them at risk for diminished effectiveness of the medication and experiencing potential health related complications. Findings include: [MEDICATION NAME] DOUBLE-DOSING Resident 32 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. The Licensed Nurse (LN) placed this on the Medication Administration Record (MAR) to be given at 8:00 AM. On 08/25/16, there was a new physician order [REDACTED]. This was placed on the MAR to be given at 6:00 AM. Now the resident received 2 daily doses of [MEDICATION NAME]. There was no documentation in the medical record the LN notified the resident of this new order or clarified with the physician the same daily dose of [MEDICATION NAME] being given two hours apart for the same diagnosis. Review of the clinical record revealed no documentation the facility pharmacist had questioned whether it was appropriate for the resident to receive 2 separate daily doses of [MEDICATION NAME] 20 mg. Review of a progress note dated 08/28/16 at 3:35 PM, revealed the resident was complaining of nausea and vomiting and was treated with [MEDICATION NAME] (an antinausea medication). Review of a progress note at 11:08 PM, revealed the resident stated she had vomited twice, was treated with [MEDICATION NAME], but she continued to throw up. Review of a progress note dated 08/29/16, revealed the resident was nauseated and vomiting and had been medicated with [MEDICATION NAME] and [MEDICATION NAME] (an antinausea medication), but they weren't helping. The resident could not keep anything she drank down, and she was not eating. The resident requested to be sent to the hospital. Review of the emergency department (ED) physician notes revealed the resident complained of chest pain which is better described as burning in her throat. The resident told the ED doctor [MEDICAL CONDITION] been worsening since she had started on the [MEDICATION NAME]. The doctor's notes stated the [MEDICATION NAME] does have an adverse reaction of [MEDICAL CONDITION] ulcer disease that may have exacerbated [MEDICAL CONDITION]. The ED doctor recommended she discontinue the [MEDICATION NAME], and he informed the resident his ED notes would be documented with that recommendation so her attending physician back at the nursing home would be aware. Review of the MARs revealed the facility did not discontinue either of the daily doses of [MEDICATION NAME] after the resident readmitted back to the facility from the hospital. Review of a Wound Clinic treatment note dated 08/30/16, revealed a note to taper the resident off of the [MEDICATION NAME]. Review of the clinical record revealed this recommendation was not acted on. Review of a physician progress notes [REDACTED]. The progress notes contained absolutely no reference to the [MEDICATION NAME] at all, despite the fact the resident required emergent hospital care and was discharged from the ED with a recommendation to discontinue the [MEDICATION NAME]. The physician also did not address the Wound Clinic provider's recommendation to taper the resident off of the [MEDICATION NAME]. Review of the MARs revealed that after the resident returned from the hospital, she received 20 doses of [MEDICATION NAME] from 08/30/16 - 09/15/16. There were at least 10 documented resident refusals when facility nurses continued to attempt to administer [MEDICATION NAME] to the resident. Review of progress notes dated 08/31/16, 09/01/16, 09/03/16 and 09/04/16 revealed the resident was complaining of throat pain. Review of progress notes dated 09/09/16 at 5:09 AM, revealed a facility nurse attempted to administer [MEDICATION NAME] to the resident and the resident stated It makes me sick, I do not take it. On 09/16/16, review of the September MARs revealed that even after the resident informed the facility nurses on 09/09/16 that she did not take [MEDICATION NAME] because it made her sick, 11 more doses were given between 09/09/16 - 09/15/16. At 1:30 PM, a review of the resident's clinical record revealed no documentation the facility had ever obtained the emergency department treatment records with the recommendation to discontinue the [MEDICATION NAME]. At 1:30 PM, the surveyor requested the facility obtain the ED treatment records. In an interview on 09/16/16 at 1:05 PM, the resident stated she did not know the facility was giving her 2 daily doses of [MEDICATION NAME]. In an interview at 1:30 PM, Staff AA, Clinical Resource, Staff MM, Clinical Resource, Staff NN, interim Director of Nursing Services, and Staff PP, Education Resource, did not know: why the resident was on 2 daily doses of [MEDICATION NAME], why the facility had not promptly obtained ED treatment records, why the facility had not considered the [MEDICATION NAME] taper recommendations of the Wound Clinic provider, or why the facility had continued to treat the resident with [MEDICATION NAME] after the emergency department doctor had recommended it be discontinued. In a joint interview at 2:00 PM with the resident and Staff NN, the resident stated she should not still be on the [MEDICATION NAME] from what the ED physician had told her. Staff NN informed the resident she had still been receiving it, and it was a medication error from the facility's perspective. The facility caused harm to Resident 32 when she experienced multiple episodes of nausea and vomiting and throat pain that required emergency hospital treatment. Facility failed practice included: 1. Double-dosed the resident with [MEDICATION NAME] 20 mg daily without the nurses considering or obtaining physician clarification. 2. The facility pharmacy service failed to identify and alert the facility and the physician of 2 daily doses of [MEDICATION NAME], even over a period of weeks. 3. The failure to inform the resident she was being treated with 2 daily doses of [MEDICATION NAME]. 4. The failure to timely obtain emergency department treatment records. 5. The failure to consider the Wound Clinic provider recommendation to taper the resident off of the [MEDICATION NAME]. 6. The failure to assess the resident's complaint the [MEDICATION NAME] was making her sick. 7. The facility continued to administer [MEDICATION NAME] to the resident even after she informed them it made her sick and she didn't want it. [MEDICATION NAME] - BLOOD THINNING MEDICATION RESIDENT 45 Review of physician orders [REDACTED]. The [MEDICATION NAME] was started on 08/12/16. Review of the Medication Administration Record (MAR) from 08/18/16 to 08/23/16, revealed the resident did not receive 16 out of 18 doses of [MEDICATION NAME]. Review of a progress note dated 08/18/16 at 5:35 AM, stated the resident had a nosebleed and the [MEDICATION NAME] was held. However, the Licensed Nurse (LN) did not document the severity of the nosebleed and the physician was not notified. Review of a progress note dated 08/18/16 at 3:15 PM, revealed Staff E, LN, documented the resident refused the 2 PM dose of [MEDICATION NAME] because she experienced a . nose bleed last night . The LN documented the physician assistant (PA) was notified of the [MEDICATION NAME] being held. There was no documentation from the PA directing the LN to hold or discontinue the [MEDICATION NAME] due to the nosebleed. Review of the progress notes from 08/19/16 - 08/23/16 revealed the resident did not experience any additional nosebleeds. There was no additional documentation why the LN documented the resident refused the [MEDICATION NAME] or education the resident received regarding the risk and benefits of not receiving the [MEDICATION NAME]. Review of the physician orders [REDACTED]. Review of the medical record revealed the resident was admitted to the hospital on [DATE] due to swelling of her left arm. The resident re-admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the hospital documentation revealed the resident had five [MEDICAL CONDITION]'s in her left upper extremity. In an interview and observation on 08/29/16 at 8:30 AM, the resident's left arm was swollen and red. The resident stated she had the initial nosebleed and after discussion with the LN, they decided to hold the [MEDICATION NAME]. The resident stated she only experienced one nosebleed. The resident stated there had been no education offered to her regarding the risk and benefits of not receiving the [MEDICATION NAME]. The resident stated she never saw the physician prior to going to the hospital. At 12:46 PM Staff E, LN, stated the resident refused the [MEDICATION NAME] because she had a nosebleed. In an interview on 08/30/16 at 10:05 AM, Staff C, LN, stated when a resident refused a medication it was documented on the MAR and in the nursing progress notes. Staff C was not able to provide any additional information regarding why the [MEDICATION NAME] refusals were not documented in the resident's progress notes. In an interview at 10:37 AM, Staff D, interim Director of Nursing Services (DNS), stated when a resident refused a medication, it was documented on the MAR and in the nursing progress notes. Staff D stated the physician was to be notified when a resident refused a medication. Staff D was not able to provide any information why the LN did not document the resident's [MEDICATION NAME] refusals or why the physician was not updated. The facility had knowledge Resident 45 was at high risk for developing [MEDICAL CONDITION]'s. The resident received two medications for [MEDICAL CONDITION] prevention. The resident did not receive 15 doses of [MEDICATION NAME] with no documentation in the medical record of why the resident refused, why the physician was not notified of ongoing resident [MEDICATION NAME] refusals or education of the resident regarding the risk factors of refusing the [MEDICATION NAME]. Resident 45 experienced actual harm and was hospitalized and received medical treatment for [REDACTED]. [MEDICATION NAME] (BLOOD THINNING MEDICATION) Review of the facility's [MEDICATION NAME] Order Guide directed the LN to ensure residents who received [MEDICATION NAME] had the following: the [MEDICATION NAME] dosage to include a stop date when the medication was to be stopped that corresponded with when the next PT/INR was to be drawn, a [DIAGNOSES REDACTED]. According to Davis's Drug Guide for Nurses - 13th Edition stated a [MEDICATION NAME] time (PT) or international normalized ratio (INR) was a lab test done to establish baseline parameters for [MEDICATION NAME] therapy and should be monitored regularly. In an interview on 09/16/16 at 5:20 PM, Staff CCC, physician for all the residents in the facility, stated he expected the LN to call with all INR results and to obtain new orders prior to administering the next [MEDICATION NAME] dose. For example if the PT/INR was done done on the 12th, the LN would contact the physician and receive a new [MEDICATION NAME] order regardless if the [MEDICATION NAME] dosage stayed the same prior to administering the next scheduled dose of [MEDICATION NAME] on the 13th. Staff CCC stated a new order would be given of when to check the next PT/INR lab. RESIDENT 36 Review of the physician orders [REDACTED]. Review of a physician order [REDACTED]. On 09/05/16, the resident was sent to the emergency department and the INR was not done. On 09/06/16, the LN administered 4 mg of [MEDICATION NAME] without obtaining an INR and without contacting the physician to clarify if the [MEDICATION NAME] was to be administered or not. Review of a physician order [REDACTED]. There was no stop date. Review of a physician order [REDACTED]. There was no stop date. Review of the September MAR revealed the resident received [MEDICATION NAME] 4 mg and [MEDICATION NAME] 4.5 mg, double dosages, on September 10, 11, 12 and 14. The resident was not to receive 8.5 mg of [MEDICATION NAME] on these days. Review of a weekly skin assessment dated [DATE], indicated the resident had a 6 centimeter (cm) x 5 cm purplish black, reddish blue bruise on the left hand. On 09/13/16, the LN documented the bruise to the back of the left hand had increased to 12.1 cm x 8 cm and there was a new bruise to the left forearm measuring 4.8 cm x 2.5 cm. The left hand bruise and new forearm bruise had increased in size after the resident received 4 double dosages of [MEDICATION NAME]. On 09/13/16, there was a physician order [REDACTED]. Review of the September MAR revealed the LN administered [MEDICATION NAME] on 09/13/16. The resident was observed on 09/16/16 at 8:45 AM, to have a large, dark purple bruise on the back of her left hand and a smaller bruise on her left upper forearm. Similar findings were found on 08/09/16, 08/01/16, 07/24/16, 07/23/16, 07/22/16, 07/19/16 where either the resident did not have a PT/INR lab drawn per the physician order, or the LN did not notify the physician of the PT/INR results, or the LN administered [MEDICATION NAME] without first clarifying the dosage with the physician, or the LN did not write a physician order [REDACTED]. Review of the [MEDICATION NAME] orders from July to September revealed the LN did not write a stop date when a new order of [MEDICATION NAME] was received per the facility's policy. In a joint interview on 09/14/16 at 12:45 PM with Staff NN, interim DNS, Staff D, former interim DNS, and Staff PP, Educational Resource, was conducted. Staff D stated they have a company that performs all laboratory draws. The lab company came drew the labs in the evening. Labs ordered by the physician Monday through Friday were done Sunday through Thursday. For example, if the lab was ordered on Monday the 13th, the lab was done Sunday the 12th for results to be communicated to the physician on the 13th. All staff members present stated the LN was to notify the physician of all INR results, and obtain an order for [REDACTED]. The LN should not administer the [MEDICATION NAME] until an order was received. When the LN obtained the new [MEDICATION NAME] order, there should be a stop date that corresponded with the next INR lab draw. The staff was not able to provide any additional information regarding Resident 36's medication-related issues. The facility had not investigated any of the medication errors. RESIDENT 32 Resident 32 received [MEDICATION NAME] daily for [MEDICAL CONDITION] prevention. The resident's INR goal was to be between 2-3. An INR was done on 09/04/16. Review of the orders, progress notes and labs revealed there was no communication to the physician regarding the INR results and the LN continued to administer the same dose of [MEDICATION NAME] (2 mg). An INR was done on 9/12/16. The LN contacted the physician and received an order to continue the same dose of [MEDICATION NAME] until the facility received the PT/INR results. The LN did not write an order to continue the medications. Additional review of the medical record revealed the LN did not contact the physician of the INR results until 09/15/16, three days after it was drawn. The resident continued to receive the same dose of [MEDICATION NAME] on September 13 and 14th without a physician order [REDACTED]. An INR was done on the August 30th without a physician order. Review of the physician orders, progress notes and labs revealed there was no communication to the physician regarding the INR results and the LN continued to administer the same dose of [MEDICATION NAME] (2mg) until 09/01/16. Similar findings were found on 08/22/16, 08/01/16, 07/28/16, 07/22/16, 07/06/16, 06/15/16, 06/14/16, 06/13/16, 06/01/16, 05/31/16, 05/12/16, 05/11/16, and 05/10/16 where either the resident did not have a PT/INR lab drawn per the physician order, the LN did not notify the physician of the PT/INR results, the LN administered [MEDICATION NAME] without first clarifying the dosage with the physician or the LN omitted a [MEDICATION NAME] dose. Review of the [MEDICATION NAME] orders from May to September revealed the LN did not write a stop date when a new order of [MEDICATION NAME] was received per the facility's policy. In an interview on 09/16/16 at 3:45 PM, with the Administrator, Staff NN, interim DNS and Staff AA and MM, Corporate Clinical Nurses were made aware of Resident 32's [MEDICATION NAME] and INR concerns. The staff was not able to provide any additional information but stated they were aware they had [MEDICATION NAME] management concerns. RESIDENT 40 Resident 40 received [MEDICATION NAME] daily for [MEDICAL CONDITION] prevention. Review of the physician's orders [REDACTED]. Review of the July 2016 MARs revealed no [MEDICATION NAME] had been documented as administered on 07/19/16. On 09/16/16 at 3:45 PM, the physician's orders [REDACTED]. The [MEDICATION NAME] Flow Sheet (CFS) entry, dated 09/13/16, revealed the [MEDICATION NAME] dose (2.5 mg) was to be increased to 3 mg due to a low INR level (1.01). The September 2016 MAR revealed 2.5 mg was administered instead of 3 mg. Review of a Medication Error Report dated 09/15/16, revealed the new order for an increased dose to 3 mg had not been processed by the LN. OTHER MEDICATION ERRORS RESIDENT 75 Resident 75 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the July physician orders [REDACTED]. Review of the July MAR revealed the resident did not receive the medication on July 25th and 26th. On 08/25/16 at 10:20 AM, the Resident and her daughter were interviewed. The resident's daughter stated she noticed the resident was starting to have memory issues and something just seemed off. The resident confirmed that she was feeling her memory and mind was not working right. he daughter stated she the resdient'sneurologist prescribed the nuplazid and she supplied it to the facility. The daughter brought a bottle of nuplazid into the facility when she was admitted . The bottle of nuplazid had 60 17 mg tablets (the resident required two tablets to equal 34 mg daily). The resident had received two doses in the hospital, leaving 56 tablets when she admitted . The daughter stated she received a call last week from the pharmacy indicating it was time for the nuplazid to be re-filled. The daughter stated she came into the facility and spoke to Staff E, LN, regarding the medication. At that time they counted out the remaining nuplazid and there were 27 tablets left. The daughter stated she told Staff E there were too many tablets left. The resident should have 10 tablets left (the resident should have used 4 tablets in the hospital and 46 tablets in the facility equally 50 tablets). The daughter stated she still had not brought in the new bottle of nuplazid. At 1:45 PM, Staff E was asked to count how many tablets the resident had left of the nuplazid. Staff E was observed to count out 17 tablets. Staff E stated the daughter had talked to her about the medication but thought the daughter was going to talk to Staff D about the medication concern. Review of the medication error log revealed no investigation was done regarding the medication error. At 2:38 PM, Staff D stated she was not aware of the medication error. The facility failed to investigate a medication error that was brought to the LNs attention. The resident was at risk to experience potential health related complications from not receiving the correct dosage of the medication. [MEDICATION NAME] Review of Resident 36's [MEDICATION NAME] (an [MEDICAL CONDITION] medication) lab result dated 09/08/16, revealed the resident's [MEDICATION NAME] level was 8.0 (which was low). The physician wrote an order, with no date, on the lab result slip to increase the resident's [MEDICATION NAME] to 200 mg in the AM and at bedtime and to recheck the [MEDICATION NAME] level in one week. Further review of the lab result slip revealed a stamped time at the top of the form indicating the lab was received on 09/10/16 at 8:38 AM to Emerald Hills West station. Review of the MAR revealed the [MEDICATION NAME] was not increased until 09/12/16, two days after the order was received. In a joint interview on 09/14/16 at 12:45 PM with Staff NN, interim DNS, Staff D and Staff PP, Educational Resource, was conducted. The staff were not able to provide any information why the [MEDICATION NAME] was not increased for 2 days.

Based on observation, interview and record review the facility failed to provide sufficient qualified staffing to treat residents with respect and dignity, receive services to improve/maintain Daily Living, answer call lights in a timely manner, prevent urinary incontinence, and provide medications timely for 14 of 25 sampled residents (3, 4, 18, 27, 29, 35, 45, 67, 75, 80, 92, 109, 111 and 138) and 3 of 3 (52, 61 and 74) sampled family members. This failure potentially put residents at risk of feelings of frustration and humiliation, diminished quality of life and unmet care needs of the residents and caused actual harm to residents. Additionally 11 of 18 sampled residents (4, 27, 29, 35, 36, 47, 52, 61, 67, 74 and 78) reviewed for bathing, were not bathed timely and regularly. Findings include: Upon entrance to the facility it was discovered that the Director of Nursing, who had been there for aproximately 9 months, left her position on 07/16/16. An Interim DNS had been appointed on 07/20/16 but was replaced by another Interim DNS on 08/30/16. There was no information supplied as to when a permanent DNS would be appointed. Residents, family members and facility staff were asked the following question: Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? RESIDENT INTERVIEWS Resident 3 stated on 08/26/16 at 11:23 AM, They need more staff, particularly more shower aides. It seems like they are short staffed. I don't think it is that they don't want to help me, they are just too busy. They need to hire more people. Resident 4 stated on 08/25/16 at 10:51 AM, Everyone keeps saying they are short staffed. They tell everybody that. I wait over an hour, sometimes 2 hours or they don't come period. They help others that need more help than me. It makes me feel stressed out. Resident 18 stated on 08/24/16 at 2:35 PM, I have gone about 1 and ½ weeks without a shower because there is no shower aide. At night my bladder is on an every 3 to 4 hour schedule and when I put my call light on they have only 3 Nursing Assistants (NAC's). One night the bed pan was half under me and I had a flooded bed. The night staff could use a few more people. Resident 27 stated on 08/24/16 at 11:05 AM, No, because sometimes you need help and you have to wait. This is mainly in the mornings. Resident 29 stated on 08/24/16 at 1:59 PM, No, they need more staff to help people because sometimes it takes a long time to get help. It is all the time. At night my neighbors yell. There is not enough staff at night. It gives me anxiety with all the screaming and yelling. We don't get our pain medication on time. Resident 35 stated on 08/24/16 at 2:15 PM, No, I have to wait a long time for anything. It takes a long time to get my pain medicine. There is nothing consistent about the staff here. Things are always late and constantly changing. They are hiring new help all the time. Pain medication takes at least an hour or more for it to arrive. The pain gets real bad. This makes me feel frustrated. Tears were observed welling up in Resident 35's eyes while she was talking. Resident 45 stated on 08/25/16 at 1:53 PM, No, waiting for my call light to be answered can take up to 2 hours. On the weekends it is worse due to lack of staffing. One evening I fell and was on the floor. I hollered and yelled for help. I finally got myself to the phone and called the front desk. It took about 20 minutes before someone came and helped. This made me feel mad and very inadequate. Resident 67 stated on 08/25/16 at 9:55 AM, No, sometimes I have to wait a long time, 40 to 50 minutes. It makes me feel unhappy, like I am being ignored. Resident 75 stated on 08/26/16 at 7:30 AM, No, when I have to go to the restroom and I have to wait too long because staff are supporting others and this happens when you are having to urinate or maybe they give you a laxative and you have to hold it. I have had an accident in the early morning or after midnight and I have called for help and they don't come. I felt terrible, laying in the dampness and was cold. Resident 80 stated on 08/26/16 at 7:50 AM, said No, it's hard to get help around shift change and between 10:00 and 11:00 AM and around 4:00 AM. When I have to wait for help I feel stupid. Resident 111 stated on on 08/24/16 at 2:27 PM, No, the morning and afternoon shift could use another NAC, especially in the morning. There is so much to do. When I lived in the North Hall, it would take forever to get help at times. I felt ticked off. Resident 138 stated on 08/22/16 at 10:44 AM, No, they tell me they do not have enough staff. I had my knee replaced on Friday and came in on a Monday, so going to the bathroom was an issue. I would ring the bell and it would take 15 to 20 minutes for anyone to come. I had an accident while waiting. This was a great, great, great embarrassment. This was urination. I had to teach myself to hobble to the bathroom and did this very quickly. They tell me they do not have enough staff. During the day I have 1 Licensed Nurse (LN) and 2 NAC's and on evening shift there could be two but usually only one. At night there is one LN and one NAC. I have not received showers as I wish. If you have to ask for something, the same thing two or three times they feel you are bothering them. I really need to go home. I have come to this point. FAMILY INTERVIEWS Resident 52's family stated on 08/22/15 at 2:43 PM, No, in the evening around 9 PM they are short staffed. Resident 61's family stated on 08/22/16 at 11:44 AM, No, sometimes it takes over an hour to get help. I was told that they try to answer it between 10-15 minutes, but that has turned out not to be true. There was blood visible on his sheets for 3-4 days. They don't even try to get him to the bathroom. Resident 74's family stated on 08/22/16 at 3:28 PM, Absolutely not! You come in here and it is like a ghost town. This is anytime of the day or night. BATHING Bathing documentation from 05/01/16 through 08/25/16 was reviewed. Resident 4 went was not showered from June 25th to July 4th, which was 9 days. In July, the resident was not showered for 12 days. Resident 27 went 11 days in May without being bathed. Resident 29 only received three showers in May. In July, the resident went 14 days without a shower. In August the resident was bathed twice. Similar findings were found with Resident's 35, 36, 47, 52, 61, 67, 74 and 78 shower schedules where the residents either did not receive showers based on their preferences or went more then a week without a shower. RESIDENT COUNCIL MEETING MINUTES The monthly meeting minutes of February 2016 through August 2016 were reviewed. Each month, there were complaints of call lights not being answered timely. 07/21/16 meeting - Some of the residents stated they were not getting their weekly shower. GRIEVANCES Resident 111 filed a grievance on 05/04/16. The resident felt like there was no one available at night. The resident stated that if the nurse was on break, the Nursing Assistant should be there. Staff met with resident. Resident said it was getting better. Resident 92 filed a grievance on 03/16/16. The Resident alleged staff fail to respond to call lights. I need help to sit up. I need to urinate. The staff just pass by. Resident 109 filed a grievance on 02/27/16. The Resident alleged the aide took a long time to get to her on night shift. MEDICATION ADMINISTRATION During a medication observation on 08/22/16, Staff C and Staff II, LN's, were observed to administered medications outside of the required time frame. On 08/26/16 at 6:12 AM, Staff II, was asked about the timeliness of administering medications. She stated it is somewhat kind of routine that med's may be late. There are 20 some people I give med's to. I prioritize my workload and do the best I can. I have lots of med's and sometimes I just am not able to give them all in the required timeframe. See F333 for additional information on significant medication errors. STAFF INTERVIEWS On 08/26/16 at 12:12 PM, Staff V, Marketing Liaison, said No. The nurses are overworked and stressed. Weekends are the worst. Residents are not getting changed. Family members complain to me. One of the resident's is always soaking wet when the family comes to visit. This was the same with a previous resident also. Another resident's room stinks all the time. Three Anonymous interviews with staff found the following information: There were too many residents assigned to one NA. The NA's were assigned to 21 residents each. Sometimes the shower aides get pulled to work on the floor. Staff Developement There was no documented evidence that the facility had an organized staff education program to ensure all employees received appropriate in-service education to maintain a level of knowledge appropriate to, and demonstrated competence in, the performance of ongoing job duties consistent with the principle of assisting the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. In an interview on 08/31/16 at 9:32 AM, the Administrator revealed the facility did not have Staff Developement Program Coordinator (SDPC). The Administrator stated she was actively hiring a one. In an follow-up interview on 09/16/16 at 2:10 PM, the Administrator confirmed there had been no SDPC since 03/17/16. Refer to F 241, CFR 483.15(a) Dignity Refer to F 253, CFR 483.15(H)(2) Housekeeping and Maintenance Services. Refer to F 312, CFR 483.25(a)(3) Assistance for Dependent Residents Refer to F314, CFR 483.25(c) Pressure Ulcer Refer to F325, CFR 483.25(1)(i) Nutritional Status Refer to F 332, CFR 483.25(m) Medication errors Refer to F333, CFR 483.25(m)(2) Significant Medication errors

Based on observation, interview and record review the facility's administration failed to effectively and/or efficiently use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with regulatory requirements which affected 35 of 40 current residents and potentially affected all residents referenced in F 253. In addition, the administration failed to ensure there was an acting Quality Assurance Committee to detect issues and a Medical Director who was overseeing the care of the residents and teaching and training staff. Failure to ensure compliance resulted in harm to at least 6 residents (67, 138, 137, 135, 124 and 45) referenced in F 241, F 314, F 325 and F 333 which impacted their care and quality of life. Findings include: 1. The administration failed to ensure care was provided in a manner that promoted and enhanced dignity for 10 of 21 residents (67, 138, 75, 135, 61, 4, 35, 36, 3 and 88) reviewed for respect and dignity. This failure placed these residents at risk for frustration, feelings of diminished self-worth and psychosocial harm. Refer to F 241, CFR 483.15(a) 2. The administration failed to identify and provide necessary maintenance and housekeeping services in resident rooms, hallways, and with individual equipment. These failures did not create a homelike environment for residents to live in and placed residents at risk for decreased quality of life, compromised dignity, and safety and potential infection control issues. Refer to F 253, CFR 483.15(h)(2) 3. The administration failed to identify Resident 137 and 135 who admitted to the facility without pressure ulcers and were identified at high risk for developing pressure ulcers and implementing pressure relieving measures. Refer to F 314, CFR 483.25(c ) 4. The administration failed to implement their policy and procedures to ensure Resident 124 maintained acceptable parameters of nutritional status. Refer to F 325, CFR 483.25(i) 5. The administration failed to identify deficiencies in regards to establishing protocols to ensure residents were free of any significant medication errors. Refer to F 333, CFR 483.25(m)(2) 6. The administration failed to ensure Nursing Assistants (NAs) received a performance evaluation every year, provide regular in-service education and provided specific training to NA's who provided care for resident's with cognitive impairment. Refer to F 497, 483.75 (e )(8)(i)(ii)(iii) 7. The administration failed to ensure NA's demonstrated competency in skills and techniques necessary to care for residents who reside in the facility. Refer to F 498, 483.75(f) 8. The administration failed to ensure the Medical Director was responsible for the implementation of resident care policies and coordination of medical care in the facility for each resident. Refer to F 501, CFR 483.75(i) 9. The administration failed to ensure the facility had a functioning quality assessment and assurance committee. Refer to F 520, CFR 483.75(o)

Based on interview and record review, the governing body failed to provide adequate oversight to the appointed administrator(s) to ensure facility policies were established and implemented to meet minimum standards of nursing care, staff training and to ensure the Quality Assessment and Assurance (QA&A) program was functional and the Medical Director was following his contract. The governing body failed to provide adequate oversight to ensure facility policies were established and implemented to ensure residents were treated with respect and dignity, significant medication errors did not occur and the facility had sufficient qualified nursing staffing to meet the needs of the resident's. These failures resulted in a substandard quality of care under federal laws pertaining to Quality of Life and Quality of Care, caused actual harm to residents and placed all 61 residents at risk for harm. Findings include: A Governing Body (GB) named Opportunities Industrialization Centers (OIC) provides administrative oversight for the facility. Facility records show there was a change in Administrators in August 2016. On the first day of the survey 08/22/16, 61 vulnerable adults with a variety of medical conditions and care needs resided at the facility. The annual QIS and Abbreviated survey from 08/22 to 08/31/16 and an extended survey from 09/14 to 09/16/16 found failed systems affecting resident care and quality of life including harm pertaining to 483.15 Quality of Life for failure to treat residents with respect and dignity and 483.25 Quality of Care for failure to have systems in place for significant medication errors. In an interview on 08/31/16 at 9:52 AM, the Administrator, who was hired August 1st, stated she had identified multiple areas of concern and systems that had not been in place prior to her arrival. The Administrator was working on several projects to improve quality of care and life to residents in the facility. In an interview on 09/16/16 at 1:30 PM with Staff AA, Clinical Resource stated she had identified system concerns to the prior Administrator. The Administrator told Staff AA he was dealing with the identified concerns. Staff AA was not aware of the multiple system failure identified during the survey. At 4:45 PM, Staff GGG, Market Leader, stated he oversaw four buildings for the corporation since the end of March 2016. Staff GGG stated the facility had several changes in their management staff over the past several months. Staff GGG recognized the facility had multiple concerns and made a change in the Administrator August 1st and soon after the Director of Nursing Services. Staff GGG recognized the facility had wide spread system failure. The Governing Body's failure to follow up on known, identified problems or concerns and failure to provide orientation and guidance to the Administrator to focus on systems supporting quality of care are reflected in the following failed practice: 1. The administration failed to ensure care was provided in a manner that promoted and enhanced dignity for 10 of 21 residents (67, 138, 75, 135, 61, 4, 35, 36, 3 and 88) reviewed for respect and dignity. This failure placed these residents at risk for frustration, feelings of diminished self-worth and psychosocial harm. Refer to F 241, CFR 483.15(a) 2. The administration failed to identify and provide necessary maintenance and housekeeping services in resident rooms, hallways, and with individual equipment. These failures did not create a homelike environment for residents to live in and placed residents at risk for decreased quality of life, compromised dignity, and safety and potential infection control issues. Refer to F 253, CFR 483.15(h)(2) 3. The administration failed to identify Resident 137 and 135 who admitted to the facility without pressure ulcers and were identified at high risk for developing pressure ulcers and implementing pressure relieving measures. Refer to F 314, CFR 483.25(c ) 4. The administration failed to implement their policy and procedures to ensure Resident 124 maintained acceptable parameters of nutritional status. Refer to F 325, CFR 483.25(i) 5. The administration failed to identify deficiencies in regards to establishing protocols to ensure residents were free of any significant medication errors. Refer to F 333, CFR 483.25(m)(2) 6. The administration failed to ensure Nursing Assistants (NAs) received a performance evaluation every year, provide regular in-service education and provided specific training to NA's who provided care for resident's with cognitive impairment. Refer to F 497, 483.75 (e )(8)(i)(ii)(iii) 7. The administration failed to ensure NA's demonstrated competency in skills and techniques necessary to care for residents who reside in the facility. Refer to F 498, 483.75(f) 8. The administration failed to ensure the Medical Director was responsible for the implementation of resident care policies and coordination of medical care in the facility for each resident. Refer to F 501, CFR 483.75(i) 9. The administration failed to ensure the facility had a functioning quality assessment and assurance committee. Refer to F 520, CFR 483.75(o)

Based on interview and record review, the facility failed to ensure the Medical Director provided the leadership role per agreement to actively assist the facility in providing quality care to residents. The failed practice affected the quality of care delivered to all residents and placed them at risk for decline in condition, injury and psychosocial harm. Findings include: In an interview on 08/31/16 at 9:52 AM, the Administrator stated Staff CCC, physician, had been appointed and the acting medical director since 12/15/15. The Administrator stated the facility had policies and procedures from the corporation and the Medical Director, per the meeting minutes, did not always participate in the facility Quality Assurance meeting where the policies were reviewed. The Administrator had recently started at the facility on 08/01/16, and scheduled a Quality Assurance meeting during the week of 9/6/16 through 9/9/16. The Administrator stated the Medical Director was expected to be there. During the extended survey on 09/14/16, the Medical Director Agreement was reviewed and noted not to be signed. The Administrator stated she was not aware the former Administrator had not signed an agreement with Staff CCC. The Administrator confirmed that Staff CCC had been the Medical Director even without a signed agreement since 12/15/15. Review of the Medical Director's Agreement, signed and effective as of 09/14/16, included the following: The Medical Director agreed to provide administrative medical services to the facility in the areas of: a. Administrative b. Professional Services c. Quality Assurance d. Education e. Employee Health f. Community g. Rights of Residents/Patients h. Social, Regulatory and Financial i. Person-Directed Care ADMINISTRATOR INTERVIEW In an interview on 09/16/16 at 4:10 PM, the Administrator was asked about the Medical Director Agreement and how involved the Medical Director was in relation to various facets of the facility's operations as listed above. The Administrator stated, Staff CCC had not met with her outside medicare meetings. She had No idea if he had performed the required annual review of the policies and procedures manual. Staff CCC was not very interactive. The Administrator also stated that Staff CCC had not participated in disciplinary actions of facility employess, I've not used him for that. The administrator did not know if Staff CCC had assured that medical records systems met the needs of facility residents. The Administrator stated she did not know if Staff CCC had adequate documentation of health care delivered at the Facility or if he had developed and periodically reviewed by-laws governing the provision of physician services. The Administrator also stated No, he had not participated in the education and training activities of nursing home staff members, or identified and suggested topics for in-service training through observation or evaluated patient care. The Administrator had not asked Staff CCC if he assured time and access to in-service training for staff. The Administrator summarized the Medical Director's overall performance and concluded he was not performing the majority of his required responsibilities as per his contract. The Administrator was asked for written documentation of the Medical Director's involvement with the items listed in A - I. The Administrator said she would have to look into it and would fax the documentation to the surveyor. As of 09/27/16, the Administrator had not faxed any of the requested information to the survey team. MEDICAL DIRECTOR INTERVIEW In an interview on 09/16/16 at 5:20 PM, Staff CCC stated he was the primary physician for all of the current residents in the facility, as well as the Medical Director. Staff CCC stated he had not been involved in or aware of any recent medication errors occurring in the facility. Staff CCC stated he recalled giving the former Director of Nursing Services information regarding standards but he had not been involved in any implementation of policies or revision of policies recently. Staff CCC was not able to clarify what standards meant. Staff CCC stated he had educated Licensed Nurses 1 on 1 regarding individualized clarification of orders and had not done any formal education with the licensed staff. Staff CCC stated he had attended a few of the Quality Assurance meetings, but was not sure when that was. Staff CCC stated he was aware of the facility's past annual and Abbreviated surveys, but was not able to state how he implemented the plan of corrections regarding failed practice. .

Based on observation, interview and record review, the facility failed to assess and implement a care plan to ensure pressure relieving measures for 2 of 4 residents (137 and 135), who were at risk for pressure ulcer development. Failure to identify residents who were at high risk for the development of pressure ulcers resulted in harm for Residents 137 and 135 who developed pressure ulcers. Findings include: According to the facility's Skin Care Policythe Licensed Nurse (LN) was responsible for assessing and evaluating the resident's condition on admission and readmission. The LN was to complete an initial skin assessment and Braden Scale to identify risk factors so that an individualized care plan could be developed. A stage II pressure injury (ulcer) was described as a partial thickness loss of skin. A stage II pressure injury may present as an intact or ruptured serum-filled blister. A Suspected Deep Tissue Injury (SDTI) was described as intact of non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration. RESIDENT 137 Resident 137 was admitted following a left [MEDICAL CONDITION] (LBKA) and had a history of [REDACTED]. Other [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed he was at risk for pressure ulcer development and required 2 person assist with bed-mobility. The initial care plan revealed Resident 137 had actual impairment to skin integrity related to a LBKA, but there were no interventions to prevent skin breakdown. The nursing admission assessment dated [DATE], documented the right foot was dry and had no skin breakdown (pressure ulcers). The general skin condition was assessed and checked to be normal. No interventions were put in place for the dry skin. The registered dietitian (RD) note dated 08/24/16, documented he had decreased mobility and no pressure ulcers were noted. There was no documented evidence that any interventions were put into place to prevent skin breakdown. By 09/12/16, a skin assessment sheet dated the same day, documented the resident had a suspected deep tissue injury (SDTI) on his right foot which measured 3 centimeter (cm) by 3 cm in size. The pressure ulcer weekly form dated 09/13/16, documented Resident 137's right heel wound was dark purple maroon with an intact blister. On 09/16/16 at 8:53 AM, Resident 137 was observed lying in bed on his right side. A specialty boot was observed on the floor. The resident stated he did not like to wear the boot as it irritates. He stated he had bruises on his heel (right). There was no documented evidence that the facility provided any alternative interventions. At 10:10 AM, he was observed seated in his wheelchair using his right foot to assist with wheelchair mobility. His right heel rested against the floor. No pressure relieving boot or device was in place to avoid pressure on the heel. At 10:42 AM, Resident 137's right heel rested against the floor without any pressure relieving device. The resident stated he used his manual wheelchair to self-propel by using his right foot and arms. He stated the bruise on his right heel had got worse and he did not have any skin breakdown on his right heel prior to admit. He stated after the right heel bruised, they gave him a boot to wear when in bed but it didn't stay on. At 10:52 AM, Resident 137's skin was assessed with [REDACTED]. The right heel had a SDTI that was dark purple in color. The current care plan was reviewed with Staff PP after the skin assessment. The current care plan had no directives regarding skin prevention for the right heel such as off-loading the heel while in bed or during wheelchair mobility. Staff PP stated preventive intervention to prevent a pressure ulcer on the right foot had not been implemented until after the wound developed on the right heel. RESIDENT 135 Resident 135 was re-admitted to the facility on [DATE] and had previously been treated for [REDACTED]. Review of a Braden skin assessment dated [DATE], identified the resident was at high risk for skin breakdown. Review of a nursing admit assessment dated [DATE], indicated the resident's heels were fragile. They identified a risk, but did not put anything in a care plan. Review of a weekly skin assessment dated [DATE], indicated the resident had developed a 4 cm x 4 cm intact blister, a stage II pressure ulcer, to the right inner heel. On 08/21/16, the LN documented the right heel blister had popped. The care plan dated 08/23/16, had only one intervention for pressure relief. The intervention was to place a pillow between the resident's legs to prevent the heels from rubbing. The care plan lacked individualized approaches to prevent skin breakdown until after the resident developed a stage II pressure ulcer to the right heel. Review of the weekly pressure ulcer assessment dated [DATE], indicated the resident's right inner heel stage II was now a 1.9 cm x 2 cm SDTI. On 08/25/16 at 9:45 AM, with Staff E, Licensed Nurse (LN), Resident 135's heel was observed. The right inner heel was observed to have several layers of skin missing. The base of the wound was pink with no drainage. In multiple observations 08/24/16 to 08/30/16, the resident was lying on her back with no pillow between her legs and her heels were rested on the surface of the mattress. In an interview on 08/26/16 at 5:53 AM, Staff H, Nursing Assistant (NA), stated Resident 135 was repositioned every two hours. Staff H was not able to provide any information why this was not done for the resident during the survey observations. In an interview on 08/29/16 at 8:49 AM, Staff J, NA, stated Resident 135 was positioned every two hours. Staff J stated the resident was compliant with all care needs. In an interview on 08/30/16 at 10:05 AM, Staff C, LN, stated the resident developed a right heel blister after she was readmitted to the facility. The facility failed to ensure Resident's 137 and 135, who were both identified as high risk for skin breakdown, were assessed and received immediate interventions to prevent their heels from breaking down.

Based on observation, interview, and record review the facility failed to promptly identify and implement interventions to prevent unplanned weight loss for 1 of 4 residents (124) and consistently assess 2 of 4 residents (124 and 45) reviewed for nutrition. Failure to monitor or respond to severe weight loss resulted in harm for Resident 124 and placed Resident 45 at risk for nutritional concerns. Findings include: Review of the facility's Nutritional Status Policy dated 03/16, directed staff to weigh residents upon admission, weekly for 4 weeks and then monthly. The Nursing Assistant (NA) recorded the resident's weight on a census sheet. The Resident Care Manager (RCM) reviewed the weight, requested a re-weight if necessary, and entered the weight into the electronic medical record. The RCM and Registered Dietician (RD) reviewed the weight variance report weekly. The policy directed staff to offer an alternative alternate if the resident ate less then 75% of the meal. If the resident refused the alternative meal, the staff were to offer a health shake (2 to 4 ounces depending on the size of the recommended portion). RESIDENT 124 Resident 124 had [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], she required extensive assistance of one person for eating. Review of the care plan identified the resident at nutritional risk related to varied intake and difficulty swallowing. The goal for nutritional risk was to prevent significant weight loss. Interventions included to provide and serve nutritional supplements as ordered and to report weight loss to the the physician. On 06/03/16 the resident weighed 111 pounds and on 08/27/16 the resident weighed 98 pounds. The resident lost 13 pounds or 11.7% in approximately 3 months. Review of the meal monitor from June 3rd to August 25th revealed the resident had variable intake of her meals. Out of 209 opportunities, revealed the resident only consumed 75% or more of her meals 7 times. The resident was offered the alternative meal 193 times but refused 103 of them. On 16 times she only consumed 75% of the alternative meal. There was no evidence the staff offered the resident a health shake when the resident refused the alternative meal. Review of the medical record revealed no documentation of the resident having a poor appetite, refusing to be weighed or notifying the physician regarding weight loss or decrease in intake. The physician order [REDACTED]. The order did not clarify the amount the resident was to consume Review of the June to August Mediation Administration Record revealed the Licensed Nurse documented the resident's intake of the 2 Cal was variable (from none to 240 cc's). During breakfast on 08/29/16 and during lunch on 08/30/16 no staff were observed to be assisting the resident. In an interview on 08/25/16 at 9:35 AM, Staff GG, RD, stated if a resident consumed less than 50% of their meal and alternative meal would be provided. Staff GG stated she relied on the staff to enter the weights in the electronic medical record (EMR) but was unaware of the referral process if the weights were not documented in the EMR. At 10:04 AM, Staff BB, RCM, stated the NAs weighed the residents on the weekends. The LN was responsible to document the weight in the EMR. The RD ran a weekly report for weight loss, and if present requested the resident to be weighed again. Staff BB was not able to provide any additional information why they resident had not been weighed per the facility's policy or what the facility was doing to prevent further weight loss. At 1:16 PM, Staff II, Licensed Nurse (LN), stated the NAs weighed the resident's on the weekends. A reweigh should be conducted if a 10% loss or gain was identified. Residents who were identified to have continued weight loss or gain were referred to the RCM for further evaluation. The facility failed to follow their own nutritional policy regarding weighing the resident and offering alternative meals when the resident indicated. On 08/27/16 the resident had significant weight loss and the LN did not obtain a re-weigh or alert the RCM, RD or physician to the significant weight loss and assess for additional interventions. RESIDENT 45 Resident 45 was re-admitted to the facility on [DATE] and 08/25/16. Review of the resident's weights indicated the last weight was obtained on 06/19/16. In an interview on 08/26/16 at 5:20 AM, Staff F, stated weights were obtained on resident's shower days. In an interview on 08/30/16 at 10:37 AM, Staff D, interim Director of Nursing Services, stated residents were weighed upon admission to the facility for three days, then weekly for the first month, and monthly thereafter.

Based on observation, interview and record review, the facility failed to provide sufficient supervision or ensure functional use of equipment to prevent accidents for 1 of 4 sample residents(1). Failure to ensure sufficient supervision for safe toileting while in bed and ensure the resident's bed would not move position during care resulted in actual harm to Resident 1, as she sustained a fractured leg. Findings include: Resident 1's Minimum Data Set assessment dated [DATE] documented the resident was cognitively intact and able to clearly communicate. The resident was assessed as requiring extensive assistance of 2 or more staff for bed mobility and 1 staff assist during toilet use. The most recent plan of care for Activities of Daily Living (ADL) Self Care Performance, dated 3/1/14, indicated the resident had ADL deficits related to poor balance, non-ambulation, was bed or wheelchair bound and had a history of [REDACTED]. Interventions related to incontinence indicated the resident required 2 person extensive assist with incontinent care. For Coping skills, interventions included monitoring behaviors such as dissatisfaction with staff performance and inconsistent behaviors towards staff. During an interview with Staff B and C on 12/17/15 at approximately 3:30pm, the staff said the resident was a 1 person assist with incontinence care/toileting prior to the resident's fall out of bed, but curently was care planned as a 2-person assist. A nursing progress note dated 12/3/15 documented the resident fell from bed at 5:25 am while receiving incontinent care with the (Staff A). When Staff A turned the resident towards the wall, the bed came unlocked and resident rolled over the edge of bed, landing on her knees. The resident stated that she hurt all over and reported her pain as being a 10/10 (0 being no pain and 10 being the worst pain. The Ambulance/paramedic team was called to get the resident up off of the the floor and then was sent to hospital for evaluation. A nursing note dated 12/4/15 documented a facility telephone call with the admitting hospital and indicated the resident was to have surgery for [REDACTED]. Written statements by Staff A who had provided care at time of the fall indicated, When the resident was being changed in bed, she had to roll over on her right side so that the bottom bed sheets could be changed. While turning against the wall the bed unlocked & moved; that was when she fell down onto her knees. Review of an initial incident description on 12/3/15 at 05:35 AM, documentation did not indicate whether the bed wheels were in a locked position nor how far the bed was from the wall immediately after the resident's fall out of bed. A Nursing/Therapy Communication Post Incident Communication dated 12/3/15 requested a referral to therapy. The referral reason was for a fall during incontinent care. The bed was not locked correctly and when resident was rolled towards wall the resident rolled off the side of bed. During an interview with Staff D on 12/17/15 at approximately 4:15 pm, Staff D stated the facility had Staff A demonstrate what had occurred just prior to the resident's fall out of bed to see if the resident's bed would move with the bedwheels locked. Staff D indicated Resident 1 was pushing against the wall just before the fall. Staff D said during one demonstration attempt, the bed moved, but on another, the bed did not move. Staff D said the facility also did a bed lock check of other residents' beds after the incident, but Staff D didn't specify whether the Resident 1's bed locks were deemed functional. Additional documentation provided by the facility on 12/18/15 indicated the bed in Resident 1's room did not have any issues with the wheels or brakes. During an interview with Resident 1 at 12 noon on 12/17/15, the resident was lying in bed. One side of the bed was against the wall. The wide bed had an air mattress with half side rails up on both sides, and a overbed trapeze grab bar. The resident was asked to describe the fall event, I was already on my right side facing the wall when (Staff A) pulled really hard on the sheet. I wasn't ready for it and I was flailing/trying to grab onto something. I went over and down between the bed and wall. I was in so much pain, I landed on my knee on the floor. He (Staff A) had already unlocked the bed in preparation for going over to wall side of the bed before he pulled on the sheet, and the bed was not right up next to the wall. There was a gap/space (gestured approximate 1.5 foot). He was on the side of bed opposite the wall when he pulled the sheet so hard and over I went. Before this fall, only 1 person was needed for turning me in bed, now it's 2. I could help by grabbing my overbed trapeze during a turn. I've had the same small 'twin' bed for years, but this one is new to me, it's really big (wide). The old one had really small grab bars on both sides, this one has longer ones. I was so in pain and upset & afraid when I was stuck between bed and wall. It took them a while to figure out what to do, and eventually they called paramedics.

Based on observation, interview and record review the facility failed to ensure female residents were free from sexual abuse by a resident with known predatory sexual behaviors. This failed practice created an ongoing environment of fear and intimidation which was unrecognized by staff until there were physical encounters by Resident 4, when he was witnessed inappropriately touching 3 female residents (5, 15 & 17). Findings include: Resident 4 was admitted to the facility 09/04/15 with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 09/11/15, indicated Resident 4 required required extensive assistance of one staff member for bed mobility and limited assist of one staff member for transfer. In his room he walked with staff supervision and set-up. In the corridor he walked with limited assist of one staff member. According to the care plan he was able to walk short distances with one person assist and used a wheelchair for distances greater than 20 feet. From the time of admission Resident 4 was receiving an anti-depressant to treat his depression and also an anti-psychotic medication for dementia with behavioral disturbances. The consent for use of the anti-psychotic did not identify what the medication was being used to treat. Nursing progress documentation revealed the following: 09/06/15 at 6:01 AM, it was documented in a Late Entry, the resident was wakeful during the shift, not able to sleep well and he lingered out of his room, staring into female patient's rooms even though he was told not to do so. The resident needed many reminders all shift about staring into rooms. 09/09/15 it was documented the resident had been inappropriate with the female staff by exposing himself. A Physician's Progress Note, dated 09/10/15, documented Resident 4 was alert and oriented, his memory was intact, mood appropriate, speech was fluent and his judgment/insight was sound. 09/11/15 it was documented the LN (licensed nurse) was doing first rounds at 6 AM, and noted, from the hallway the resident was exposed in his bed without pants on and showing inappropriate behavior without the curtains being pulled. 09/11/15 it was documented, the resident had been sitting outside female resident's doors staring at the females. He was told by the LN the behavior was inappropriate and made others feel very uncomfortable. 09/18/15 it was documented, the ED (executive director) spoke with the resident on 09/17/15 regarding his inappropriate sexual behavior with female staff members. 09/22/15 it was documented, the resident was inappropriate in the hallway today. The LN told the resident that he could not sit out in the hallway and touch himself. If he wanted to do this he would have to go to his room shut the door or pull the curtain. 09/29/15 it was documented, the resident exposed himself to a CNA (certified nursing assistant) 2 time during the day. The LN talked to the resident and told him if he wanted to be naked to go behind the curtain. 10/02/15 it was documented, the resident was masturbating in front of a CNA, who went to provide care with the resident's roommate, and refused to close his curtains for privacy. The resident opened the curtain after the CNA closed them. 10/03/15 at 5:02 AM it was documented, the resident made no inappropriate statements, but had penis out of pants when this LN was working with his roommate. This LN closed the curtain and told the resident the curtain was being closed for his privacy. 10/03/15 at 1:55 PM it was documented, Resident 4 was seen being inappropriate by Resident 18, who saw him touching Resident 5 and reported to the LN. The LN redirected Resident 4 to go back and stay in his room. The LN told him that his behavior was inappropriate. He came to the hallway again exposing his penis and was being inappropriate to one of the care staff. The resident was reminded to stay in his room. 10/05/15 it was documented the resident had two inappropriate behaviors. At around 3:30 PM care staff reported to the LN that Resident 15, reported that Resident 4 walked into her room and touched her breast. The second incident was around 6:20 PM when care staff reported to the LN that she observed Resident 4 touching Resident 17's right breast in the hallway. There was no actions taken to protect female residents until 10/05/15 after he made physical contact with female residents. At that time the facility reported to law enforcement and the state hotline. On 10/08/15 at 8:15 AM Resident 4 was interviewed. He was observed sitting up on the side of his bed, appropriately dressed and groomed. He was alone in his room and his mobility status was discussed. He stated he could walk around his room, to and from the bathroom but not much else because he could not be too far away from his oxygen. He was not using oxygen when first approached but placed the oxygen cannula independently during the interview. He stated he had a fall at the assisted living where he was residing and was transferred to the hospital. He did not know what the plans for discharge might be and offered no further information. On 10/08/15 at 8:25 AM and 4:00 PM Resident 18 was interviewed. When asked whether she had experienced any issues with any of the other residents. She stated Resident 4 had been sexually harrassing her and other residents. She said it had started on or around 09/10/15 just after she returned from a surgical procedure. She had chosen to wear the hospital gown rather than her regular clothing because it was easier for her at the time. Resident 4 was sitting in his wheelchair near her room, looked at her and stated, I'm feeling horny. I'm going to look up your gown. She was asked if she reported it to staff. She reported it to one of 2 staff members, but could not say for sure which one she told. Resident 18 also shared the more recent observation, a few days ago, when Resident 4 approached Resident 5 in the dining room where they were playing bingo. Resident 18 reported it to the LN, who directed Resident 4 to leave the dining room. About 15 minutes later Resident 4 returned and put his hand on the thigh of Resident 5. On 10/08/15 at 9:15 AM Resident 5 was interviewed. When asked about any inappropriate behavior by other residents toward her, she began to tell the surveyor about a man who had touched her breast. She was unable to describe him and said she did not know his name. She said a policeman came and talked to her recently. She said she felt shy and didn't feel she could really tell them anything. Referring to Resident 4, she stated, I don't know why someone would do that. Review of the police investigation revealed Resident 4 had approached Resident 5 and began trying to touch her breasts by moving his hand underneath her clothing. Resident 5 said Don't while swatting his hand away and trying to push him away. Resident 5 was not able to move her body away because she was in a wheelchair. Resident 4 persisted and was able to grab Resident 5's breast. Resident 5 said she was very afraid of the man and stated, he scared the crap out of me. Resident 5 was concerned the man would come into her room while she slept or assault her again while she was in the hallways. Resident 15 and Resident 17 were approached for interview but found to not be interviewable. On 10/08/15 at 3:30 PM Staff B was interviewed regarding Resident 4. He indicated facility staff were not aware of any sexual inappropriate behavior history for Resident 4 prior to admit. Clinical records had revealed a need for a level two PASRR (preadmission screening and resident review) for Resident 4. When asked about the Level two evaluation Staff B stated he had faxed the request for the Level two evaluation on 09/07/15. The Level two evaluator reported to Staff B that she was behind. When asked about behavior monitoring for Resident 4, with use of the anti-psychotic and known behaviors directed at staff, he stated monitoring had not been initiated until 10/08/15. On 10/08/15 at 4:15 PM the Director of Nursing Service, Staff G, was interviewed and asked about the allegation of sexual harrassment by Resident 4 on or about 09/10/15. She stated there was no investigation because she was unaware of the allegation.

Based on record review and interview the facility failed to provided the necessary care and services to prevent and/or treat pressure ulcers for 3 of 4 sample residents (10, 14, 15) with pressure ulcers. The failed practice caused harm to Resident 10 who developed a pressure ulcer to the buttocks after admission to the facility, which deteriorated to a stage 4, became painful, infected and required IV antibiotics. Findings include: Per the Resident Assessment Instrument (RAI) Manual a Stage 4 pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle. Suspected Deep Tissue Injury (SDTI) is defined as purple or maroon area of discolored intact skin due to damage of underlying soft tissue. Pressure ulcers covered with slough and/or eschar are unstageable because the true anatomic depth of soft tissue damage cannot be determined. Eschar is defined as dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color and may appear scab-like. Slough is defined as non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Undermining is defined as the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface. The facility's policy and procedure titled Wound Management directed the Licensed Nurse (LN) to complete and document weekly any identified wound. The LN would: - document using a Skin User Defined Assessment tool in the electronic medical record - wound documentation would include the wound size (size and depth), drainage, odor, color and a short statement on the progress. - treatment orders will include the frequency and duration - a care plan and Minimum Data Set (MDS) assessment will be completed upon the identification of a pressure ulcer RESIDENT 10 Resident 10 was admitted to the facility 08/27/15 with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 08/31/15, indicated Resident 10 required extensive assistance of 2 staff members for bed mobility and transfer. She did not ambulate and was dependent on 1 staff member for wheelchair locomotion. Her skin was intact and she had no cognitive impairment. Per clinical and formal assessment she was identified as at risk of developing pressure ulcers. Review of the clinical record revealed the following: On 09/25/15 the weekly skin assessment/evaluation stated, no noted skin issue at time of assessment, dry skin, at risk for skin breakdown r/t (related to) decrease mobility/pain. On 09/26/15 a skin pressure ulcer weekly form revealed reddish/bluish skin discoloration, blancheable area measuring 4 by 7 centimeters (cm) and identified as a SDTI on the left buttock that was discovered during care. The documented interventions were: a low air loss mattress, a multivitamin supplement, repositioning and pain management. On 09/27/15 the Braden Scale for predicting pressure sore risk, change of condition, was completed. It indicated her ability to change and control body position was very limited, nutrition was adequate and she required moderate to maximum assistance in moving. On 09/29/15 the Braden Scale for predicting pressure sore risk, change of condition, was again completed, this evaluation noting nutrition for Resident 10 probably inadequate. On 09/29/15 the skin pressure ulcer weekly form stated the wound bed was black/brown eschar. The skin is now open and unstageable. It measured 7 by 8 cm without any depth. On 10/06/15 the skin pressure ulcer weekly form described the wound as unstageable with slough/eschar. It measured 6 by 8.5 cm and was 0.1 cm in depth. On 10/12/15 a nutrition risk review was done by the Registered Dieticitian (RD). Resident 10 had experienced a 26 pound weight loss (greater than 10%) since her admission to the facility related to a combination of diuresis (increasing urine output to reduce fluid volume related to heart failure and generalized [MEDICAL CONDITION]) and less than optimal calorie intake. Resident 10 had appropriate vitamin supplements in place. The RD recommended Glucerna (diabetic nutrition shake) and a protein supplement to ensure optimal nutrition to meet the resident's increased needs. On 10/13/15 the weekly skin assessment/evaluation stated Resident 10 had unstageable pressure ulcer on her left buttock with a large necrotic area in the center. Plan was to request the PA (physician assistant) to debride the wound. A wound culture was obtained. Resident and staff were instructed to turn the resident from side to side every 2 hours and on her back only for meals. On 10/14 15 the skin pressure ulcer weekly form measured the unstageable wound as 9 by 8.5 cm with a depth of 1.5 cm. Prior documentation related to Resident 10's pain noted it to be generalized, chronic pain. On this date Resident 10 complained of pain to the wound bed site. She had orders to have Tylenol, [MEDICATION NAME] (opioid [MEDICATION NAME]) for moderate pain and [MEDICATION NAME] (opioid [MEDICATION NAME]) for severe pain. On 10/16/15 the wound was debrided by the PA. On 10/19/15 the skin pressure ulcer weekly form revealed the unstageable wound had been debrided, was 7 by 9 cm, with a depth of 4 cm. There was now undermining extending 5 cm distally. On 10/21/15 the skin pressure ulcer weekly form revealed the unstageable left buttock wound measured 7 by 8 cm, was 3 cm deep and now had 2 areas of undermining - one extending 2.5 cm and the other 6.5 cm. The resident had complaints of pain at a site of undermining demonstrated by moaning/crying, guarding and irritability. On 10/22/15 an antibiotic was initiated to treat a wound infection. On 10/23/15 a skin evaluation stated a second debridement had been done yesterday by the PA. The wound was 90 percent slough with a moderate amount of foul smelling drainage. On 10/25/15 Resident 10 was transferred to the hospital intensive care unit secondary to decreased level of consciousness, decreased intake and output. Her speech was slurred and she was unable to hold her cup. Hospital clinical records revealed the left buttock wound was a Stage 4 sacral decutitus ulcer. IV antibiotics were intiated. Her pain and anxiety over falling increased her mobility and discomfort with turning. A wound vac (promotes wound healing through negative pressure/vacuum using a patented dressing that helps draw wound edges together, remove infectious materials and actively promote healing) was initiated 10/27/15. The care plan for Resident 10 included a focus related to actual impairment to skin integrity related to fragile skin and unstageable pressure ulcer to the left buttock. Interventions included: Explain and educate the resident for potential for breakdown with refusals to make significant positional changes while in bed. Needs wheelchair adjusted every 2-3 hours for position changes, off loading pressure and comfort. Treatment as ordered. Reposition/turn during care. Keep skin clean and dry. The care plan also included a focus related to at risk for activity of daily living self care perfomance with the intervention: Requires 2 extensive staff participation to reposition and turn in bed every 2-3 hours. Position for comfort and encourage resident to change position as resident allows, change positions slowly. There was little documentation addressing turning/repositioning in the clinical record. There was no documentation addressing whether the ordered treatments and plan for prevention and treatment of [REDACTED]. Were the appropriate pressure reducing devices meeting the individualized needs of Resident 10? Was the turning/repositioning program assessed to meet the increasing needs of Resident 10? Resident 10 was readmitted to the facility 11/2/15. An interview was conducted with the resident at 3:25 PM. She was awake in bed. The bed was a bariatric bed. She had family with her. She said she was waiting for the wound vac supplies to be delivered to have the dressing reapplied to her wound. She was asked about care and services, whether she was able to move herself in bed before discharge to the hospital and presently. She stated then and now she was able to move a little on her own. She said she did not like turning before she got the wider bed. She also said the other air mattress made noise, which was bothersome to her. Resident 10 and family stated she had never had [MEDICATION NAME] before and believed it had contributed to the change in her level of consciousness prior to going to the hospital. The [MEDICATION NAME] was discontinued in the hospital. The resident said she was disappointed that her planned discharge would now be delayed because of the wound. The above information related to Resident's 10 wound development and decline was presented to Staff C, Director of Clinical Services, on 11/02/15 at 3:30 PM. A request was made for any further information related to potential failure to provide the necessary care and services to prevent and treat pressure ulcers. All that was provided was an incident report summary, dated 09/29/15, when staff noted a brownish skin discoloration on the resident's left upper buttock. The report stated to prevent further skin breakdown the SDTI was covered with foam dressing, non-sting barrier was appled to surrounding skin, resident was to be repositioned at least every 2 hours, advised to minimize sitting on her chair, encouraged to lay in bed after meals and releasing the pressure on the left buttock at least every 2 hours. RESIDENT 14 Resident 14 was admitted to the facility August 24, 2015 with [DIAGNOSES REDACTED]. Review of the nursing admission assessment stated the resident had a left heel open area. There were no measurements or description of the open area. Review of a skin assessment, dated 08/29/15, identified the resident had a 10 cm x 10 cm unstageable left heel wound. The wound had eschar and was intact. A physician order [REDACTED]. The order was not put on the Treatment Administration Record (TAR) until 08/28/15. Review of the August TAR revealed the resident did not receive any wound care to the left heel pressure ulcer in August. There was documentation reflecting the resident refused wound care on 08/28/15. The TAR was blank for the remainder of the month. Resident 14 had no skin/pressure ulcer care plan implemented identifying risk factors, current goals or interventions implemented to prevent further breakdown. The resident had been discharged from the facility and unavailable for interview. In an interview on 11/02/15 at 12:50 PM, the DNS (newly hired) and Staff C were made aware the resident had no care plan implemented identifying the current pressure ulcer and risk factors for skin breakdown. The DNS and Staff C were made aware a treatment order was not obtained for 3 days after admission and the resident did not receive any treatment to the left heel ulcer for the month of August. RESIDENT 15 Resident 15 was admitted to the facility August 19, 2015. According to the admission MDS assessment, dated 08/26/15, the resident had a stage II pressure ulcer and three unstageable pressure ulcers present. Resident 15 required extensive assist of two people for bed mobility and transfers. Review of the admission assessment revealed the resident had the following pressure ulcers: - 1 cm long x 1 cm wide x 0 deep unstageable pressure ulcer on the right heel - 1 cm long x 1 cm wide x 0 deep unstageable pressure ulcer on the right toes - 5 cm long x 5 cm wide x 0.1 cm deep unstageable pressure ulcer on the left heel - 2 cm long x 1 cm wide x 0.1 cm deep stage II pressure ulcer on the sacrum Review of the physician orders [REDACTED]. The four pressure ulcers were to be cleansed daily with normal saline, patted dry and a foam dressing placed over the wounds. Review of the August TARS revealed the pressure ulcer treatments were not implemented until 08/24/15, 5 days after admission. Additionally, an intervention was implemented on 08/21/15 to off load the resident's heels while in bed. There was no documentation this was done on 11 out of 30 shifts. There was no interim pressure ulcer care plan implemented until 09/02/15. The resident had been discharged from the facility and unavailable for interview. In an interview on 11/02/15 at 11:45 AM, Staff D and C, LN ' s, stated the when a resident is admitted to the facility the LN was expected to clarify and obtain orders from the physician immediately. This included treatments for wound care. If the admitting LN was not able to obtain the orders, they would pass this to the next shift and the expectation was the oncoming shift would obtain the orders. They were made aware this did not happen for Resident 15.

Based on observation, interview and record review the facility failed to provide services to maintain the nutritional status for 2 of 2 residents (4 and 50) reviewed for nutrition. This resulted in actual harm related to significant unplanned weight loss for both residents. Findings include: RESIDENT 4 Resident 4 was a [AGE] year-old female admitted in January 2011 with care needs related to a traumatic upper leg fracture, [MEDICAL CONDITIONS], and muscle weakness. The Minimal Data Set (MDS) assessment dated [DATE] documented a weight of 111 pounds. The Care Area Assessment identified the resident at risk for weight loss due to cognitive problems and functional limitations in range of motion. Review of her care plan identified a nutritional problem. The nutritional goal was to attain a weight of 115 pounds and to have no signs or symptoms of [MEDICAL CONDITION] through the next 90 days. The physician was to be notified of any significant weight loss. The Registered Dietician's (RD) assessment, dated 12/06/12, identified the resident's usual body weight as 110 pounds and recommended a special nutrition program including fortified foods. The RD's summary stated that the resident's weight was "up slightly over past quarter. Many medications discontinued with transition to comfort measures in past quarter . . . ." The goal was to "support plan of care and resident wishes." This included continuing the current diet, and encouraging meal intake, milkshakes and a fortified cookie daily. A nursing assessment dated [DATE] noted that the resident needed assistance with setting up for meals, was able to feed herself, and was taking in 75% or more of her meals on average for the month. Her weight was identified as "stable" at 102.4 pounds. Review of the facility's nutrition policy and procedure revealed that any resident meeting the criteria for weight loss (weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days) would be weighed weekly. Weekly weights would be reviewed each week during the meeting of the Nutrition Committee. Resident's weights from 7/16/11 until 1/10/13 ranged from 110 to 113 pounds. On 1/23/13 resident's weight was 104 pounds, a 6.8% loss in her body weight in thirteen days. On 1/29/13 the RD was interviewed regarding the process of identifying residents for the nutrition committee. The RD stated that the weights were printed out weekly and assessed for weight loss or gain. The nutrition committee usually met weekly and was attended by the RD and Resident Care Manager (RCM). The RD stated that she "looks at the whole house in a rough look every week." When asked why the resident had not been reviewed in the nutritional committee, the RD reported the resident would be seen this week. On 1/29/13 at 3:20 p.m., the RCM (Staff D) was interviewed regarding the process of residents being weighed. Staff D reported residents were weighed on their shower days, and he entered the weights into the computer. If there were any discrepancies, he would ask for a reweigh. The surveyor then asked for the resident to be weighed, and she weighed 105 pounds. The physician was not notified of the resident's significant weight loss. RESIDENT 50 Resident 50 was a [AGE] year-old man admitted in October, 2012 with care needs related to a left leg fracture and fall history, depression, cardiac and respiratory issues. The MDS assessments indicated the resident had a 10.5% weight loss during his first 60 days at the facility, going from 171 lbs to 153 lbs. Nursing progress notes indicated he had a "good appetite" until 11/6/12, when his intake started to decline. The care plan, initiated on 11/20/12, included "Potential Nutritional Problem related to diet restrictions." A dietary supplement, 2-Cal, was ordered on [DATE], 120 cc three times a day. Nurses were signing their initials that they were giving it, but were not documenting how many ccs (milliliters) the resident actually took. This order was increased to 180 ccs three times a day on 11/27/13. There was no monitoring of number of ccs consumed daily until January 24, 2013, over two months after the supplement was first ordered. It was not possible to know what the resident's prior daily caloric intake was, or the amount of nutrients he was receiving from the supplements between November 15 2012 and January 23, 2013. On 12/6/12, the dietician documented that the resident reported some difficulty swallowing, that food "builds up" in his mouth and then he "can't swallow." The resident was also missing his dentures, which had not come with him to the facility, and the dietician noted his eating problem could be related to chewing. The dietician documented that the resident started a pureed diet and the resident said, "I can actually get this down." In an interview on 1/24/13 at 11:12 a.m., the resident was asked if he liked the food at the facility: "No! "I don't like the way they fix stuff. But I'm pretty picky about that." On 1/28/13 at 1:52 p.m. a female friend of the resident who was visiting the resident in his room was observed to pour a pile of boxed packaged desserts on the resident's bed, and said "He'll eat this." When asked why he was not eating, the resident said, "I just don't like the food." On 1/29/13 at 2:44 p.m. Staff I, the LN, reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She said "They should have been monitoring it." Staff I also said that she believed the reason the resident was not progressing in his physical and occupational therapy was his "failure to thrive," reflected in weight loss. In an interview on 1/30/13 at 11:00 a.m. Staff P, Director of Social Services, was asked about her note on 12/31/12 that the resident had told her he was depressed every day. The resident had wanted the physician to consider increasing his anti-depressant. Staff P said that she faxed the request for the physician to "take a look at his meds" on 1/28/13, almost a month after she received the request from the resident. When asked if depression was affecting the resident at all, she said, "Not that I know of." She said she had no opinion about whether his depression could affect his appetite. Staff L, the RCM, stated on 1/30/13 at 12:25 p.m. that nutritional supplements like the 2-Cal ordered three times daily for this resident should be monitored, as far as number of ccs consumed. She said that she expected nurses to do this now, but had not known that this should be done until the State surveyor pointed it out the previous day. In an interview on 1/31/13 at 8:30 a.m., the dietician, Staff S, described the resident as having had a "dramatic weight loss-he stopped eating all of a sudden." He was placed on [MEDICATION NAME] to stimulate appetite. Staff S said she expected nurses to document the amount of a nutritional supplement the resident actually took in: "I was under the impression they were signing the amount." When asked why the resident stopped eating, she said, "That would be a good question for nursing." She said she tried to talk to the resident, but "He wasn't able to answer my questions." When asked if there had been any effort to get the resident's dentures, she said it would be up to social services to do that. The resident's most recent weight in the medical record, dated 1/24/13, was 152.8 lbs. This is a repeat citation from 5/1/12. .

Based on interview and record review the facility failed to readmit 1 of 3 sampled residents (1). This failure resulted in harm for the resident, who was unnecessarily admitted to the hospital due to an inappropriate involuntary discharge from the facility. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was alert and oriented, English was not his native language. On 5/15/12 at 10 a.m., the hospital discharge planner (LN 1) was interviewed. She stated that the resident was sent to the hospital's emergency department (ER) on 5/2/12, was stabilized the same day and did not need acute care in the hospital. "He came to the ER for nothing serious, he did not need to be sent to the hospital. All he was given was pain medication and he was medically cleared." LN1 said that the facility refused to readmit Reisdent 1 as they could not meet his needs, because they could not communicate with him. However, while the resident was at the hospital, the nurses there and the resident were able to communicate. Record review revealed Resident 1 was transferred to the hospital on [DATE]. According to a nursing note dated 5/3/12, "Resident 1 was confused, screaming and unable to answer simple questions ...difficult to determine if resident understands English. Resident behavior, screaming escalating. Physician notified, orders obtained to transfer resident to hospital." During an interview with the Director of Nursing (DNS) on 05/15/12 at 12:00 p.m., the Director of Nursing Services (DNS) was asked why the facility did not accept the resident back from the hospital. She replied, "We couldn't communicate with him, we couldn't meet his needs." In a a subsequent interview with LN 1 on 5/18/12 at 1:30 p.m., LN 1 stated the resident remained in the hospital unnecessarily for 5 days before he was discharged to another nursing facility. Resident 1 was refused readmission to the first nursing facility, who stated they could not meet his needs. However, the ability of another nursing facility to admit the resident for care and services less than a week later, indicated that Resident 1's needs were not beyond the level of nursing home care. Refer to citation written under CFR 483.15(g)(1)- F 250, Provision of Medically related Social Service/

Based on interview and record review the facility failed to ensure medically related social services were provided for 1 of 1 sampled residents (1), reviewed for communication needs and unplanned discharge. This failure resulted in harm for the resident, who was inappropriately discharged and refused readmission to the facility. Findings include: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1 was alert and oriented, the resident was of Asian ethnicity and English was not his native language. On 5/2/12, the facility sent the resident to the hospital due to unrelieved pain and the inability of staff to effectively communicate with the resident. Once the resident's pain was relieved in the emergency room , the facility refused to readmit the resident, stating they could not meet his needs. Record review found the facility failed to provide medically related social service interventions for the resident regarding communication and discharge planning. The facility did not identify and seek ways to support the resident's communication needs or to seek and involve the resident's family to meet the resident's needs. When interviewed on 5/15/12 at 12:00 p.m., the Director of Nursing (DNS) stated that the facility currently did not have a Social Worker. Failure to assess and meet the resident's communication needs resulted in the resident having unrelieved pain, prevented staff from developing a plan to treat the resident's pain. In addition, this failure resulted in the resident being sent to the hospital and refused readmission to the nursing home.

Based on observation, interview and record review the facility failed to treat residents with respect and dignity. This effected 2 of 5 (2 & 5) resident reviewed for dignity. The failure resulted in mental harm for Resident 2. Findings include: Resident 2 Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation in the Social Worker (SW) progress notes showed that on 4/12/12, the SW reported a conversation with the resident. The SW discussed with the resident that her Home and Community Services (HCS) Case Manager would be in the facility the following day (4/13/12) to discuss financial issues. On 4/13/12 the SW documented in the progress notes that nursing staff told the SW that the resident was upset and tearful due to a conversation she had with Staff B, the Business Office Manager, regarding her finances. Review of the facility's investigation of the incident revealed statements from multiple staff documenting the resident was crying and upset due to the incident. The facility ruled out abuse and neglect, concluding it was not what staff B said to Resident 2, but how she said it, that caused the resident's distress. In an interview on 4/25/12, the resident stated that on the morning of 4/13/12, staff B was "very rude and demanding and accused my son of taking my money." The resident was observed to still cry and say she was upset about the incident with Staff B that happened 12 days prior. The resident said Staff B had called the resident's son and told him that if the resident did not pay the money, the resident would have to move out in 10 days. The resident stated she was very upset by the conversation. "It wasn't what she said, but how she said it," that caused the resident to feel depressed. Resident 5 Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident required one person assistance with toileting. In an interview on 4/26/12 at 10:31 a.m., the resident's family member stated that she told the facility " I could not pick up my mom until after 4 pm when I got off work on 3/16/12. They put her in a wheelchair and parked her in a room so they could give her room to another resident. They treated her like a sack of potatoes. What would have happened if I would have gotten into a car accident and was not able to pick her up? Would they have put her in the street? " The family member stated that she did not arrive at the facility until about 4:30 pm. On 4/27/12 at 11:30 am, the Resident stated a man came and asked her to wait in another area of the building because they were admitting someone else to her room. " I waited for hours for my daughter to arrive. I didn ' t want to cause any problems and felt too uncomfortable to say no. " The resident went on to say that her daughter was upset about her setting up so long without being able to lay down and rest. Interview with Staff L found that the resident received her last her intravenous antibiotics while she was sitting in the common area. In an interview on 4/26/11 at 1:10 pm, the Director of Nursing Services (DNS) stated that she was not aware of the incident and was just learning of it herself. In an interview on 4/26/12 at 1:20 pm, Staff P stated that on 3/16/12, the resident went to the doctor. When she returned to the facility, Staff A spoke with the Resident and asked her if it would be "ok" for her to sit out in the hall, because someone else was admitting into her room. The resident still needed one more dose of intravenous antibiotics. In an interview on 4/26/12 at 1:40, Staff I stated that Resident 5 went to the doctor and when she came back they had her sit in the hall. He did not understand why they did not put the new admit in another room. In an interview on 4/27/12 at 2:30 pm, the Administrator stated that he asked the resident if it would be ok for her to sit in a common area and wait for her family to pick her up. The resident stated it was ok. The Administrator could not offer any further information about why the new resident could not be admitted to one of the empty rooms in the facility until Resident 5 left the facility. The LN stated that she administered the resident's last dose of IV antibiotics while the resident sat in the common area. Record review on 4/27/11 showed the resident was discharged at 1:30 pm.

Based on observation, record review, and interview, the facility failed to provide treatment and services for 1 of 5 sampled residents (3) related to pain management. Resident 3 experienced pain and suffering due to lack of pain management, which limited his ability to participate in therapies and turn in bed which resulted in skin breakdown. The lack of interventions for pain management resulted in harm to resident. Findings include: The facility policy for "Pain Management" indicated that "pain was assessed and managed by an interdisciplinary team who worked together to achieve the highest practicable outcome. Management: 1. Documentation on the care plan any preventative or care interventions (pharmacological and non-pharmacological) for any resident admitted with pain. 2. Document all finding in Nursing Notes. 3. Medication(s) received, refused and response to medication will be documented on the Medication Administration Record (MAR). If a resident is admitted to the facility for pain management, Pain Management Flow Sheet will be used to document response to the treatment plan." Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was moderately impaired in his cognition. The MDS also indicated that he was taking pain medications but still was almost constantly in pain, making it hard for him to sleep at night. The resident reported his pain level at the time of the assessment on a scale of 1 - 10 (10 being the most severe) was a 9. Record review showed that on 4/13, 19 & 26/12, Physical Therapy (PT) documented the resident refused to participate in PT activity due to pain in his left lower extremity. On the same days the resident refused Occupational Therapy services, who documented that the resident refused therapy "secondary to pain and fear of moving to increase pain." On 4/13/12 the resident reported he had a pain level of 8 and received one pain pill at 12:00 p.m. At 1:00 p.m. the LN documented the pain pill was "effective" even though his pain level was reported at a 6, which per the facility policy indicated moderate pain. On 4/19, & 26/12 the resident was not medicated at all for pain. A review of the resident's Medication Administration Record (MAR) found that the "Pain Assessment Flow sheet" was blank. The front of the MAR indicated the resident received pain medications 12 times, but on the back of the MAR the pain medication was only documented as given 3 times. A review of the resident's care plan directed staff to document every shift on the numerical scale and to administer a pain medication every 8 hours for pain management. There was no evidence these interventions happened. In an interview on 4/26/12 at 10:30 a.m., the resident stated that he had never had complete pain control. He stated he was in constant pain and especially when staff moved him or turned him. In an interview on 4/26/12 at 1:43 p.m., the Director of Nursing stated the physician wrote the wrong order for pain medication and the resident never received the increased dosage.

Based on interview and record review the facility failed to prevent the development of avoidable pressure ulcers for 3 of 3 residents (Resident 1, 6, 7) who were identified at risk for pressure ulcer formation. Failure to evaluate and implement the need for pressure relief measures for Resident 1 resulted in harm and the development of a pressure ulcer. Failure to consistently provide hand/nail care for Resident 6 resulted in the development of an avoidable pressure sore/blister. Lack of preventive intervention for Resident 7 resulted in the development of an avoidable painful blister formation/pressure sore on his right heel. Findings include: RESIDENT 1: Resident 1 was admitted for rehabilitation on 3/1/12. The resident had pain due to her fractured ribs, arthritis in her knees and left shoulder. The nursing admission assessment, documented Resident 1's coccyx area was red and when she was positioned on her right side in bed, it was painful for her, because of her fractured ribs. The March 2012 Treatment Administration Record (TAR) documented that the licensed nurses (LNs) applied a barrier cream every shift to the resident's coccyx area. The Minimum Data Set (MDS) assessment, dated 3/8/12, revealed that Resident 1 required extensive assistance of two staff for bed mobility, was incontinent of urine and bowel, and was at risk for the development of pressure sores. The MDS documented that the resident had a pressure reducing device for her bed and wheelchair. Both the Care Plan and the " In room plan of care", directed staff to apply house barrier cream after each incontinent episode and staff were to reposition Resident 1 every two to three hours, noting it was too painful at times for her to to lay on her right side. During an interview on 4/19/12, Resident 1 was observed at 2:35 p.m. seated in her wheelchair. She reported she had repeatly informed the facility staff that her " butt was sore". She stated when a therapy staff member was assisting her, they reported to to the resident that she had "a sore on her butt". She stated "if the nursing assistants (NAs) had seen the sore, they should have reported it to the licensed nurses". Resident 1 was observed to have an inflated air mattress on her bed. She stated this air mattress was put on her bed "weeks after the sore had developed", and her cushion in her wheelchair was put in the chair about a week ago. On 4/20/12, the Licensed Nurse (LN O) stated Resident 1 had a red area on coccyx when she was admitted to the facility and remained in her bed most of the day. LN O said the resident was only out of bed for skilled therapy sessions, and remained positioned "most of the time on her left side". This LN also said Resident 1 had a "big problem with incontinence", used the bedpan and required staff to assist her with bed positioning. On 4/20/12, the Nursing Assistant (NAC E) who had worked with Resident 1, confirmed that the resident had not gotten out of bed, due to her knee pain, used a bed pan and barrier ointment was to be applied to her buttocks. The NAC stated that the resident needed assistance and cueing for positioning in bed. The Weekly Pressure Ulcer Assessment Report, dated 3/14/12, documented that the resident had a Stage 2 pressure sore on her left buttocks. (A Stage 2 pressure sore involves partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough). The pressure sore measured 3.2 centimeter (cm) by 2.4 cm in size with a red wound base, had a scant amount of serous exudate and no surrounding tissue redness around the wound. The care plan was updated on 3/14/12, and identified the resident was at high risk for further skin breakdown due to the superficial open area. The plan directed staff to apply a dressing every 5 days and prn (as needed) to the pressure sore. The next entry on the Weekly Pressure Ulcer Assessment form, dated 3/19/12, documented that the Stage 2 pressure sore on the left buttocks had a small amount of serosanguineous drainage and now had 2 cm of [DIAGNOSES REDACTED] (redness) around the wound. By 3/27/12, the pressure sore on the left buttocks had deteriorated to a Stage 3. (Stage 3 pressure sore-full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The sore presents clinically as a deep crater with or without undermining adjacent tissue). The wound bed contained 60% yellow slough (dead tissue). The MDS, dated [DATE], documented the resident had a Stage 3 pressure sore and required extensive assistance of two staff members for bed mobility and toileting and had pressure reducing devices in her wheelchair and bed. There was no documented evidence that a turning/positioning schedule was initiated during this assessment period even though the resident required extensive assistance with bed mobility and the pressure sore had deteriorated. On 4/2/12, the pressure sore was still assessed to be a Stage 3 pressure wound and "unstageable". It had slough in the wound bed. Resident 1 confirmed that the sore on her buttocks was painful. The reported reported that her pain level ranged from a 4-8 on a 0-10 pain scale (0 is no pain and 10 being the highest level of pain). When interviewed on 4/20/12, the SDC who was responsible to track skin issues, verified that a mattress was ordered for Resident 1's bed after the facility realized the resident was not getting pressure relief to the avoidable pressure sore on the resident's left buttock. The resident's Treatment Administration Record (TAR) for April 2012 revealed that the air mattress was ordered on [DATE] and documentation revealed that it was not put on her bed until 4/8/12. (As noted above, the Stage 2 pressure sore was first documented on 3/14/12, approximately 3 1/2 weeks earlier.) Not until the Stage 2 pressure sore deteriorated to an unstageable pressure sore which caused pain for Resident 1, did the facility order a special mattress for pressure relief. Even though the facility staff were aware of the resident's limited mobility, that Resident 1 remained in bed the majority of the time and preferred to be positioned on her left side due to shoulder pain, there was no documented evidence found in the clinical record that pressure relief measures such as a positioning/turning schedule had been implemented to avoid pressure on her left buttock area. RESIDENT 6: Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admit assessment, dated 1/30/12, documented Resident 6 was totally dependent on staff for all her care needs and was identified to be at high risk for skin breakdown. The "Joint Mobility Assessment", dated 2/9/12, indicated the resident had "severe" contractures of her fingers. The Plan of Care directed staff to remove her palm guards (type of hand splint) from her hands twice a day, to wash her hands with soap and water, pat them dry, and then reapply the palm guards. The Care Plan indicated weekly skin assessments were to be done and the staff was to check skin folds and creases daily for any redness when dressing the resident. On 4/20/12, during an interview with the occupational therapist (OT), she stated Resident 6's right hand rested in a clenched position. She said the palm guard was padded and the device rested between the resident's finger and against her palm. The device had an elastic strap which rested on the knuckle area of the hand. The OT stated that it was important to keep the skin under the splint device clean and dry, and to make sure her finger nails were cut short to avoid the fingernails from digging into the palm of her hand/skin. The Treatment Administration Record (TAR) for February 2012 revealed the Licensed Nurses were to perform nail care weekly. The TAR indicated that the nail care was not documented as being completed on 2/15 or 2/22. The TAR also documented that on 2/22/12, the staff were to monitor a blister on a knuckle on the resident's right hand. Even after the blister developed, the LN did not document whether nail care had been completed during the entire month of March 2012. There was no documented evidence in regard to monitoring of the blister on the TAR or weekly skin assessment forms to evaluate the progress or decline in the resident's blister formation. At 1:10 p.m., on 4/20/12, the SDC (Staff K) verified the blistered area that developed on Resident 6's knuckle area was the "exact match as to where the splint was". He stated that the elastic portion of the hand guard that was in contact in the top of her hand was then padded for protection. A facility incident report documented Resident 6 was dependent of staff for all care, had bilateral hand contractures/tightness to fingers, and wore a splint on her right hand. The report revealed the resident had developed a fluid filled blister to the knuckle area of right hand. The facility concluded that friction may have caused the blister. The plan to prevent this from happening again read: close attention to area by nursing/therapy. The Care Plan, dated 2/24/12, read: right hand with small blister to splint site. Review of the clinical record revealed there was no further documentation regarding the blister after 2/22/12, even though the TAR for April 2012 documented licensed nurses were to monitor the blister. The facility staff was to provide skin care to the hands with removal of the splint twice a day in addition to weekly nail care however there was no documented evidence of skin redness or irritation prior to the 1 centimeter blister formation on the knuckle area of her right hand underneath the elastic portion of the hand guard/splint. RESIDENT 7: Resident 7 was admitted on [DATE], from the hospital with [MEDICAL CONDITION] of his left foot. The nursing admit assessment note indicated the resident had a Stage 4 pressure sore on his left heel that had required surgical debridement during his hospitalization . (A Stage 4 pressure sore involves full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). The Treatment Administration Records (TARs) found that the licensed nurses (LNs) provided a daily treatment to his pressure sore on his left heel. The plan of care directed the LNs to assess the resident's feet and his foot ulcer on the left heel. The plan of care also indicated that the nursing assistants were to bridge Resident 7's heels off the bed with pillow when in bed. The Minimum Data Set (MDS) assessment, dated 11/16/11, documented that Resident 7 was at risk for developing pressure ulcers and received ulcer care to his foot. The MDS, dated [DATE], revealed that the resident was independent with ambulation and bed mobility. Interview with SDC K on 4/20/12, stated Resident 7 frequently walked for long periods, did not have proper fitting foot wear, and his slippers would be soiled and wet when he returned from going out for social events. Staff K stated when the resident was out of the facility he would stand on his feet for prolonged periods which caused pressure to his heels. Review of the facility's skin ulcer site sheet, dated 2/27/12, documented that the resident had developed a blister on his right heel, which was painful for the resident. Review of the facility's incident report summary, dated 3/1/12, for the blister formation on the right heel revealed that when the LN provided wound care to the resident left heel, the resident had shown the LN his blister on his right heel. The resident informed the staff that he had the blister 2 weeks prior. Review of the TARs did not reveal how the LNs were monitoring the bridging of Resident 7's heels when in bed. There was no documented evidence that facility staff had modified or removed improper footwear, even though staff were aware Resident 7 frequently got his socks wet, which placed his feet at risk for skin irritation and development of pressure sore. Review of the incident report summary indicated that action taken would include assessment of bilateral feet and educate the resident regarding wearing appropriate footwear in inclement weather and wearing socks to prevent rubbing/irritation from shoes/sandals.

Based observation, interview and record review the facility failed to ensure medically related social services were provided to attain or maintain Resident 1's the highest level of psychosocial well being; failed to aggressively advocate and evaluate the resident or plan psychological interventions to assist Resident 1 who was reviewed for behaviors. Failure to assess and set up acute mental health services allowed hallucinations & delusions to intensify to the point that her psychosocial well being affected and her vital health needs were at risk. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] indicated the resident was moderately impaired in her cognitive status; she had disorganized thinking with hallucinations and delusions. Documentation on the Medication Administration Record (MAR) showed the resident refused to take life sustaining medications. From [DATE] to [DATE], the resident's blood sugars indicated the resident's diabetes was not being controlled. From [DATE] to [DATE] the resident refused to have all routine blood sugar tests and / or laboratory tests performed and refused medications including her psychoactive medications. The resident began to have daily delusions and hallucinations that were disturbing to the resident. On [DATE] & [DATE], the Social Worker (SW) documented in the progress notes that the resident was refusing her medications and didn't care if she died . The SW assessed the resident for suicide and determined she was not actively suicidal. The SW indicated that the Licensed Nurse (LN) was going to follow up with the physician. The facility did not contact the physician/practitioner until the evening shift on [DATE]. The practitioner instructed staff to continue to offer medications and call the family in order to have a discussion. A message was left for the family. There was no further documentation about a discussion with the family until [DATE] when the Mental Health Professionals were called. On [DATE], the SW documented she placed a call to the Mental Health Professionals (MHP) to make a referral for a mental health assessment based on the resident's refusal to take medications that were vital to sustaining her health. On [DATE], the MHP documented on a "Mental Health Assessment Form" recommendations for the facility. The MHP recommended: -The facility needed to follow up with the primary care physician to request a urinalysis / and or other tests to rule out infections / medical conditions. -The facility was to increase their documentation of behaviors, number of times medications were offered/refused and delusional statements or statements of hopelessness. -The facility was to have the physician review the resident's psychotropic medications because there had not been any increases in the medications to control delusions/hallucinations. There was no further documentation from the SW, no interventions were developed and the plan of care went unchanged, even though the resident continued to refuse medications, care and was having active hallucinations. Review of the progress notes showed that from [DATE] to [DATE], there was no documentation by licensed staff even though the MHP recommended that staff increase their documentation. Documentation in the progress notes on [DATE] indicated that the resident was having delusions. There was no evidence the SW/staff intervened or developed a care plan for the delusions. Documentation in the progress notes on [DATE] indicated the resident developed two stage II open areas on her buttocks. The physician ordered a routine treatment. Treatment sheets showed that the resident refused the treatments. There was no evidence the SW/staff intervened, assessed the resident to determine why she was refusing treatments or developed a plan of care to address the resident refusal of care. On [DATE], documentation in the progress notes by a licensed nurse (LN) indicated the resident's refusal of medications and treatments for two months had placed the resident at "great harm to herself." The LN provided document to the Mental Health Professional who deemed the resident gravely disabled and the resident was sent to the hospital. On [DATE], hospital documentation showed the resident complained of facial burning, urinary frequency, pubic discomfort and inability to empty her bladder. The resident was evaluated and diagnosed with [REDACTED]. There was no evidence the facility had provided ongoing assessments of the symptoms the hospital documented. Hospital documentation showed that while the resident was in the hospital the resident continued to refuse some medications and laboratory work. The hospital documented the resident could not be treated on their psychiatric floor due to her inability to participate in the treatment programs, so the resident was medically cleared to return to the nursing home without any psychiatric interventions being provided. On [DATE], the resident was readmitted to the facility even though hospital documentation showed the resident continued to refuse medications, laboratory tests, and the resident had not received psychiatric treatment. The SW documented the plan was for the resident to be monitored and she would be followed by the facility's "psych committee". On [DATE], the resident started to refuse her insulin/medications and treatments on a daily basis. There were no follow up with Mental Health, documented assessments or interventions put into place. On [DATE], the resident's care plan was updated and directed staff to notify the SW if the resident refused care or treatments. There were no documented interventions by the SW except to notify the SW if she refused care or medications. On [DATE], the SW documented the resident was "psychotic". There was no follow up with the resident refusing her medications and there was no interventions put into place to address her being "psychotic". On [DATE], there was documentation on a care conference summary form that the resident's refusal of blood sugar testing was discussed. The resident indicated she refused the tests "because it hurts." There was no evidence that the facility provided any follow up to the resident refusing her medications or care. There was no further documentation from the SW and there were no further revisions to the care plan. The resident continued to refuse medications and treatments. On [DATE], the facility sent the resident to a hospital to ensure the resident ' s safety. When the resident arrived at the hospital the resident reported that she did not trust anyone at the facility because they had been placed live vipers around her neck. She stated the snakes had been biting her neck, face and eating her hair. The hospital determined the resident had high blood sugar, a urinary tract infection, and she was at baseline by refusing her medications and the resident returned back to the facility. From [DATE] to [DATE] the resident was taking her medications, but the SW did not revise the plan of care to direct staff on how they should respond if the resident began to refuse her medications / treatments or was having active delusions / hallucinations per documentation on the MARs. There was no follow up with mental health to ensure the resident reached her highest level of functioning. The facility SW did not aggressively intervene to ensure the resident was not at risk for complications from diabetes and the only plan that was put in place was to notify Social Services if she refused medications and care. There were no follow up to ensure laboratory tests scheduled. The facility failed to ensure Mental Health Services were started.

Based on observation, interview and record review the facility failed to ensure staff followed the care plan for 1 of 1 sampled resident, Resident 2. This failure resulted in harm for Resident 2 as evidenced by having a fall and receiving a skin tear. Documentation on an "Incident Report" dated 11/9/11, indicated a Nursing Assistant (NA) attempted to transfer Resident 2 from the bed to a wheel chair. The resident received a skin tear on her left elbow that measured .4 centimeters (cm) by .4 cm and .1 cm deep. The resident's care plan dated 10/19/11 directed staff to use extensive assistance of two persons to transfer the resident. Staff was also to ensure the resident had her foot brace (AFO) on prior to transfers. The facility completed an investigation and determined the care plan not being followed, the staff member was transfered the resident alone, was not using a gait belt and the resident did not have an AFO on. In an interview on 11/21/11, a business office staff person reviewed the employee file and stated that the NA was hired on 9/10/11. There was no documentation that the NA had the facility general orientation. Documentation showed that the NA was trained on night shift for 2 days and 2 days on evening shift by shadowing another staff member then given an assignment to work unsupervised on evening shift.

Based on observation, record review and interview, the facility failed to ensure 1 of 9 residents in the sample (1) was free from a significant medication error. Resident 1 was given [MEDICATION NAME], a blood thinning medication despite a critically high lab result, without communicating with the physician prior to administration of the medication. This failure resulted in the resident having a gastro-intestinal bleed and having an extensive hospitalization . Findings include: Resident 1 was admitted to the facility on [DATE]. The resident had a [DIAGNOSES REDACTED]. The facility policy for [MEDICATION NAME] administration directed staff to hold [MEDICATION NAME] if a resident's INR, (International Normalized Ratio) was "in the critical range greater than 3.5 until the physician can be notified and new orders received the day the INR is received." Resident 1's most recent INR, was completed on 9/1/11 and the results indicated the INR range was 4.17. The result indicated the level was in the critical range. Instead of directly notifying the physician, Licensed Nurse (LN) 1 faxed the laboratory results. LN 1 did not follow the facility policy, the LN did not document in the nursing notes or place the resident on alert charting for assessment of bleeding. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 9/1/11 the physician wrote an order to discontinue the [MEDICATION NAME] for 3 days. The September MAR indicated [REDACTED]. Documentation showed that on 9/6/11 at 3:00 am, the resident reported to an LN that there was blood in his stool. The LN assessed the resident and there was "frank blood" in the toilet. The LN reviewed the lab reports, noted the high INR and sent the resident to the hospital. On 9/6/11, after the resident was at the hospital his INR was 8.0 so the resident received 2 units of fresh frozen plasma. By 9/12/11 the resident was still in the hospital. In an interview on 9/12/11 the Director of Nursing (DNS) stated that LN 1 reported to LN 2 that the resident's INR had been high and a fax was sent to the physician. LN 1 did not attempt to contact the physician prior to giving the [MEDICATION NAME] and neither did the other evening nurse who continued to give the medication over the next 4 days. The DNS also indicated the LNs had not followed normal protocols by holding the [MEDICATION NAME], placing the resident on alert charting, or by calling the physican instead of sending a fax.